Microsurgical Resection of Vascular Malformations of the Upper Extremity.

Vascular malformations that circumferentially surround end or near-end arteries are challenging to manage. Minimally invasive treatment options such as sclerotherapy can directly damage these vessels and cause ischemia. Surgical resection is desired without sacrificing or injuring a patent artery, especially in end organs like the upper limb. Microsurgical resection of these lesions provides a viable option for treatment. Methods: The records of nine patients who presented with vascular malformations that circumferentially surrounded an artery in the upper limb were reviewed. The main indications for surgical intervention were pain or persistent growth. In each case, microsurgical technique using a microscope and microsurgical instruments was used to dissect the lesions free from the affected end arteries. Four digital arteries, three radial arteries, one brachial artery and one palmar arch were involved. Results: There were six venous malformations, two fibro-adipose vascular anomalies, and one lymphatic malformation. There were no cases of distal ischemia, bleeding, or functional compromise. Two patients experienced delayed wound healing. After a minimum follow-up of 1 year, only one patient experienced a small area of recurrence but had no pain. Conclusions: Microsurgical dissection using a microscope and microsurgical instruments is a viable technique for resection of difficult vascular malformations that surround major arterial channels in the upper limb. This technique allows preservation of maximum blood supply while treating problematic lesions.

Trends in Outcomes and Variation by Race and Ethnicity in Pediatric Plastic Surgery in the United States.

The American College of Surgeons' National Surgical Quality Improvement Project-Pediatric Data manages a multicenter dataset for monitoring outcomes in pediatric surgical care. We explored trends in outcomes in the most frequently sampled current procedural terminology codes related to craniofacial and cleft lip and palate (CLP) surgical procedures over a 7-year period. Methods: We used National Surgical Quality Improvement Project-Pediatric Data on 28,147 pediatric patients who underwent plastic surgical procedures between January 1, 2012, and December 31, 2018. Eighteen relevant current procedural terminology codes were selected and sorted into two procedure groups: CLP and craniofacial. For each group, we explored trends in readmission, reoperation, extended length of stay, morbidity, and racial and ethnic variation. Results: The proportion of readmissions following CLP repair saw a significant reduction per year (from 3.6% to 1.7%). African American or Black CLP patients had significantly higher rates of readmission and extended length of stay when compared to the overall cohort. Asian and White CLP patients had significantly lower rates of experiencing an extended length of stay. For craniofacial cases, extended length of stay decreased significantly per year (from 7.7% to 2.8%). One possible driver of this change was a decrease in transfusion rates during the study period from 59% to 47%. Conclusions: Pediatric CLP and craniofacial cases saw significant improvements in safety, as indicated by reductions in readmission and extended length of stay. Given the racial differences observed, especially among CLP patients, continued research to identify and address systems of racism in health care remains a priority.

Patient Experience with Virtual Preoperative Consultations in Pediatric Surgical Specialties.

BACKGROUND: A cross-sectional study was conducted to assess the comparative effectiveness of virtual visits for preoperative evaluation and surgical decision-making in three pediatric surgical subspecialties. METHODS: Patients who underwent surgical procedures in the departments of Urology, Ophthalmology, and Plastic and Oral Surgery at a tertiary care pediatric hospital over a one-year period during the COVID-19 pandemic were included. Patients were assigned to one of three clinical pathways based on their preoperative visit(s): only in-person visit(s) (IP), a combination of in-person and virtual visit(s) (IP/VV), and only virtual visit(s) (VV). Demographics, procedure information, and patient experience survey results were collected. We then assessed variations in procedure types and patient experience scores in these three patient groups. RESULTS: There were 431 patients who completed the modified patient experience survey. The most common procedures were circumcision (17%), excision of lesion (16%), and strabismus repair (11%). Survey results were positive, with 90% of participants rating that they would recommend the service to others. No significant differences were found among groups in their demographics, overall care rating, and duration between preoperative clinic visit and procedure. Post-hoc power analysis indicated 87% power to detect a 10% difference in survey ratings between IP and VV cases, confirming non-inferiority in patient satisfaction for virtual preoperative visits. CONCLUSION: This study demonstrated the non-inferiority of preoperative virtual visits in three pediatric surgical subspecialties as measured by patient experience scores. Additional studies with more granular scope are necessary to further elucidate telemedicine's safety and efficacy for select diagnoses. LEVEL OF EVIDENCE: III.

