Secondary reconstruction of a giant congenital lentiginous dermal nevus with serial, large-volume tissue expansion

Giant congenital pigmented nevi pose a substantial reconstructive challenge for the treating physician. Due to the increased risk of malignant transformation in such lesions, complete excision with tissue expansion or skin grafting is the generally accepted treatment. These modalities can, however, leave the patient with secondary deformities that also require complex reconstructive procedures. The following case details a patient requiring secondary reconstruction with large-volume tissue expansion 12 years after excision of a giant nevus, and split-thickness skin grafting. This patient illustrates a severe secondary deformity and the usefulness of large-volume serial expansion in such patients.     

应用皮肤切削术治疗胸背部巨痣临床分析

目的:观察应用皮肤切削术治疗胸背部巨痣的临床效果,探讨治疗巨痣较为有效的方式。方法:于巨痣部位以切削方式削除黑色素痣病变组织,继发创面以愈邦(纳米银抗菌医用敷料)覆盖,术后逐层揭去外层敷料,直至创面愈合,愈后综合抗瘢痕治疗。结果:胸背部巨痣可一次性手术完成,创面均Ⅰ期愈合,愈后无明显瘢痕增生或挛缩,皮肤色泽及弹性可。结论:应用皮肤切削术治疗胸背部巨痣手术次数少,无需植皮。     

手术治疗面部皮肤色素痣的临床应用

目的：探讨手术治疗面部皮肤色素痣的临床应用方法和效果。方法：应用直接切除缝合、皮瓣转移、软组织扩张、游离皮片移植等方法手术治疗面部皮肤色素痣。结果：自2006年以来完成手术126例,患者面部皮肤色素痣均得到较好整复。结论：根据面部皮肤色素痣的部位和大小采取不同的手术方式,临床应用效果良好,可临床推广应用。     

脱细胞异体真皮与自体表皮复合移植修复创面

目的　研究应用脱细胞异体真皮与自体表皮复合移植修复创面的临床效果。　方法　 2 0 0 0年 7月～2 0 0 2年 8月 ,应用脱细胞异体真皮与自体表皮构成的复合皮对 34例头颈、躯干及四肢等部位的创面进行修复 ,创面最小5 cm× 10 cm,最大 12 cm× 19cm,其中陈旧性肉芽创面 2例 ,巨大色素痣切除创面 4例 ,皮肤广泛毛细血管瘤切除后创面 6例 ,瘢痕切除后创面 2 2例。观察移植皮片的成活率及愈后皮片色泽、功能情况。　结果　临床应用 34例 ,术后移植复合皮全部成活 ,30例获 3个月～ 2年随访 ,移植皮片颜色与周围正常肤色接近 ,皮片柔软 ,瘢痕增生不明显 ,功能改善显著。　结论　脱细胞异体真皮与自体表皮复合移植较单纯自体表皮移植后 ,皮片质量及关节部位功能上均有明显改善 ,尤其适合于四肢创面修复。     

疣状痣的整形外科治疗

目的探讨整形外科手术方法在疣状痣治疗的应用。方法对我科在1999年7月至2004年10月采用整形外科方法行手术切除及修复的10例疣状痣患者的临床资料,进行回顾性分析。结果10例患者28处手术部位除1处因面积过大及皮肤牵张带被过度牵引导致皮缘裂开需植皮修复创面,2处因局部病损刮除过浅致复发予再次手术外,余手术部位均治疗成功无并发症。结论手术切除为疣状痣的首选治疗方法。为了安全和取得良好疗效,对于病损面积大及头面部等关键部位的疣状痣,宜采用整形外科方法行肿物切除及创面修复。     

Tissue expansion in a patient with extensive nevus comedonicus.

Nevus comedonicus is a rare developmental abnormality of the pilosebaceous apparatus that presents as an aggregation of dilated follicular orifices filled with pigmented keratinous material. Occurrence of extensive or giant lesions is even more rare. Indications for treatment include recurrent infections and cosmetic reasons. Therapeutic approaches include topical keratolytic agents, manual extraction of comedones, dermabrasion, and excision of smaller lesions. Increasing clinical experience with tissue expansion has suggested that it might be used effectively in the definitive treatment of an extensive nevus comedonicus previously considered too large to excise without the use of a skin graft, despite the potential risk of infection within the lesion during the course of expansion. We report the first patient with giant nevus comedonicus to be treated using tissue expansion. This patient demonstrates that prompt treatment of cellulitis and abscesses within the lesion will keep this process isolated from the adjacent expanders and will not compromise a planned excision and reconstruction.     

Giant congenital cellular blue nevus of the scalp of a newborn with an underlying skull defect and invasion of the dura mater

A case of a giant congenital cellular blue nevus of the scalp of a newborn with focal areas of malignant melanoma is presented. The nevus was associated with focal invasion of the underlying soft tissues, calvarium, epidural space, and dura mater. The later appearance of pigmented nevi in the submandibular region, sternocleidomastoid muscle, and testicular hydrocele raises the question of future metastases despite the nonmalignant microscopic appearance. Therapy consisted of total excision with cranioplasty and rotation and split skin grafts after temporary closure with silicone mesh.     

