Complete osseous regeneration of a large skull defect in a patient with cutis aplasia: a conservative approach

Large aplasia cutis congenita of the vertex conservative management

BACKGROUND

Aplasia cutis congenita (ACC) of the vertex with bone defect is a rare and begnin anomaly that can involve the epidermis, dermis, and subcutaneous tissues of the scalp with significant bone defect Bajpai and Pal (J Pediatr Surg 38(2):e4, 2003). When associated with skull defect, this rare malformation carries the risk of severe complications such as rupture of the superior sagittal sinus or infections.

METHODS AND RESULTS

We report a case of aplasia cutis congenita of the scalp with skull defect measuring 9 × 10 cm and an exposed sagittal sinus in a newborn. Both conservative and surgical methods have been proposed to treat this condition. In our case, conservative treatment was planned led to complete epithelization and the patient was healing well at 5 years of follow-up.

CONCLUSIONS

ACC of the vertex with a large scalp defects present a management dilemma Rocha et al. (Clin Case Rep 3(10):841-4, 2015). Based on a review of the literature, we report this case to demonstrate that even for the largest skin and bone defects, an initial conservative approach may allow for complete wound closure without the need for early surgical intervention.

Use of Ultra-high-frequency Ultrasound for Aplasia Cutis Congenita of the Scalp

Aplasia Cutis Congenita (ACC) in the scalp is a rare congenital malformation. The treatment for ACC with large defects involving the scalp, bone, and the dura is challenging. Local debridement of necrotic tissue is important to prevent lethal complications such as infection and meningitis. However, debridement has the risk of damaging the sagittal sinus or the dura. Recent developments in ultra-high-frequency ultrasound(US) systems provide frequencies of 70 MHz and capability resolution as fine as 30 μm, which could allow precise imaging of small and thin anatomical structures. The study aimed to describe the methods of precise evaluation of the defect in the scalp and safe debridement using ultra-high-frequency US. This is the first report on direct observation of a newborn’s brain using ultra-high-frequency US. The boy was delivered spontaneously with a large defect of the scalp and bone. After 14 days, due to signs of infection, local debridement was performed carefully under ultra-high-frequency US-based evaluation. The dura, the sagittal sinus, and the small anatomical structures such as arachnoid granulations could be observed. Because the brain herniation gradually aggravated, dural reconstruction using fascia lata and scalp reconstruction using transposition flap was performed. Finally, good skin coverage over the defects was obtained. This method minimizes the risk of damaging the sagittal sinus and the brain parenchyma, which may cause fatal complications. Although further clinical investigations will be required to confirm its efficacy, ultra-high-frequency US has the potential to be a useful device for ACC treatment.

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.

Early Composite Cranioplasty in Infants with Severe Aplasia Cutis Congenita: A Report of Two Cases

Objective

Severe cutis aplasia congenita has traditionally been treated with initial soft tissue coverage and delayed cranioplasty. We advocate the technique of early composite reconstruction of both bone and soft tissues.

Methods

Two cases of cutis aplasia congenita with large skull defects (6 × 10 cm, 8 × 8 cm) of superficial layers, skull, and dura are presented. In each case, composite reconstruction was undertaken before 2 weeks of age with restoration of bony and soft tissue coverage through autologous, full-thickness cranial bone grafts and scalp flaps. Both children have been followed up over 2 years with clinical examination and computed tomography (CT) scans.

Results

In both cases, defects were completely repaired postoperatively and remained closed 2 years later. Complete regeneration of calvarial bone graft donor sites were documented by CT scan. Head shape and circumference were normal at 2-year follow up.

Aplasia cutis congenita: Two case reports and discussion of the literature

Background:

Aplasia cutis congenita (ACC) is a part of a heterogeneous group of conditions characterized by the congenital absence of epidermis, dermis, and in some cases, subcutaneous tissues or bone usually involving the scalp vertex. There is an estimated incidence of 3 in 10,000 births resulting in a total number of 500 reported cases to date. The lesions may occur on every body surface although localized scalp lesions form the most frequent pattern (70%). Complete aplasia involving bone defects occurs in approximately 20% of cases. ACC can occur as an isolated defect or can be associated with a number of other congenital anomalies such as limb anomalies or embryologic malformations. In patients with large scalp and skull defects, there is increased risk of infection and bleeding along with increased mortality and therefore prompt and effective management is advised.

