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Although tissue expansion is unlikely to replace skin grafting and other basic reconstructive procedures in the horse, its continued success in humans will undoubtedly stimulate client interest in its use. Its biggest advantage is the advancement of full-thickness skin over large defects where grafting techniques would not provide the same degree of protection. The resulting cosmetic appearance of the wound is also better.
Posttransfer tissue expansion has been used to negate concern for the aesthetic donor site deformity following 15 free tissue transfers involving donor sites of the scalp, trunk, and extremities. There appears to be no contraindication to placing these implants immediately, as was done in 87% of cases, although it is recommended that expansion be delayed until adequate wound healing has occurred at any skin graft interface. This technique has had major positive benefits for refining the radial forearm flap and hair-bearing temporoparietal fasciocutaneous flap defects, which may have heretofore been avoided secondary to aesthetic concerns. Tissue expansion techniques should be considered as an important adjunct for any microsurgical reconstructive effort.
BACKGROUND: Immediate tissue expansion has been reported to expand skin sufficiently to permit primary closure of large facial defects up to 5 cm in diameter. OBJECTIVE: We wished to evaluate and compare skin hooks with foley catheters in producing tissue expansion. METHODS: Seven patients with post-Mohs surgery defects measuring 3.0 to 5.5 cm in diameter and located on scalp, temple, or forehead skin were treated with immediate tissue expansion. RESULTS: Immediate tissue expansion provided a 16 to 36% increase in the tissue available for closure, over and above what was achieved by undermining alone. In each case, adequate stretching of skin was achieved to permit primary closure relatively easily, which was not possible with undermining alone. Skin hooks were found to be equivalent to foley catheters in their ability to produce tissue expansion. At the one year follow-up visit, some spreading of the scar was noted, ranging from 1 to 7 mm, which appears in part to be related to the degree to which the skin was expanded. CONCLUSION: These findings support the concept that immediate tissue expansion is a separate and distinct process from undermining, which provides additional tissue for reconstructive surgery.
BACKGROUND: Chronic tissue expansion is an extremely useful addition to the dermatologic surgeon's skills. OBJECTIVE: To review chronic tissue expansion. METHODS: The relevant literature is summarized. Two case histories are presented as examples of the utility of chronic tissue expansion. RESULTS: The history of tissue expansion is briefly reviewed. Indications pertinent to the practice of dermatologic surgery are discussed. The devices themselves are described, as well as new experimental advances. The general procedure for utilizing tissue expanders is outlined, as well as relevant histologic changes that occur in expanded skin. Both common and rare complications are covered, with attention to prevention. CONCLUSION: Chronic tissue expansion provides an excellent means for obtaining extra tissue for cosmetic and reconstructive surgery.
Tissue expansion in soft-tissue reconstruction is described. The main principle is to develop donor tissue by expansion adjacent to the defect. Such a donor flap is doubled in size by intermittent injections of normal saline into the expander. After sharing the expanded flap for reconstruction, the donor site is well preserved, while the defect is reconstructed with contiguous tissue of similar texture, color, thickness, and sensation. There is minimal scar formation. Over 130 patients were reconstructed with expanded flaps. The average time of flap development was 3 to 6 weeks.
Tissue expansion is of value in the repair of some defects produced by Mohs micrographic surgery. In particular, defects of the nose, forehead, temple and scalp as well as extensive defects in other areas may require expansion. Tissue expansion should be considered prior to Mohs micrographic surgery in these cases. Intraoperative and rapid expansion are useful adjuncts to other repair options. Complications of expansion are frequent and must be anticipated.
Although tissue expansion is being used extensively in humans, many fundamental scientific questions remain to be addressed which can best be answered using an animal model. Presently, no single animal has been identified for research of this kind which is comparable both subjectively and objectively to humans. This study evaluates the skin of the rat, guinea pig, pig, and dog and identifies the dog as the best model based on biomechanical and practical considerations.
Tissue expansion is a helpful technique in reconstructive plastic surgery. Unfortunately, tissue expansion still needs to be improved. Twenty-four male Wistar rats were used to evaluate the effect of estriol on tissue expansion. The agents hyaluronidase, estriol, and base cream (as a control) were applied topically to separate animal groups for 5 weeks, and their effects were studied on tissue expansion. Both hyaluronidase (p < 0.05) and estriol (p < 0.001) enhanced the rate of expansion when compared with control animals. Estriol was more effective than hyaluronidase (p < 0.05). Breaking strengths were measured in the estriol and the control groups. Breaking strength was not evaluated in the hyaluronidase group because of the necrotic changes seen at the end of the fifth week. The breaking strength was higher in the control group than in the estriol group (p < 0.05). The authors suggest that topical estriol be used as an adjunctive agent to facilitate tissue expansion.