应用削除及磨削法治疗体表先天性巨痣疗效分析

目的探索应用削除或磨削法治疗成人体表先天性巨痣的操作与效果。方法综合先期进行的病理学检查结果、病变具体位置及患者的治疗心理预期等相关因素后,使用滚轴取皮刀切取刃厚或中厚皮片,或者使用高速的“西瓜”磨头磨削肿物浅层病变的方法治疗巨痣,治疗区保持在湿润状态下愈合,治疗按部位分1～2次进行,共治疗10例。结果10例中5例患者取得较为理想的效果,肤色接近正常,病理学检查未发现痣细胞明显残留,4例明显改善,1例有所复发,多数治疗效果均达到患者的心理预期。结论削除或磨削法对曾用其他方法治疗效果不佳或须付出较大代价的体表先天性巨痣有明显的实用效果,特别是由于综合考虑了多种相关因素,有利于在治疗效果与治疗代价之间取得较好的平衡,值得在临床上加以推广。     

复合皮混合移植治疗深Ⅱ度烧伤患者创面疗效观察

目的观察深Ⅱ度烧伤患者创面削痂术后应用复合皮混合移植治疗的效果。方法对23例烧伤患者的30个深Ⅱ度烧伤肢体在伤后3d内分次行削痂术,削至浅筋膜后移植大张异体脱细胞真皮基质,然后切取大张自体刃厚皮(0.10～0.25mm)覆盖于其上。术后10—12d计算移植皮片的存活率,记录创面愈合时间。观察随访3—6个月时患者的肢体外观及功能恢复情况。取1例患者随访3个月时的愈合创面皮肤标本,行病理学观察。结果本组患者复合皮片成活率为93%,7%的皮片因术中固定较差,移植后自体刃厚皮与异体脱细胞真皮基质分离致皮片坏死,或因感染致皮片溶解。随访3—6个月,移植部位皮肤外观、弹性及功能恢复良好。病理学观察显示,成活皮片表皮、真皮结构正常。结论烧伤后早期削痂立即移植复合皮是治疗深Ⅱ度创面的有效方法。     

Upward migration of cultured autologous keratinocytes in Integra artificial skin: a preliminary report.

The combination of cultured autologous keratinocytes with the dermal regeneration template Integra could offer increased possibilities for reconstructive surgery and wound healing. A single-step application of cells, centrifuged deep into an Integra-like matrix at the silicone-matrix junction, has been described but might prove technically complex for clinical use. We have investigated the possibility of simplifying this procedure by applying cultured cells directly to the underside of the Integra or directly to the wound bed immediately prior to grafting. The objective was to see whether cells would migrate through the matrix in an upward direction. We tested the principle of this concept using a pig wound healing model. Integra was seeded directly with cultured cells and grafted onto fresh full-thickness wounds, or unseeded Integra was applied to freshly excised wound beds that had just been seeded with the same number of cells. Biopsies were taken at 3, 7, 11, and 14 days. Histological sections showed that the cells moved through the Integra to give a confluent surface epithelium. Direct seeding onto the Integra was the most efficient method. Transduction of cultured autologous keratinocytes in vitro with a MFGlacZnls retrovirus confirmed that the epidermis was derived from the cultured autologous keratinocytes.     

Use of human keratinocytes cultured on fibrin glue in the treatment of burn wounds

Keratinocytes isolated from a small skin biopsy and cultured according to the method of Rheinwald and Green (Cell 1975, 6: 331) are able to undergo rapid expansion in vitro and have been used successfully in the treatment of burn wounds. One of the inconveniences of this method involves the transfer of the epidermal sheet from the culture flask onto the wound bed. One way to facilitate this process is to use fibrin glue (Biocol) as a culture bed for the keratinocytes. Burns are then grafted by simply placing the sheet of fibrin glue and keratinocytes onto the wound bed. This process has been successful in two patients, permanently covering areas of 720 cm2 and 5342 cm2. The newly formed epidermis was fully differentiated and histologically normal after 1 year. The efficiency of this improved, faster procedure could lead to a new approach in the treatment of extensive burn wounds.     

Autologous Epidermal Cultures and Narrow-Band Ultraviolet B in the Surgical Treatment of Vitiligo

BACKGROUND: Vitiligo is an acquired skin disorder with a great social impact. It can be successfully treated with autologous epidermal grafting. OBJECTIVE: To evaluate the possibility of treating vitiligo by autologous grafting of epidermal cells and narrow-band ultraviolet B (UVB). METHODS: Autologous epidermal cultures were prepared starting from small biopsies of normally pigmented skin. Cells were cultured on hyaluronic acid membranes using medium supplemented with patient's serum. Cell cultures were grafted onto laser-abraded depigmented areas. Patients underwent narrow-band UVB therapy 3 weeks after grafting. RESULTS: Repigmentation of the grafted areas started 1 month after transplant and continued until 4 months after grafting. All patients were evaluated 3, 6, 12, and 18 months after grafting. At the 18-month follow-up, repigmentation was observed in 75% of patients with focal and segmental vitiligo and in 30% of patients with generalized vitiligo. CONCLUSIONS: This therapy can be considered for the treatment of stable vitiligo (especially focal and segmental) resistant to standard therapies. Their results are encouraging from the clinical and esthetic point of view, although the treatment is costly and highly specialized.     

