Management of large scalp and skull defects in a severe case of Adams-Oliver syndrome

Integra® Dermal Regeneration Template: From Design to Clinical Use

Integra^® Dermal Regeneration Template (IDRT, Integra LifeSciences, Princeton, NJ, USA) is a bilayer membrane developed, by Yannas and Burke in the 1980s, to fulfill the unmet need of surgeons having a readily available off-the-shelf dermal regeneration method. IDRT is composed of a sheet of porous cross-linked type I collagen and glycosaminoglycans, with a semi-permeable silicone sheet cover. IDRT is bio-engineered, from adult bovine Achilles tendons and chondroitin-6-sulfate derived from shark cartilage, in a multi-step process involving cross-linking using glutaraldehyde. By design, the composition, porosity, and biodegradation rate of IDRT guides the mechanism of wound repair towards a regenerative pathway. Its mechanism of action involves four distinct phases: imbibition, fibroblast migration, neovascularization, and remodeling/maturation. Originally developed for the post-excisional treatment of deep-partial to full-thickness burns where autograft is limited, over the years its use has expanded to reconstructive surgery.

Case report: Recombinant human epidermal growth factor gel plus kangfuxin solution in the treatment of aplasia cutis congenita in a case with Adams-Oliver syndrome

Background

Aplasia cutis congenita is a congenital disorder with the absence of skin, muscle and(or) bone. It usually affects the scalp. The presence of a large scalp defect can be potentially serious when complicated with hemorrhage and infection. Early healing of this condition is beneficial to improve the prognosis of infants.

Study case

A full-term newborn male was born with a round-shaped defect at the vertex of the scalp and skull (dimensions, 8 cm × 9 cm). The infant had a large deletion encompassing the 15.1 region of chromosome 15, including the DLL4 gene. Genetic testing was positive for Adams-Oliver syndrome (AOS). After two months of recombinant human epidermal growth factor gel combined with kangfuxin solution therapy, the skin defects of the scalp healed remarkably. The infant had regular follow-up appointments. At the age of 5 months, the defect became smaller, hairless, and showed good granulation tissue. At 2 years of age, the child's Gesell Developmental Schedules was 70.

Conclusion

Recombinant human epidermal growth factor gel combined with kangfuxin solution was a successful conservative treatment for an infant with a large scalp defect accompanied by AOS.

Relevance of Notch Signaling for Bone Metabolism and Regeneration

Notch1-4 receptors and their signaling pathways are expressed in almost all organ systems and play a pivotal role in cell fate decision by coordinating cell proliferation, differentiation and apoptosis. Differential expression and activation of Notch signaling pathways has been observed in a variety of organs and tissues under physiological and pathological conditions. Bone tissue represents a dynamic system, which is constantly remodeled throughout life. In bone, Notch receptors have been shown to control remodeling and regeneration. Numerous functions have been assigned to Notch receptors and ligands, including osteoblast differentiation and matrix mineralization, osteoclast recruitment and cell fusion and osteoblast/osteoclast progenitor cell proliferation. The expression and function of Notch1-4 in the skeleton are distinct and closely depend on the temporal expression at different differentiation stages. This review addresses the current knowledge on Notch signaling in adult bone with emphasis on metabolism, bone regeneration and degenerative skeletal disorders, as well as congenital disorders associated with mutant Notch genes. Moreover, the crosstalk between Notch signaling and other important pathways involved in bone turnover, including Wnt/β-catenin, BMP and RANKL/OPG, are outlined.

Decompressive craniectomy with scalp expansion graft using a temporary synthetic skin substitute in the pediatric population: case series and review of the literature

INTRODUCTION

The use of decompressive craniectomy in children is controversial and often reserved for patients with refractory intracranial hypertension. Following decompression, skin closure in select cases can be challenging due to brain herniation and swelling through the craniectomy defect. In these cases, partial cortical debridement is sometimes performed.

METHODS

We describe two cases in which a synthetic skin substitute was used to facilitate a tension-free closure, rather than performing a partial lobectomy.

RESULTS

At 6-month follow-up, both patients are at preoperative cognitive baseline, with some residual hemiparesis.

DISCUSSION

We believe that use of a synthetic skin substitute for skin closure after decompression is a suitable option for closure of traumatic scalp wounds and may contribute to improved functional outcome in patients with severe intraoperative brain swelling.

Treatment of a Large Skull Defect and Brain Herniation in a Newborn With Adams-Oliver Syndrome

Adams-Oliver syndrome (AOS) is a rare congenital disorder characterised by a wide variety of clinical expression ranging from the occurrence of aplasia cutis congenita (ACC), transverse limb defects, and cutis marmorata telangiectica to extensive lethal anomalies. In this article, we present the conservative and surgical management of a male newborn infant diagnosed with AOS. Surgical treatment included wound management, the removal of protruding brain, and treatment of cerebrospinal fluid (CSF) leakage. After spontaneous reepithelization of the wounds, conservative treatment was chosen instead of reconstruction with an occipital flap; this was continued until the total healing of the dermal defect after eight months, during which the patient was continuously treated with antibiotics. At 17 months, the child was in good physical condition with a three-month development delay in comparison with infants of his age and no evidence of neurological deficit.