Case Description:

We describe two cases of ACC, involving a 4 × 3 cm defect managed conservatively and a larger 10 × 5 cm defect managed surgically with the use of a temporo-occipital scalp flap. Both cases had an excellent outcome.

Conclusions:

Multiple treatment regimens exist for ACC, but there is no consensus on treatment strategies. Conservative treatment has been described and advocated, but many authors have emphasized the disadvantages of this treatment modality. Decision between conservative and surgical management must be individualized according to lesion size and location.

Conservative Treatment of Large Aplasia Cutis Congenita of the Scalp With Bone Defect With Basic Fibroblast Growth Factor Application

The object of this report is to share our experience of conservative management of giant aplasia cutis congenita (ACC) of the scalp with the topical application of basic fibroblast growth factor (bFGF). Complete epithelialization of the 9 × 8 cm sized defect was achieved in 33 weeks. Careful conservative management could eliminate the requirement of surgery for giant ACC defects of the scalp with bone defects and should be tried if surgery is thought to be risky or has consecutive morbidity. Topical bFGF application seems to accelerate healing, also providing a better epithelium for later reconstructive treatments and its usage could be standardized in the future.

Outcomes of Tissue Expander Application for Scalp Reconstruction in Extensive Aplasia Cutis Congenita

INTRODUCTION

Aplasia cutis congenita (ACC) is a rare congenital disorder. The purpose of this study was to present outcomes of tissue expander application for scalp reconstruction in extensive ACC.

PATIENT/METHODS

In this retrospective study, medical records were reviewed for six patients who underwent serial tissue expander application for scalp reconstruction in ACC between 2000 and 2015. Patient average age was 14.5 (range, 4-25 years). One of the six cases had frontal bone defect, the others had bone and soft tissue defect at the vertex. In the newborn period, all patients have been managed by split-thickness skin grafts without cranioplasty procedures. After grafting and calvarial regeneration, one (or more) sessions of tissue expanders and scalp flap applications were performed for alopecia and soft tissue correction. Radiologic and clinical examination was performed for complications and outcomes.

RESULTS

Computerized tomography showed intact calvarium with patchy hyperostosis in all patients. The mean size of grafted areas was 69.5 cm(2) (range, 32-148.5 cm(2)). Minimal distal flap necrosis (6 × 1 cm) was observed in one patient. Serial scalp tissue expansion was performed with at least one session in a 1-year interval. One expander was extracted due to exposition and infection. No total flap losses and no calvarial defects were observed during follow-up (mean; 8.6 years). Clinical examination revealed acceptable cosmetic results in all patients.

CONCLUSION

We advocate late expander scalp reconstruction for management of extensive ACC cases.

LEVEL OF EVIDENCE IV

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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.

Aplasia cutis congenita: a conservative approach of a case with large, extensive skin, and underlying skull defect

Aplasia cutis congenita is a disease in which skin, bone, and dura mater can be absent. In majority of the cases it affects the scalp. We report a baby girl born at term with a large scalp and skull defect measuring 9 × 10 cm. Conservative treatment led to complete epithelization.

Conservative Healing of an 11 × 9-cm Aplasia Cutis Congenita of the Scalp with Bone Defect

Objectives Aplasia cutis congenita is a rare congenital condition, and it is difficult to find scientific support for optimal treatment strategies. In addition, these may vary due to defect size, tissue layers involved, contemporary malformations, and the physiologic status of the affected child.

Clinical Presentation This case report describes complete skin coverage in 20 weeks and uneventful healing of a large 11 × 9-cm defect of the vertex, involving both skin and skull bone, using conservative treatment. To prevent infection and promote healing, the defect was kept moist and covered at all times, and it was treated with surgical debridement when necessary. For infection control, ionized silver-coated dressings were used in addition to prophylactic antibiotics over the first 3.5 weeks. Follow-up was 2 years.

Conclusion Surgical treatment is usually preferred for larger aplasia cutis congenita defects, but it is accompanied with potential risks and will exacerbate secondary reconstruction of alopecia or skull bone defects. This case shows that even very complex defects may be treated conservatively.

Type V aplasia cutis congenita: case report, review of the literature, and proposed treatment algorithm

Aplasia cutis congenita (ACC) is the congenital absence of skin. There are a number of different classifications based on distribution and associated findings. Type V ACC is unique in that the lesions are typically symmetric and found primarily on the trunk but can also include the upper and lower extremities. Type V is associated with the loss of a monozygotic co-twin during the late first or early second trimester. Here we present an extensive case of type V ACC and a review of the literature, including a summary of treatment and outcomes. From the available literature, it appears that there is no benefit from early surgical intervention, and therefore we propose a treatment algorithm that starts with conservative management.

