Combination of Autologous Fat Grafting and Negative-Pressure Wound Therapy for the Treatment of Scalp Linear Scleroderma.

ABSTRACT: Scalp linear scleroderma (LSc) is a subtype of localized scleroderma which typically affects young patients and which can be severely disfiguring. Traditional treatment options include bone grafting or tissue expansion. in this report, we present the case of a patient with scalp LSc successfully treated with scar release, autologous fat grafting, and negative-pressure wound therapy (NPWT). A 55-year-old female, with a history of craniectomy for a benign sellar tumor 10 years previously, developed LSc over the frontal scalp with exposure of titanium plates and screws. She was treated with removal of metalwork, scar release, autologous fat grafting from the abdominal wall and immediate application of NPWT. At 3-month postoperative follow-up, the appearance of the depressed lesion and of its margins had significantly improved. Our experience suggests that the combination of autologous fat grafting and NPWT is an effective treatment modality for scalp LSc.

Long-Term Utility of Follicular Unit Excision in Lichen Planopilaris-Correlation of Graft Survival With Histopathological and Ultrasound Biomicroscopic Parameters.

BACKGROUND: Hair transplantation in scarring alopecia is challenging and transplant surgeons are hesitant due to fear of poor graft survival apart from the risk of reactivating the disease. OBJECTIVE: Survival rate of hair follicles transplanted in cases of lichen planopilaris (LPP). To correlate histopathological and ultrasonography findings and their impact on graft survival. METHODS: In 32 patients of inactive LPP included, a 5-cm2 recipient area was tattooed. The follicular unit density of the transplanted area was 20 to 25 FU/cm2. Postoperative follow-up was conducted at 6, 12, and 24 months. The recipient area density and ultrasound biomicroscopic parameters were assessed at each follow-up visit. RESULTS: The survival of grafts was 78.62% at 12 months, and 79.96% at 24 months. Histopathology variables studied at the time of transplantation such as epidermal atrophy, fibrosis, and inflammatory infiltrate were not found to have any effect on the graft survival. Ultrasonography parameters of the involved scalp skin were found to be markedly improved on follow-up. This suggests that the overall health of the scalp improved after hair transplantation. CONCLUSION: Follicular unit excision is a ray of hope for cases of primary cicatricial alopecia such as LPP because the result is satisfying to both the patient as well as the doctor.

Trichilemmal Cysts With Divergent Ductal Differentiation: A Series of 4 Cases.

ABSTRACT: Trichilemmal cysts are common clonal tumors with a predilection for the scalp. They are composed of an outer epithelial wall resembling the outer root sheath in the isthmus of the hair follicle and a central core of compact keratin. Sweat duct differentiation is exceptional with only one convincing case reported to date. Here, we sought to characterize the clinicopathological characteristics of sweat duct differentiation in trichilemmal cysts. We reviewed all cases of trichilemmal cyst diagnosed at our institution between 2008 and 2019. Ductal structures were found in 4 of 411 cases (0.97%). Subjects included 2 male and 2 female patients with a median age of 37.5 years (range 34-55). The ducts were lined by attenuated epithelial cells and immunoreactive for polyclonal carcinoembryonic antigen and cytokeratin 7. Ductal differentiation involved a median of 7.5% (range 1%-50%) of the cyst wall. All 4 cases were from the scalp and treated with local excision. No recurrence was identified with a median follow-up period of 1.5 years (range 1-12 years). In summary, sweat duct differentiation in trichilemmal cysts is rare but likely under recognized. Conceptually, we suggest it represents a type of divergent cellular differentiation within a clonal neoplasm rather than a retention cyst or hybrid cyst.

Syringocystadenoma papilliferum of the scalp.

Syringocystadenoma papilliferum is a rare, benign adnexal tumor of eccrine or apocrine origin that typically presents at birth or before puberty. Syringocystadenoma papilliferum is associated with a nevus sebaceus in about 40% of cases. We present a 50-year old woman with a pink-orange plaque and nodule on the scalp, consistent with syringocystadenoma papilliferum that arose within a nevus sebaceus.