Extensive aplasia cutis congenita associated with cephalocranial disproportion and brain extrusion

Aplasia cutis congenita (ACC) is a rare congenital disorder which can be linked with a variety of other abnormalities. However, the association of this anomaly with cephalocranial disproportion and brain extrusion is rarely reported. In this report, we present a neonate with an extensive ACC with exposed dura mater and sagittal sinus, who later presented with brain extrusion from the defect and an acrocephalic-like feature required decompressive surgery during the first month of life. Theories regarding etiology and progression of acrocephalic feature and brain protrusion in this case have been discussed.

Use of an epidermal growth factor-infused foam dressing in a complicated case of Adams-Oliver syndrome

Adams-Oliver syndrome is a rare disorder with varying degrees of scalp and cranial bone defects as well as limb anomalies, which can range from mild to more pronounced manifestations. In mild cases, closure of these defects can be achieved with a conservative approach. However, surgical closure is recommended in cases where the defect is extensive and includes cranial involvement. Several complicated cases of Adams-Oliver syndrome have been reported, in which flap failures were encountered and other alternatives had to be used to close critical scalp defects. Here, the case of a 4-year-old child with Adams-Oliver syndrome and a complex cranial defect with exposed titanium mesh is described. The patient was successfully treated with epidermal growth factor (EGF) infused foam dressings and subsequent split-thickness skin grafting. The EGF has been highlighted for its essential role in dermal wound repair through the stimulation of the proliferation and migration of keratinocytes, and showed accelerated wound healing when used in partial or full-thickness skin wounds.

Adams-Oliver Syndrome: A Case with Full Expression

Adams-Oliver syndrome (AOS) is characterized by the combination of congenital scalp defects (aplasia cutis congenita) and terminal transverse limb defects of variable severity. It is believed that Adams-Oliver syndrome without major organ abnormalities does not necessarily alter the normal lifespan. We present a case without detectable major organ abnormality contrary to life but with poor weight gain. A male infant with scalp and skin cutis aplasia, generalized cutis aplasia, dilated veins over scalp and trunk, hypoplastic toes and nails of feet, glaucoma, poor feeding and poor weight gain. This report shows a case of AOS without major multiple organ abnormalities but with poor feeding and abnormal weight gain that may be alter the normal lifespan.

Aplasia Cutis Congenita of the Scalp, Composite Type: The Criticality and Inseparability of Neurosurgical and Plastic Surgical Management

BACKGROUND/AIMS

The object of this report is to review the management of patients having the composite type of aplasia cutis congenita in the context of the relevant literature on this condition.

METHODS

Clinical records, neuroimaging and photographic documentation of identified cases of composite type aplasia cutis congenita, with a comprehensive review of the literature, are the material basis of this report.

RESULTS

Two neonates with composite type aplasia cutis congenita are described as examples of this disorder, and their management, including complications, is discussed. Both had satisfactory outcomes.

CONCLUSIONS

Early aggressive surgical management with scalp rotation flaps has a low rate of complications, provides satisfactory functional and esthetic outcome, minimizes hospital stays, and should provide cost-effective care by reduction of the time to secure wound closure. Most bony defects, even large ones, commonly ossify completely. Optimal case management requires a synchronized neurosurgical and plastic surgical team. Intuitive nonsurgical and surgical approaches by the inexperienced can be hazardous.

A Novel Treatment of Denuded Areas in Newborns: A Report of 2 Successful Cases

Covering denuded areas in the extremes of life is challenging for the plastic surgeon. In newborns, this becomes a greater challenge because of the immaturity of all of their systems, making any injury a potential risk for death. We present in this case report a successful treatment of 2 cases covered with cultured autologous keratinocytes. In this procedure, a small skin biopsy is taken from the retroauricular area and the keratinocytes are cultured. After 5 days, a membrane with the cells cultured is applied covering the denuded area. We find the autologous keratinocyte method a suitable option for the treatment of denuded areas in newborns, without causing any additional morbidity and in a very short period of time.

Dilemmas and challenges in the management of a neonate with Adams-Oliver syndrome with infected giant aplasia cutis lesion and exsanguination: a case-based update

BACKGROUND

Aplasia cutis is a rare developmental anomaly usually involving the calvarium, associated with a variable extent of defective formation of the scalp. Adams-Oliver syndrome is a condition mainly characterized by the congenital absence of skin, known as "aplasia cutis" which is usually limited to the vertex scalp and transverse limb defects.

CASE REPORT

A 17-day-old term female neonate was referred to us with an infected scalp lesion of the vertex. The lesion which is about 10 × 9 cm had signs of infection with necrotic eschar. We started the neonate on systemic parenteral antibiotics with local dressings. On day 3 of conservative management, the neonate had exsanguination due to bleeding from the midline with severe hemodynamic compromise requiring cardiopulmonary resuscitation. After controlling the bleeding with local tamponade and resuscitating the child, she was taken for early surgery. Debridement and bipedicled rotation flap of the scalp to cover the raw area was performed. On day 18, the flap started showing signs of necrosis. The neonate was taken up for debridement, and subsequently, maternal allograft of split-thickness skin was placed as a temporary wound cover. Meanwhile, the wound showed progressive epithelialization. At 1 year, the patient continued to have a non-healing area, which was later successfully covered with a split-thickness skin graft. We plan to revaluate the need for cranioplasty at around 3-4 years of age.

DISCUSSION

We discuss the dilemmas and challenges involved in the successful management of a neonate with Adams-Oliver syndrome with infected aplasia cutis and an episode of life-threatening exsanguination.

CONCLUSION

Aplasia cutis is a rare developmental anomaly usually involving the calvarium, associated with defective formation of the scalp to a varying extent and severity, requiring various timely strategies.