The role of tissue expansion in the management of large congenital pigmented nevi of the forehead in the pediatric patient

Serial Tissue Expansion and Skin Grafts in the Management of a Giant Congenital Nevus of the Face: Review of Literature and Case Report

Giant congenital nevi, especially on the head and neck, pose a challenge for plastic surgeons. This requires extensive experience in detailed planning, combining different techniques, and selecting appropriate materials for reconstruction. There have been reports of using a tissue expander, serial resection method, and full-thickness skin grafts for this type of nevus. However, the best way to completely remove a giant congenital nevus is endless. In this article, we would like to present a case of a left hemifacial giant congenital nevus in which we used multiple tissue expansion to fully replace the nevus, along with some of our modification techniques.

A 20-Year Experience with Tissue Expansion for Large Cervical Fascial Defects: An Algorithm Based on Different Clinical Flap Designs

Over the past 20 years, we have designed various types of expanded cervical flaps for large facial defects and achieved excellent tissue matching. This study was performed to propose a treatment strategy for flap selection for the reconstruction of different facial units. The authors retrospectively reviewed the application of cervical expanded flaps for facial rehabilitation in our department between January 2003 and January 2023. The study included 122 patients with unilateral (62.3%) and bilateral (37.7%) facial deformities ranging from the zygomatic arch to the chin. The median area of the tissue defect was 15.2 × 8.5 cm2 (ranging from 6 × 4 cm2 to 27 × 12 cm2). The expansion period ranged from 61 to 175 days (mean: 86.5 days). Maximum and minimum sizes of pre-expanded cervical flaps were 30 × 13 cm2 to 7 × 5 cm2. All the flaps could be summarized into type 1, an advanced expanded cervical flap; type 2, a wing-shaped expanded cervical flap with overlapping tissue expansion; and type 3, an expanded single-lobed transposition flap rotated based on the anterior neck. Cervical flaps reliably meet the reconstructive requirements for different facial units, especially for large cutaneous defects in the clinic. The selection of these flaps can be planned preoperatively according to the location and size of the defect or lesion.

Surgical outcomes and psychosocial impact of giant congenital melanocytic nevus surgery: A single-center case series of 136 patients

PURPOSE

The aim of this study was to evaluate the outcomes, complications and psychosocial impact of surgical treatment of giant congenital melanocytic nevus (GCMN).

METHODS

Patients with surgically treated GCMN who attended our clinic between May 2014 and May 2018 were included. Patient demographics and data on the characteristics of the nevus, surgical treatment, and the psychosocial impact (including C-DLQI/DLQI questionnaires) were collected.

RESULTS

One hundred thirty-six patients were included (median age 9 years). Mean age at first surgery was 34 (+/- 61.45) months; 5.53 (+/- 3.69) surgical interventions were necessary to completely excise the nevus. The expanded skin flap was the preferred surgical technique in most locations. Complications were common but not severe. Of the patients studied, 70.4% reported that the surgery had a minor impact on their quality of life (QoL). Patients and caregivers stated that surgical treatment should begin as soon as possible, even in cases where early treatment did not have an impact on their QoL nor on their satisfaction with the surgery (p < 0.05). The lower the patient age at first surgery, the higher the surgeon's satisfaction (p < 0.01).

CONCLUSIONS

Surgical treatment is a safe option for management of GCMN, and has a low impact on QoL. Patients, caregivers, and surgeons agree that the treatment should begin as soon as possible. This is the largest single-center study evaluating surgical treatment in GCMN patients and its psychosocial impact, and the first to take into account the patient, caregivers and dermatologists opinion of surgical results.

Closure of Challenging Pediatric Scalp Wounds by a Tension-Relief System

ABSTRACT

Pediatric scalp defects may be challenging, due to their variant tension level and specific etiologies. Tissue characteristics and pre- and post-management considerations may pose difficulties to reconstruction in the pediatric patient. Primary closure is the preferred surgical technique but is not always possible. Various techniques have been described for facilitating primary wound closure, by reducing tension from the skin wound margins. The authors use a tension-relief system in some challenging scalp wounds when simple primary closure cannot be achieved. This enables primary closure without tension on the surgical margins, and may thus preclude the need for other closure techniques such as tissue-expanders, grafts, and flaps. The authors describe our use of a tension-relief system in 21 pediatric patients treated during 2017-2020, for congenital deformities, vascular malformations and other skin lesions, traumatic wounds, burn scars, and complicated surgical wounds with and without hardware exposure. A tension-relief system is a prompt, simple-to-use, safe, and low-cost surgical solution that offers several advantages over other techniques when tension-free primary intention closure is not possible. These benefits include less extensive surgery, fewer surgeries and associated anesthesia, shorter treatment period and hospitalization, better scarring, lower distress and burden to patients and their families, better pain-control, the absence of donor-site with its comorbidities, and less bleeding and risk of damaging adjacent structures. Based on our experience and the system characteristics detailed, the authors recommend using the described technique, which is convenient, accessible, and reliable, to close challenging scalp wounds in pediatric patients.

Forehead deformities after tissue expansion: Retrospective analysis and recommendations

BACKGROUND

Tissue expanders can lead to bone deformity as well as bone resorption. Not all changes in the cranial bone can be completely normalised after tissue expander extraction. This study aimed to investigate the potential factors for persistent forehead deformities after tissue expansion.

