The role of tissue expansion in pediatric plastic surgery.

The ability to increase available local tissue by controlled soft tissue expansion (TE) has led to a rapid increase in the use of TE in clinical practice. This article reviews some general guidelines when using TE in children and addresses some of the concerns previously expressed regarding the effects of TE on growth in infants and children.

An approach to excision of congenital giant pigmented nevi in infancy and early childhood.

This paper presents a timely coordinated approach to complete excision of congenital giant pigmented nevi in infancy and early childhood based on a review of 78 patients with giant pigmented nevi of the head and neck, trunk, and/or extremity. Giant pigmented nevi in those selected for review measured from a minimum of 2 percent up to 45 percent total body surface (TBS). Giant nevi of the scalp were treated most effectively using tissue expansion, beginning as early as 3 months of age. Expanded forehead and neck flaps in combination with expanded full-thickness skin grafts were used in early excision of giant pigmented nevi of the face. Giant nevi of the trunk were treated using a combination of abdominoplasty technique, tissue expansion, and split-thickness skin graft, with early "large segment" excision and grafting being the most effective treatment of giant nevi covering the posterior trunk. Giant nevi of the extremities were treated most effectively with excision and graft. Expanded full-thickness skin grafts gave excellent coverage on the hands and feet.

Expanded full-thickness skin grafts in children: case selection, planning, and management.

Since our initial presentation of our experience with tissue expansion as a means of harvesting large full-thickness skin grafts in children in 1987, we have continued to "expand" both the size of full-thickness skin grafts harvested and the range of reconstructive problems to which we have applied the technique. Sixteen expanded full-thickness grafts have been used for immediate reconstruction following giant nevus excision and in postburn reconstruction. Patients ranged in age from 6 months to 15 years, with follow-up ranging from 6 months to 6 1/2 years. Grafts ranging in size from approximately 60 cm2 (excluding the dimensions of one submental graft) to greater than 700 cm2 were harvested from expanded donor sites on unilateral or bilateral groin/lower abdomen, clavicular, and a single submental expansion. Five expanded full-thickness grafts were used in facial reconstruction for single aesthetic unit coverage, multiple unit, and one single-sheet full facial graft. One expanded full-thickness graft was used on the breast. Three grafts were used in dorsal hand and finger coverage, and seven were used on the lower extremity, including an entire plantar surface and toes. Graft loss was confined to a 6.25-cm2 area on one cheek in the full facial expanded full-thickness grafts and a 9-cm2 area on the non-weight-bearing area of the full plantar graft. Donor-site complications were negligible. The anatomic confines of the donor sites and size of the patient may require expander replacement (in situ serial expansion) in order to obtain a large enough graft and accomplish primary donor-site closure. Expander and injection port placement in children for ease of injection and planned expander change must be anticipated. Our protocol from preoperative teaching through graft take is reviewed. Experience has demonstrated that expanded full-thickness grafts maintain all the characteristics of non-expanded full-thickness skin grafts and are an excellent reconstructive option in children.

An approach to excision of congenital giant pigmented nevi in infancy and early childhood.

Complete prophylactic excision of "large" and "giant" congenital nevocellular nevi (CNCN) often involves multiple surgical procedures begun in early infancy and not completed until late adolescence. Timely use of combined modalities of excision and reconstruction, beginning in infancy, and recognizing the benefits and limitations of each technique in each body region may allow completion of the excision of even the most extensive lesions in early childhood. In addition to minimizing the risk of malignant transformation, early complete excision may minimize the late psychologic stress caused by the appearance of the lesion and the late decision to attempt total excision. Tissue expansion and extensive excision and grafting in infancy and early childhood may significantly improve the final cosmetic result following treatment of these extensive lesions.

Retrograde fibreoptic intubation in a child with Nager's syndrome.

PURPOSE: The authors describe a retrograde fibreoptic technique for tracheal intubation in a micrognathic child with a tracheo-cutaneous fistula. CLINICAL FEATURES: A four-year-old child with Nager's syndrome presented for surgical closure of a tracheocutaneous fistula. A tracheostomy tube had been placed in the neonatal period for management of upper airway obstruction due to severe micrognathia. At 2 1/2 yr of age, after a successful mandibular advancement procedure, the tracheostomy was removed and the child allowed to breathe through the natural airway. Preoperative physical examination revealed an uncooperative child, unable to open her mouth due to limited temporo-mandibular motion. The child was first anaesthetized with ketamine, 70 mg im, then halothane by mask. The authors were unable to open the child's mouth sufficiently to allow rigid laryngoscopy. Attempts at oral and nasal fibreoptic intubation were unsuccessful. Ultimately, the authors were able to intubate nasally by passing an ultrathin Olympus LF-P laryngoscope under direct vision through the tracheocutaneous fistula in a cephalad direction, through the larynx and nasopharynx, then out the nares. An endotracheal tube was then advanced over the fibreoptic scope and positioned distal to the tracheocutaneous fistula. The surgical procedure was successfully accomplished and the trachea was extubated postoperatively without difficulty. CONCLUSION: Retrograde fibreoptic intubation may be an option for airway management of a select group of children who cannot be intubated by traditional techniques.

Nevus cells and special nevomelanocytic lesions in children.

Nevomelanocytic lesions in children represent a wide spectrum of proliferative neurocristopathies, ranging from the common small and benign congenital nevi to the garment-type congenital lesions. Included in this spectrum are some rare entities like neurocutaneous melanocytosis, malignant melanoma simulants, and special variants of congenital pigmented nevi. Here, we analyze some tissue culture characteristics of nevomelanocytic cells from giant and small congenital nevi, neurocutaneous melanocytosis, and a rare variant of nevus named "bulky nevocytoma." Correlations with their histological, immunohistochemical, and ultrastructural features are addressed.

Anaesthetic management of Miller's syndrome.

Miller's syndrome is a rare congenital disorder with facial features similar to that of Treacher-Collins syndrome. This report details the anaesthetic management of an infant during multiple surgical procedures, beginning with pylormyotomy at one month of age. Airway management was difficult because of severe micrognathia and was accomplished using an awake intubation with a conventional straight blade modified for continuous administration of oxygen ("oxyscope"). Due to recurrent upper airway obstruction and the anticipated need for multiple surgical procedures in the first years of life, a tracheostomy was placed. Because of the multiple airway, orthopaedic, and nutritional difficulties, it is important that a prospective, multidisciplinary approach be used in these patients' care. Consideration should be given to early tracheostomy for airway maintenance.