Trends in Pediatric Head and Facial Trauma During the COVID-19 Pandemic.

INTRODUCTION: The effect of physical-distancing policies and school closures on pediatric health has been a topic of major concern in the United States during the coronavirus disease 2019 (COVID-19) pandemic. The objective of this study was to assess the immediate impact of these public policies on patterns of head and facial trauma in the pediatric population. MATERIALS AND METHOD: The Pediatric Health Information System (PHIS) was queried to identify patient encounters at 46 children's hospitals across the United States in 2016-2020. Encounters were included if resultant in ICD-10 diagnosis for head or facial trauma in a child under 18 between April 1 and June 30 in 2020 (first COVID-19 school closures) and during the same period in the previous 4 years (for comparison). RESULTS: A total of 170,832 patient encounters for pediatric head and facial trauma were recorded during the study period, including 28,030 (16.4%) in 2020 and 142,802 (83.6%) in 2016-2019. Patient encounters declined significantly in 2020 among children of all age groups relative to previous years. Relative reductions were greatest in children aged 11 to 17 (middle/high school) and 6 to 10 (elementary school), at -34.6% (95% confidence interval: -23.6%, -44%; P <0.001) and -27.7% (95% confidence interval: -18.4%, -36%; P <0.001). Variation in relative reductions by race/ethnicity, sex, and rural/urban status were not statistically significant. CONCLUSIONS: Physical-distancing policies and school closures at the start of the COVID-19 pandemic correlated with significant reductions in pediatric head and facial trauma patient encounters. As in-person activities resume, reductions in head and facial trauma during the pandemic may indicate a range of possible preventable injuries in the future.

Presentation and Referral Patterns in Pediatric Closed Hand Fractures.

BACKGROUND: Although pediatric hand fractures are common and generally have good outcomes, they remain a considerable source of anxiety for non-hand surgeons, who are less familiar with these injuries. We hypothesized that this anxiety may manifest as inefficiency in referral patterns. METHODS: The records of pediatric patients with isolated, closed hand fractures without concurrent trauma seen at our institution by a hand surgeon between January 2017 and December 2018 were retrospectively reviewed. RESULTS: There were 454 patients included; 62.1% were men, and the mean age was 9.6 years at initial encounter. Most patients (89.6%) were treated nonoperatively and incurred few complications (0.5%). Roughly half of all cases (n = 262) initially presented to an outside provider. Of these, 24.0% (n = 64 of 262) were evaluated by 2+ providers before a hand surgeon. Most commonly, these patients were referred from an outside emergency department (ED) to our ED before hand surgeon evaluation (n = 45 of 64). Forty-seven patients required surgery; however, none were performed urgently. Although a greater proportion of 7- to 11-year-old patients saw 2+ providers prior to a hand surgeon (P = .007), fewer required surgery (P < .001). CONCLUSIONS: Pediatric closed hand fractures are mainly treated nonoperatively and nonemergently with generally excellent outcomes. Our data suggest that many patients continue to be referred through the ED or multiple EDs/providers for treatment. These inefficient referral patterns demonstrate the need for better education for ED and primary care providers, as well as better communication between these providers and local pediatric hand surgeons. Advancements in these areas are likely to improve efficiency of care and decrease costs.

Effectiveness of Preoperative Symptom Screening in Identifying Pediatric SARS-CoV-2 Infections: A Retrospective Cohort Analysis.

Evidence-based protocols identifying COVID-19 cases in pediatric preoperative settings are lacking. With COVID-19 positioned to remain a threat to children, this study examines effectiveness of preoperative COVID-19 symptom screening in pediatric patients. Methods: This retrospective cohort study included hospital billing/medical record queries of (1) procedures performed under conscious sedation/general anesthesia and (2) laboratory-confirmed COVID-19 (+) cases from April 6, 2020, to June 15, 2020. Descriptive analyses were performed for demographic, procedural, symptom, and COVID-19 test result data obtained from medical records. Bivariate analyses examined associations between SARS-CoV-2 test results and symptom, demographic, and procedural data. Results: Among 2900 surgical cases, median (interquartile range) age was 8.1 (12.8) years. The majority were male (n = 1609, 55.5%), white (n = 1614, 55.7%), and not Hispanic/Latino (n = 1658, 57.2%). Additionally, 85.4% (n = 2412) of cases were non-emergent. Fifteen COVID-19 (+) cases were identified, for a 0.5% positivity rate. COVID-19 positivity was not associated with sex, American Society of Anesthesiologists physical status, or preoperative symptom status. Notably, 92.9% (n = 13) of COVID-19 (+) cases were asymptomatic. COVID-19 (+) patients were significantly older (15.6 years) than COVID-19 (-) patients (8.0 years). Patients who were not white, were Hispanic/Latino, or had a relatively lower economic status, were more likely to test positive. Conclusions: Preoperative symptom screenings insufficiently identified COVID-19 (+) patients. During outbreaks, testing protocols should be implemented to identify COVID-19 (+) patients. Future research should examine if observations are similar for other variants, and how health disparities associate with COVID-19.