PATIENTS AND METHODS

Cases of forehead tissue expansion performed from 2011 to 2015 were retrospectively reviewed. Demographic and clinical data were collected. Two plastic surgeons (Y.Q. and C.Q.) evaluated changes in the forehead by comparing preoperative and most recent postoperative photographs. The Fisher exact, chi-square and Student t tests, and univariate and multivariate logistic regression analyses were performed in this study.

RESULTS

Sixty-seven patients underwent forehead expanded flap reconstructions and continuous follow-ups were done in the outpatient service. The mean duration of the follow-ups after expander removal was 33.86 months. Overall, 28 (41.8%) patients had forehead changes. Age, sex, indications for tissue expansion and follow-up time were not associated with forehead changes. There were significant differences in the total injection volume and expansion period between patients with forehead changes (41.8%) and those without (58.2%). No significant negative correlation was found between the duration of pressure bandage usage post-operatively and the occurrence of forehead changes.

CONCLUSIONS

Our recommendations for performing tissue expansion in the skull area are as follows: (1) always choose expanders with the largest base dimension; (2) perform tissue expansion as quickly as possible and (3) do not cause overexpansion. In addition, there was no proven benefit of using pressure bandages when skeletal changes occurred.

Multiple Tissue Expansion for Giant Congenital Melanocytic Nevus

OBJECTIVE

Tissue expansion is the preferred technique for the treatment of giant congenital melanocytic nevus (GCMN) located on the face, abdomen, and legs. We believe that the use of multiple tissue expanders in the same surgery is a safe and effective technique for the treatment of GCMN.

MATERIALS AND METHODS

A total of 14 patients were treated between 2013 and 2016 for GCMN removal with placement in the same surgery of 3 or more tissue expanders. We analyzed esthetic results and complications.

RESULTS

The locations of the GCMN on the 14 patients were on the abdomen, thigh, and shoulder. The number of tissue expanders placed was 3 in 5 patients, 4 in 6 patients, 5 in 1 patient, and 6 in 2 patients. The average stay was 4.29 days (1-9 days), and the average time until the removal of the expanders was 84.71 days (47-127 days). Only 2 patients had postoperative complications, with one having dehiscence of the surgical wound and the other an infection of the expander.

CONCLUSIONS

The use of multiple tissue expanders for GCMN is a safe technique that reduces the number of surgical interventions, achieving a total excision of the nevus in less time and at a younger age. The esthetic results are similar, and we have not observed a higher rate of complications.

Fragility of epidermis in newborns, children and adolescents

Within their first days of life, newborns' skin undergoes various adaptation processes needed to accommodate the transition from the wet uterine environment to the dry atmosphere. The skin of newborns and infants is considered as a physiological fragile skin, a skin with lower resistance to aggressions. Fragile skin is divided into four categories up to its origin: physiological fragile skin (age, location), pathological fragile skin (acute and chronic), circumstantial fragile skin (due to environmental extrinsic factors or intrinsic factors such as stress) and iatrogenic fragile skin. Extensive research of the past 10 years have proven evidence that at birth albeit showing a nearly perfect appearance, newborn skin is structurally and functionally immature compared to adult skin undergoing a physiological maturation process after birth at least throughout the first year of life. This article is an overview of all known data about fragility of epidermis in 'fragile populations': newborns, children and adolescents. It includes the recent pathological, pathophysiological and clinical data about fragility of epidermis in various dermatological diseases, such as atopic dermatitis, acne, rosacea, contact dermatitis, irritative dermatitis and focus on UV protection.

Changing the Donor Site Selection Concept of Facial Skin Expansion from Pure Healthy Tissue to Defect and Healthy Tissue Combination

Facial defect reconstruction is a challenge for plastic surgeons due to unique esthetic and functional properties of the region. Facial tissue expansion provides an ideal reconstruction resource. However, the donor site is limited in the facial region. Thus, a cost-effective expansion management is crucial for an efficient reconstruction. In this article, the evolution of our donor site preference for tissue expansion from pure healthy tissue to a defect-healthy tissue combination is presented. Fifteen patients underwent skin reconstruction with local tissue expansion for facial and cervical defects. The full facial or cervical region including the defect and healthy tissue combination was determined as the donor expansion site. The donor site was not limited only to pure healthy tissue. The largest size rectangular expander suitable for the combined expandable donor site size was placed under the defect and healthy tissue border, paying attention to carry the expander far beneath the defect site. The defect site and most adjacent healthy tissue were expanded simultaneously. Major complications such as infection, hematoma, rupture, or flap necrosis were not observed. The expansion of defect-healthy tissue border presented successful reconstruction results with acceptable scars. In the traditional tissue expansion concept, using a large size expander to provide more abundant flap gain does not comply with the limited size of healthy donor site in the face. Expanding the whole facial region, without restriction of the defect, supplies excess donor tissue area for larger size expander use. Eventually, defect-healthy tissue border expansion with large expanders results in minimum final scar and less tissue loss in flap relocation and enables optimal flap gain. This method can easily be adapted to any tissue expansion site of the body.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[The congenital melanocytic nevi of the face in child: What's new?]

