Kathrin Neuhaus

Stigmatization Predicts Psychological Adjustment and Quality of Life in Children and Adolescents With a Facial Difference

OBJECTIVES This cross-sectional study assessed psychological adjustment and health-related quality of life (HRQOL) in children and adolescents with congenital or acquired facial differences and identified potential predictors of adjustment. METHODS Data were obtained from 88 children, ages 9 months to 16 years, by means of parent questionnaires (n = 86) and standardized interviews with children ≥7 years old (n = 31). Evaluation measures included the Child Behavior Checklist (CBCL), KIDSCREEN-27, TNO-AZL Preschool Quality of Life Questionnaire (TAPQOL), and Perceived Stigmatization Questionnaire. RESULTS Psychological adjustment, as measured by the CBCL, was within norms. Parent-reported HRQOL was good in preschool children. Parent- and self-reported HRQOL of participants 7-16 years old was impaired in several dimensions, including psychological well-being. Psychological adjustment (especially internalizing behavior problems) and HRQOL were predicted primarily by perceived stigmatization. CONCLUSIONS Identification of stigma experiences and appropriate support may be crucial to enhancing psychological adjustment and quality of life in children with facial disfigurement.

Characterization of pigmented dermo-epidermal skin substitutes in a long-term in vivo assay

In our laboratory, we have been using human pigmented dermo‐epidermal skin substitutes for short‐term experiments since several years. Little is known, however, about the long‐term biology of such constructs after transplantation. We constructed human, melanocyte‐containing dermo‐epidermal skin substitutes of different (light and dark) pigmentation types and studied them in a long‐term animal experiment. Developmental and maturational stages of the epidermal and dermal compartment as well as signs of homoeostasis were analysed 15 weeks after transplantation. Keratinocytes, melanocytes and fibroblasts from human skin biopsies were isolated and assembled into dermo‐epidermal skin substitutes. These were transplanted onto immuno‐incompetent rats and investigated 15 weeks after transplantation. Chromameter evaluation showed a consistent skin colour between 3 and 4 months after transplantation. Melanocytes resided in the epidermal basal layer in physiological numbers and melanin accumulated in keratinocytes in a supranuclear position. Skin substitutes showed a mature epidermis in a homoeostatic state and the presence of dermal components such as Fibrillin and Tropoelastin suggested advanced maturation. Overall, pigmented dermo‐epidermal skin substitutes show a promising development towards achieving near‐normal skin characteristics and epidermal and dermal tissue homoeostasis. In particular, melanocytes function correctly over several months whilst remaining in a physiological, epidermal position and yield a pigmentation resembling original donor skin colour.

Novel Treatment for Massive Lower Extremity Avulsion Injuries in Children: Slow, but Effective with Good Cosmesis

BACKGROUND Extended avulsion injuries are associated with significant loss of skin and subcutaneous fat, leaving the reconstructive surgeon with the challenge of substituting all tissues lost in the best possible way. We wanted to test whether the combined use of a Vacuum Assisted Closure system (VAC) and Integra Dermal Regeneration Template (IDRT) matched the required treatment profile encompassing initial control of infection, remodeling of body contours, and reconstruction of near normal skin. MATERIALS AND METHODS 4 children with massive lower extremity avulsion injuries were treated with early necrosectomy, VAC application for 3-5 weeks for wound cleansing and wound bed conditioning, subsequent implantation of IDRT, and finally autologous split thickness skin grafting (STSG) for definitive wound closure. Thereafter, a standard rehabilitation program was used. The key parameters of VAC and IDRT application, take rates of IDRT and STSG, complications, length of stay, and final outcome were recorded. RESULTS In all patients, early removal of necrosis and infection control was successfully achieved. Continuous VAC application fostered the formation of a several millimeters thick new tissue layer partly compensating for the lost hypodermis. IDRT implantation and subsequent STSG yielded take rates of nearly 100% and both functionally and cosmetically excellent long-term results. There were no major complications. CONCLUSION The combination of VAC and IDRT in children with massive leg avulsion injuries is feasible, safe, and delivers high-quality long-term outcomes that appear to justify the multiple operative procedures, the long hospitalization times, and the comparatively high costs entailed.

