Neuron-specific enolase and its mRNA are highly expressed in large congenital nevi: a study using immunocytochemistry, biochemical assay, and in situ hybridization.

The malignant transformation of congenital nevocellular nevi, both large and small, is controversial and presents problems in management. The size of the lesion is taken to indicate potential malignant transformation, but this is an arbitrary scale. A more reliable biological indicator is needed to help predict the lesions at risk. Following the localization of neuron-specific enolase to most cells of the diffuse neuroendocrine system and their neoplasms (including benign and malignant melanocytic lesions), it has been suggested that its level is related to tumor activity. In a prospective trial, the presence of neuron-specific enolase immunoreactivity, its concentration, and gene expression in nevus cells were studied in 31 congenital melanocytic nevi of various sizes (1.5 cm to bathing trunk) using immunocytochemistry, biochemical assay, and in situ hybridization. Twenty-five of the 31 congenital nevi were immunoreeactive to neuron-specific enolase antiserum, with stronger immunostaining in the larger lesions. There is an apparent linear relationship between the size of the nevi and the level of neuron-specific enolase (expressed as nanograms per milligram protein). Neuron-specific enolase mRNA was highly expressed in most of the large congenital nevi (greater than 15 cm in diameter), as revealed by autoradiography following in situ hybridization. Our results show that neuron-specific enolase and its mRNA are expressed to a greater extent in large congenital nevi compared with the smaller lesions. This might prove to be a useful indicator of those lesions at risk of malignant transformation.

Locked intramedullary nailing of open tibial fractures.

We report the use of Grosse-Kempf reamed intramedullary nailing in the treatment of 41 Gustilo type II and III open tibial fractures. The union times and infection rates were similar to those previously reported for similar fractures treated by external skeletal fixation, but the incidence of malunion was less and fewer required bone grafting. The role of exchange nailing is discussed and a treatment protocol is presented for the management of delayed union and nonunion.

The pulsed tuneable dye laser as an aid in the management of postburn scarring.

Permanent erythematous scarring following burns is a common problem which may be disfiguring and distressing for the patient. In this case the pulsed tuneable dye laser (585 nm) was used to treat the areas of scarring and also used prophylactically on an active scar.

A role for lasers in the treatment of pigmented skin grafts.

The development of aberrant pigmentation represents an unwelcome complication to an otherwise successful split skin graft resulting in a loss of colour match and, so it follows, of cosmesis. We present two cases where lasers have been successful in the treatment of this problem.

The incidence of malignant melanoma (0 to 15 years of age) arising in "large" congenital nevocellular nevi.

While the association between large congenital nevocellular nevi and malignant melanoma has been established beyond reasonable doubt, its magnitude is the subject of wide controversy. In this study an attempt is made to estimate the risk of malignant transformation during the first 15 years of life in a sample of 39 congenital nevocellular nevi occupying a mean of 17 percent of the total body surface area collected from plastic surgical centers in England and Wales. During the period of observation, which totaled 337 years, two patients developed and died of metastatic malignant melanoma. A melanoma risk of 8.52 percent during the first 15 years of life is calculated. Although a high risk of melanoma must weigh heavily in favor of early prophylactic excision, the management of large congenital nevocellular nevi is considered to be too complicated to permit the invariable adoption of a wholesale excisional policy.

Does the pulsed tunable dye laser have a role in the management of infantile hemangiomas? Observations based on 3 years' experience.

Over a 3-year period, 50 patients with strawberry hemangiomas and 7 patients with postinvolutional redness or telangiectasia were treated with the SPTL-1 laser (Candela Corporation, Wayland, Mass.). The SPTL-1 laser emits pulsed light at a wavelength of 585 nm with a pulse duration of 450 ms. Lesions with a superficial red component were treated even if they had a significant subcutaneous component; however, wholly subcutaneous lesions were excluded. The series included 42 female patients aged between 1 and 72 months (mean 14 months) and 8 male patients aged between 3 and 12 months (mean 7 months). The mean number of treatments administered was 3.8 (range 1 to 8), and the average number of pulses per patient was 55 (range 2 to 350). This series also included 7 patients (6 female and 1 male) with postinvolutional redness or telangiectasia with a mean age of 12 years (range 2 to 23 years). They received an average of 3.4 treatments per patient (range 2 to 8) with an average of 35 pulses per treatment session (range 3 to 150). In this study group, life-threatening complications secondary to the hemangioma were rare in that only one patient suffered from an airway obstruction requiring a tracheostomy and three patients suffered from complete visual occlusion. A significant improvement in color was achieved in 30 patients (53 percent), but there was no appreciable reduction in bulk in any of the lesions despite repeated exposure to laser light.