Congenital melanocytic nevi of the face are a frequent reason for consultation in paediatric plastic surgery. Usually of small size, they raise a complex problem of reconstruction when they are large and giant. The indication of excision is generally stated on aesthetic criteria whereas the risk of melanoma is especially important in the giant nevi. Simple suture, full thickness skin graft and expanded skin flaps are the techniques of choice. The treatment must be carried out precociously, follow a surgical planning, respect the aesthetic units of the face and the periorificial areas, adapt to the age of the child and bring psychological benefit to the child.

Expanded forehead flaps for reconstruction of different faciocervical units: selection of flap types based on 143 cases

BACKGROUND

Forehead flaps have been used in the reconstruction of one particular faciocervical region, such as the nose and periorbital unit. The aims of the present study were to determine whether all the unit/multiunits of the face and neck could be aesthetically reconstructed by using expanded forehead flaps and to propose a strategy for flap selection for the reconstruction of different faciocervical units.

METHODS

The authors systematically reviewed the application of expanded forehead flaps for cervicofacial rehabilitation in their center from 2000 to 2013.

RESULTS

Four types of expanded forehead flaps were used for the faciocervical reconstruction of 143 patients. Type I was a pre-expanded local flap used for repairing defects of the partial forehead unit, subunits of the periorbital unit, or partial involvement of the two adjacent units. Type II was an expanded paramedian forehead flap used for resurfacing the nose, orbital unit, upper cheek unit, and partial involvement of these adjacent units. Type III was a bilateral pedicled expanded forehead flap for the reconstruction of the lower face and anterior neck. Type IV was a unilateral pedicled expanded forehead flap, based on the superficial temporal vessels, used to reconstruct the ipsilateral part of the middle face.

CONCLUSIONS

The four types of expanded forehead flap can be used for the reconstruction of different faciocervical units. Based on the location and size of the defect or lesion, the selection of these flaps can be planned preoperatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Management of challenging congenital melanocytic nevi: outcomes study of serial excision

BACKGROUND

Large congenital melanocytic nevi (CMN) cause significant deformity and are at risk for malignant degeneration. Techniques used to remove difficult CMN include serial excision, skin grafting, or tissue expansion. Some authors prefer skin grafting or tissue expansion if several stages would be required to serially resect the CMN. The purpose of this study was to determine the efficacy of serial excision for CMN requiring ≥3 procedures.

METHODS

Medical records and clinical images of patients with CMN treated between 2007 and 2013 were reviewed. Inclusion criteria were: (1) lesions that required ≥3 serial excisions to remove and (2) CMN that could have been treated reasonably with skin grafting or tissue expansion. Patient age, gender, location of the lesion, size of the CMN, number of serial excisions, and complications were recorded.

RESULTS

The study included 21 patients. Lesions were located on the lower extremity (38.1%), head/neck (33.3%), upper extremity (14.3%), or trunk (14.3%). Nevus size was 2.2%±1.2% total body surface area. The age during the first operation was 4.3 years (range 3 months to 15 years). The number of excisions was 3.5±0.7, spaced 8.2±4.3 months apart. Partial suture line dehiscence occurred after 2/72 operations and seroma resulted after 1/72 operations; there were no infections.

CONCLUSION

Challenging CMN amenable to serial excision can be removed effectively and safely using this technique. Children are left with a favorable linear scar, do not have donor or recipient site morbidity from skin grafting, and are not subjected to potential tissue expander complications and injections required for expansion.

The shifting paradigm in the management of giant congenital melanocytic nevi: review and clinical applications

SUMMARY

Congenital melanocytic nevi remain a subject of controversy with respect to risk of malignant transformation and recommended management. Recent studies indicate a lower malignant risk (0.7 to 2.9 percent) than had previously been estimated. Surgery has not been proven to reduce malignant risk or improve quality of life, and may result in undesirable aesthetic and functional outcomes. In this article, the authors review key controversial issues in the management of congenital melanocytic nevi and re-evaluate indications for surgical treatment. An updated review of controversial topics in the management of congenital melanocytic nevi is presented, and clinical applications are demonstrated through clinical cases. Updates regarding the risks and outcomes of congenital melanocytic nevi patients open a renewed debate with respect to the indications for surgery as well as the extent of surgery that may be suitable. Treatment should be tailored to achieve optimal aesthetic results whereby complete nevus excision is not the goal. As such, nonsurgical management and incomplete nevus excision should be integrated as legitimate parts of any treatment algorithm.

The biomechanical properties of the skin

BACKGROUND

The skin possesses unique biochemical properties that allow it to protect and conform to the body that it covers. Elements constituting the dermis-collagen and elastin-primarily afford these properties.

OBJECTIVES

To define these properties and explore their relevance with regard to aging skin and dermatologic surgery.

MATERIALS AND METHODS

In the first part of this review, the determinants of mechanical properties of the skin will be outlined, through an extensive review of the literature. General physical properties that explain the behavior of skin will be defined, and diseases that manifest the extremes of those properties will be discussed. In the second half of this discussion, the surgical implications of skin biomechanics will be reviewed.

RESULTS

Emphasis will be placed on understanding how dermatologic surgeons may optimally use skin properties to produce the best cosmetic and functional outcomes possible.

CONCLUSION

Understanding of the biomechanical properties of skin is paramount to obtain the best cosmetic outcomes in dermatologic surgery.

