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PubMed1997

Tissue expansion in children: a retrospective study of complications.

We retrospectively reviewed 105 consecutive children in whom 191 tissue expanders were placed by the Plastic Surgical Service at The Children's Hospital from 1987 to 1995. The age range was 1 month to 28 years. The series included 68 females and 37 males. The indications for tissue expansion were congenital pigmented nevus (N = 55), craniofacial anomaly (N = 13), aplasia cutis congenita (N = 7), meningomyelocele (N = 7), posttumor resection (N = 5), unstable scar (N = 4), burn scar (N = 3), and miscellaneous disorders. The expanders were located in the scalp (N = 59), cervicofacial area (N = 23), back (N = 18), chest (N = 6), and extremities (N = 6). A single expander was used in 47 patients and the mean number of expanders per patient was 1.8. All patients were given preoperative intravenous antibiotics. There were 25 complications in 20 patients (19%), which comprised 13% of all expanders. The most common complications were infection (6%, N = 11), deflation (3%, N = 6), and exposure (2%, N = 5). These complication rates were not related to either the gender, site of implantation, number of expanders, use of closed suction drains, or the indication for expansion. The complications were related to age, being higher in children (age 1-12 years) compared with infants and adolescents. Tissue expanders can be successfully used in children to construct and reconstruct a variety of cutaneous defects, but there is an irreducible minimum for the three major complications.

Adolescent↗
PubMedDate not supplied

Cranio-maxillo-facial tissue expansion, experimentally based or clinically empiric? A review of the literature.

The literature over 10 years covering tissue expansion in cranio-maxillo-facial surgery is reviewed. Since 1981, an evolving set of indications for application of the soft-tissue expansion technique has been published. However, it seems to be based much more on clinical experience (empiricism) than on the results of thorough experimental research. The direction of future research should be aimed at effects on bone, cartilage and mucosa at a microscopical level, and at the influence on growth and development of cranio-maxillo-facial structures.

Face↗
PubMed1988

Tissue expansion in head and neck reconstruction.

The present study reviews our clinical experience with tissue expansion in head and neck reconstruction. The clinical series consists of 33 expansions performed in 29 patients between 1983 and 1986. The results of tissue expansion in the head and neck were distinguished by a high complication rate, necessitating some revision in the original treatment plan in 48 percent of patients. Despite this high incidence of complications, sufficient tissue was generated to successfully complete the planned reconstruction in 79 percent of patients. Specific complications were observed with particularly high frequency within distinct anatomic sites. The highest incidence of complications occurred in the cheek and neck (69 percent) and forehead (50 percent) regions. Complications in the eyelid region (33 percent) and scalp (17 percent) were less common. Implant exposure was the most frequently observed complication. Other sequelae noted in this series included intractable pain, infection, and bone resorption.

Adolescent↗
PubMed1990

Tissue expansion in the correction of burn alopecia: classification and methods of correction.

Correction of burn alopecia using tissue expansion has recently gained acceptance. Yet, the technical approach to correction of this problem remains one of trial and error. Between January 1985 and December 1988, 102 children underwent placement of tissue expanders for correction of burn alopecia. Two hundred twenty-two expanders were placed during the 178 operative settings. Mean age was 9.1 +/- 4.3 years (range, 3-17 years). Forty-two patients previously underwent partial excisions or rotation of flaps to reduce or camouflage the initial burn alopecia. A review of our experience has dictated that proper classification of burn alopecia can influence operative planning and is essential for establishing guidelines for the correction of this problem. We have developed a classification scheme that addresses this problem. Patients are classified as type I, uniform alopecia; type II, segmental alopecia; type III, patchy alopecia; and type IV, total alopecia. The role of tissue expansion is reviewed in each group.

Adolescent↗
PubMed1991

Dimethylsulfoxide (DMSO) for human single-stage intraoperative tissue expansion and circulatory enhancement.