Management of burn wounds.

Small and moderate scalds in toddlers are still the most frequent thermal injuries the pediatric surgeons have to face today. Over the last years, surgical treatment of these patients has changed in many aspects. Due to new dressing materials and new surgical treatment strategies that are particularly suitable for children, today, far better functional and aesthetic long-term results are possible. While small and moderate thermal injuries can be treated in most European pediatric surgical departments, the severely burned child must be transferred to a specialized, ideally pediatric, burn center, where a well-trained multidisciplinary team under the leadership of a (ideally pediatric) burn surgeon cares for these highly demanding patients. In future, tissue engineered full thickness skin analogues will most likely play an important role, in pediatric burn as well as postburn reconstructive surgery.

Management of "difficult" wounds.

Pressure sores (PSs) and wounds in immunocompromised children are rather rare conditions. No doubt, their management is often complex and difficult, even for experienced pediatric plastic surgeons. As there are no algorithms for standard care, the therapeutic approach is individual.Successful PS management always implies primary and secondary prevention. With a PS present, rapid relief of pressure is crucial. If local wound care fails to restore skin integrity within a short period of time, surgical defect closure is mandatory. Overall, full-thickness skin grafts and local flap surgery are the most suitable methods regarding result quality, procedure complexity, and risks. Negative pressure wound therapy (NPWT) plays an instrumental role in wound bed preparation before definitive coverage. Recurrence rate is high (the complication). It does not much depend on the surgical technique employed, but rather depends on whether the various pathogenic factors leading to PS can be eliminated or alleviated.In both temporarily and permanently immunocompromised children, wound healing is significantly impaired. At the same time, these patients have no or low host defense activity. Thus, they are at high risk not only for local wound infection but also for potentially life threatening septic complications. Rapid and definitive wound closure is therefore essential. When conservative therapy fails, simple surgical techniques granting rapid and definitive wound closure should be used.

Osmotic expanders in children: No filling – no control – no problem?

BACKGROUND Self-filling, hydrogel-based osmotic tissue expanders have been successfully used for several years, mainly in adult patients. We wanted to test this novel device in pediatric plastic and reconstructive surgery. MATERIAL AND METHODS Between November 2004 and September 2009, we implanted 53 osmotic tissue expanders following standard surgical principles in a total of 30 children and adolescents with burn scars, congenital nevi, alopecia, or foot deformities. RESULTS All expanders reached their predicted volume within 6 weeks and 51 (96.2%) produced a sufficient amount of additional skin for the intended coverage of the defect. A serious infection precluding the planned reconstructive procedure occurred with 2 expanders (3.8%). Minor complications occurred at 6 implantation sites (11.4%), and consisted of small necrotic areas and perforations (n = 3) and minor infections (n = 3). These problems could be controlled and did not interfere with the subsequent plasty. The final results recorded at the last follow-up (mean: 21 months, range: 9-48 months) were rated as excellent in 25, good in 19, moderate in 6, and poor in 1 patient. CONCLUSION This is apparently the largest pediatric series in which self-filling expanders have been used. The data obtained indicates that self-filling expanders can be safely and effectively used for various plastic, reconstructive and orthopedic procedures in children and adolescents. The fact that numerous painful and distressing filling sessions are obviated with these expanders is particularly beneficial for those children too young to understand and cooperate. Moreover, this approach minimizes the risk of infection and lowers costs.