Treatment of a congenital melanocytic nevus on the forehead with immediate tissue expansion technique: a three-year follow-up

The aim of this case report was to determine the method and basic principles of immediate tissue expansion using a Foley catheter in the forehead region for treating a medium-sized congenital melanocytic nevus. A 4-year-old child presented with a supraorbitally located forehead congenital melanocytic nevus, close to the midline. Total excision and reconstruction with intraoperatively expanded forehead skin below the hairline was performed. Intraoperative tissue expansion using a Foley catheter allowed us to obtain expanded and enhanced local tissue, which had tissue characteristics similar to those of the forehead skin, and thus closure of a medium-sized defect without distorting important anatomic structures such as the brow and frontal hairline was possible. Of the two methods of tissue expansion, immediate expansion using a Foley catheter is a good alternative in single-stage reconstruction of head and neck defects because it has the advantage of omnidirectional expansion.

Refinements of tissue expansion for pediatric forehead reconstruction: a 13-year experience

BACKGROUND

Reconstruction of the forehead in children when 25 percent or more of the forehead is involved presents a complex reconstructive challenge because of the confluence of highly visible aesthetic units. The present study was performed to develop an algorithm for lesions involving 25 percent or more of the forehead.

METHODS

A 13-year retrospective review was performed of all pediatric patients who completed reconstruction for lesions involving at least 25 percent of the forehead by a single surgeon (A.K.G.). All lesions were classified on the basis of percentage of forehead involved and involvement of adjacent subunits.

RESULTS

Twenty patients completed reconstruction. The median number of surgical procedures required was six (range, two to 11), with a median of three (range, one to four) expansion procedures. Simultaneous expanders were placed in the scalp (16 patients) and cheek (eight patients). Five patients underwent correction of eyebrow ptosis at a final procedure. Reconstruction involved 25 to 70 percent of the forehead in 19 patients, 17 of whom were reconstructed with serial forehead expansion and advancement flaps. One patient with a pigmented nevus occupying more than 75 percent of the forehead received an expanded full-thickness skin graft from the lower abdomen. For all groups, the entire extent of the visible lesion was excised and complete skin coverage achieved.

CONCLUSIONS

Reconstruction of 25 to 70 percent or more of the forehead in children is best accomplished using tissue expansion and direct advancement of adjacent tissues. Simultaneous expansion should be performed in the cheek and scalp if indicated. Brow ptosis should be addressed with each advancement. Lesions greater than 70 percent of the forehead are best accomplished with distant tissues.

Congenital melanocytic nevi of the eyelids and periorbital region

BACKGROUND

Congenital melanocytic nevi of the eyelids and periorbital region are unusual. Although their malignant potential can be debated, they present a significant aesthetic concern and also disturb lid function. In this article, the authors present an expanded approach to evaluation and treatment of these patients.

METHODS

Forty-four consecutive patients, aged 6 months to 18 years, were treated from 1980 to 2008. All patients had congenital nevi involving one or both eyelids, with or without extension into the surrounding periorbital area and face. Follow-up ranged from 6 months to 20 years.

RESULTS

All patients were treated successfully with excision and reconstruction of their congenital eyelid and/or periorbital nevi. The involved ciliary border was preserved in all but one case, where the exophytic lesion presented function concerns. Complications included asymptomatic lateral ectropion in three patients. Asymmetry of the palpebral apertures, before treatment, was present in at least half of the patients with extensive facial nevi, and the abnormalities causing these differences may impact efforts to obtain final lid symmetry. A single patient died as a result of extensive metastatic melanoma from an extracutaneous site.

CONCLUSIONS

Early evaluation and treatment of these nevi may help in preventing the aesthetic, functional, and health-related issues for the patients. Although the current group of infants and young children will not reach full facial growth for more than another decade and a half, and therefore await critical assessment of their long-term outcomes, the authors hope that the experience gained to date will assist surgeons in managing these complex reconstructions.

Expanded narrow subcutaneous-pedicled island forehead flap for reconstruction of the forehead

To reconstruct the subsequent defects after resection of a unilateral large forehead lesion, we devised a revised method, "expanded narrow subcutaneous-pedicled island forehead flap." After unilateral forehead skin was expanded by a tissue expander, the flap was designed on the upper half of the expanded forehead skin nourished by the subcutaneous adipomuscular pedicle, including the supratrochlear or supraorbital artery. The elevated flap was then transposed or rotated 180 degrees toward the defect. The donor site was closed with upward advancement of the lower half of the expanded skin. Four patients were treated with this method. The flaps survived completely without serious complications, and acceptable results were obtained in all patients. This method has the advantage of increased freedom of flap design and transfer, providing an effective use of unaffected skin, less scars left on the forehead, and less formation of the dog-ear compared with the conventional procedure.

A Combination of Dual-mode 2,940 nm Er:YAG Laser Ablation with Surgical Excision for Treating Medium-sized Congenital Melanocytic Nevus

BACKGROUND

There are various treatment options for congenital melanocytic nevus (CMN), including surgical excision, dermabrasions, curettage, laser treatment, chemical peels and cryosurgery. The proper choice of treatment depends on the size, location, thickness and clinical appearance of the nevi, the risk for developing melanoma, the psychological effect and the cosmetic component.

OBJECTIVE

THE PURPOSE OF THIS STUDY IS TO EVALUATE THE OUTCOME OF A COMBINATION OF SURGICAL EXCISION WITH ER: YAG laser ablation for treating CMNs.

