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.

Tissue humoral response to intact and ruptured silicone gel-filled prostheses.

Biopsies of the fibrous capsule in 31 women undergoing explanation of gel-filled breast prostheses and in 3 women with silicone gel-associated granulomas were tested for the presence of IgG, IgM, IgA, C3 complement, and fibrin using fluorescent antisera. Of a total of 41 prostheses removed, 9 were found to be ruptured but contained within the fibrous capsule or immediately adjacent to it. In the 3 women undergoing granuloma excision only, the sites were the arm (2) and the chest/axilla (1). In one patient, IgG, C3, and fibrin were detected in the capsule of an intact prosthesis. C3 and fibrin were present in the capsule surrounding one ruptured prosthesis. Fibrin was detected in the capsule of one other patient. Bilateral capsules surrounding intact prostheses removed from 4 patients with collage-vascular diseases were negative for C3, fibrin, and immunoglobulins, as were the 3 granulomas from distant sites. Hematoxylin and eosin stains revealed a typical foreign-body response to gel in almost all cases. Both T- and B-cell lymphocytes are present in the infiltrate surrounding silicone gel. In this study, chronic exposure to silicone gel-filled prostheses did not result in antibody deposition or complement activation in the fibrous capsule or in the tissue surrounding gel droplets.

The vascular supply to the proximal interphalangeal joint.

Four methods were used to identify the vascular branches that supply the proximal interphalangeal joint in 55 cadaver fingers. They were intra-arterial injection of radiopaque dyes, microscopic dissections of the arterial system, selective injection of specific branches followed by sectioning of the joints and examination of the areas stained, and histologic sectioning. Our studies show that the major branches of the digital artery to the joint arise from the dorsal aspect of the vessel, while smaller branches that run to the soft tissue arise from the palmar side. Three branches supply the proximal interphalangeal joint. The first arises 1.5 to 2.5 cm proximal to the joint and divides into branches to the dorsal skin, the bone proximally, the vincular system, the lateral surface of the joint, and the palmar plate. The other two branches arise distal to the joint space; the first has branches to the palmar aspect of the joint of the middle phalanx and the vincular system. The most distal of the three perfuses the dorsal surface of the joint.

Retardation of finger growth after injury to the flexor tendons.

The absence of any part of the total mechanical force (i.e., flexor tendons) may be responsible for retardation of bone growth during a child's growth phase. The cause of retardation may be dedifferentiation of cartilage cells at the epiphyseal plate. Four cases in which unrepaired flexor tendons in digits caused retardation of growth illustrate this possible phenomenon. We feel that this is not a well recognized problem and thus deserves mention to stimulate further study. We believe that meticulous primary repair in children is desirable not only to preserve function, but also to prevent growth disturbances.

Aquaplast for nasal splinting.

A nasal splint ideally should be sturdy, moldable, light, easy to apply, and inconspicuous. Plaster, dental compound, and aluminum are currently used but each has limitations. We have found that Aquaplast, a material softened by immersion in hot water, more closely conforms to the qualities of the ideal nasal splint. Aquaplast is sturdy, light, thin, very moldable, easy to apply, and allows for passage of air and moisture.

The comparative strengths of internal fixation techniques.

The strengths of internal fixation techniques have been compared by transecting human cadaver metacarpals, reducing and fixing the fractures, and then applying forces to mechanically bend the bone during simulated flexion. Kirschner wires alone, intraosseous wire loops with and without Kirschner wires, and bone plates were tested. Intraosseous loops were tested in three configurations, each with four different wire gauges. Intraosseous loops were stronger than Kirschner wires. Right-angle loops were the best of the intraosseous configurations. The addition of a Kirschner wire strengthened the best dorsopalmar intraosseous loops but not the best right-angle loops. Dorsal bone plates were comparable with the best intraosseous loop configurations of 26-gauge wire.

Intraosseous wiring of complex hand fractures.

Our results with the use of intraosseous wires for 72 complex, open fractures are reported. The technique is described, and attention to detail is emphasized. The technique is indicated especially for articular or comminuted fractures with multiple small fragments. It also provides solid, anatomic fixation for other types of fractures and for replants. A K-wire may be added if necessary and is usually used if there has been some bone loss. Complications have been few, most the result of displacement at the fracture site due to improper use of the technique. A major advantage of the solid fixation obtained with this technique is that it avoids or minimizes the need for postoperative splinting and allows early active and passive range of motion. It is our impression that this has minimized joint stiffness and tendon adhesions and improved functional results.

Anatomy of the mandibular branches of the facial nerve.

In operative dissections of mandibular branches of the facial nerve, we identified certain branches below the inferior border of the mandible in all cases. These usually supplied the depressor labii inferioris and mentalis muscles, though infrequently the branch to the depressor anguli oris was also below the mandible. At least 3 nerve branches were identified in all dissections. The clinical applications of this include the necessity to identify and protect these nerve branches during operations in the submandibular triangle, as well as when incising the platysma muscle or removing fat from over the body of the mandible in a face-lift procedure.

Medial plantar sensory flap for coverage of heel defects.

A sensory flap, based on the medial plantar artery and incorporating the cutaneous branches of the medial plantar nerve, is described for the coverage of heel defects.

Skin graft survival on avascular defects.

Full-thickness skin grafts placed on bare rabbit ear cartilage were revascularized, whereas split-skin grafts on the same kinds of areas failed. The contrast is most likely due to differences in the skin graft thickness and the vascular patterns in the grafts. Full-thickness rat skin grafts placed over the same sized underlying silicone sheet implants did not survive. When the graft was made 3 mm larger on all sides than the implant, all or a portion of the graft over the implant survived. Quantitation of the area of graft survival is presented. Prepared grafts (replaced on their donor areas for 48 hours) on prepared beds and fresh grafts on prepared beds had slightly larger areas of graft surviving over an avascular defect. On the basis of this investigation, we suggest that a full-thickness skin graft placed on a prepared peripheral bed may make possible the greatest area of bridging over an avascular defect.