A Critical Assessment of the Transgender Health Care Workforce in the United States and the Capacity to Deliver Gender-Affirming Bottom Surgery.

BACKGROUND: Gender-affirming surgery is a critical component of transgender health care, but access information is limited. The study aim was to assess workforce capacity to perform gender affirming bottom surgeries (GABSs) in the United States. METHODS: A questionnaire was administered via email, phone call, or fax from February to May 2020 to 86 practices identified as performing GABS by searching 10 Web-based databases with standardized keywords. Questions assessed training capacity, surgical capacity, and surgeon experience. RESULTS: Thirty-two of 86 practices responded, 20 met the inclusion criteria. Practices were identified in 15 states, with an average 2.4 (SD, 1.3) surgeons performing GABS per year. States with the greatest number of total providers offering GABS were Illinois (n = 21), Texas (n = 10), and Massachusetts (n = 13). No significant correlation between number of GABS types offered and geographic population density (r = -0.40, P = 0.08), or between number of providers and geographic population density (r = 0.19, P = 0.44). Vaginoplasty was most frequently performed, with the longest waitlists and highest number of waitlist additions per month. Phalloplasty was the second most common procedure, and waitlist additions per month exceeded provider capacity to perform the procedure. Most surgeons performing GABS were plastic surgeons and urologists, whereas obstetricians/gynecologists performed the majority of hysterectomies. CONCLUSIONS: This study demonstrated a shortage of providers with requisite training and experience to provide GABS. Although more robust studies are needed to better characterize the relationship between the number of patients seeking GABS and available providers, these findings indicate a need for improved training.

Distraction Lengthening of the Apert Thumb.

BACKGROUND: The thumbs of patients with Apert syndrome are characteristically short and radially deviated, contributing to functional hand impairment. The authors report a two-staged technique for distraction lengthening of the Apert thumb using a robust cohort of pediatric patients. METHODS: The authors retrospectively reviewed medical records of pediatric patients with Apert syndrome who underwent thumb distraction lengthening between 1999 and 2019. The technique was two-staged: (1) application of uniplanar distractor and phalangeal osteotomy, followed by (2) distractor removal, bone grafting, and fixation. Clinical records, preoperative and postoperative radiographs, and photographs were reviewed. RESULTS: Twenty-two patients (41 thumbs) with Apert syndrome were identified and treated (mean age at initial distraction, 11.5 years). A mean distraction gap of 31.3 mm was achieved over a median time of 40.0 days. The mean healing index was 26.3 days per centimeter. The thumbnail complex was lengthened a median length of 3.0 mm. The median follow-up time was 5.0 years, with complications occurring in 36.4 percent (eight out of 22) of patients. A delayed bone union occurred in one patient, and rotational malunion occurred in one patient. CONCLUSION: Although long-term outcomes data are needed, thumb distraction lengthening following syndactyly release in patients with Apert syndrome is safe and should be considered to augment the overall appearance and functionality of the hand. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Syndactyly Release in the Hand: Surgical Technique.

SUMMARY: Syndactyly is one of the most common congenital differences treated by hand surgeons. Although dozens of techniques for syndactyly release have been described, a reliable method is based on a dorsal rectangular flap for commissure construction and a combination of interdigitating zigzag flaps and skin grafts for digital coverage. In this article, the authors present a detailed description of syndactyly release emphasizing principles integral to successful outcomes.

Parkes Weber syndrome with lymphedema caused by a somatic KRAS variant.