METHODS

A total of 13 patients were included in this study. The nevus was excised as much as possible and only dermal suturing was performed, without epidermal suturing, for the primary closure. We then ablated the whole lesion, including the suture lines, by using a dual-mode 2,940 nm Er:YAG laser with three to five passes. All the lesions were followed up for 6 months and they were evaluated with respect to the healing status, infection, erythema, scarring, textural change and pigmentary change. Subject satisfaction was scored at the 16(th) week by the patients.

RESULTS

Eleven (83%) of the 13 patients were clinically rated as having a good to excellent result by the physicians' Global Assessment Scale (GAS) scores for the lesions' reduction of size, the degree of scarring and the pigmentary change with only a one stage procedure. 10 (77%) of the total 13 patients reported a good to excellent result at four months after treatment.

CONCLUSION

A combination of surgical excision with Er:YAG laser ablation as a one stage procedure is a safe, effective modality and it should be considered as one of the options for treating medium-sized CMNs.

Combination of preoperative embolization and surgery in the treatment of a giant congenital neuroid nevus of the forehead and scalp in a child. Case report

Congenital melanocytic nevi of neuroectodermal origin are composed primarily of melanocytes and occasional neural elements. A subset of large/giant congenital melanocytic nevi is characterized by neuroidal differentiation resembling the histological pattern of neurofibroma (neuroid congenital melanocytic nevi). The authors report the case of a male infant born with a neuroid congenital melanocytic nevus presenting as a large mass covering extensive portions of his scalp and forehead. The atypical feeding arteries to the nevus were larger in diameter then the patient's internal carotid arteries and formed a rich network of large blood vessels in the nevus. Selective preoperative embolization using calibrated particles was followed by a complete excision and staged reconstruction with tissue expanders. The authors believe that this multidisciplinary approach allowed for a safe surgical procedure with minimal blood loss for this most unusual pediatric head and neck tumor.

Results of the early use of tissue expansion for giant congenital melanocytic naevi on the scalp and face

SUMMARY INTRODUCTION

Giant congenital melanocytic naevi (GCMN) are uncommon, have a significant morbidity and require extensive treatment. This paper presents results after complete excision of GCMN on the scalp, forehead or periorbita after early tissue expansion. Based on 15 years of experience, we want to show that performing tissue expansion at a young age is advisable.

PATIENTS AND METHODS

We included 17 consecutive patients in whom 38 tissue expanders were used. Early and late complications were noted. Patients were seen for a clinical follow up in which scars and re-pigmentation were evaluated with a validated scar scale (POSAS).

RESULTS

All GCMN could be excised completely with early tissue expansion. The age at treatment ranged from 4 months to 2 years of age. With a mean follow-up period of 8.7 years, mild re-pigmentation was seen in only three patients and none of the patients developed a malignant melanoma. Complication rates are comparable with the literature.

CONCLUSION

Tissue expansion is a good method for removing GCMN located at the scalp or face with good cosmetic and oncological results. Performing tissue expansion at a young age is advisable.

Dermatofibrosarcoma Protuberans of the Forehead and Scalp with Involvement of the Outer Calvarial Plate: Multistaged Repair with the Use of Skin Expanders

BACKGROUND AND OBJECTIVE

Dermatofibrosarcoma protuberans (DFSP) is a locally aggressive and infiltrative tumor that requires Mohs' micrographic surgery or wide excision to treat. Adequate excision often leaves a cosmetic disfiguring defect, particularly if the tumor is located on the head and neck. Complex defects of the face present special problems, such as distortion, ectropion, and retraction of normal tissues.

PATIENT AND METHODS

We present a case of an infiltrating DFSP of the forehead and scalp in a young woman. The tumor was removed, and the defect was reconstructed with multistaged repair, which included bone coverage, local and regional flaps, and the use of expanders.

RESULTS

A multistaged repair was performed with good clinical outcome and satisfactory cosmetic results.

CONCLUSION

Multistaged repair of the face is a viable alternative surgical approach to preserve facial contours and minimize distortion in the treatment of DFSP. This case illustrates the degree of complexity that the treatment of DFSP may involve.

Skin Regeneration for Giant Pigmented Nevus Using Autologous Cultured Dermal Substitutes and Epidermis Separated From Nevus Skin

We have developed a modality of treatment of giant pigmented nevus of intradermal type. This method involves application of autologous cultured dermal substitute (CDS), followed by grafting of epidermis separated from the patient's nevus skin. To prepare the wound bed, autologous CDS was applied onto a full-thickness skin defect after complete excision of the nevus. The excised nevus skin was preserved for 1 week, after which the epidermis was separated from the nevus skin by enzymatic treatment with dispase. The epidermis thus obtained was grafted onto the resulting wound bed. This procedure was used to treat a giant pigmented nevus on a 7-year-old patient. The grafted region was soft with good tone 1 year after epidermis grafting. These results indicate that the present method can achieve complete excision of giant nevus, with esthetically acceptable results, although it requires careful monitoring for a long time.