Dimethylsulfoxide (DMSO) has been in clinical use since the early 1960s. In 1967 the discovery that DMSO can greatly reduce ischemia in experimental pedicle flaps stimulated its use in plastic surgery by the authors since 1976. In 1987 its ability to soften collagen, thus permitting degrees of immediate intraoperative tissue expansion hitherto unknown, was applied clinically for the first time. Evolving use of topical 70% DMSO alone, in combination with intravenous DMSO, and intravenous DMSO alone with greater efficacy is discussed. Cases of intraoperative tissue expansion for large lesion excision and use in abdominoplasty to maximize skin resection are discussed. In breast reconstruction, maximal tissue expansion in minutes with immediate placement of large permanent prostheses ends the delay of reconstruction and problems of chronic tissue expander capsule formation and gives this technique a clear advantage over other reconstructive techniques.

Abdomen↗
PubMed1990

Clinical experience with immediate breast reconstruction using tissue expansion or transverse rectus abdominis musculocutaneous flaps.

We retrospectively reviewed our experience with immediate breast reconstruction in 103 consecutive patients with stage 0 or I breast carcinoma between May 1983 and April 1988. Two reconstructive techniques were used, that is, either tissue expansion with secondary prosthesis implantation (60%) or transverse rectus abdominis musculocutaneous (TRAM) flap (40%). Chemotherapy was administered in 22% of patients without delay or compromise. The mean length of follow-up is 30 months. The complication rate was equal for both groups (24%) with infection being most common in the group of patients with tissue expansion and partial flap necrosis being most common in the group of patients with TRAM flaps. Aesthetic results were superior with use of the TRAM flap. Our experience concurs with previous reports that documented satisfactory results with immediate breast reconstruction without compromising further therapy. We conclude that although the tissue expansion technique yields acceptable results, the TRAM flap yields superior aesthetic results in terms of both appearance and consistency.

Abdominal Muscles↗
PubMed1996

Impact of tissue expansion on flap prefabrication: an experimental study in rabbits.

This study was designed to determine whether tissue expansion after vascular pedicle implantation would increase the survival area of prefabricated skin flaps. In 20 New Zealand white rabbits, the vascular pedicle consisting of the central artery and vein of the left ear was implanted into the neck. At the time of pedicle implantation a subcutaneous pocket was created measuring 5 x 14 cm beneath the implantation site. Tissue expanders of three different sizes and volumes were implanted in the rabbits of three treatment groups. No tissue expander was implanted in the animals of the control group. All flaps were transposed after 3 weeks to the contralateral ear, and flap survival was assessed 1 week later. The increased area of the flap survival was statistically significant in all three treatment groups compared to the nonexpanded flaps (P = 0.003, P = 0.004, P < 0.0001, respectively). In addition there was a statistically significant larger area of survival using a 100-cc expander measuring 5 x 14 cm (the same size as the elevated flap) compared to 40-cc (3 x 5 cm) or to 60-cc (4 x 8 cm) expanders (P < 0.001, P = 0.004, respectively). The one-way analysis of variance and the t-test were used to show statistical differences. We conclude that the time necessary for neovascularisation of the skin flap could be used to expand the tissue, not only increasing the amount of available tissue, but also enhancing the vascularity.

Analysis of Variance↗
PubMed2003

Enhancement of Tissue Expansion by Calcium Channel Blocker: A preliminary study.

BACKGROUND: Reconstruction of the defects after surgical resection of tumors is one of the important issues in surgical oncology. It is essential that the defect should be covered with a tissue quite similar to the original one and is best achieved by harvesting tissue from an area adjacent to the defect. Tissue expansion is one of the most frequently used reconstructive techniques. A number of studies evaluated blood circulation, capsule formation, tissue tolerance, histomorphological changes and complications of expander placement. However, only a few attempted to enhance tissue expansion. This study we aimed to evaluate verapamil, a calcium channel blocker, to enhance tissue expansion. MATERIAL AND METHOD: Twelve New Zealand rabbits weighing between 900 gm and 1200 gm were assigned into study and control groups. High volume expanders (100, 200 or 300 cc) were placed into the subcutaneous tissue. Rabbits in the study group received verapamil. Expanders in the control group were inflated every three days to achieve same pressure as the study group. The size of the flaps was assessed by applying pressure on tip of the flap to demonstrate the contraction. Histopathological examinations were performed. RESULTS: By administering liquid earlier and more quickly less flap retraction was observed in the study group. In the control group expanders were exposed in two rabbits while no complication occurred in the study group. Following extraction of the expanders, the flaps were elevated and less retraction was observed in the study group compared to controls. CONCLUSION: Verapamil is safe when used topically and provides less retracted flaps. It can be suggested that verapamil acts on the myofibroblasts in the capsule around tissue expanders and thus increases efficiency of the expanders.

