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Controlled tissue expansion and fasciocutaneous flaps are useful in the aesthetic and functional reconstruction of scar areas. We present three cases, in which we have combined both methods with improved results. Large scar areas were reconstructed with minimal donor-site morbidity.
The following guidelines are suggested for the use of tissue expansion in ear reconstruction based on both personal experience and my evaluation of the reported results of expansion in the hands of other surgeons experienced in ear reconstruction: 1) Cases should be carefully selected to avoid those with excess scarring from previous surgery or trauma as well as avoid the other common contraindications to the use of tissue expansion. 2) In most congenital cases the expander should be placed through a remote incision within the postauricular hairline, and excision of the cartilage vestige delayed until expansion is completed and the framework is ready for placement. 3) A remote valve expander of a crescent shape with a volume of 60-100cc is ideal; low profile expanders may even be safer. 4) The pocket for the expander should be dissected immediately above the fascia and against the cartilage remnant. 5) Rapid expansion should be avoided; ideally injections should be carried out one time each week and with relatively small quantities (5-10cc per injection). 6) At the time of expander removal and placement of the cartilage framework the capsule should be meticulously excised to allow tight skin-cartilage coaptation. This is further enhanced by effective suction drainage following wound closure.
Tissue expansion is a well-established technique for the management of soft tissue deficiencies. In congenital hand surgery the construction of an adequate first web is paramount. We used tissue expansion in four hands in three patients with complete complex syndactyly of the first web space. Two of these patients had Apert's syndrome and the other an isolated mitten hand anomaly. The expander is preferably placed early in life so that first web construction is completed in the first year. Tissue expander ports are left exposed. There have been no infections, flap or expander loss in our series.
The technique of tissue expansion can now be used to prepare skin for reconstructive operations. This method has been propagated during the last 15 years, but its use has varied from great enthusiasm with exaggerated expectations to disillusion due to high complication rates. For an efficient and successful application of skin expansion an understanding of skin reactions and their control is mandatory. In this review, the biological principles of expansion, various expansion protocols and their objectives, control during the filling phase and preventive measures to avoid complications are described. For clinical use it is important that there is not one but three distinct types of expansion: an intraoperative, intermittent expansion for gentle subcutaneous skin mobilization, a short time period for expansion (between 1-2 weeks) to increase the dermal microcirculation and the "classic" prolonged period of expansion to create new skin for the reconstruction required.
Epidermal mitotic activity during tissue expansion has been assessed in the guinea pig using tritiated thymidine and other confirmatory techniques. Implant inflation results in a threefold elevation of epidermal mitotic activity within 24 hours, followed by a gradual return to normal baseline over 2 to 5 days. Implant deflation, conversely, causes a transient decrease in epidermal mitotic activity. Neither of these phenomena has been previously described. It confirms previous animal studies which illustrate the highly responsive nature of the epidermis to physical stimuli and supports the view that tissue expansion is a highly useful manipulation of normal physiologic processes.
In the present study, a porcine model for controlled skin expansion was investigated to improve our understanding of epidermal and vascular responses following stretching. The model is of outstanding importance not only for the clinical use of tissue expansion but provides interesting data for skin physiology and oncology, too. Thirteen out of 15 animals, who underwent silicone tissue expander implantation showed good clinical results. In all of them, skin biopsies were taken at the end of a controlled tissue expansion procedure (final expander volumes 350 or 500 ccm): one tissue specimen was obtained from the centre of the expanded skin area and a second from the neighbouring but nonexpanded skin. The tissue specimens were immediately frozen in liquid nitrogen and processed to 4 microns thick acetone-fixed frozen sections. Lectin histochemistry and immunohistology were performed using the following techniques: direct and indirect immunofluorescence technique (DIFT, IIFT), immunoperoxidase technique (POX) with either 3,3'-diamino-benzidine (DAB) or 3-amino-9-ethyl-carbazole (AEC). The histochemical findings were supplemented by measurements of the number of vital epidermal cell layers, the epidermal thickness (microns), and the papillary vascular count per visual field. There was a significant diminuation of the vascular count (mean +/- S.D. = 55.0% +/- 12.5%; U-test: p less than 5%). By immunohistochemistry, a loss of the basal cell reactivity for the following antibodies was noted: ACAM (against calmodulin), K 8.12 (against keratins 13 +/- 16) and A51-B/H4 (against keratins 8, 14, 18). There was a remarkable increase of filaggrin expression in the uppermost spinal cell layers in expanded skin, which was most pronounced in those specimens with the shortest interval to the last fluid injection into the expander. We gained no evidence for alterations of the expression of suprabasal epidermal keratins, lectin binding sites (UEA I, PNA, ConA, WGA), and vascular lectin- and immunoreactivity due to tissue expansion. The subdermal capsule, which had formed around the silicone expander, was strongly vimentin-reactive. In conclusion, controlled tissue expansion is capable to change the basal cell phenotype--a feature which is shared with a number of conditions with increased proliferative activity and with the epidermis covering different skin tumours. The regular expression of suprabasal keratins and epidermal lectin binding sites provides evidence for a normal epidermal cell differentiation. Furthermore, the porcine skin is a reliable model for studying physiology and pathophysiology of human skin.
