Removal of the Outer Table of the Skull for Reconstruction of Full-Thickness Scalp Defects with a Dermal Regeneration Template

BACKGROUND The reconstruction of large defects of the scalp after wide excisional surgery of cutaneous malignancies is challenging. When the pericranium must be resected due to safety considerations, the exposed bone complicates reconstructive approaches.
OBJECTIVE The objective was to develop an improved technique for reconstructive surgery of full-thickness scalp defects.
METHODS Full-thickness scalp defects of up to 126 cm² in size with exposure of denuded bone were treated by partial removal of the outer table of the skull. The diploic space exposed by this treatment showed petechial bleeding and was covered with a dermal regeneration template (Integra, Integra Lifesciences Corp., Plainsboro, NJ). After transformation of the template by vascularization and by proliferation of fibroblasts, an ultrathin skin graft was transplanted onto the neodermis.
RESULTS Thirteen patients with cutaneous malignancies of the scalp were treated using this technique. The defects were transplanted within a median postoperative time period of 29 days (± 4 days) and showed good cosmetic results and stable scars. After a follow-up period of 6 months, no local recurrences were observed.
CONCLUSION This reconstructive procedure allows closure and rapid healing of large scalp defects in which the pericranium had to be resected.     

The mononuclear phagocyte–dendritic cell dichotomy: myths,facts, and a revised concept

Since Aschoff 's reticuloendothelial system was abandoned a few decades ago, classification and characterization of the mononuclear phagocyte and dendritic cell systems have evolved separately or even in competition with one another. New information has now become available indicating that monocytes/macrophages and dendritic cells have a common origin in the bone marrow, and may even transdifferentiate. Morphological and functional distinctions—although valid under certain conditions—have been blurred by revelation of the versatility of monocytes/macrophages and dendritic cells in response to different contextual needs in inflammation and immunity. Monocytes/macrophages and dendritic cells share a sentinel, receptor/effector, and presentation mode, and may either activate or silence specific immune reactions. In keeping with the view of monocytes/macrophages and dendritic cells as interactive sentinels, we suggest that the mononuclear phagocyte and dendritic cell systems be replaced by the custocyte system (custos, Lat = sentinel, guard) as a unifying concept. Within the custocyte system, we recognize type I, type II, and type III custocytes. Type I and II custocytes exhibit predominance of presentation or effector/presenter interdependency, respectively, while type III custocytes are bipolar, passing through type I- and type II-like phases during their development and in inflammatory responses. The custocyte system brings into view monocytes/macrophages and dendritic cells as dynamic players in immunity and inflammation with a high degree of derivational, phenotypic, functional, and molecular plasticity.     

Chronic urticaria,arthralgia, raised erythrocyte sedimentation rate and IgG paraproteinaemia: a variant of Schnitzler's syndrome?

Schnitzler's syndrome is a distinct disease entity characterized by the association of chronic urticaria, intermittent fever, arthralgia, elevated erythrocyte sedimentation rate and IgM macroglobulin-aemia. We report a patient with the same symptoms, but a monoclonal IgG instead of IgM gammopathy. Histological examination of the urticarial lesions showed signs of mild leucocyto-clastic vasculitis. Except for the different class of the monoclonal immunoglobulin, the clinical symptoms, laboratory findings and histology in this patient were identical with those in classical Schnitzler's syndrome. IgG and IgM paraproteins may be equivalent with regard to the putative pathophysiology of the disease process in Schnitzler's syndrome. We therefore suggest that the spectrum of Schnitzler's syndrome is expanded to include patients with chronic urticaria and monoclonal IgG gammopathy, as a closely related variant.