Journal Article↗
PubMed1996

Tissue expansion: a method to preserve bone length and joints following traumatic amputations of the leg--a follow-up of five legs amputated at different levels.

Tissue expansion of adjacent intact skin and subcutaneous tissue has in five legs provided high-quality soft-tissue coverage of the distal end in legs amputated at different levels without further shortening of the bone. The sensitivity of slowly expanded flaps is temporarily affected but eventually seems to return to normal. Expanded flaps have endured both sitting and the use of prostheses for 4 to 5 years. In one case the technique made it possible to save the knee joint. Besides being a functional reconstruction, the appearance of the reconstructed parts much improved. A technique of overexpansion and double flap coverage of the bone utilizing deepithelialization is described.

Adolescent↗
PubMed1992

Tissue expansion in a patient with extensive nevus comedonicus.

Nevus comedonicus is a rare developmental abnormality of the pilosebaceous apparatus that presents as an aggregation of dilated follicular orifices filled with pigmented keratinous material. Occurrence of extensive or giant lesions is even more rare. Indications for treatment include recurrent infections and cosmetic reasons. Therapeutic approaches include topical keratolytic agents, manual extraction of comedones, dermabrasion, and excision of smaller lesions. Increasing clinical experience with tissue expansion has suggested that it might be used effectively in the definitive treatment of an extensive nevus comedonicus previously considered too large to excise without the use of a skin graft, despite the potential risk of infection within the lesion during the course of expansion. We report the first patient with giant nevus comedonicus to be treated using tissue expansion. This patient demonstrates that prompt treatment of cellulitis and abscesses within the lesion will keep this process isolated from the adjacent expanders and will not compromise a planned excision and reconstruction.

Buttocks↗
PubMed1995

Repair of complete syndactyly by tissue expansion and composite grafts.

Repair of complete syndactyly by a combination of tissue expansion and composite grafts from the glabrous non-weight bearing areas of the foot has been performed on three syndactylies in two patients. The commissure and the lateral areas of the proximal and middle phalanges were covered with expanded skin and the separated fingertips were covered with composite grafts. Without using an ordinary skin graft, this method can provide aesthetically excellent results with good skin colour and texture.

Female↗
PubMed2003

A new method: perforator-based tissue expansion for a preexpanded free cutaneous perforator flap.

Recent advances in concepts of preexpanded free flaps have made it possible to replace larger postburn contracture area. Free anterolateral thigh (ALT) cutaneous perforator flaps are popular due to constant, reliable anatomy and various clinical applications in our department. Combination of preexpansion, perforator-based prefabrication of tissue expansion and a free anterolateral thigh flap is first introduced and developed to resurface the large territory of postburn cervical contracture in a 33-year-old female patient with second to third degree flame burn with a 45% total body surface area (TBSA) involvement. The limited lateral flexion and rotation was noted despite aggressive rehabilitation for 6 months. The 650cm(3) kidney-shaped tissue expander was inserted around the myocutaneous perforator under the fascia via the midlateral thigh incision in first stage. Two months later right lateral neck scar (size=25cm x 13cm) was excised after serial clinic saline injection. The preexpanded free flap (size=29cm x 15cm) combined with z plasty and capsulectomy was harvested and covered in the contracture defect. A flap totally survived. One-staged resurfacing was achieved with immediate postoperative improvement. The hospital stay was 6 days. The donor site was closed primarily. After 6 months follow-up, the functional improvement was assessed as follows: an increase in rotation of 14 degrees (preoperative 74 degrees to postoperative 88 degrees ); and an increase in lateral flexion of 10 degrees (preoperative 30 degrees to postoperative 40 degrees ). The prefabrication of the free cutaneous perforator flap by perforator-based tissue expansion above the muscle has several advantages: (1) it provides accurate and safe expansion without damage of any perforator compared with the blunt dissection; (2) larger territory of free flaps can be used for burn reconstruction; (3) donor site is primarily closed with low tension; (4) it is not a random expanded flap due to direct expansion of specific skin territory around the perforator. The disadvantages are two-staged procedures, complications of tissue expansion (e.g. infection, extrusion), the possibility of compression of pedicles.