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.

Two different management modalities in a two sibling case report of Adams Oliver syndrome

The authors report two-sibling case of Adams Oliver syndrome. One was managed with early surgical intervention after a period of failed conservative management and the other conservatively managed until reconstruction and surgical correction of alopecia. The goal of treatment is to achieve a complete closure of the defect without encountering any fatal complications such as haemorrhage and infection or causing any long-term neurological morbidity. Various papers have been published related to ACC, yet there is no consensus on the therapeutic approach. The management decision hinges upon balancing the risks of complications including spontaneous sagittal sinus haemorrhage and the risk of surgical intervention. Both treatment modalities proved successful in these cases.

Herniation of the brain after conservative treatment of a large congenital skull defect in an infant with Adams-Oliver syndrome

We report the case of a newborn baby with a large congenital skull defect owing to Adams-Oliver syndrome. An initial attempt at conservative treatment failed and led to disruption of the leptomeningeal membrane and prolapse of the brain. After local debridement, delayed and stepwise surgical closure was complicated by cerebrospinal fluid leakage, which required the insertion of a cerebrospinal fluid shunt. This case report highlights the potential serious risks of nonsurgical management of largely extended congenital skull defects.

A case of extensive aplasia cutis congenita: a conservative approach

Aplasia cutis congenita is a rare, sporadic congenital malformation characterized by skin defects, sometimes extending to the underlying bone. We report a case of a boy born with a large rhomboid scalp and skull defect measuring 8 × 12 cm with no other anomalies. Conservative treatment led to the complete epithelization of the skin defect with secondary closure of the cranial vault without need for surgical intervention.

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

Adams-Oliver syndrome is a rare congenital disorder that includes congenital scalp and skull defects, variable degrees of terminal transverse limb anomalies, and cardiac malformations. Cutis aplasia occurring in 75% of patients is a potentially life-threatening condition. Large skin defects that cannot be closed primarily present a management dilemma, and may require skin grafting or flaps, or a combination of both operative and conservative modalities. The authors' experience in management of huge scalp and bone defects with the Integra Dermal Regeneration Template and regular dressing changes showed good scalp repair and no serious complications attributed to this approach.

A case of extensive Aplasia Cutis Congenita with underlying skull defect and central nervous system malformation: discussion of large skin defects, complications, treatment and outcome

Aplasia Cutis Congenita (ACC) is a rare condition characterized by the absence of a portion of skin at birth. Skin defects are usually small (0.5 to 3 cm) and located on the scalp. Although there can be other physical or genetic abnormalities, ACC is most often a benign isolated condition. Rarely is an underlying bony defect present, and this association increases the rate of complications. We report a case of a newborn male with ACC of the entire crown and vertex scalp, non-ossified parietal skull and dysplastic corpus callosum. The patient's skull and skin defects were treated non-surgically, and he recovered well.

Aplasia cutis congenita. A case of scalp defect repair using two opposing bipedicled local flaps

Aplasia cutis congenita is a rare congenital condition characterised by the absence of some or all layers of the skin. It may also be associated with absence of underlying muscle and bone. Where dura is exposed there exists a risk of ulceration and haemorrhage and thus primary closure is indicated. We report a case of cutis aplasia successfully closed with opposing bipedicled flaps. To our knowledge this is a novel approach which offers a simple safe technique that can be applied in the neonate.

Split Rib Cranioplasty for Aplasia Cutis Congenita and Traumatic Skull Defects

Aplasia cutis is a rare skin defect usually presenting over the vertex of the skull. An underlying bone defect is found in approximately 20% of patients. Most skull defects close spontaneously. However, when there are no signs of ossification, closure is mandatory. We present our experience in three patients. Our first patient had an aplasia cutis with a skull defect. The split rib graft procedure was used without complications, and a good cosmetic and functional result was achieved. The second patient was operated on for cerebral bleeding after an arteriovenous aneurysm, and a bony defect could not be closed after that procedure. At a later stage, the defect was filled with split rib grafts, and sufficient protection was achieved and documented after more than 30 years. The third patient was born with an aplasia cutis congenita with a skull defect. The bony defect was filled with split rib grafts without complications at an age of 5 years. Follow-up shows a functional result with a firm skull. Patients with aplasia cutis may have skull defects that will not close by themselves. We present three patients with a bony defect who were reconstructed with split rib grafts. After a long period of follow-up, there remains good cosmetic and functional results. Defects of the skull in children can be reconstructed with split rib grafts that will accommodate the growing skeleton and give good protection of the brain from an early age on.