Beare-Stevenson Syndrome With Blepharoptosis as a Complication of Front-Orbital Advancement and Remodeling.

Beare-Stevenson syndrome (BSS) is an extremely rare genetic disorder characterized by a broad range of congenital malformations including craniosynostosis, cutis gyrata, facial deformities, and abnormal genitalia. The authors report a case of a 7 month old female who developed a mechanical ptosis secondary to dermatochalasis as a complication of fronto-orbital advancement and remodeling (FOAR) surgery which subsequently required multiple lid surgeries to reverse ptosis. This is the first report of blepharoptosis correction in a child with BSS as a complication of FOAR.

Posterior Distraction First or Fronto-Orbital Advancement First for Severe Syndromic Craniosynostosis.

PURPOSE: Posterior calvarial vault expansion using distraction osteogenesis is performed for syndromic craniosynostosis as the first choice. This procedure allows far greater intracranial volume than fronto-orbital advancement (FOA). This study aimed to determine the most suitable timing of posterior distraction or FOA to sufficiently increase the intracranial volume and remodel the skull shape. PATIENTS AND METHODS: From 2014 to 2017, the authors performed posterior distraction in 13 patients with syndromic craniosynostosis. Data on premature suture fusion, age at first visit, age at surgery, skull thickness, and complications were collected. RESULTS: Five patients underwent posterior distraction at approximately 12 months of age and had no complications, including cerebrospinal fluid leakage or gull wing deformity. However, during the waiting period for the operation, the skull deformity continues to extend upward (turribrachycephaly). To prevent progress of the skull deformity, the authors performed the operation at approximately 6 months of age in 7 patients. However, in 3 of 7 patients whose lambdoid sutures were opening, gull wing deformity occurred. From these results, in a patient with severe Beare-Stevenson syndrome, the authors performed FOA first at 5 months of age, followed by posterior distraction at 12 months of age, and achieved favorable results. CONCLUSIONS: Treatment patterns are patient specific and should be tailored to premature suture fusion, specific skull deformity, and required intracranial volume of each patient.

Acute otitis externa because of negative pressure wound therapy applied over the head and ear canal for scalping treatment.

Scalping is considered a complex wound with difficult treatment, requiring early surgical intervention, reconstructive plastic surgery, and a multidisciplinary team. The reconstruction of the scalp frequently requires a combination of therapies, including temporary coverage, such as negative pressure wound therapy (NPWT). Complications of NPWT, such as bleeding, infection, and pain, have been described. However, there is no report of acute otitis externa (AOE) because of NPWT. In this article, we present an unprecedented clinical case - a female patient who developed AOE after scalping treatment with NPWT applied over the head and ear canal. We consider that it may be a result of the direct physical action of subatmospheric pressure, the presence of dressing covering the external meatus, and alteration of the bacterial population.

Plasma Exeresis Treatment for Epidermoid Cysts: A Minimal Scarring Technique.

BACKGROUND: Epidermoid cysts are cutaneous benign tumors commonly seen in young or middle-aged adults. Plasma exeresis is an innovative technique for several skin conditions: it causes ionization of the atmospheric gas between the proximal tip of the device and the tissue to be treated, creating sublimation of the tissue. OBJECTIVE: To remove the cyst with a novel technique that allows a good cosmetic result. MATERIALS AND METHODS: Patients with clinical diagnosis of at least one epidermal cyst, aged between 18 and 70 years were enrolled. A standardized procedure was used. After administration of topical and sometimes local anesthesia (for cysts bigger than 1 cm), a tiny hole was created with plasma exeresis. The content of the cyst was then extruded and Micro Hartman Alligator Ear Forceps pulled out the loosened capsule. RESULTS: Twenty patients aged between 18 and 68 years were enrolled: 11 males (55%) and 9 females (45%). Twenty-eight cysts were successfully removed. The diameter ranged from 3 to 24 mm. No side effects were observed. The scar measured not more than 3 mm. CONCLUSION: This study suggests that plasma exeresis could represent a good and safe option to remove noninfected cysts on cosmetic areas, although further study is required.