Parkes Weber syndrome is a vascular malformation overgrowth condition typically involving the legs. Its main features are diffuse arteriovenous fistulas and enlargement of the limb. The condition has been associated with pathogenic germline variants in RASA1 and EPHB4 We report two individuals with Parkes Weber syndrome of the leg and primary lymphedema containing a somatic KRAS variant (NM_004985.5:c.35G > A; p.Gly12Asp). KRAS variants, which cause somatic intracranial and extracranial arteriovenous malformations, also result in Parkes Weber syndrome with lymphatic malformations.

Discrepancies between Conference Abstracts and Published Manuscripts in Plastic Surgery Studies: A Retrospective Review.

BACKGROUND: Inconsistency in results and outcomes between presented abstracts and corresponding published articles can negatively affect clinical education and care. The objective of this study was to describe the frequency of clinically meaningful change in results and outcomes between abstracts presented at the American Association of Plastic Surgeons annual conference and the corresponding published articles, and to determine risk factors associated with discrepancies. METHODS: All abstracts delivered as oral presentations at the American Association of Plastic Surgeons conference (2006-2016) were reviewed. Results and outcomes were compared with those in corresponding articles. We defined clinically meaningful discrepancy as any change in the directionality of an outcome, or a quantitative change in results exceeding 10%. RESULTS: Four hundred eighty-six abstracts were identified. Of these, 63% (N = 305) advanced to publication. Of the published studies, 19% (N = 59) contained a discrepancy. In 85% of these (N = 50), discrepancies could not be explained by random variation. Changes in sample size were associated with heightened risk for a discrepancy (OR 10.38, 95% CI 5.16-20.86, P < 0.001). A decrease in sample size greater than 10% increased the likelihood of a discrepancy by 25-fold (OR 24.92, 95% CI 8.66-71.68, P < 0.001), whereas an increase in sample size greater than 10% increased the likelihood of a discrepancy by eight-fold (OR 8.36, CI 3.69-19.00, P < 0.001). CONCLUSIONS: Most discrepancies between abstract and published article were not due to random statistical variation. To mitigate the possible impact of unreliable abstracts, we recommend abstracts be marked as preliminary, that authors indicate whether sample size is final at time of presentation, and that changes to previously reported results be indicated in final publications.

Lower Extremity Reconstruction in the Pediatric Population.

Indications for lower extremity reconstruction in children are unique because most result from congenital conditions (eg, constriction ring, lymphedema, syndactyly, nevi, vascular anomalies). Like adults, pediatric patients also suffer from effects following extirpation and trauma. Principles of reconstruction are based on the condition and type of deformity. The pediatric population typically has fewer comorbidities than adults that can negatively affect outcomes (eg, diabetes, peripheral vascular disease), although children can be less compliant with postoperative care. Growth, development, appearance, and postoperative compliance are variables that especially influence operative management of children.

Legislation, Market Size, and Access to Gender-affirming Genital Surgery in the United States.

The value of gender-affirming genital surgery (GAGS) has been established for certain transgender or gender non-conforming patients. This study aimed to determine the availability of GAGS by state and region in the United States, and to query possible associations of access to care with healthcare legislation and local market size. METHODS: This was a cross-sectional study reporting on the distribution of hospitals and private practices offering GAGS in the United States. A list of prospective gender surgeons was compiled from 18 online databases. All surgeons were individually verified and were excluded if they did not perform phalloplasty, metoidioplasty, or vaginoplasty. Pertinent legislative and transgender or gender non-conforming population data were derived from the Movement Advancement Project and the Williams Institute. RESULTS: Seventy-one practices in the United States offered GAGS in 2019. Forty-seven percent of states did not have a practice offering GAGS. A large prospective transgender or gender non-conforming market size increased the odds of GAGS availability in a state more than did local healthcare legislation supporting insurance coverage for gender-affirming care in 2019. CONCLUSIONS: Access to gender-affirming genital surgery was highly disparate in 2019. Factors that predicted access to care, including state healthcare legislation and prospective market sizes, may indicate strategies for overcoming disparities.

Digital Transfer for Hand Reconstruction in Cleft Hand and Foot Differences.