Treatment of congenital facial nevi

The treatment of congenital facial nevi is often difficult and challenging. Previous authors have reported their techniques, results, and complications when treating these lesions. Our objectives are to simplify the treatment planning by subdividing the lesions with a new classification and using this to formulate a surgical algorithm. One hundred and two patients with congenital facial nevi were reviewed. All of these patients have had surgical excision for the lesions. We have subgrouped the lesions into three groups, according to size, number of aesthetic units involved, and number of reconstructive stages required. Group I included lesions 1 to 3 cm in maximal diameter, within one aesthetic unit, and requiring one or two reconstructive stages. This group included 29 patients. Group II included lesions 3 to 12 cm in maximal diameter, covering one or two aesthetic units, and requiring not more than two stages of reconstruction. This group had 41 patients. Group III consisted of extensive lesions, over 12 cm in maximal diameter, covering several aesthetic units, and requiring several stages of reconstruction. In this group, we had 32 patients. On the basis of our experience in treating congenital facial nevi in this series, we have developed a surgical algorithm for reconstruction. We are optimistic that this will assist the surgeon in surgical planning and treating this complex patient population. The algorithm is arranged according to the new classification of congenital facial nevi that is presented.

Congenital melanocytic nevi needing treatment

Patients presenting with congenital melanocytic nevi (CMN) need individualized treatment based upon nevus size, thickness, location, risk for developing melanoma, and psychological characteristics of the patient and family. The present authors review CMN types and prognoses, as well as absolute and relative indications for treatment. Risks and benefits of several treatment options are discussed, including surgical options, such as excision, chemical peels, dermabrasion and curettage, and laser therapy. The main focus of treatment is, in all cases, to address the concern for developing melanoma, at the same time optimizing the aesthetic and functional outcomes.

Pediatric cervicofacial tissue expansion

INTRODUCTION

Tissue expanders have long been used for reconstructing large cutaneous and fascio-cutaneous defects in children. Previous studies have examined tissue expansion for all body regions, touching upon the head and neck regions. We present a focused review of our experience with cervicofacial tissue expansion in the pediatric population.

MATERIALS AND METHODS

We retrospectively reviewed 89 children who underwent tissue expansion of the head and neck regions at Children's Hospital of Los Angeles. Most patients underwent multiple expander placements bringing the total expander number to 182. Indications for expansion included congenital nevus [N=39], burn scar [N=14], hemangioma/lymphangioma/arteriovenous malformation [N=11], scar due to trauma [N=10], congenital anomaly [N=5], sebaceous nevus [N=3], cutis aplasia [N=2], tumor [N=2], infection [N=2] and scleroderma [N=1].

RESULTS

Of the 182 expanders placed, 56 had an associated complication (30.8%). The most frequent complications included exposure, infection, leakage, migration, flap necrosis, wound separation, and skull bone remodeling. Expanders placed in the neck appeared to have the highest complication rate.

CONCLUSIONS

This retrospective review identified a high complication rate in pediatric cervicofacial tissue expansion, which is similar to previously published studies. Despite these findings, tissue expansion in pediatric patients should continue to remain a viable reconstructive option, however, proper patient selection; patient education and informed consent involving a discussion of the expected treatment course and risk profile should be undertaken.

Congenital Nevus: The Indiana University??s Approach to Treatment

The article will review the different treatment modalities for congenital nevi and the senior author's approach to these lesions. The management of congenital melanocytic nevus presents a diagnostic dilemma. Treatment must weigh the risk of malignancy, psychological distress to parents and child, and potential morbidities of excision. Excision of every nevus is neither applicable nor practical. Most plastic surgeons would agree that a large nevus mandates excision because of the risk of malignancy. However, debates occur regarding treatment of small and medium size nevi. Opinions differ regarding the types of reconstruction, malignant potential, and psychological impact of leaving a lesion untreated.

Scalp Reconstruction

The unique properties of the human scalp affect the surgeon's ability to reconstruct defects in this area. The scalp has a rich vascular supply, the ability to withstand wounds of greater tension than other regions, and often has hair that can camouflage resulting scars or asymmetries. Nevertheless, most of the scalp is relatively inelastic and is ideally reconstructed with hair-bearing skin. These properties compromise the ease of effective reconstruction. However, multiple reconstructive options exist. The selection depends on the size and thickness of the defect, its location on the scalp, limiting comorbidities of the patient, and the need for immediate or delayed reconstruction. These options are reviewed in a systematic manner, organized by the factors outlined previously.

Soft Tissue Reconstruction of the Forehead and Temple

Soft tissue reconstruction of the forehead and temple challenges facial plastic surgeons to balance esthetic goals with functional concerns. Understanding the muscular and neurovascular anatomy is essential to achieve these ends. Reconstructive considerations include maintaining hairlines and eyebrows, minimizing scarring, using relaxed skin tension lines, and preserving motor and sensory function. Reconstructive options range from healing by secondary intention to primary closure, skin grafts, local flaps, island flaps, or any combination of these techniques.

Tissue expansion in pediatric patients

Tissue expansion has become a well-recognized technique for reconstructing a wide variety of skin and soft tissue defects. Its application in the pediatric population has allowed the plastic surgeon to achieve functional and aesthetic goals that were previously unobtainable. This technique can be applied to a variety of reconstructive problems, including the management of giant congenital nevi and the secondary reconstruction of extensive burn scars. This article reviews the use of tissue expansion in the pediatric population, with particular emphasis on indications, operative technique, and regional considerations. The authors also address concerns that have been expressed about the complications associated with this technique.