Adult↗
PubMed1996

[Use of tissue expansion on defective amputation stumps of the lower limbs. Apropos of 5 cases].

Skin flaps are usually required to cover amputation stumps, especially below the knee. Cross-leg flaps or free flaps can be used when local tissue is insufficient, but as emphasized by Rees in 1986, tissue expansion offers another interesting possibility for local coverage. The risk of complications, especially infection, in below-knee tissue expansion is well known, requiring rigorous patient selection based on an evaluation of skin quality, vascularization, and the patient's metabolic and psychologic status. We used this method in 5 patients (3 females, 2 males; mean age 30.4 years) who had been amputated below (n = 4) and above (n = 1) the knee. In 4 cases, amputation of a healthy limb was required after trauma and in 1 case due to purpura fulminans. Seven tissue expanders were used with slow intermittent expansion applied daily. The mean expansion period was 89.4 days. Mean hospital stay for the two operations was 5.66 and 7.33 days, respectively. Assessed on the basis of subjective and objective criteria, functional outcome was excellent in 3 patients and good in one patient. Failure occurred in one case due to infection. Despite the longer treatment period, tissue expansion for skin coverage of defective amputation stumps appears to have several advantages. It is a simple, reliable and reproducible method with a minimal scar area while preserving skin sensitivity. In addition, the length of the tibial shaft can be spared and minimal modifications are needed to fit the prosthesis.

Adolescent↗
PubMed1993

Comparison between rapid and slow tissue expansion in breast reconstruction.

Fifty women scheduled for breast reconstruction surgery with tissue expansion were randomly divided into two groups. In the first group the tissue was expanded rapidly, i.e., once a day, starting 1 week postoperatively, and in the other group it was expanded slowly, i.e., once a week, starting after 2 weeks. The expansion periods were 14 and 41 days, respectively. In both groups the expansion volume was about 200% of the final breast prosthesis. The expanders were replaced by textured, gel-filled implants after 3 months. Follow-up examinations were made after 6 and 12 months to evaluate breast softness. A subjective method, Breast Augmentation Classification, and an objective method, applanation tonometry, were used and showed good correlation. Subjectively, the capsular contraction rate after 1 year was 33.5% in the whole series: 40% in the rapid expansion group and 27% in the slow expansion group. Objectively, the capsular contraction rate was 50.5% in all patients: 60% in the rapid group and 41.5% in the slow group. There was no statistically significant difference between the two groups at any time with either method. Irradiated patients included in the study did not show poorer results. The results obtained after 6 months remained stable up to 12 months after the implantation of the permanent prosthesis. The importance of objective evaluation to compare different series is discussed.

Breast Neoplasms↗
PubMed2001

A histologic analysis of three-dimensional versus two-dimensional tissue expansion in the porcine model.

OBJECTIVE: Recently, a two-dimensional Silastic Dacron stretching skin device has been developed for scalp reduction surgery. Attached subgaleally, this device stretches skin over time, while avoiding the visible volumetric distention that is typical of three-dimensional tissue expanders. Unlike three-dimensional expanders, the histological changes observed with a two-dimensional stretching device have not been described in the literature. The present study compares the histological effects of two-dimensional and three-dimensional skin tissue expansion in the porcine model. STUDY DESIGN: A university Institutional Review Board-approved study in which 16 domestic piglets were used. The 16 piglets were divided evenly into four cohorts as follows: 1, 1-week control cohort; 2, 1-week experimental cohort; 3, 4-week control cohort; and 4, 4-week experimental cohort. METHODS: Tissue expanders (three-dimensional) and Dacron Silastic tissue stretchers (two-dimensional) were surgically inserted into the lateral skin of 16 domestic pigs. Animals were killed at either 1 or 4 weeks based on group assignment. Light microscopic ocular micrometry and stereological point counting were used to determine the depth of the epidermis, dermis, and subdermal adipose tissue layer; width of the panniculus muscle; diameter of sweat gland follicles; percentage ratio of dermal collagen, blood vessels, and tissue space; and epidermal mitotic index in 100 specimens. One-way ANOVA was used to evaluate statistical differences. RESULTS: Both tissue expanders yielded increased values compared with control subjects, with respect to epidermal, dermal, and fat widths and blood vessel counts, whereas adnexal structures in the panniculus muscle width were unaltered. CONCLUSIONS: Although statistically the two types of expansion produced histologically similar changes, the degree of change varied according to the type of expander that was used and the duration of tissue expansion. Most notably, three-dimensional expansion produced more tissue gain per unit area expanded at both the 1-week and the 4-week time intervals, and early (1-week) two-dimensional tissue expansion stimulated a greater angiogenic response than three-dimensional expansion. These findings will assist the surgeon in understanding the physical changes that occur with these two forms of tissue expansion, as well as the potential clinical advantages and shortcomings of each method.

