Aggressive melanoma in an infant with congenital melanocytic nevus syndrome and multiple, NRAS and BRAF mutation-negative nodules.

We report the case of a newborn boy with multinodular NRAS and BRAF mutation-negative congenital melanocytic nevi and cerebral lesions compatible with congenital intraparenchymal melanosis. Histopathology from skin lesions showed atypical nodular melanocytic proliferation with marked melanocytic atypia and a large number of mitoses and apoptosis, indicating aggressive proliferation. The child developed several new subcutaneous tumors and multiple internal lesions, which were confirmed to be metastases, and died at 5 months of age. This case may represent an infantile melanoma developing from a giant congenital melanocytic nevus or a congenital melanoma.

Simple limbal epithelial transplantation: Current status and future perspectives.

Damage to limbal stem cells as a result of injury or disease can lead to limbal stem cell deficiency (LSCD). This disease is characterized by decreased vision that is often painful and may progress to blindness. Clinical features include inflammation, neovascularization, and persistent cornea epithelial defects. Successful strategies for treatment involve transplantation of grafts harvested from the limbus of the alternate healthy eye, called conjunctival-limbal autograft (CLAU) and transplantation of limbal cell sheets cultured from limbal biopsies, termed cultured limbal epithelial transplantation (CLET). In 2012, Sangwan and colleagues presented simple limbal epithelial transplantation (SLET), a novel transplantation technique that combines the benefits of CLAU and CLET and avoids the challenges associated with both. In SLET a small biopsy from the limbus of the healthy eye is divided and distributed over human amniotic membrane, which is placed on the affected cornea. Outgrowth occurs from each small explant and a complete corneal epithelium is typically formed within 2 weeks. Advantages of SLET include reduced risk of iatrogenic LSCD occurring in the healthy cornea at harvest; direct transfer circumventing the need for cell culture; and the opportunity to perform biopsy harvest and transplantation in one operation. Success so far using SLET is comparable with CLAU and CLET. Of note, 336 of 404 (83%) operations using SLET resulted in restoration of the corneal epithelium, whereas visual acuity improved in 258 of the 373 (69%) reported cases. This review summarizes the results of 31 studies published on SLET since 2012. Progress, advantages, challenges, and suggestions for future studies are presented.

An Aesthetic Factor Priority List of the Female Breast in Scandinavian Subjects.

Background: There is little consensus about the relative determinative value of each individual factor in female breast aesthetics. When performing breast surgery with an aesthetic goal, certain factors will be more important than others. The purpose of this study was to make an aesthetic factor rank list to determine the relative contributions to overall breast aesthetics. Method: Volunteers were scanned using the 3-dimensional Vectra system. Ten Scandinavian plastic surgeons rated 37 subjects, using a validated scoring system with 49 scoring items. The correlation between specific aesthetic factors and overall breast aesthetic scores of the subjects were calculated using Pearson's r, Spearman's ρ, and Kendall's τ. Results: A very strong correlation was found between overall breast aesthetic score and lower pole shape (0.876, P < 0.0001). This was also true for upper pole shape (0.826, P < 0.0001) and breast height (0.821, P < 0.0001). A strong correlation was found between overall breast aesthetic score and nipple position (0.733, P < 0.0001), breast size (0.644, P < 0.0001), and breast width (0.632, P < 0.0001). Factors that were only moderately correlated with aesthetic score were intermammary distance (0.496, P = 0.002), nipple size and projection (0.588, P < 0.0001), areolar diameter (0.484, P < 0.0001), and areolar shape (0.403, P < 0.0001). Perceived symmetry was a weak factor (0.363, P = 0.027). Conclusions: Aesthetic factors of the female breast can be ranked in a priority list. Shape of the lower pole and upper pole and breast height are primary factors of female breast aesthetics. These should be prioritized in any aesthetic breast surgery. Vertical dimensional factors seem to be more determinative than horizontal factors.

Spontaneous reinnervation of deep inferior epigastric artery perforator flaps after secondary breast reconstruction.

