B.J. Mayou

The Laser Doppler flowmeter for microvascular monitoring: a preliminary report

A preliminary report is presented of a free-flap monitoring technique using the Doppler shift of Laser light. It has provided useful information in five patients with free flaps. The technique is non-invasive and the apparatus is compact, portable and simple to use. Although a long term evaluation with a larger number of patients is required the technique has many advantages over others currently available and is sufficiently promising to warrant further investigation.

The scapular flap—an anatomical and clinical study

The scapular flap is a medium-sized flap combining many of the good qualities of others, such as thinness and minimal donor site deficit, with the potentialities of a consistently long pedicle that allows combination with other adjacent flaps. The anatomy of the flap and its application in nine clinical cases is described.

A prospective study of congenital melanocytic naevi: progress report and evaluation after 6 years

Summary A prospective study of children with large congenital melanocytic naevi (CMNs) is in progress. Its aims are to observe the natural history and inheritance of CMNs, to record associated pathologies, and eventually to evaluate the effects of treatment. Information is obtained by patient‐completed questionnaires and clinical assessment. One hundred and thirty‐three children have been followed for a total of 452 patient years. The female/male ratio is 3:2. The characteristics, size and distribution at birth of the CMNs in this group of patients, and their development and associated abnormalities, are documented. After 5 years, affected children were compared with a matched cohort of normal children. Although the prevalence of neurological and developmental defects was higher in affected children, no malignant melanomas have been reported to date. The families of affected children had higher numbers of naevi and café‐au‐lait spots than those of normal children, suggesting a possible hereditary component. The mothers of affected children also reported an increased incidence of influenza‐like Illness and of severe nausea and vomiting in pregnancy. This study will continue for a further 4 years, in the first instance, after which we will seek relationships between characteristics of the naevi and outcome.

Free microvascular and microneural transfer of the extensor digitorum brevis muscle for the treatment of unilateral facial palsy.

The operation of transfer of the extensor digitorum brevis muscle to the face in the treatment of unilateral facial palsy (Thompson and Gustavson, 1976) has been further modified by immediate anastomosis of its vascular pedicle to the superficial temporal vessels. Six of our ten patients showed some new movement but in only three did this approach symmetry with the other side. Long term follow-up showed that improvement can be expected for up to two years after transfer. Our technique is assessed critically and suggestions are made for further improvement.

Experience in the surgical management of the hand in Dystrophic Epidermolysis Bullosa

Between 1981 and 1990, 45 patients (80 hands) underwent 122 hand operations, involving extensive release of contractures and pseudosyndactyly, with split skin grafting of secondary defects. Other procedures included the use of Kirschner wires, tendon release and arthroplasty. A postoperative programme of long term night splintage was employed. Finger extension was significantly improved for up to 5 years postoperatively, with a mean extension deficit preoperatively of 139 degrees, at 1 year postoperatively 60 degrees (p < 0.0001) and 4 years 84 degrees (p < 0.05). Preoperatively, pseudosyndactyly was present in 64.3% of web spaces, in comparison to 13.3% at 1 year, 37% at 4 years (p < 0.01) and 66.6% at 5 years (N.S.) postoperatively. Adduction contracture of the thumb was significantly improved for 2 years postoperatively. Functional assessment of 18 hands showed significant improvement postoperatively.

Cultured keratinocyte allografts and wound healing in severe recessive dystrophic epidermolysis bullosa

BACKGROUND Patients with recessive dystrophic epidermolysis bullosa (RDEB) frequently have painful erosions that are slow to heal. There is no definitive treatment; therefore any therapy that improves wound healing would be beneficial to these patients. OBJECTIVE Our purpose was to assess the effects of cultured allogeneic keratinocytes on wound healing in RDEB. METHODS Ten patients with RDEB and dermatome-induced superficial dermal wounds were studied. Cultured keratinocyte grafts were applied to part of the wound, with another part left ungrafted. Both sites were assessed clinically and microscopically, particularly with regard to basement membrane zone reconstitution. RESULTS Apart from minor differences in keratinocyte differentiation and a moderate analgesic effect induced by the graft, there were no other distinguishing findings in wound healing in the grafted and nongrafted sites. CONCLUSION There was little clinical benefit from cultured keratinocyte allografts in wound healing in RDEB. However, this study showed that RDEB keratinocytes have an inherent capacity to express some type VII collagen epitopes transiently during wound healing, although this was not associated with the detection of anchoring fibrils.

The surgical management of dystrophic epidermolysis bullosa (excluding the hand)

Fifty patients with Dystrophic Epidermolysis Bullosa (DEB) underwent surgery including release of limb, oral, anal, eye and penile contractures and treatment of chronic skin ulceration or skin tumours. Correction of contractures involves extensive release of skin and underlying tissues, with split skin grafting of secondary defects. Specific regions are discussed. Recurrence is inevitable due to ongoing disease; however, functional improvement is obtained for several years. Management of chronic skin ulceration with split skin grafting has failed to produce long term healing, with local flaps successful but limited by the problem of donor site instability. Nine of the 17 patients over 20 years of age developed squamous cell carcinomas (29 lesions), benign hyperkeratosis (9) or malignant melanoma (1) requiring excision and skin grafting or amputation of digits. Local recurrence was infrequent (3 squamous cell carcinomas), with distant metastatic spread occurring in 1 patient.

The clinical spectrum of lipoatrophic panniculitis encompasses connective tissue panniculitis

Two patients with widespread, chronic, relapsing panniculitis resulting in disfiguring lipoatrophy are reported. Histology in both cases showed a mixed septal and lobular panniculitis, with lipophagia. The clinical appearance and histology suggested a diagnosis of lipoatrophic panniculitis. Both cases had features of connective tissue panniculitis, which is likely to be a subtype of this condition. Treatment of lipoatrophic panniculitis can be difficult. Our first patient initially responded well to antimalarial therapy. allowing plastic surgical repair of the defects to be carried out.

Pain and forehead expansion

Tissue expansion of the forehead by intermittent bolus injection in three patients was noted to be extremely painful. This stimulated a prospective study in four patients whose discomfort was found to be related to a sharp rise in intraluminal pressure after bolus inflation. Tolerable infusion volumes were small (mean 6.25 cc) and associated with high pain scores (mean 7/10). Adequate expansion was protracted (mean 45 1/2 days) and was limited by pain. To eliminate the sharp rises in pressure associated with expansion by bolus injection, a syringe pump was used in two further inpatients. Adequate expansion was both quicker (mean 8.5 days) and less painful (mean pain score 2.6/10).

(17) Histopathology of giant congenital melanocytic naevi: implications for treatment

Giant hairy naevi pose not only cosmetic problems, but also therapeutic difficulties because of the increased risk of malignant melanoma. Prophylactic full thickness excision and grafting have previously been recommended for such lesions, but because of the large size this is not always practical. Following observations that in the neonatal period, naevus cells are superficial (predominantly in the papillary dermis) and only later migrate into reticular dermis, some authors have suggested that dermabrasion or shaving of the naevi must be performed soon after birth, as an alternative therapy. We studied 26 children with giant congenital melanocytic naevi to assess: (i) the histological progression with age; (ii) correlation of clinical and histological appearance; and (iii) results of shaving in the treatment of these naevi.