BACKGROUND: Digital transfer for hand reconstruction in children with cleft hand and foot differences present unique challenges with anomalous anatomy and rare opportunities to dramatically improve function of one- or two-digit hands. METHODS: Medical records were reviewed for patients with cleft hand and foot treated at two pediatric institutions between 1996 and 2018. Hospital records, clinical photographs, radiographs, and alginate molds were available on all patients. Patient characteristics, indications for transfer, associated syndromes, donor and recipient anatomy, and complications were examined. RESULTS: Twenty digital transfers were identified in 16 patients. The mean age at time of transfer was 6 years (range: 3-18 years). Associated syndromes in this study included ectrodactyly ectodermal dysplasia clefting (EEC) syndrome and Goltz's syndrome. Recipient sites included the thumb (n = 17) and index ray (n = 3) in 10 hands with monodactyly, 6 hands with a two-digit ulnar syndactyly, and 3 hands with central deficiency and associated polydactyly or other anomalies. Donor sites included the great toe (n = 7), fifth toe (n = 9), great toe polydactyly (n = 2), thumb polydactyly (n = 1), and second toe (n = 1). All transfers survived. Revisions included tenolysis (n = 2), repeat fixation for nonunion or malunion (n = 2), and fusion for instability (n = 3). CONCLUSION: Digital transfer in cleft hand and foot patients is a functional endeavor. The transferred digits provide sensation, mobility, and stability for opposition. Technically challenging due to small structures and atypical anatomy, these rare cases represent unique opportunities to improve function and appearance in the pediatric hand. This is a therapeutic study and reflects level of evidence IV.

Is Clitoral Release Another Term for Metoidioplasty? A Systematic Review and Meta-Analysis of Metoidioplasty Surgical Technique and Outcomes.

INTRODUCTION: There has been an exponential increase in referrals for transmasculine patients seeking genital affirmation surgery. Despite transgender men's equal interest in metoidioplasty and phalloplasty, research has primarily focused on phalloplasty. AIM: To summarize and investigate the relationship between surgical technique, complications, and patient-satisfaction. METHODS: We performed a systematic review and meta-analysis of surgical techniques and physician- and patient-reported outcomes of gender-affirming clitoral release and metoidioplasty (PROSPERO# 158722) with literature from PubMed, Google Scholar, and ScienceDirect. Data were extracted using PRISMA guidelines. All searches, extractions, and grading were independently completed by 2 authors. MAIN OUTCOME MEASURES: Main measures were surgical technique, patient satisfaction, voiding, urethral stricture, and urethral fistula. RESULTS AND CONCLUSION: A total of 7 non-overlapping articles on metoidioplasty were identified, with a total of 403 patients. We identified 4 metoidioplasty techniques: Hage, Belgrade, labial ring flap, and extensive metoidioplasty. All techniques included urethral lengthening. The reported neophallus length ranged from 2 cm to 12 cm, with the smallest neophallus occurring with the labial ring flap technique and extensive metoidioplasty the largest. Across techniques, voiding while standing was reported in most patients, with the lowest rate reported with the labial ring flap (67%). Complications were impacted by surgical technique, with the lowest rates of fistula and stricture occurring with the Belgrade technique. Fistula rates ranged from 5% to 37%, while stricture ranged from 2% to 35% of patients. The Belgrade technique reported significantly lower rates of fistula and stricture (P = .000). The patient-reported outcomes were described for the Belgrade technique and extensive metoidioplasty. Both techniques showed high aesthetic and sexual satisfaction. Transgender individuals can achieve an aesthetically and sexually satisfactory neophallus using a variety of metoidioplasty techniques; however, urethral outcomes vary significantly by technique. The Belgrade technique reported the best outcomes, although data remains limited. Patient priorities should be used to determine surgical technique. Jolly D, Wu CA, Boskey ER, et al. Is Clitoral Release Another Term for Metoidioplasty? A Systematic Review and Meta-Analysis of Metoidioplasty Surgical Technique and Outcomes. Sex Med 2021;9:100294.

Index Finger Pollicization for Hypoplastic Thumb: Surgical Technique.

SUMMARY: Pollicization can be performed for secondary thumb reconstruction after traumatic injury or for primary thumb construction in cases of congenital thumb hypoplasia. Given the complexity of this operation, intimate familiarity with the involved anatomy and surgical principles is key to successful surgical outcomes. In this Video Plus article, the authors present a step-by-step approach to pollicization in case of Blauth type IIIB thumb hypoplasia.

Outcomes following Microvascular Mandibular Reconstruction in Pediatric Patients and Young Adults.