The deep inferior epigastric artery perforator (DIEAP) flap is the gold standard of free flaps in breast reconstruction. However, until now little attention has been paid to reinnervation of the flap. The aim of this study was to examine the spontaneous reinnervation of the DIEAP flap after breast reconstruction. The study was cross-sectional, and included 29 women who had all previously had secondary reconstruction with a DIEAP flap after mastectomy for breast cancer. Pressure thresholds were analysed on the skin island of the flap using Semmes-Weinstein monofilaments. The measurements showed measurable sensation in 29 of the 30 flaps. Nine patients had normal or diminished light touch in one or more areas. We also found significant better pressure sensitivity when the medial was compared to the lateral side and the inferior to the superior side of the flap. Our data showed that DIEAP flaps reinnervate after breast reconstruction although there is no sensory nerve repair. We suggest that nerve ingrowth takes place from the sides and this seems to be more pronounced in the inferomedial part of the flap.

Complications, risk factors, and patients-reported outcomes after skin-sparing mastectomy followed by breast reconstruction in women with BRCA mutations.

BACKGROUND: Women with a BRCA mutation have the option of undergoing prophylactic mastectomy and immediate breast reconstruction; however, the potential negative effects of reconstruction on women's physical and psychological well-being are unclear. This study aimed to investigate complications, patient-reported pain, health-related quality-of-life (HRQoL) and satisfaction following reconstructive surgery at Oslo University Hospital between 2006 and 2013. METHODS: Data were collected retrospectively from the records of 238 patients. A cross-sectional survey was conducted to collect patient-reported HRQoL and satisfaction with outcome using the Short Form-12 questionnaires and Breast-Q. The self-administered Leeds assessment of neuropathic symptoms and signs was used to assess neuropathic pain. RESULTS: The majority of participants (89.5%) underwent implant-based breast reconstruction (IBBR); the remainder underwent autologous-tissue breast reconstruction (ATBR). Overall, 28.6% had complications within 30 days of surgery and 14.6% required resurgery because of complications. Women who underwent IBBR had a later onset of complications than those undergoing ATBR. Participants in the survey (n = 175 of 219, response rate 79.9%) reported similar HRQoL to an age-matched general female population. Few (2.9%) reported neuropathic pain. Patients who underwent IBBR were significantly less satisfied with the reconstructed breast (p = .001) and overall outcome (p = .02) than those who underwent ATBR, but there were no significant differences in HRQoL scores between the two groups. CONCLUSIONS: Overall, 28.6% of the women had complications within 30 days and 14.6% needed resurgery. Few had neuropathic pain. Women who underwent ATBR were more satisfied with the overall outcome than those who underwent IBBR.

Coordinated collective migration and asymmetric cell division in confluent human keratinocytes without wounding.

Epithelial sheet spreading is a fundamental cellular process that must be coordinated with cell division and differentiation to restore tissue integrity. Here we use consecutive serum deprivation and re-stimulation to reconstruct biphasic collective migration and proliferation in cultured sheets of human keratinocytes. In this system, a burst of long-range coordinated locomotion is rapidly generated throughout the cell sheet in the absence of wound edges. Migrating cohorts reach correlation lengths of several millimeters and display dependencies on epidermal growth factor receptor-mediated signaling, self-propelled polarized migration, and a G1/G0 cell cycle environment. The migration phase is temporally and spatially aligned with polarized cell divisions characterized by pre-mitotic nuclear migration to the cell front and asymmetric partitioning of nuclear promyelocytic leukemia bodies and lysosomes to opposite daughter cells. This study investigates underlying mechanisms contributing to the stark contrast between cells in a static quiescent state compared to the long-range coordinated collective migration seen in contact with blood serum.

Microcirculation in single and multiple-based perforator flaps in an experimental model of rats.