Bold to do — bald to be? Outcomes decades after harvesting the scalp in burned children

BACKGROUND The scalp is the only hidden donor site for split thickness skin grafts. Nevertheless, it is underappreciated due to fear of iatrogenic scarring alopecia. Long-term data showing whether androgenetic hair loss can reveal previously hidden scarring alopecia is unavailable. We aimed to evaluate results and patient satisfaction up to 30years after skin harvest from the scalp. METHODS Burn patients, hospitalized between 1977 and 1987 at the University Childrens Hospital Zurich with scalp skin harvest and currently over 30years old, were studied. Medical records and patient satisfaction were analyzed, and a clinical scalp examination was performed. RESULTS Thirty-two patients (18 males, 14 females) with a current age of 34.13±3.42years participated. Mean follow-up time was 27.09±3.04years. Fifty-four scalp harvests were performed with 1.69±0.96 sequential harvests. Hair growth was considered normal in 97% patients. Androgenetic alopecia (AGA) type Norwood II-VI was seen in 11 patients. Scalp examination revealed 11 unknown likely harvest-related alopecias with a mean size of 0.7cm2. CONCLUSIONS Long-term morbidity of scalp skin harvest and the risk of clinically significant alopecia is very low while patient satisfaction is high. AGA is unlikely to reveal harvest damage previously hidden by regrown hair.

Infektionen der Haut und Weichteile

In diesem Kapitel werden die Infektionen der Haut und Weichteile besprochen, bei denen es zu ausgedehnten Haut- und Weichteilnekrosen kommen kann. Hierzu gehoren u. a. die Purpura fulminans und die nekrotisierende Fasziitis, die beide mit einer hohen Mortalitat behaftet sind. Ebenfalls zu teils grosflachigen Hautnekrosen kann auch das Ecthyma gangraenosum fuhren. Die Entscheidung, ob und wann ein aggressives chirurgischen, oftmals mutilierendes Vorgehen indiziert ist, sollte von einem erfahrenen Chirurgen beherzt getroffen werden. Auserdem wird auch auf die klassischen Infektionen der Haut und der Weichteile, die Phlegmone und das Erysipel, sowie auf das wichtige, im Kindesalter allerdings sehr selten anzutreffende Pyoderma gangraenosum eingegangen. Einen hohen didaktischen Stellenwert hat auch das Toxic-shock-Syndrom, das unerkannt fatale Folgen haben kann und leider die haufigste Todesursache bei kleinflachigen thermischen Verletzungen im Kleinkindesalter darstellt.

Kongenitale melanozytäre Nävi

Grose angeborene Pigmentmale stellen Betroffene, Eltern und Arzte vor erhebliche Herausforderungen. Die Indikation zur chirurgischen Therapie wird heute nicht mehr in erster Linie in der Reduktion des Melanomrisikos gesehen, da dieses nicht so hoch ist wie fruher angenommen. Dagegen kann die Exzision eine erhebliche psychosoziale Verbesserung fur die von dieser stigmatisierenden Erkrankung Betroffenen bedeuten. Neben der seriellen Exzision wurde insbesondere die expandergestutzte Chirurgie in den letzten Jahren weiterentwickelt. Die Dermabrasion stellt wegen der regelmasig auftretenden Repigmentierungen nur ein Verfahren der zweiten Wahl dar, auch weil das Melanomrisiko hierdurch vermutlich nur geringfugig beeinflusst wird. Entscheidend fur die erreichbare Verbesserung sind eine sorgfaltige Planung des zeitlichen Ablaufs der Exzisionen unter Berucksichtigung der Belastungen fur Kind und Familie sowie die Durchfuhrung in einem erfahrenen Team aus Pflegepersonal, Psychologen und Arzten.

Wundheilung und Wundmanagement

Auf dem Gebiet der Wundbehandlung hat sich in den letzten Jahren sehr viel verandert. Ziel dieses Kapitels ist es, dem Leser die Pathophysiologie der Wundheilung nahezubringen, aus der sich das moderne Wundmanagement ergibt. Dieses ist haufig individuell und phasengerecht. Gleichzeitig wird eine Ubersicht uber aktuelle Wundauflagen gegeben. Daruber hinaus werden die komplexen Wunden behandelt, zu denen u. a. Druckgeschwure und Wunden bei immunkompromittierten Kindern und Jugendlichen zahlen. Ihnen gemeinsam ist die Komplexitat des Managements im interdisziplinaren Team. Auf die konservative und, wenn notwendige, chirurgische Therapie sowie die Pravention wird ebenso eingegangen.