OBJECTIVE: To investigate the effect of local application of bFGF and sucralfate during continuous tissue expansion (CTE). METHODS: CTE combined with local administration of bFGF and sucralfate was used in twelve patients with scar and nasal tip defects. Twenty three expanders were placed in the subcutaneous pockets through intralesion short incisions. Continuous expansion began at 1-3 days after expander implantation. The histomorphological changes and epidermal cell proliferation were observed. The clinical results were investigated. RESULTS: The average inflation time was 8.9 days. The average interval of the two operations was 13.5 days. The average hospitalization was 28.4 days. The average immediate stretch-back rate of the expanded skin was 25.7%. The clinical results were satisfactory without any complications. Histological examinations showed that the epidermal, granular and spinous layer became thicker. The basal cells increased significantly. The dermis thinned slightly and the collagen fibers became thicker. The elastic fiber regenerated significantly. Fibroblast and capillary density increased obviously. The immunohistochemistry analysis showed that the proliferation of epidemic basal cells was significant postoperatively. CONCLUSION: Local application of exogenous bFGF and sucralfate during CTE was feasible in patients. It could accelerate tissue expansion and improve the quality of expanded skin flap.
Despite the advent of free tissue transfer, breast reconstruction by tissue expansion is an important technique in the armamentarium of the reconstructive breast surgeon. The concept is deceptively simple and yet in reality can produce difficult complications and poor results. A database was compiled of all the patients receiving tissue expanders and/or implants for cosmetic, congenital and reconstructive purposes between 1986 and 1998. 189 patients had 197 delayed two-stage tissue expansion breast reconstructions following mastectomies for malignant breast disease between 1986 and 1997. 103 breasts (52%) had two uncomplicated stages. The remainder had one or more complications, revisional procedures for complications or alterations to the reconstruction for size, position or shape. Overall each breast reconstruction required 2.9 procedures (range 2-9). The complications and additional procedures are discussed. In particular, capsular contracture of the definitive implant (12%) was related to implant type and not to the speed of tissue expansion or the degree or duration of over-expansion. Although 17% of patients received radiotherapy, none of those who developed contracture around the definitive implant had this adjuvant therapy, P< 0.05. Twelve reconstructions (6%) totally failed due to complications of which six underwent secondary flap reconstruction. Twenty-one patients have subsequently developed metastatic disease of which 15 have died to date. Breast reconstruction by tissue expansion is still an important technique. It should be used carefully and thoughtfully by surgeons trained to deal with any complications. Patients need to be carefully selected and counselled prior to undertaking this process.
The ability to increase available local tissue by controlled soft tissue expansion has led to a rapid increase in the use of this technique in clinical practice. Our experience in the treatment of children with a wide variety of lesions, in all body areas, demonstrates the advantages and benefits of this relatively new procedure for the pediatric age group. While complications such as infection, implant exposure, deflation, hematoma, and seroma may occur and alter the timing of reconstruction, they rarely compromise the final result. Tissue expansion offers many advantages in soft tissue reconstruction in children when tissue of color, texture, and characteristics similar to that of the defect may be limited.