Our aim was to evaluate the effect of single and multiple-based perforator flaps on the microcirculation in rats. Two symmetrical abdominal flaps were raised around the midline in 17 rats, and sutured into their original positions after dissection. All major perforators in the flap were left intact on one side, and on the opposite side only one perforator was retained. The microcirculation in the flaps was measured with laser Doppler perfusion imaging at different time intervals. Before dissection of the flap the mean (SD) microcirculation was 5.5 (1.6) units in the multiple-based perforator flap and 5.5 (1.4) in the single-based perforator flap. Within the first two hours after the flap had been raised the highest microcirculation was found after 30 minutes with 7.3 (1.3) units in the multiple-based perforator flap compared with 6.5 (1.4) units in the single-based perforator flap (p = 0.002). We conclude that the microcirculation in the single-based perforator flap was not reduced after dissection. However, a reactive hyperaemic response was found only in the multiple-based perforator flap.

Skin viability and wound strength in single and multiple based perforator flaps in an experimental rat model.

Our aim was to evaluate the effect of single and multiple based perforator flaps on the skin viability and wound strength in rats. We used 17 Wistar rats in which two symmetrical abdominal flaps were raised around the midline. On one side all major perforators to the flap were left intact, and on the other side only one perforator was retained. After dissection, the flaps were sutured back in their original position. After seven days each rat was killed and the skin viability and wound strength were measured. The multiple based perforator flap had a mean skin viability of 98% compared with 95% in the single based perforator flap (p =0.08). The mean (SD) wound strength was 3.8 (0.9) N in the multiple based perforator flap compared with 3.0 (1.1) N in the single based perforator flap (p =0.02). We conclude that there is significantly greater wound strength at day 7 with the multiple based perforator flap than with the single one.

Green urine after surgical treatment of pressure ulcer.

We describe a 58-year-old man who developed green urine after operation on a pressure ulcer. The discolouration disappeared gradually after two days. We think that the use of methylene blue dye during the revision of the wounds and the use of the sedative propofol could have caused it.

Patient-reported outcomes after breast reconstruction with deep inferior epigastric perforator flaps.

We assessed patient-reported outcomes in 34 women who had had their breasts reconstructed with a deep inferior epigastric perforator (DIEP) flap, and compared them with those of 24 patients who were waiting for breast reconstruction. Both groups completed the Short Form 36 (SF-36) questionnaire. The DIEP flap group also assessed their preoperative conditions retrospectively and completed a study-specific questionnaire. The DIEP group reported higher SF-36 mental health scores after the operation than before, but no difference on other SF-36 scales. There was no difference on any SF-36 scale between patients who had had DIEP flaps and those waiting for reconstruction. Most of the DIEP group was satisfied with their bodies, the appearance of their breasts after reconstruction, and would have chosen operation again. In conclusion, there was little improvement in generic health-related quality of life after reconstruction with a DIEP flap. However, patients' satisfaction was high after the procedure.

Optimization of Storage Temperature for Retention of Undifferentiated Cell Character of Cultured Human Epidermal Cell Sheets.

Cultured epidermal cell sheets (CES) containing undifferentiated cells are useful for treating skin burns and have potential for regenerative treatment of other types of epithelial injuries. The undifferentiated phenotype is therefore important for success in both applications. This study aimed to optimize a method for one-week storage of CES for their widespread distribution and use in regenerative medicine. The effect of storage temperatures 4 °C, 8 °C, 12 °C, 16 °C, and 24 °C on CES was evaluated. Analyses included assessment of viability, mitochondrial reactive oxygen species (ROS), membrane damage, mitochondrial DNA (mtDNA) integrity, morphology, phenotype and cytokine secretion into storage buffer. Lowest cell viability was seen at 4 °C. Compared to non-stored cells, ABCG2 expression increased between temperatures 8-16 °C. At 24 °C, reduced ABCG2 expression coincided with increased mitochondrial ROS, as well as increased differentiation, cell death and mtDNA damage. P63, C/EBPδ, CK10 and involucrin fluorescence combined with morphology observations supported retention of undifferentiated cell phenotype at 12 °C, transition to differentiation at 16 °C, and increased differentiation at 24 °C. Several cytokines relevant to healing were upregulated during storage. Importantly, cells stored at 12 °C showed similar viability and undifferentiated phenotype as the non-stored control suggesting that this temperature may be ideal for storage of CES.