Congenital giant nevocellular nevus of the back with deep extension to the fat and fascia

The presence of deep pigmentation in a giant congenital nevus makes its complete removal very difficult and should be taken into consideration when planning for treatment. A clinical case in which the pigmented lesion was found to extend deep into the muscle fascia is described. The lesion was surgically removed with an acceptable functional and aesthetic result through the utilization of tissue expansion. The development of new surgical techniques and the expansion of laser technology will possibly provide new treatment options in the future. Emphasis should be placed on aesthetics and function, because the excision based only on oncological anticipation is no longer valid. The presence of deep pigmentation makes certain treatment options less effective than surgical ablation.     

断层皮片移植治疗耳廓大面积黑色素痣

目的探索耳廓前面软骨膜表面及耳廓后面皮下层植皮治疗耳廓大面积黑色素痣的疗效。方法对6例先天性耳廓大面积黑色素痣或巨痣累及耳廓的患者，采用彻底切除病变组织，耳前、后面分期两行断层皮片移植的方法进行治疗，观察其疗效。结果移植之皮片全部成活，随访1～2年，植皮无挛缩，耳廓无变形。结论采用分期断层皮片移植治疗耳廓大面积黑色素痣，方法简单，疗效可靠。     

Demonstration of epidermal transfer from a polymer membrane using genetically marked porcine keratinocytes

The culture of keratinocytes on flexible membranes has been proposed as a means to simplify, accelerate and improve the efficiency with which proliferating cells are delivered to full thickness or non-healing skin defects. However, there have been no studies that monitor the transfer of cells from such membranes to the wound bed. We have used a porcine model of lacZ gene marked cultured autologous keratinocyte grafting to demonstrate unambiguously the transfer of cultured cells to cutaneous wounds from the EpiGen polymer membrane developed by Smith & Nephew Group plc. Full thickness wounds enclosed within rigid chambers were first grafted with autologous de-epidermalised dermis (DED). Keratinocytes were cultured on EpiGen membranes and applied to the wound beds 7 days after the DED grafts. Epidermal remnants persist within the DED and the resultant epidermis is therefore, a mixture of wound regeneration and delivered cultured cells. Unequivocal evidence for keratinocyte transfer from the membrane was obtained through the observed macroscopic surface staining for lacZ transduced cells and lacZ positive cells detected in sections through deeper layers of epidermal tissue. This method offers a general approach for evaluating the efficiency of keratinocyte delivery using upside-down flexible membrane transfer.     

皮肤色素痣不同治疗方法疗效分析比较

目的：比较冷冻、激光及手术治疗皮肤色素痣的疗效及美容效果。方法：皮肤色素痣患者4682例,分为三组：液氮冷冻组600例,用手持式冷冻刀或医用棉签行液氮冷冻治疗;激光组1882例,分别用超脉冲CO2激光和Q开关翠绿宝石激光治疗;手术组2200例,采用切除缝合或切除后邻近皮瓣修复。治疗后对疗效及副作用进行评价。结果：液氮、激光治疗较表浅的色素痣和雀斑样痣疗效较好,对皮内痣及混合痣疗效差且易产生瘢痕;手术切除缝合可治疗各种类型的色素痣,治疗次数少、术后不良反应少并且无明显切口瘢痕。结论：皮肤色素痣治疗应首选手术切除,同时术后应行组织病理学检查。对于较表浅的色素痣和雀斑样痣可选择冷冻和激光治疗,皮内痣和复合痣不宜采用冷冻和激光治疗。     

Congenital giant pigmented nevus and intracranial arteriovenous malformation

We describe a case with congenital giant pigmented nevus and intracranial arteriovenous malformation. This association should be included in the spectrum of neurocutaneous syndromes related to congenital giant pigmented nevus.     

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.     

Recipient wound bed characteristics affect scarring and skin graft contraction

The use of autograft skin is essential in the treatment of full thickness burns and large cutaneous defects. Both autograft thickness and condition of the wound bed modulate aesthetic and functional outcomes. Thicker autografts contract less and maintain greater functionality as the scar matures. The presence of hypodermis can also positively affect the eventual appearance and functionality of the wound site by modulating contraction and alleviating inflammation and cellular stress responses. In this study, we characterize wound‐site physical and cellular characteristics following split‐thickness skin grafting onto hypodermis vs. onto fascia. Compared to autografts grafted onto fascia, identical thickness autografts grafted onto fat demonstrated reduced contraction, enhanced mobility and vascularity, and reduced topographical variability. Grafts onto fat also showed reduced levels of myofibroblasts and leukocytic infiltration. The status of the wound bed prior to engraftment is an important contributor of skin quality outcome. The presence of hypodermis is associated with improved functional and aesthetic qualities of split thickness skin grafts, which are correlated with reduced presence of myofibroblasts and leukocytic infiltration.