Efficacy of ablative fractional laser-assisted photodynamic therapy with short-incubation time for the treatment of facial and scalp actinic keratosis: 12-month follow-up results of a randomized, prospective, comparative trial.

BACKGROUND: Photodynamic therapy (PDT) using methyl aminolevulinate (MAL) is an effective first-line treatment for actinic keratosis (AK). Erbium:yttrium-aluminium-garnet (Er:YAG) ablative fractional laser-assisted MAL-PDT (AFL-PDT) has shown significant benefit for the treatment of AK. OBJECTIVES: The objectives of this study were to compare the efficacy, recurrence rate, cosmetic outcome and safety between AFL-PDT with 2 and 3 h of incubation vs. Conventional MAL-PDT in patients with facial and scalp AK. METHODS: This prospective randomized trial initially enrolled 440 facial and scalp AK lesions in 93 patients. Patients were randomly assigned to AFL-PDT with a 2-h incubation time (2h-AFL-PDT), 3h-AFL-PDT and 3h-MAL-PDT. All patients underwent one session of MAL-PDT using a red light-emitting diode lamp at 37 J/cm(2) , and AFL-PDT groups were assigned to pretreatment with Er:YAG AFL. Patients were followed up at 1 week, 3 months and 12 months post treatment. Efficacy, cosmetic outcomes and adverse events were assessed. Finally, 427 facial AK lesions in 88 patients were analysed in this study. RESULTS: Three months after the last treatment session, 3h-AFL-PDT (91.7%) was significantly more effective than 2h-AFL-PDT (76.8%) and 3h-MAL-PDT (65.6%, P < 0.001), and differences in efficacy remained significant at the 12-month follow-up. The recurrence rate was significantly lower for 3h-AFL-PDT (7.5%) than for 3h-MAL-PDT (22.1%) at 12 months (P = 0.002);however, no significant difference was found between 2h-AFL-PDT and 3h-MAL-PDT. No significant difference was found in cosmetic outcomes or safety between the three groups. CONCLUSIONS: We recommend 3h-AFL-PDT rather than classic MAL-PDT or short-incubation AFL-PDT for treating AK.

Scalp necrosis overlying a ventriculoperitoneal shunt: a case report and literature review.

BACKGROUND: The use of ventriculoperitoneal (VP) shunts has become ubiquitous in neurosurgery for the treatment of hydrocephalus. VP shunts work by creating a conduit for cerebrospinal fluid (CSF) to flow from the cerebral ventricles to the peritoneum and thus relieving pressure. Although typically safe, VP shunt complications are extremely common, occurring in up to 29% of adult cases and approximately half of pediatric cases. These complications may require patients to undergo several revisions throughout their lifetime Purpose: We describe a man who developed scalp necrosis overlying his VP shunt. We also summarize the potential complications of VP shunts. We discuss the presentation and pathogenesis of scalp necrosis in these patients. MATERIALS AND METHODS: A PubMed search of the following terms was performed and relevant citations were assessed: ventriculoperitoneal shunt, VP shunt, shunt complications, scalp necrosis, skin necrosis, ventriculoperitoneal shunt induced scalp necrosis, ventriculoperitoneal shunt induced skin necrosis. RESULTS: A 73-year-old man developed VP shunt-induced scalp necrosis leading to loss of skin overlying the shunt valve. The patient was emergently referred to neurosurgery and admitted for revision of the shunt due to the significant risk for infection. The VP shunt was replaced with an external drain and a skin flap was used to repair the defect. CONCLUSION: VP shunts are devices that are frequently used for reducing intracranial pressure associated with hydrocephalus. The insertion of the shunt beneath the scalp sets the stage for potential pressure-induced scalp necrosis. The early recognition and diagnosis of VP shunt-induced scalp necrosis is essential to prevent infections and future complications.

