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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.
BACKGROUND: Elongation of peripheral nerve by the use of a tissue expander is helpful to repair nerve defects. This study was designed to investigate the effects of some antineoplastic agents on the peripheral nerves under a surgical tissue expansion procedure. MATERIALS AND METHODS: Twenty-five Wistar rats were used in this study. Following the exposition of the sciatic nerve and placement of two 10/0-nylon sutures in the epineurium 20 mm apart, a tissue expander was then placed under it. Inflation of the expander was immediately accomplished by the separate percutaneous injections of 6, 6, and 8 ml for every 3 min under general anesthesia. The expander was fully deflated at the end of each 3 min The distance between two sutures was measured 1 h later to measure the rate of elongation. Rats were randomly divided into five groups (according to the administered drugs), each consisting of five rats (10 sciatic nerves). Normal saline (1 ml) in the control group (group I), cyclophosphamide (15 mg/kg) in the group II, cisplatinum (3 microg/kg) in the group III, mitomycin-C (0.5 mg/kg) in the group IV and 5-fluorouracil (10 mg/kg) in the group V were injected intravenously. Intravenous injections of drugs were performed via the tail vein 30 min before expansion, 48 and 96 h after removal of expander. The incision was reopened on the third and seventh postoperative days, and five sciatic nerves of each group were exposed and then the pinching test was performed to measure regeneration distance. Electroneurographic changes were recorded. The expanded portion of the sciatic nerve between two sutures was harvested for histological evaluation. RESULTS: There is no significant difference between the elongation rates of all groups (P < 0.05). Histologic evaluation showed that inflammatory changes, vacuolization, intraneural edema, demyelination, axonal changes in the control group, the cisplatinum group, and the mitomycin-C group. These changes were significantly decreased in the cyclophosphamide group and the 5-fluorouracil group. In the cyclophosphamide group and the 5-fluorouracil group, the amplitude of compound action potential (CAP) values were significantly higher and the latency was significantly shorter (P > 0.05). CONCLUSION: We believed that cyclophosphamide and 5-fluorouracil may be helpful in tissue expansion of peripheral nerves, by decreasing the effects of the ischemia-reperfusion injury on the expanded peripheral nerves.
The surgical treatment of pressure sores has improved with the development of many techniques to provide coverage of these defects. Few deliver sensate coverage. This report describes tissue expansion of back skin to provide definitive sensate coverage of a pressure sore, thereby preventing its recurrence. Follow-up of 5.5 years is presented with a review of the literature.
In vaginal agenesis, a vagina can be treated by tissue expansion vaginoplasty. We have performed 17 such procedures. One procedure was abandoned because of infection of the temporary implant. In four women the first stage had to be repeated: in one the implant was placed too superficially, in another it did not provide adequate expansion, in a further instance the implant became infected and the fourth woman received a surgical wound to her labia. The second stage was successful in all 16 women who now have a vagina lined with viable epithelium. The vaginal length was satisfactory in all but one. Two women complained of a vaginal discharge due to hair at the vaginal vault, two women developed postoperative haematomas and one experienced introital stenosis. The disadvantage of the procedure is that it requires two operative stages and involves a prolonged hospital stay but it is not technically complex and results in a full length vagina that does not require dilatation.
BACKGROUND: A patient with congenital vaginal agenesis was unsuccessful in the use of dilation to create a vaginal orifice and rejected the option of a buttock graft. CASE: Two tissue expanders were introduced beneath the labia majora bilaterally and slowly expanded over 4 weeks. Redundant labial tissue was advanced as a bipedicle flap to line the neovagina created intraoperatively. Postoperative stent placement and dilation resulted in a vaginal canal lined by full-thickness mucosa exceeding 8 cm in depth. CONCLUSION: A modified method of tissue expansion vaginoplasty using a bipedicle flap is an option for the surgical creation of a vaginal orifice.
This paper presents the results and complications in the correction of partial scalp alopecia in ten patients using the technique of 'tissue expansion'. The average size of defect that was covered by expanded hair bearing scalp was 45.9 cms2, and the largest defect covered measured 11 X 6 cm. This series indicates that tissue expansion is now one of the most promising methods available for dealing with the difficult problems of partial alopecia which can present to surgeons and physicians in a wide range of specialties.
Aim of this paper is to present a computer program able to provide objective and quantitative data useful to guarantee the selection of the proper implant in order to obtain symmetry with the contralateral breast, in case of unilateral breast reconstruction by tissue expansion, especially for surgeons without experience or for occasional operators. Our C++ program provides the final implant volume using the measurements of the semi-circumference and projection of the contralateral breast performed on the supine patient. The aim is the symmetry of the two breasts. According to personal experience in breast reconstruction by tissue expanders, this program allows non invasive and simple measurements of the breast volume, useful to obtain the mammary symmetry. In case of breast reconstruction by tissue expansion, the preoperative evaluation is usually based on the surgeon experience and on the empirical observation without knowing the correct volume to reach. Since this program is useful to know the precise necessary volume for breast reconstruction, it allows the surgeon to obtain a better plastic result.
During the period December, 1983 to August, 1984, 14 patients were treated for alopecia of the scalp using tissue expansion in the Northern Ireland Plastic and Maxillo-Facial Service. Nine of the defects were due to burns. Representative case reports are presented and the planning of advancement and rotation flaps described. The management and prevention of complications are discussed, and the conclusion drawn that tissue expansion is a valuable technique in the treatment of alopecia, allowing reconstruction of defects previously beyond adequate surgical repair.
