Salvage reconstruction of an extensive facial deformity due to congenital giant hairy nevus

Repeated tissue expansions on split-thickness skin graft in a patient with neurocutaneous syndrome

Soft tissue expansion is a mechanical process that increases the surface area of local tissue available for reconstructive procedures. In most cases, adjacent tissue that matches the recipient site in color, texture, and hair-bearing quality is preferred for tissue expansion. In this particular case with neurocutaneous syndrome, the defects that resulted from removal of parts of a giant hairy nevus overlying the latissimus dorsi muscle bilaterally were grafted with a split-thickness skin graft. Two expanders were then placed under the latissimus dorsi muscles. After full expansion of the grafted area, some part of the remaining nevus surrounding the grafted area was removed and the defects were covered with the expanded skin graft obtained after deflation of the expanders. The expanders placed under the latissimus dorsi muscle in the first operation were reused in the second operation to obtain a second expansion of the skin graft. After the second expansion of the skin graft, the expanders were deflated and another portion of the remaining nevus surrounding the grafted area was removed. The resulting defects were again covered with the excess expanded skin graft. Although repeated expansion of the skin graft is a time-consuming and laborious process, it eliminates the need for taking repeated skin grafts; it decreases skin graft donor site morbidity; it decreases possible infectious complications of tissue expansion by decreasing the number of surgical interventions to the expander pocket; and it increases the aesthetic outcome by keeping all the surgical scars around the grafted area without extending them into healthy surrounding skin.

[Early preventive pressure therapy in extensive skin grafts on children's face, a comeback of classic methods? A retrospective study on 8 cases]

INTRODUCTION

One of the common techniques in the treatment of giant facial naevi is the excision covered by a skin graft. It's functional and esthetic results are not always excellent. Physiotherapy including immediate postsurgical preventive pressure therapy could ameliorate these results and shorten the period of scarring.

PURPOSE

Evaluation of scarring results with early pressure therapy in skin grafts of congenital facial naevi.

PATIENTS AND METHODS

Retrospective study on 8 children being 1 to 9 years old and presenting congenital facial naevi. All of them were treated by excision followed by full thickness skin grafting. The associated physiotherapy was realized by a transparent rigid or elastic mask. The pressure was started after skin graft uncovering between 7 and 20 days. The period for this treatment was depending on the maturing of the scar. Evaluation was established by 3 examinators on: time till scar maturing, trame quality and esthetic quality.

RESULTS

The period till definitive scar maturing was showed to be between 8 and 14 month; trame quality was mostly evaluated as excellent, the esthetic result oscillated between good and medium.

CONCLUSION

Physiotherapy seems to be an essential association for the treatment of facial full thickness skin grafts in children. Early pressure therapy could better the functional and esthetic result and accelerate scar maturing. Simple skin grafting could become the first treating option in this indication. Future prospective studies are expected to confirm these results.

Salvage of Silicone-Treated Facial Deformities Using Autogenous Free Tissue Transfer

BACKGROUND

Silicone, in the form of injectable liquid and prosthetic blocks, has been used to correct facial contour defects. However, silicone also has been associated with many complications including malposition, dyschromia, dysesthesia, contractures, infection, and fistula. Complications related to injectable-liquid and prosthetic-block silicone use in treatment of facial deformities pose a challenging surgical dilemma.

METHODS

Over a 15-year period, microvascular free flap technique has been used successfully as a surgical tool to correct severe soft-tissue complications of the face resulting from silicone treatment of facial contour deformities. Surgical treatment guidelines, methods, and results for treating this difficult problem with free tissue transfer are presented.

RESULTS

In 23 patients, 24 free tissue transfers (22 inframammary extended circumflex scapular free flaps and two superficial inferior epigastric free flaps) were performed. Flap survival was 100 percent. Both hematoma and skin necrosis were encountered in three of 24 cases (12.5 percent). Revisional surgery combined with aesthetic surgical procedures was required in 20 of 24 cases (83 percent).

CONCLUSIONS

We recommend the following surgical treatment guidelines for this unique subset of patients: silicone excision with immediate microvascular free flap reconstructive procedure when the skin and soft tissue are mildly to moderately affected, or silicone excision with delayed reconstructive procedure when the skin and soft tissue are severely affected. Free tissue transfer is a useful surgical tool for salvaging severe facial skin and soft-tissue deformities caused by previous silicone treatment.

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.

Giant congenital nevi: a 20-year experience and an algorithm for their management

A variety of treatment options exists for the management of giant congenital nevi. Confusion over appropriate management is compounded because not all giant congenital nevi are pigmented, and malignant potential varies between different types. The present study sought to define factors in the presentation of giant congenital nevi that could provide an algorithm for their management, with respect to both the extent of resection and subsequent reconstructive options.A retrospective review of all patients who presented with a congenital nevus of 20 cm2 or greater since 1980 was performed, distinguishing among nevi involving the head and neck, the torso, and the extremities. Sixty-one patients with giant congenital nevi were evaluated (newborn to age 16 years), of which 60 nevi in 55 patients have been operated on. Giant congenital nevi having malignant potential were pigmented nevi (53 patients) and nevus sebaceus (four patients). Those not having malignant potential were verrucous epidermal nevi (three patients) and a woolly hair nevus (one patient). Of the 60 giant congenital nevi operated on, expanded flaps were used in 25, expanded full-thickness skin grafts were used in 10, split-thickness or nonexpanded full-thickness skin grafts were used in 13, and serial excision was used in 30. After 1989, operations tended to use multimodality treatment plans, with an increased use of expanded full-thickness grafts and immediate serial tissue expansion. The use of serial excision, particularly in the extremities, also increased after 1989. Serial excision was the treatment of choice when it could be completed in two procedures or less, which occurred in more than 80 percent of cases using serial excision alone. Expanded flaps were the most common mode of reconstruction in the head and neck region and were used in 49 percent of these procedures. Serial excision was the most common form of treatment in the extremities, used in 50 percent of procedures. Tissue expansion in the extremities was infrequently used to provide an expanded flap (8 percent of procedures), whereas it was frequently used to provide expanded full-thickness skin grafts harvested from the torso (used in 31 percent of procedures). On the basis of these data, algorithms for the extent of resection and subsequent reconstructive options for giant congenital nevi were developed. Their management should be formulated relative to pigmentation, malignant potential, and anatomic location of the respective lesions.

Long-term results of surgical excision and skin grafting for a giant hairy naevus of the face: time for a return to conventional wisdom?

In a publication climate demanding modern innovative treatments for congenital giant hairy naevi, we report a case with excellent long-term results following early surgical excision and split-thickness skin grafting.