Aplasia Cutis Congenita of the Scalp and Calvarium

Aplasia cutis congenita is a rare congenital disorder of skin and most commonly involves the scalp. The skull and dura underlying the defective skin may also be affected, relative to severity of the disease. The typical lesion is present at birth and ranges in size from 0.5-3 cm. The main complications of larger defects include infection, bleeding and trombosis that may be deadly. Therefore, prompt diagnosis and appropriate treatment are critical for avoiding the adverse outcomes. Controversy exists in the literature regarding the treatment of aplasia cutis congenita; both surgical and conservative treatment modalities have their proponents and opponents. We present a case of full thickness aplasia cutis congenital lesion bigger than 3 cm in diameter that healed with the application of novel wound dressing materials without any complications. The physiopathology, classification and treatment options of the disease are discussed.

Aplasia cutis congenita of the scalp: is there a better treatment strategy?

BACKGROUND

Aplasia cutis congenita (ACC) is a rare disease of unknown etiology, involving any site of the body. The scalp is the most frequent location, followed by the forearms, knees, both sides of the trunk, and neck, in decreasing order of frequency. Superficial lesions may heal spontaneously and seldom result in morbidity or mortality. However, in patients with large scalp and skull defects, there are risks of infection and bleeding. Conservative treatment has been described and advocated, but some authors have highlighted the disadvantages of this treatment modality. On the other hand, several authors claim that aggressive surgical treatment has an important role for large defects.

MATERIALS AND METHODS

In this paper, we report three newborns with ACC of the scalp, two large defects and a medium one, respectively, treated conservatively and surgically.

CONCLUSION

The management of ACC of the scalp is still controversial. Our series suggests that conservative treatment should be performed for initial management in newborns.

Ectopic bone formation facilitated by human mesenchymal stem cells and osteogenic cytokines via nutrient vessel injection in a nude rat model

In vivo studies using bone marrow-derived mesenchymal stem cells are still uncommon. Applications for bone defect replacement in undesirable clinical circumstances such as large defects, bacterial or other pathogen-contaminated fields, and irradiated surgical wound bed necessitate vascularized bone regeneration. Use of a fascial flap including regenerated bone would be a very powerful tool for treatment. It would be especially beneficial in cases where normal bone regeneration is not expected due to a lack of sufficient blood supply, extensive surgical scarring, or bacterial contamination. In this study, we used nude rats in which the superficial epigastric flap of the experimental group was used to wrap around a mixture of human mesenchymal stem cells, bone morphogenetic protein-2, and basic fibroblast growth factor cytokines in a gelatin carrier. These rats showed significantly higher bone mineral density at 4 weeks compared to the other experimental groups containing phosphate buffered saline, human mesenchymal stem cells alone, or the two cytokines alone (p < 0.01). There were no remarkable histologic differences up to 7 days. At 2 weeks, more progressive vascularity and perivascular tissue deposits were seen in the experimental group. Basophilic mineral structure surrounded the fibroblast-like mesenchymal stem cells at 4 weeks, presumably osteoblastic or osteoclastic cell lining. Bone marker immunohistochemistry against alkaline phosphatase and osteocalcin revealed diffuse and distinct immunoreactivity in osteoblastic cells in the experimental group at 4 weeks. Further transcriptional expression of polyomavirus enhancer binding protein 2alphaA suggested that the human transplanted cells proceeded to osteogenic lineage in 4 weeks. These results may be useful as a new approach for bone regeneration.

Congenital Scalp and Calvarial Deficiencies: Principles for Classification and Surgical Management

Congenital defects of the scalp and skull present a challenge for care providers because of a combination of their rarity and the magnitude of potential morbidity. Recent advancements in autogenous and alloplastic cranioplasty and scalp reconstruction techniques argue for a comprehensive consideration of this problem. This article (1) reviews the causes of congenital scalp and calvarial defects; (2) proposes a classification system based on defect type, similar to the tumor-node-metastasis classification, in that defect location, defect size, and extent of neuromeningeal involvement are the critical variables; and (3) presents algorithms for care based on the defect classification. A set of management principles on which treatment plans can be based for these unique problems is provided.