Effect of Storage Temperature on the Phenotype of Cultured Epidermal Cells Stored in Xenobiotic-Free Medium.

PURPOSE: Cultured epidermal cell sheets (CECS) are used in the treatment of large area burns to the body and have potential to treat limbal stem cell deficiency (LSCD) as shown in animal studies. Despite widespread use, storage options for CECS are limited. Short-term storage allows flexibility in scheduling surgery, quality control and improved transportation to clinics worldwide. Recent evidence points to the phenotype of cultured epithelial cells as a critical predictor of post-operative success following transplantation of CECS in burns and in transplantation of cultured epithelial cells in patients with LSCD. This study, therefore assessed the effect of a range of temperatures, spanning 4-37 °C, on the phenotype of CECS stored over a 2-week period in a xenobiotic-free system. MATERIALS AND METHODS: Progenitor cell (p63, ΔNp63α and ABCG2) and differentiation (C/EBPδ and CK10) associated marker expression was assessed using immunocytochemistry. Immunohistochemistry staining of normal skin for the markers p63, ABCG2 and C/EBPδ was also carried out. Assessment of progenitor cell side population (SP) was performed using JC1 dye by flow cytometry. RESULTS: P63 expression remained relatively constant throughout the temperature range but was significantly lower compared to control between 20 and 28 °C (p < 0.05). High C/EBPδ together with low p63 suggested more differentiation beginning at 20 °C and above. Lower CK10 and C/EBPδ expression most similar to control was seen at 12 °C. The percentage of ABCG2 positive cells was most similar to control between 8 and 24 °C. Between 4 and 24 °C, the SP fluctuated, but was not significantly different compared to control. Results were supported by staining patterns indicating differentiation status associated with markers in normal skin sections. CONCLUSIONS: Lower storage temperatures, and in particular 12 °C, merit further investigation as optimal storage temperature for maintenance of undifferentiated phenotype in CECS.

Extraordinary Large Giant Congenital Melanocytic Nevus Treated with Integra Dermal Regeneration Template.

Garment-like giant congenital melanocytic nevi are very rare, and those being treated are most often offered excision and split-thickness skin transplantation. Due to the risk of restricted mobility secondary to shrinkage and hypertrophic scarring of the transplant, we treated to date the largest reported giant congenital melanocytic nevus (16% total body surface area) with Integra dermal regeneration template (Integra Life Sciences, Plainsboro, N.J.), giving a more functional skin reconstruction. In addition, the dermal regeneration template had to be covered with split-thickness skin transplant including multiple smaller nevi due to lack of larger area with normal skin.

Microcirculatory evaluation of deep inferior epigastric artery perforator flaps with laser Doppler perfusion imaging in breast reconstruction.

We have made a quantitative analysis of the microcirculation in the classic perfusion zones of the deep inferior epigastric artery perforator (DIEAP) flap on 10 consecutive women having breast reconstruction with a unilateral DIEAP. Laser Doppler perfusion imaging was used for operative scans. Data were recorded 10 minutes after successful microanastomosis. The mean (SD) perfusion for each perfusion zone was calculated. Zone I = 44.2 (6.2); zone II = 35.1 (10.3); zone III = 39.9 (9.2); and zone IV = 21.9 (10.0). There were significant differences between zones I, II, and III and zone IV (p < 0.001), and zones I and II (p = 0.02). However, there was no significance between zones I and III (p = 0.9), and zones II and III (p = 0.6). The perfusion of zone IV was significantly lower than those in all other zones, which is in keeping with clinical practice in which zone IV is normally discarded to avoid partial necrosis of the flap in unilateral breast reconstruction. Higher values are expected in zone I than zone III, and in zone II than zone III. However, we could not confirm this. We conclude that there are no differences in skin perfusion between zones I and III, and zones II and III. However, the perfusion of zone IV was significantly less than that in all other zones immediately after revascularisation of the DIEAP flap.