Extended application of the biceps femoris musculocutaneous flap.

Since its description in 1977, the use of the biceps femoris musculocutaneous flap has been largely limited to reconstructions around the hip and perineum in paraplegic patients. The safety with which this flap can be transposed has been questioned owing to the segmental nature of its blood supply. Cadaver dissections in 10 fresh lower limbs showed that anterolateral transposition could be achieved without the need to sacrifice any of the major vascular pedicles (numbering two to three) which penetrate the long head of the muscle within 10 to 14 cm of the ischial tuberosity. We report on the use of this flap to resurface the anterolateral aspect of the lower thigh and restore stability and extension to the knee joint following extensive damage to the quadriceps mechanism.

The island posterior calf fasciocutaneous flap: an alternative to the gastrocnemius muscle for cover of knee and tibial defects.

The gastrocnemius muscle remains the workhorse for providing soft tissue over the knee and upper tibia. Nevertheless, we have found the island posterior calf fasciocutaneous flap to be a valuable alternative. We describe 10 cases in which an island posterior calf fasciocutaneous flap was used to cover defects over the knee and tibia. Three cases were after knee arthroplasty wound dehiscence, three cases were of traumatic soft-tissue loss, three cases involved replacement of unstable skin, and one case required closing a synovial fistula. This series is compared with 10 contemporaneous consecutive cases of soft-tissue loss around the knee that were reconstructed with a gastrocnemius muscle flap. Nine posterior calf fasciocutaneous flaps survived completely, and one flap had to be replaced because of poor flow. Although this flap is technically more demanding, we have found that it offers some advantages over the gastrocnemius. These include a greater flexibility of size and shape, a longer arc of rotation to reach suprapatellar defects, the provision of sensate skin with protective though crude sensation, less bulk, and the avoidance of a twitch. The flap is also easy to re-elevate from the recipient site for subsequent orthopedic work.

Treatment of nevi aranei with the pulsed tunable dye laser at 585 nm.

One hundred children aged < or = 12 years with spider nevi of the face have been treated with the SPTL-1 laser. The laser emits pulsed light at a wavelength of 585 nm, with a pulse duration of 450 microseconds. The series included 37 boys and 63 girls. Patients whose spider nevi were previously treated with other methods were excluded. In 97 cases the lesions were completely removed, but 29% of them required more than one treatment session. Six months later, two patients had mild recurrence of the nevi, which required further treatment. No signs of scarring or of textural or permanent pigmentary changes have been noted.

The role of cross-finger flaps in the primary management of untidy flexor tendon injuries.

This is a report of five patients who sustained untidy division of flexor tendons in zones 1 and 2, associated with overlying soft tissue loss. Contrary to traditional teaching, the tendon injuries were repaired primarily, and the tissue loss was made good with a cross-finger flap. At final evaluation, three cases were assigned excellent grades and two cases fair grades by Kleinert criteria. This unexpectedly favourable outcome may be due to a quality of the inner surface of the cross-finger flap and/or to staggering of the skin and tendon suture lines.

Functional deficit following loss of continuity of the long extensors of the fingers: a method of assessment.

A method for assessing hand function following loss of the long finger extensors in Zones 6 and 7 (Verdan, 1968) is described. It relies on a number of mechanical and functional tests combined with a detailed questionnaire.

Long term hand function without long finger extensors: a clinical study.

This study examines the premise that, following severe injuries to the dorsum of the hand, reconstruction of the long extensor tendons of the fingers may not be necessary for many patients. The long-term hand function of nine patients who sustained such injuries and had operations to provide skin cover only, has been comprehensively assessed using objective tests and a detailed questionnaire. It is concluded that provision of skin cover followed by intensive early mobilisation may be an adequate management of these injuries.

A case report of frontonasal dysplasia.