Tissue expansion is used to facilitate reconstruction procedures following trauma and cosmetic breast augmentation. This article describes tissue expansion, reviews intraoperative expansion techniques, and discusses the nurse's role in the procedure.
Tissue expansion offers a new alternative in plastic surgery. Its applications are numerous for reconstruction of the scalp, head and neck, trunk, breast, and extremity. Over the past year I have used tissue expansion for reconstruction in 13 patients, with multiple expanders in six patients. Complications included two exposed expanders requiring early removal, and two mechanical malfunctions requiring replacement. Expansion of previously irradiated tissue has been unsatisfactory.
Tissue expansion is a recent advance in skin cover technique. Its empirical use has enabled many previously difficult reconstructions to be completed without recourse to distant flaps. Its high complication rate and lack of basic scientific understanding at present restrict its use to selected cases, but the quality of repairs possible by this method encourage further serious scientific study.
Since modern tissue expansion was introduced in 1976, it has proved to be a safe and effective technique for obtaining extra tissue where traditionally distant flaps and grafts had been used. However, the lengthy expansion times and prolonged gross deformity of conventional expansion protocols have often deterred both physician and patient from choosing this reconstructive option. Over the past decade, attempts to shorten the total expansion time have centered around decreasing the time intervals between injections. Recently, researchers at Washington University have developed the technique of continuous tissue expansion (CTE), using a custom-designed, computerized pump. With CTE, expansion times have been shortened from 2 weeks to 3 days. At our institution, we have demonstrated that CTE can be safely and economically performed with the use of equipment already existent in most medical centers. We describe the equipment and technique and present two cases of successful clinical application of CTE.
Tissue expansion is indicated in the reconstruction of various scalp defects when there is inadequate adjacent tissue to allow either primary closure of the defect or repair with a local flap. It is the most important armamentarium for aesthetic hair-bearing scalp reconstruction in cases of congenital or required defects. This technique was used sequentially without interval to achieve scalp reconstruction for 12 patients with a defect ranging from 30% to 75% of the scalp (average, 55%). For 12 patients, 32 expansion treatments were undertaken between September 1997 and January 2002. The 12 patients included 3 women, 4 men, and 5 children with a mean age of 20 years (range, 45 days to 36 years). All patients had more than one period of treatment. The most common conditions treated were burns (n=7), trauma (n=1), congenital naevi (n=2), and male pattern baldness (n=2). Reconstruction of 12 large scalp defects has been performed with a 3.1% rate of major complications. Results show that tissue expansion is a safe and efficient but time-consuming technique for aesthetic scalp reconstruction, especially in the case of "sideburn" scenario or large defects. There was no significant alteration in ratio of complications although tissue expansions were made sequentially.
Tissue expansion has become a major reconstructive modality in the past 30 years. Its application in the pediatric population has allowed the plastic surgeon to achieve functional and esthetic goals that were previously unobtainable. Tissue expansion is a major treatment modality in the management of giant congenital nevi and secondary reconstruction of extensive burn scars, allowing sensate tissue of similar color, texture, and thickness to be used to resurface the affected areas. One must be prepared for complications when using tissue expanders, however, because complications are inherent in the process of expanding skin utilizing repeated filling of implanted foreign bodies. Complication rates increase when serial expansion of the same tissues is performed repeatedly or if expanders are placed in the lower extremities. Outcomes are dependent on thorough planning, meticulous technique, close follow-up, and patient compliance. Tissue expansion has revolutionized plastic surgery in the last 30 years. This technique can be applied to a considerable breadth of reconstructive problems in the pediatric population. Tissue expansion has permitted the plastic surgeon to achieve the goals of reconstruction with tissue of similar color, texture, and thickness, with minimal donor site morbidity. Preservation of sensation in a durable flap has allowed the surgeon to achieve acceptable functional as well as esthetic goals simultaneously.