Treatment of large and giant nevi

Excision of large and giant melanocytic nevi presents a distinct challenge to the pediatric plastic surgeon. The exact risk of malignant degeneration remains unknown. These unsightly lesions can be psychologically damaging to both parent and child. The pediatric plastic surgeon must have an armamentarium of techniques for reconstructing the various body areas and must always balance aesthetic and functional outcomes against an unknown but low risk of malignancy.

The Expanded Transposition Flap: Shifting Paradigms Based on Experience Gained from Two Decades of Pediatric Tissue Expansion

The authors present their experience with the design of expanded skin flaps gained over the past two decades in a large series of 995 expanded flap reconstructions performed in 626 operations in 430 patients. The indications for tissue expansion were giant congenital pigmented nevi (72.7 percent), scar contractures (11.2 percent), and a remainder for a variety of congenital and acquired deformities. Surgical strategies were reviewed retrospectively to determine the location in the body where the tissue expansion was performed, the number of procedures required to accomplish the reconstructive goal, and the design of the expanded flap that was used to reconstruct the involved area. Specific points that were noticed included contour deformities (such as webbing, dog-ears, or decreased limb circumference) following flap reconstruction, anatomic distortions (such as distortion of the eyebrow or the distance from the brow to hairline) following reconstruction, final position of the scars in relation to anatomic landmarks, borders of aesthetic units, and relaxed skin tension lines, and the potential for later scar contracture. Careful examination of reconstruction by region of involvement demonstrated significant advantages in the use of expanded transposition flaps over pure advancement. These advantages and the modifications in the design of expanded flaps for each body region are discussed in a series of representative cases. They emphasize the ability of transposition flaps to dissipate tension away from the flap apex and distribute it more proximally, thus redirecting the tension lines so there is less likelihood of anatomic distortion in the reconstructed area. Also, flaps designed in this manner allow improved contour by avoiding webbing, tenting across concavities, and bunching of skin laterally. The authors conclude that restricting the expanded flap design to advancement alone to minimize potential scarring severely limits the reconstructive capabilities of the added tissue and distracts from the surgeon's ability to accomplish the initial reconstructive goal. The cost of additional incisions is worthwhile to achieve better final contour of the reconstructed part, lesser risk of anatomic distortion, better position of the scars, and lowered risk of scar contracture.

Pediatric tissue expansion: indications and complications

Tissue expansion has become a major reconstructive modality in the past 30 years. Its application in the pediatric population has allowed the plastic surgeon to achieve functional and esthetic goals that were previously unobtainable. Tissue expansion is a major treatment modality in the management of giant congenital nevi and secondary reconstruction of extensive burn scars, allowing sensate tissue of similar color, texture, and thickness to be used to resurface the affected areas. One must be prepared for complications when using tissue expanders, however, because complications are inherent in the process of expanding skin utilizing repeated filling of implanted foreign bodies. Complication rates increase when serial expansion of the same tissues is performed repeatedly or if expanders are placed in the lower extremities. Outcomes are dependent on thorough planning, meticulous technique, close follow-up, and patient compliance. Tissue expansion has revolutionized plastic surgery in the last 30 years. This technique can be applied to a considerable breadth of reconstructive problems in the pediatric population. Tissue expansion has permitted the plastic surgeon to achieve the goals of reconstruction with tissue of similar color, texture, and thickness, with minimal donor site morbidity. Preservation of sensation in a durable flap has allowed the surgeon to achieve acceptable functional as well as esthetic goals simultaneously.

Large and Giant Congenital Pigmented Nevi of the Upper Extremity: An Algorithm to Surgical Management

The timing and choice of treatment of congenital giant pigmented nevi continues to evolve under the influence of changing opinions regarding the risk of malignant degeneration and the impact of excision and reconstruction on the affected child. Many studies exist to support a notable enough risk of malignancy to warrant excision, yet other series and pigmented lesion clinics suggest that the risk of malignancy does not warrant the potential scarring and deformity that has followed the surgery necessary to remove these giant lesions. To satisfy both sides in this controversy, we have been challenged to modify our surgical techniques in a manner that minimizes the risk of malignant degeneration and at the same time provides optimal functional and aesthetic outcomes for these complex reconstructions. Thirty consecutive patients with large and giant nevi of the upper extremity were treated over a 23-year period (1979-2002) by the senior author. These patients represent a subset of 259 children (12%) with large or giant congenital pigmented nevi treated and followed during this period of time. In proximal upper extremity lesions, expanded transposition flaps from the upper back and shoulder have effectively eliminated contour defects or circumferential constriction in the upper arm and axilla. An expanded free transverse rectus abdominis musculocutaneous flap has offered a possible avenue for larger lesions (shoulder and upper extremity to below the elbow), and pedicle flaps from the flank (both expanded and nonexpanded) have offered ways of improving the long-term contour in the forearm. Expanded and nonexpanded full-thickness skin grafts were chosen for reconstruction of the hand and the fingers. The authors describe in detail the surgical strategies and the techniques for reconstruction of each region of the upper extremity and then bring these ideas together in an algorithm for assessment and treatment of these challenging lesions.

Reconstruction of Complex Scalp Defects

OBJECTIVE

To demonstrate the use of multiple, large, local flaps in the reconstruction of large scalp defects.