Controlled tissue expansion using a 100 cc rectangular silicone elastomer expander was performed in the mid-antebrachium and mid-crus of eight adult mixed-breed dogs. Two expander inflation schedules were followed. Group 1 dogs (n = 4) underwent expander inflation using 10 cc sterile saline every other day, and group 2 dogs (n = 4) underwent expander inflation using 15 cc sterile saline every other day until the nominal volume (100 cc) was attained. Significant mean postexpansion increases in skin surface area of 94.1 cm2 (35.9%) and 108.9 cm2 (37.3%) were measured in the antebrachium and crus, respectively (p < .05). In a second procedure, the expanders were removed and skin flaps were developed from the redundant tissue generated during the expansion process. Single pedicle advancement flaps and transposition flaps were used to cover surgically created defects measuring 5 x 10 cm in the antebrachium and crus. Single pedicle advancement flaps consistently measured 10 x 10 cm and could be advanced to cover defects involving one third of the mid-antebrachial or mid-crural circumference. Transposition flaps were rotated up to 170 degrees and the donor site defects were easily closed under minimal or no tension. Complications included an abscess in one dog and seroma formation in four dogs. Differences in success or complication rates between group 1 dogs and group 2 dogs were not observed; an accelerated inflation schedule using 15 cc sterile saline every other day was recommended.
Our experience with 29 patients treated using the tissue expander technique at the Breast Unit, Longmore Hospital, Edinburgh, UK was evaluated. A morbidity rate of 19%, of minor complications only, was seen with expander insertion, tissue expansion and insertion of the permanent prosthesis. Twenty-two women completed questionnaires, two of whom had undergone bilateral reconstruction. In the opinion of the patients, the improved freedom of dress and improved naked appearance after reconstruction, compared with after mastectomy, more than compensated for the abnormal sensation over or around the reconstructed breast; 19 patients rated their clothed appearance as good as that before mastectomy. Twenty of these women were assessed by a four-person panel. A range of end results was noted; symmetry, cosmesis and size were generally better when wearing a brassiere. Lack of ptosis, surgical scars and firmness on the reconstructed side were the main reservations. Tissue expansion breast reconstruction is highly acceptable to patients and has satisfactory surgical results.
Progressive tissue expansion induces significant gross, histologic, and bony changes in skulls and long bones of neonatal miniature swine. These bony changes consist of erosion underlying tissue expanders, with bony lipping and bone deposition at the periphery of the expander. Cranial suture lines underneath expanders appear effaced and convoluted. Serial CT scans reveal decreased bone thickness and volume (p less than 0.02) but identical bone density (p = 0.60) beneath expanders. Increased bone volume and thickness occur at the periphery of expanders (p less than 0.02). Bone density (CT number) is unaffected by tissue expansion in both cranial and long bones. These findings have histomorphometric correlates: Osteoclastic bone resorption occurs underneath expanders with periosteal reaction at the periphery of expanders. Cranial sutures are similarly affected, but no cranial synostosis results. No changes to the inner table of the skull or stigmata of increased intracranial pressure were observed either in CT scans or in behavioral changes in long-term animals. The pathophysiology of bony changes is a remodeling effect, not one of simple pressure deformation. Increased bone resorption and complete inhibition of bone formation occur until the pressure is removed. Cranial bone is significantly more affected than long bone. After removal of the expanders, reparative bone remodeling begins within 5 days and nearly complete healing of the cranial defects occurs within 2 months (p less than 0.02). No plagiocephaly results despite early coronal suture changes. On the basis of this study, we conclude that tissue expansion causes significant but reversible effects, readily monitored by high-resolution CT scans, on neonatal and infant cranial and long bones.
Tissue expansion is a well known way of repairing soft tissue defects. However, traditional tissue expanders have certain disadvantages such as the need for repeated outpatient visits for the filling of the expander and a long period of time required before the final result is achieved. A series of other devices have recently been developed. We have evaluated one of these, a skin extender developed by Blomqvist and Steenfos, in 10 lesions of the extremities in nine adult patients. The defects ranged from 3.5-10 cm wide and the extenders were inserted under local anaesthesia. The patients were taught how to tighten the extenders themselves, so there was no need for repeated visits to the outpatient department. Nine of the 10 defects were excised within 14 days; the remaining one developed a wound infection. The results show that this skin extender is a simple, fast, and economical device for repairing soft tissue defects, and in certain cases it is more suitable than a traditional tissue expander. Its major drawback is unsightly scars in the normal skin beside the previous defect.
