Conservative management of large avulsions of the lip and local landmarks.

Large lip avulsion injuries that involve significant tissue loss to the lip vermilion and other local landmarks can often pose a surgical dilemma for the reconstructive surgeon. Immediate reconstruction of these injuries are frequently performed using local flaps and adjacent tissue transfer to close the defect, but these repairs frequently suffer from the unfortunate consequence of increased associated scarring and further permanent distortion of the local anatomy. We present 2 patients sustaining dog bite injuries associated with extensive traumatic tissue loss to the lip vermilion and other local landmarks. These patients were treated conservatively with excellent functional and cosmetic results. A single minor surgical revision of 1 patient's cupid's bow was performed 1 year after injury. In cases of significant traumatic avulsion involving the lip vermilion and the perioral composite soft tissue, even with injuries including delicate anatomic landmarks, healing by secondary intention can be instituted as the initial treatment of choice in younger patients, often providing optimal results.

Complete osseous regeneration of a large skull defect in a patient with cutis aplasia: a conservative approach.

Cutis aplasia (or aplasia cutis congenita) is a congenital absence of all skin layers, often extending through bone. This defect usually occurs in the scalp and can be extensive, exposing the dura mater, and deeper meninges. Treatment regimens for cutis aplasia have included early operative intervention, including skin and bone grafts, local scalp flaps, or free flaps to close the defect. In addition to the significant perioperative risks, these invasive procedures may inhibit the osteogenic potential of the dura to initiate and sustain bony closure of the defect. We report a case of an infant with Adams-Oliver syndrome and cutis aplasia involving a large portion of the skull that was treated conservatively with topical Silvadene dressings. No surgical treatment of bone or soft tissue reconstruction was necessary. This case report is the first to our knowledge to document complete bony restoration of the cranial vault through serial three-dimensional CT scans. The intensive therapeutic intervention in this case report allowed early discharge from the hospital, a gradual amelioration of the patient's alopecia as the hair-bearing scalp slowly covered the defect, and precluded the need for any subsequent bony reconstruction of the cranial vault. We hypothesize that conservative treatment of cutis aplasia maintains dural induction of osseous regeneration, and any treatment plan for bony defects of cutis aplasia should consider maintenance of dural integrity. Although further investigation is warranted, an initial trial of antimicrobial dressing care might optimally promote secondary closure of the cranial vault without the need for surgical intervention.