Latissimus dorsi breast reconstruction with implants has been criticized for Baker III or IV capsular contractures in as many as 30% of patients. Also criticized is muscle atrophy and loss of breast volume and definition. This study evaluated 2 modifications of the classic latissimus reconstruction: muscle transferred as an innervated functional unit and tissue expansion posterior to the latissimus but anterior to the pectoralis muscle. After expansion, a permanent prosthesis was placed (46 silicone gel and 3 saline). Forty-nine such reconstructions were done in 32 patients (17 bilateral and 15 unilateral), with average follow-up of 19 months. Only 4 Baker III capsular contractures (8%) and no Baker IV contractures occurred. All patients demonstrated excellent retention of breast shape/definition. This study demonstrates that functional muscle transfer and tissue expansion results in low capsular contracture rates and excellent retained breast shape.
We describe a two-stage technique for scrotal sac reconstruction using tissue expansion, best described as a tissue expanded V-Y scrotoplasty. This technique has been used after extensive scrotal skin loss, providing excellent functional and cosmetic outcomes.
As our knowledge of cutaneous disease increases, areas emerge in which our intervention with patients at an early age can significantly alter the progression of disease. This article discusses three major topics of new advances in the treatment of children with cutaneous disorders. These include laser therapy of various skin anomalies, the use of tissue expansion in congenital nevi, and the role of sun protection in children.
The functional or aesthetic burn deformity invariably is the consequence of a local skin shortage. The ideal solution would be replacement with new normal tissues, and these can now be created via an adaptation of the natural phenomenon of tissue expansion. Representative examples of hypertrophic scars, skin grafts, and in particular burn alopecia are presented to demonstrate the superior improvements previously not possible with conventional techniques. The concept of tissue expansion deserves an important place in secondary burn reconstruction.
Nipple-sparing total mastectomy remains an alternative for management of patients with high risk breast disease or patients with various types of symptomatic breast problems. In a patient with large breasts, however, achieving good cosmesis while still performing a thorough mastectomy remains a challenge. This report includes 10 patients who underwent unilateral nipple-sparing total mastectomy and 10 patients who underwent bilateral nipple-sparing total mastectomy. Tissue expansion was used as the reconstructive technique in this consecutive series done from 1985 through 1988. All expanders were placed in the submuscular position, and hyperbaric oxygen was used when intraoperative fluorescein administration identified marginally perfused areas. The average volume of breast tissue removed was 800 gm. The average permanent implant size was 767 cc. Complications included partial skin or nipple loss, infection, and problems related to the implants themselves. The complication rate, however, was not excessive, and results have been good as measured by cosmetic results, capsule grade, and lack of development of cancer in operated breasts. This reconstructive technique is recommended as an alternative in those patients undergoing nipple-sparing total mastectomy.
Thirty women who were to undergo breast reconstruction by tissue expansion were randomly divided into two groups. Those in the first group were to undergo expansion once a day (rapid expansion) and the second group once a week (slow expansion). When the expanders were replaced by permanent prostheses, biopsy specimens were taken from the capsules around the expanders, and were examined by transmission electron microscopy at a magnification x 22,000. The diameters of the collagen fibrils in the capsules were analysed by an interactive image analysis system and measured. An analysis of variance was performed on a test series to optimize the sample. Ninety fibrils from each patient (two patients were excluded), were analysed and there were no significant differences in collagen fibrillar diameters (about 50 nm) between those who had undergone rapid or slow expansion, or between patients who had also undergone radiotherapy to the chest wall and those who had not. These results indicate that the collagen fibrils may still be in a transitional stage, and that further longer term studies are desirable. It is difficult, however, to see how they could be justified ethically in patients who are otherwise well.
Survival of island flaps after tissue expansion has been studied. Expanders were placed under each buttock flap of six minipigs and one side was expanded while the other was left empty as a control. Both flaps were then raised and isolated on their vascular pedicles in order to compare flap survival 7 days later. It was found that the survival lengths of the expanded flaps were approximately 50 percent greater than those of the delayed controls. Microangiography suggested that the diameter of the axial artery increased following expansion. In clinical practice this technique would provide a larger flap for reconstruction and the possibility of direct closure of the donor site. In addition, the observed increase in vessel caliber should facilitate the free tissue transfer of expanded flaps.
The aim of the study was to investigate the effect of controlled soft tissue expansion on the peripheral nerve field. The rat model was used with single neurone recordings at the dorsal root level related to areas of skin previously expanded over a period of 2-4 weeks. Parameters measured were: stimulation threshold, receptive field size, conduction velocity and afferent disconnection. Results indicated a sparing of neural function despite an expansion in skin area of 110%.
When local tissue is insufficient for the revision of unhealed below-knee stumps tissue expansion offers an interesting alternative for local coverage. We used this method in seven patients (five men, two women; mean age 30 years) who had had below-knee amputations, six of them after injury to a healthy limb and one for purpura fulminans. Ten tissue expanders were inflated slowly and intermittently either weekly or twice weekly depending on the patients. The mean expansion period was 92 days. Mean hospital stay for the two operations was 5.8 (range 4-9) and 7.6 (range 6-10) days, respectively. Using subjective and objective criteria, functional outcome was excellent in five patients and good in one. Expansion failed in one because of infection. Expanded skin flaps allow good cover with a minimal scar area in appropriate cases, while preserving the skin sensitivity and length of the tibial shaft.
Our initial experience with tissue expansion in the reconstruction of the burned scalp is discussed. We discuss the complications encountered, their management and how these may be minimized.