METHODS

A retrospective review of 4 cases in which the "banana peel" method of scalp reconstruction, originally described by Orticochea, was used as a method for closure of moderately large to extensive scalp defects.

RESULTS

In all 4 cases, closure of the scalp defects was accomplished. Major morbidity included hair-bearing skin in the forehead in 1 patient, an inconsequential small flap dehiscence requiring closure in the same patient, and a partial loss of a small skin graft to a donor site defect in 1 patient.

CONCLUSIONS

While other techniques may be optimal for the management of most scalp defects, such as 1- to 2-flap rotation-advancement flaps in small to moderate-size defects and microvascular free tissue transfer and secondary tissue expansion for larger defects, we conclude that the multiple-flap reconstruction method as described by Orticochea may be useful in a small subset of patients. The latter includes older, severely debilitated patients who would be optimally treated with microvascular tissue transfer but cannot tolerate lengthy general anesthesia and young patients who will not accept a significant area of alopecia that might exist with other techniques, such as secondary intention, skin grafts, or free flaps.

Enhancement of Tissue Expansion by Calcium Channel Blocker: A preliminary study

BACKGROUND: Reconstruction of the defects after surgical resection of tumors is one of the important issues in surgical oncology. It is essential that the defect should be covered with a tissue quite similar to the original one and is best achieved by harvesting tissue from an area adjacent to the defect. Tissue expansion is one of the most frequently used reconstructive techniques. A number of studies evaluated blood circulation, capsule formation, tissue tolerance, histomorphological changes and complications of expander placement. However, only a few attempted to enhance tissue expansion. This study we aimed to evaluate verapamil, a calcium channel blocker, to enhance tissue expansion. MATERIAL AND METHOD: Twelve New Zealand rabbits weighing between 900 gm and 1200 gm were assigned into study and control groups. High volume expanders (100, 200 or 300 cc) were placed into the subcutaneous tissue. Rabbits in the study group received verapamil. Expanders in the control group were inflated every three days to achieve same pressure as the study group. The size of the flaps was assessed by applying pressure on tip of the flap to demonstrate the contraction. Histopathological examinations were performed. RESULTS: By administering liquid earlier and more quickly less flap retraction was observed in the study group. In the control group expanders were exposed in two rabbits while no complication occurred in the study group. Following extraction of the expanders, the flaps were elevated and less retraction was observed in the study group compared to controls. CONCLUSION: Verapamil is safe when used topically and provides less retracted flaps. It can be suggested that verapamil acts on the myofibroblasts in the capsule around tissue expanders and thus increases efficiency of the expanders.

Radical resection of giant congenital melanocytic nevus and reconstruction with meek-graft covered integra dermal template

BACKGROUND

Giant congenital melanocytic nevi represent a surgical challenge, particularly in cases in which the size of the nevus exceeds certain extend and malignant transformations have to be considered.

OBJECTIVE

To discuss through case report considerable surgical options when extensive giant congenital melanocytic nevi with malignant transformation are encountered.

METHODS

We present an unusual case of a giant congenital melanocytic nevi of the entire back of a 44-year-old patient. To achieve radical resection with direct appropriate wound closure and acceptable outcome, the integument of the entire back was excised and covered with Integra, followed by split-thickness skin grafting after stable integration of the matrix.

RESULTS

The approach resulted in a complete excision of the tumor and acceptable cosmetic and excellent biomechanical outcome.

CONCLUSION

The introduced practice demonstrates a useful alternative to established methods, particularly if tumor excision in large areas and subsequent wound closure might be achieved in one procedure.

Surgical management of the cutaneous manifestations of linear nevus sebaceus syndrome

Linear nevus sebaceus syndrome is characterized by the association of nevus sebaceus covering extensive areas on the head and scalp with abnormalities of the central nervous system, ophthalmologic and skeletal changes, and malignancies. The incidence is approximately one per 10,000 live births, and there is no sexual predilection reported. The original description of this syndrome was followed by extensive literature describing the dermatologic, neurologic, and ophthalmologic manifestations of this disease. The objective of this report is to describe the surgical approach for the excision and reconstruction of giant sebaceous nevi of the face and scalp in children with linear nevus sebaceus syndrome on the basis of a consecutive series of five patients treated over 10 years in the same institution. To the authors' knowledge, this report represents the largest surgical series and suggests a reliable approach to the treatment of the cutaneous manifestations of this syndrome.

Nevo melanocítico congênito

O nevo melanocitico congênito está presente em aproximadamente 1% dos recém nascidos. As lesões classificadas como pequenas e medias são relativamente comuns, ao passo que o nevo gigante, maior que 20 cm no maior diâmetro, é uma condição mais rara cuja a incidência esta estimada em 1 para cada 20 mil nascimentos. As lesões melanociticas congênitas pequenas e médias têm um risco de degeneração maligna baixo, raramente ocorrendo na infância. Por outro lado, estima-se um risco entre 5 a 12 % de um melanoma se desenvolver a partir ou relacionado com um nevo gigante, e de regra, metade dos casos ocorrem antes dos 3 anos de idade. Alem da possibilidade de degeneração maligna, o acometimento neurológico e as implicações psicológicas devido ao aspecto estético são dois aspectos importantes relacionados com as lesões gigantes, influindo também na decisão e na abordagem terapêutica.