Adipose Tissue↗
PubMed1992

Tissue expansion as an alternative to skin grafting for closure of skin deficits.

Recent advances in the technical aspects of tissue expanders for closure of skin deficits have led to an overall reduction in the high rate of complications typically associated with their usage. The authors provide a review of the recent refinements in the technique of the tissue expansion process. A discussion of current and future applications using this technique in the treatment of various lower extremity pathologies, including clubfoot, is presented. A case report on the use of a subcutaneous tissue expander for the treatment of a failed skin graft of the medial ankle is included.

Adult↗
PubMed1998

The effects of tissue expansion on skin lymph flow and lymphatics: an experimental study in rabbits.

Histomorphological, physiological, and biomechanical changes of the skin and tissue that are being expanded have been extensively studied in the past. The purpose of this study was to investigate whether the skin lymph flow and lymphatics may be influenced during tissue expansion, and also to study different pattern of vascular supply of skin on lymph flow during tissue expansion. The skin lymph flow was quantitatively assessed by 99mTc-dextran lymphoscintigraphy, and the structure of dermal lymphatics was evaluated by histological examination in 12 rabbits. Lymphoscintigraphic results showed that lymph flow is significantly reduced both in expanded and non-expanded (sham-operated) skin. Histologically, we saw widespread lymphatic distension in both expanded and non-expanded skin. There were no quantitative differences in the number of lymphatic vessels compared with control skin. We did not see any lymphatic capillaries in the subdermal capsule of either expanded or non-expanded skin. These results show that lymphostasis has an obstructive (mechanical) aetiology, and the tissue expander itself reduces the lymph flow regardless of expansion, and interferes with the formation of new lymphatic vessels.

Animals↗
PubMed1999

Topical application of DMSO as an adjunct to tissue expansion for breast reconstruction.

The aim of this study was to evaluate the effectiveness of topical 60% dimethyl sulphoxide (DMSO) prior to tissue expansion for breast reconstruction in reducing expander pressure and length of treatment. Forty patients undergoing immediate breast reconstruction with tissue expanders following modified radical mastectomy were consecutively divided into two groups of 20 subjects each: group A (control) and group B (experimental). Patients from group A underwent traditional tissue expansion, while, to patients of group B, before each filling session, topical 60% DMSO was applied to the skin overlying the expander by soaking-wet surgical sponges left in place for 30 min. The average inflated volume was 395 cc (range 250-580 cc) in group A, and 410 cc (range 240-620 cc) in group B; no statistically significant difference was found between these values. A statistically significant difference was found between the expansion time of group A (mean 6 sessions; range 4-10 sessions with one filling session per week) and group B (mean 4 sessions; range 2-6 sessions with one filling session per week). A statistically significant difference was also found between the average inflated volume per session of group A (90 cc; range 60-130 cc) and group B (120 cc; range 90-160 cc). According to the data obtained by tonometry, a statistically significant difference was found between the average pre-filling and post-filling pressures of group A (28.4 and 66.5 mmHg, respectively) and group B (22.1 and 64.3 mmHg, respectively). Clinical benefits of pre-filling topical applications of 60% DMSO observed in our trial were an enhancement of the total volume inflatable per session and a significant shortening of the total expansion period.

Administration, Cutaneous↗