The following report describes a case of mild frontonasal dysplasia, a rare congenital anomaly affecting the nose and frontal bone. Our patient was referred at 2 months of age with a complex nasal skin and tip deformity. This report outlines management of this patient and reviews the literature with regard to presentation and classification of this condition.

The ad hoc perforator flap for contracture release.

Release and autografting remains a mainstay of treatment of cutaneous and joint-associated contractures. However, owing to secondary contraction of grafts and the increase of children undergoing burn reconstructive surgery, recurrence of contractures is not uncommon. Locally available, well-vascularised tissue that will contract minimally and grow with the patient is the ideal for contracture release. Many 'predesigned' cutaneous flaps have been described, but use of these may involve tailoring a defect to fit a known flap. We introduce the concept of the 'ad hoc' perforator flap, an improvised island flap based on a perforator, innominate or otherwise, that happens to be adjacent to a particular soft-tissue defect and can be reliably raised on scarred skin. We carried out a retrospective analysis of all patients undergoing contracture release within our unit. Twenty-three ad-hoc perforator flaps in 20 patients were carried out between 2000 and 2005. Eleven of the 20 patients were children, and all but one case was subsequent to a burn injury. Fifteen of the 23 flaps were upper limb. In one case, a significant complication involving total flap loss occurred. Only one patient required a skin graft to close the flap donor site, and no patients required revisional surgery for contracture recurrence. The ad hoc perforator flap is a safe and simple technique for the management of contractures, and fulfils the ideal of well-vascularised tissue that can grow with the patient. The flap can be designed as required and, with experience, the concept is applicable not only to contracture release, but many other reconstructive scenarios.

Treatment of small congenital nevocellular naevi using a combination of ultrapulse carbon dioxide laser and Q-switched frequency-doubled Nd-YAG laser.

This report describes treatment combining Ultrapulse CO(2) laser and Q-switched frequency-doubled neodymium:yttrium-aluminum-garnet (Nd-YAG) laser for a number of congenital nevocellular naevi (CNN). The Ultrapulse CO(2) laser removes the superficial component, which contains most of the color, preserving the integrity of the reticular dermis. At a later stage, any residual color is targeted using the Nd-YAG laser. To date, a total of 10 histologically proven CNNs have been treated at the Laser Suite. The median age of the patients was 18 years (range, 13-24 years). All the patients were white females. The patients accepted for treatment had relatively small lesions (mean surface area, 352 mm(2); range, 50-1,092 mm(2)), but the lesions were either cosmetically sensitive or located in an anatomically critical area in which excision could result in a scar that would be unpredictable. The median follow-up period was 24 months. The overall results have been satisfactory, with reduction of color and no significant scarring. The minor textural and pigmentary changes were acceptable to the patients.

Results of argon laser treatment of port-wine stains: a method of assessment.

In this review of over 100 cases of argon laser treated port-wine stains, four parameters, including lesion colour, skin texture, make-up habits and scarring, are assessed and changes allocated appropriate numbers. The sum of these numbers is used to classify results as Excellent, Good, Fair or Poor, and these were found to correlate well with the level of patient satisfaction.

Experience with the adipofascial turn-over flap.

Use of the adipofascial turn-over flap has been extended to cover such complex wounds of the extremities as defects over exposed joints and fracture sites. Experience with 10 consecutive cases and long-term follow-up confirmed that this flap is easy to plan and quick to raise, with minimum donor site morbidity and high success rate.

Clinical experience with the PLDL-1 (Pigmented Lesion Dye Laser) in the treatment of pigmented birthmarks: a preliminary report.

Twenty patients aged between 2 years and 17 years (mean 9 years) with pigmented birthmarks, mainly of the head and neck, were treated with the PLDL-1 laser (Pigmented Lesion Dye Laser--Candela Corporation, Wayland, Massachusetts, USA) which emits light with a wavelength of 510 nanometers and a pulse duration of 300 +/- 50 nano-seconds. Nine patients (45%) showed excellent results after a test-patch was performed. Two patients (10%) showed some lightening of colour after initial test-patch. Six patients (30%) showed no improvement and 3 patients (15%) showed some hyperpigmentation at the test-patch sites which had not disappeared at 6 months follow-up. There was no change in the clinical behaviour at 6 months follow-up and no evidence of scarring was encountered.