The etiology and treatment of complex mandibular defects in children differ markedly from those of adults, although treatment with free bone flaps is historical in both groups. While adult outcomes and complication rates are well known, few pediatric data exist, especially for patients with congenital deficiencies. This study reports early and late outcomes from a cohort of young, primarily syndromic patients undergoing microvascular mandibular reconstruction. METHODS: This is a retrospective case series of patients who underwent microvascular mandibular reconstruction between 1995 and 2016. RESULTS: Thirteen patients received a total of 13 fibula transfers and 1 medial femoral condyle transfer. Most patients carried a congenital diagnosis (77%), and the average age during surgery was 11.7 ± 5.7 years. The median (interquartile range) [IQR] length of follow-up was 6.3 (5.7) years. There was a 100% flap survival rate, although 86% of all patients experienced at least one complication. Half of all procedures resulted in an early complication. Nine patients (69%) developed late complications, of which temporal mandibular joint ankylosis was the most common (n = 5; 38%). CONCLUSIONS: This study is one of few detailing outcomes following mandibular reconstruction by free flap transfer in pediatric patients. These patients were primarily syndromic with appreciable complication rates higher than in other adult and pediatric studies. Some complications are manageable or self-resolving, but others lead to functional problems that may require late operative interventions to correct. Microsurgical treatment should be reserved for children with large, complex mandibular defects when other options are unavailable or have been exhausted.

Median Nerve Neuropathy following Radial Forearm Free Flap Phalloplasty: A Case Report.

As the transgender population increases, gender-affirming surgeries are being performed at unprecedented rates. Despite this increase, complications and long-term outcomes of gender-affirming interventions are largely understudied. We present a transgender patient who underwent radial forearm free flap (RFFF) phalloplasty as part of gender affirmation. Immediately following surgery, the patient reported paresthesia in the donor arm in the median nerve distribution followed by a neuropathic pain after 1 week. The patient complained of shooting and burning pain and reported a loss of sensation and function at the donor site. Electromyography and magnetic resonance imaging results indicated median nerve damage several inches above the donor site. The symptoms persisted for several months before spontaneously resolving. The spontaneous resolution and location of injury suggest that nerve damage occurred as a result of pneumatic tourniquet application despite adherence to all clinical guidelines for a safe tourniquet application of the same. This is the first reported case of neuropathic pain following RFFF phalloplasty occurring at the donor site. Given the large donor area and the long time of tourniquet application, surgeons offering RFFF phalloplasty must be aware of and actively counsel patients seeking this procedure about the potential for nerve-related damages before surgery.

Congenital Disseminated Pyogenic Granuloma: Characterization of an Aggressive Multisystemic Disorder.

OBJECTIVE: To describe the clinical, radiologic, and histopathologic features of "congenital disseminated pyogenic granuloma" involving various organs with high morbidity related to cerebral hemorrhagic involvement. STUDY DESIGN: We searched the database of the Vascular Anomalies Center at Boston Children's Hospital from 1999 to 2019 for patients diagnosed as having multiple vascular lesions, visceral vascular tumors, congenital hemangiomatosis, multiple pyogenic granulomas, or multiple vascular lesions without a definite diagnosis. A retrospective review of the medical records, photographs, histopathologic, and imaging studies was performed. Only patients with imaging studies and histopathologic diagnosis of pyogenic granuloma were included. RESULTS: Eight children (5 male, 3 female) had congenital multifocal cutaneous vascular tumors. Lesions also were found in the brain (n = 7), liver (n = 4), spleen (n = 3), muscles (n = 4), bone (n = 3), retroperitoneum (n = 3), and intestine/mesentery (n = 2). Less commonly affected were the spinal cord, lungs, kidneys, pancreas, and adrenal gland (n = 1 each). The mean follow-up period was 21.8 months. The cerebral and visceral lesions were hemorrhagic with severe neurologic sequelae. The histopathologic diagnosis was pyogenic granuloma with prominent areas of hemorrhage and necrosis. The endothelial cells had enlarged nuclei, pale cytoplasm and were immunopositive for CD31 and negative for D2-40 and glucose transporter 1. CONCLUSIONS: Congenital disseminated pyogenic granuloma is a distinct multisystemic aggressive disorder that primarily affects the skin, brain, visceral organs, and musculoskeletal system. Differentiation of this entity from other multiple cutaneous vascular lesions is critical because of possible cerebral hemorrhagic involvement.