The tissue extension method was applied in 13 patients with cicatricial alopecia of the scalp. Eighteen Soviet-made tissue expanders were used. Clinical experience showed that the sequelae of burns of the scalp attended by alopecia should be treated by tissue extension. The growth of hair can be restored on up to half of the scalp surface by expansion of the local tissues by their direct transfer and by additional formation of grafts for contour plastics. Plastics by expanded tissues is indicated for closure of naked bones of the vault of the skull.
Intraoperative tissue expansion is an adjunct that has been used during rhytidectomy to rejuvenate the face and neck. This technique has been thought to allow for additional skin resection and, thus, increased skin tightening during rhytidectomy. The stretch of the skin by expansion should allow for additional skin resection before closure. Also, when the force of the underlying expander is removed, the expanded skin would recoil and the advancement of the flap should become tighter, with improved results. The technique achieved some popularity a few years ago but has received little recent attention. In this study, the authors attempted to compare face-lift results of adjunctive intraoperative tissue expansion during rhytidectomy with similar techniques without intraoperative expansion. The results of 50 female patients who underwent rhytidectomy for midface rejuvenation by a single operating surgeon composed the study group. Twenty-five of the patients had undergone rhytidectomy that addressed the cheek, chin, and neck areas without expansion (nonexpanded rhytidectomy group). The other 25 patients (expanded rhytidectomy group) had adjunctive intraoperative tissue expansion performed with the rhytidectomy. A tissue expander was temporarily placed beneath the rhytidectomy flaps on each side and expanded in a standard manner before final skin resection and closure. Frontal and lateral photographs were evaluated by 54 examiners. Preoperative and postoperative photographs of the 50 patients were viewed side-by-side by the examiners. The patients were presented in blind fashion and random order. The examiners graded the results of each patient on a scale of improvement from 1 to 10, with 10 being the maximum level of improvement. The scores were recorded and statistically evaluated by using the two-sample test. Evaluation of the examiners' scores showed that the mean rating given to patients in the expanded rhytidectomy group was 5.07 (SD = 1.12). The mean rating for the nonexpanded rhytidectomy group was 5.27 (SD = 1.57). When the two groups were compared using the two-sample test, the difference between the two was not statistically significant (p = 0.6127). Intraoperative tissue expansion as an adjunct to rhytidectomy did not result in improved facial rejuvenation in this patient series. The authors' impression is that the benefits of tissue expansion do not justify the added expense, time, and risks associated with using tissue expansion during rhytidectomy.
OBJECTIVE: To explore an improved method of reconstructing the scalp soft tissue defect with the expanded skin soft tissue and treating and preventing the related complication. METHODS: From October 2002 to June 2005, 32 patients (20 males and 12 females, aged 5-48 years) underwent reconstruction of the scalp soft tissue defects with the expanded scalp soft tissue in the two-stage operation. In the first stage, a tissue expander (cylindrical form, 50-250 ml) was implanted into the skin to achieve a skin soft tissue expansion. After a sufficient skin expansion (8 cm X 5 cm to 25 cm X 23 cm) was made by the routine water effusion for 6-16 weeks, a properly-designed skin flap was taken and transferred to reconstruct the scalp soft tissue defect in the second-stage of the operation. All the scalp defects were left after the resections of the scalp lesions, which ranged in size from 7 cm x 5 cm to 20 cm x 20 cm. RESULTS: After operation, all the 32 patients had their scalp defects repaired and reconstructed well. The expanded skin flaps of all the 32 patients survived except 1 patient who had a necrosis of the distal epidermis of the flap, which healed after the dressings of the wound. The hair grew well and the scars were hidden with a satisfactory appearance. Four patients developed complications (necrosis of the distal flap in 1 patient, hematoma in 1, expander exposure in 1, and wound rupture in 1). CONCLUSION: Reconstruction of the scalp soft tissue defect with the skin soft tissue expansion is an ideal method.
OBJECTIVE: To summarize our experiences with 18 cases of repeated tissue expansion for treating extensive scalp and facial soft tissue defects. METHOD: Tissue expansion was performed for 1 or 2 times after the primary expansion for repairing large scalp and facial soft tissue defects ranging from 9 cm x 5 cm to 16 cm x 12 cm using re-expanded flaps. The indications, complications and experiences in the treatment were discussed. RESULT: Satisfactory results were obtained in all the 18 cases. On the follow-up conducted 6 months postoperatively, the repaired defects presented excellent appearance and functional recovery without additional scars. CONCLUSION: Repeated tissue expansion is an effective technique for repairing large tissue defects in the head and face.