Hair transplantation in the surgical treatment of central centrifugal cicatricial alopecia.

BACKGROUND: Central centrifugal cicatricial alopecia (CCCA) is a progressive primary scarring alopecia that occurs mainly on the vertex of the scalp and expands centrifugally. To date, there is a paucity of published prospective studies reporting successful surgical therapy for CCCA. OBJECTIVE: To evaluate the efficacy of hair transplantation using the round (punch) grafting technique in African American women with CCCA. MATERIALS AND METHODS: We describe 2 African American female patients with CCCA who had endured nearly 5 to 6 years of progressive hair loss on the crown of the scalp. After a scalp biopsy and hair transplant test session, both patients underwent hair transplantation with the use of round grafts. Digital photographs were obtained before and after hair transplantation to determine the hair growth success and response rates. RESULTS: Hair growth was visibly observed at the recipient sites in both patients beginning between 4 to 5 months post-test session. No postoperative scarring in the recipient or donor areas of the scalp were noted in either patient. CONCLUSION: Hair transplantation is a safe well-tolerated procedure to improve hair loss in African American women with end-stage CCCA who histologically display a lack of inflammation on scalp biopsy.

A substitute for skin grafts, flaps, or internal tissue expanders in scalp defects following tumor ablative surgery.

BACKGROUND: The skin of the scalp is relatively thick, minimally mobile, with distinct hair distribution. TopClosure® is a novel device for skin stretching and secure wound closure. OBJECTIVES: To evaluate the efficacy of the TopClosure® system in primary closure of moderate and large scalp defects, as a substitute for skin grafts, flaps, and tissue expanders. METHODS: We report a retrospective series of 8 patients requiring resection of 9 scalp tumors resulting with moderate to large size defects that otherwise would have required reconstruction with skin grafts, flaps, or tissue expanders. TopClosure® was applied for intraoperative cycles of stress-relaxation, followed, when indicated, by additional steps of mechanical creep and scar secure. RESULTS: Skin defects, averaging 3.5 cm, were managed by TopClosure®, enabling, primary closure in all wounds. Immediate wound edge approximation was reached through stress-relaxation in 2 wounds by heavy tension sutures within one hour. Further skin stretching by mechanical creep was required in 7 wounds, achieving staged primary closure in an outpatient setting. TopClosure® was further applied to secure the skin for up to 3 weeks following surgery. CONCLUSIONS: The TopClosure system, effectively, aided closure of moderate and large scalp defects by stress-relaxation and mechanical creep and serving as a topical tension-relief platform for tension sutures, allowing mobilization of skin and subcutaneous tissue without undermining or need of drainage, for early, direct wound closure. Local complications were minimal and donor site morbidity was eliminated. Surgical time, hospital stay and costs were reduced, and post-operative wound aesthetics were improved.

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.

Chronic scalp ulceration as a late complication of fluoroscopically guided cerebral aneurysm embolization.

Fluoroscopy-induced chronic radiation dermatitis resulting from prolonged exposure to ionizing radiation during interventional procedures has been documented in the medical literature. However, this condition often requires a high clinical suspicion in order to establish a correct diagnosis. In this report, the development of deep scalp ulceration with bone exposure following the endovascular coiling of an anterior communicating artery aneurysm 8 years before is described. A skin biopsy specimen demonstrated changes consistent with chronic radiation dermatitis and ruled out malignancy. This case report expands the clinical manifestation spectrum of fluoroscopy-induced chronic radiation skin injury and highlights the importance of recognizing these lesions early to prevent morbidity related to radiation-induced skin damage.

"Magic goggles": a distraction technique for pediatric dermatology procedures.

The sight of needles and surgical equipment can often cause anxiety in children. We describe the use of "Magic Goggles," a distraction technique of use in pediatric dermatology procedures.