Tissue expansion has gained increased acceptance in postburn reconstruction. In this study, the clinical outcome in 17 paediatric burn patients is outlined. A total of 46 tissue expanders were inserted for the reconstruction of postburn scalp alopecia (n = 11) and burn scars (n = 6). The average size of soft tissue defect was 124 cm2. Mean followup was 19 months. The overall outcome in most cases was excellent, however, complications were common (37%) and included infection, exposure, port loss, and partial flap necrosis. Five patients in the scalp reconstruction group required transfusion (45%). Tissue expansion in paediatric burn reconstruction is a useful technique which may yield superb results, however, careful surgical planning is essential to avoid complications.
OBJECTIVE: This study was to investigate the somatic symptoms and sychological specialties in trauma-deformed patients during tissue expansion. METHODS: Using our own questionnaires, fifty-seven patients were solicited to answer the questionnaires in three different treatment periods. RESULTS: It was found that local distension, pain and tickle were the common symptoms during expansion, while distension was most specific (P < 0.01). Pain and tickle also happened before implanting and after taking out of the expander. The patients often had high expectation toward tissue expansion. They felt nervous and anxious (P < 0.01) during expansion. Their emotion and healthy self-evaluation changed obviously in different treatment periods (P < 0.01). CONCLUSION: Local distension is the most specific symptom during tissue expansion. Nervousness and anxiety are common in patients at that time. Their emotion change from depression to happy at first, and then from happy to slight depression.
OBJECTIVE: To investigate a more simple and effective method to repair cicatrix by tissue expansion. METHODS: The dilator with the capacity of 80 - 500 ml was implanted into the subcutaneous pocket under the cicatrix. After dilating for one to two months, the dilator was taken out and the wound surface of the cicatrix was removed. The expanded skin flap was advanced or rotated to cover the defects. The procedure was used on 203 cases. RESULTS: The dilatation was achieved successfully in all the cases, followed by cicatrix removing and repair. The incision scar was not noticeable. CONCLUSIONS: Tissue expansion under the cicatrix has the advantages of safety, less trauma and less extra incisions. It is a reasonable choice to obtain more flexible surgical designs and more economical skin flap applications. It is suitable for most of the treatment for cicatrix.
Opinion remains divided over the advisability of tissue expansion in previously irradiated skin. We examined the properties of, and complications associated with, tissue expansion in previously irradiated rabbit scalps. Irradiation injury was produced using fractionated roentgen rays, with a total dose of 5000 cGy over a 5-week interval. Following a 20-week convalescence interval, expansion was incrementally conducted over 4 weeks. Monitored parameters included cutaneous perfusion as indicated by fiberoptic dermofluorometry, intraluminal pressure, linear surface gain, and area of surface necrosis. The incidence and severity of complications, including surface necrosis, were significantly higher among irradiated animals. Furthermore, the overlying skin of irradiated animals demonstrated a significantly decreased compliance and measurable area gain. Given the inferior expansibility and higher tendency toward complications with contemporary expansion techniques in previously irradiated skin, alternate reconstructive options are preferable in this setting.
A retrospective study of 245 patients with 299 hemangiomas treated from May 1981 to April 1994 was done. A subset of 175 of these patients (58.5%) had hemangiomas of the head and neck. Six of the 175 (3%) required reconstruction following laser therapy. Tissue expansion was chosen for each of these reconstructions. Five females and 1 male underwent tissue expansion. The age of the patients at the time of tissue expansion ranged from 2.5 to 12 years, with an average of 6 years. Tissue expander sizes were 50 cc and 100 cc. Infection was seen during the course of expansion in 1 patient. Satisfactory results were achieved after reconstruction in all cases. Tissue expansion is the treatment of choice for reconstruction of head and neck hemangioma deformities following laser or other surgical procedures as well as involution.