TISSUE EXPANSION

Grabb & Smith Plastic Surgery 2007

Read by : Hartono Kartawijaya (HKW)

TISSUE EXPANSION
Reliable method providing additional cutaneous tissue match color & contour

Backgrounds

Distraction Osteogenesis

Mechanical stress on tissue could lead to lengthening

Neumann in 1957 Charles Rodovan 1976 Eric Austad 1982 1st National Tissue Expansion 1982

Regional site Distant site

Physiology
Constant mechanical stress applied to skin over time Mechanical Creep Biological Creep Gap junction disruption + tissue surface area Cell proliferation Growth of the tissue Resting tension restores to baseline

Cell is stretched
Morphologic change on cellular level

Epidermis get thicker Dermis get thinner Alignment of collagen fibrils Improved vascularity Molecular changes :

Cytokines ( VEGF ) Hormones Adhesion molecules Cytoskeleton Signal transduction protein

Similarity of

Expanded Flap Delayed Flap

Delay Phenomen

Types of Prostheses

Shape : round, rectangular, crescent Size : round 100 2000 cc rectang. 100 1000 cc Type of filling port

Integrated into prosthesis Connected to the device by silicone tubing

Expanded Flap Design

Consider :

Incisions Expander placement Flap movement in relation to defect Post operative scar
Match color, texture, contour Free of infection Scar ( stable scar ) Free of trauma

Donor Site :

Techniques of placement

Incision within the lesion to be excised Gentle tissue handling Port placed over region with firm skeletal support Partial fill 10-20% with saline Closed suction drains Closed watertight sutures Dressing : non-adherent + soft padding

Techniques of expansion

Serial within 8-12 weeks Start on 7-10 days post insertion Remove drains in 3-10 days Can be done on home expansion protocol Point : not until extremely painful not until skin compromise occurred

Movement of expanded flap : Advancement, transposition, rotation

Scalp

Indications : large congenital nevi, scar, skin graft alopecia, craniofacial reconstruction SAFE : no distortion on cranial sutures temporary cranial molding Not induced proliferation of hair follicles Can doubled size of scalp without obvious alopecia Pay attention to major arteries : superf.temporal, post.auricular, occipital, supraorbital Placement on subgaleal above periosteum Best port placement : pre-auricular

Forehead

Most challenging Potential disfigurement of upper facial structures : brow asymmetry, brow ptosis, altered hair direction, anterior hair line asymmetry Respect to aesthetic subunits

Forehead

Techniques to minimize complication :

Bilateral expansion Serial expansion Supra-orbital & temporal nevus use transposition from medial of the nevus Temporal region use parietal expanded skin Brow elevation use interposing with nonhair bearing forehead skin

Face and Neck

Subunit principle Scar hidden in natural creases Complication with tension on lower face : lower lip drooping, oral incompetence. To minimize : use transposition & rotation from lateral cheek, neck, post.auricular Expansion useful in enlarging donor site for FTG : perioral / periorbital

Above the clavicula Expanded = unexpanded

Trunk

Indications : giant nevi, vascular malformations, contour defects Anterior trunk Lower abdomen

Most easily For excision of adjacent lesions Donor tissue for free TRAM flap to aid donor site closure Donor for FTG Use anterior trunk limited in children

Trunk

Posterior trunk Use commonly for giant nevi in back /buttock Reconstruction at age 6 months

Breast

Post Mastectomy Reconstruction : Autologous tissue Expander implant Losken,et al :Fewer secondary procedure with expander.

Mastectomy + placement expander subpectoral Exchange with permanent prosthesis + nipple areola complex reconstruction + balancing procedure

(Top) Preoperative and post-expansion, with full expanders in place. (Bottom) Permanent textured, shaped silicone gel implants in place.

Breast

Congenital Breast Anomalies

Breast agenesis ( Poland Syndrome ) Idiopathic unilateral breast hypoplasia Iatrogenic breast asymmetry
Face problem : self-esteem, body-image, sexual identity Solution : expander Maturity Aged : replaced with permanent implant + balancing procedure

Traditional : wait for maturity

Extremities

Unfavorable donor for an expanded flap Complication rates higher ( 47% vs. 23% ) Cassanova : 19.4% of 200 cases ( 15.4% major complication, 4% failure )

Lower Limb Expansion in lower limb is feasible Remote incision lead to lower infection, extrusion & flap failure rates Contra-indication : unstable wound, infected wound Large defect : expanded free flap (TRAM,Scapular)

Upper Limb Proximal arm elbow

Non-circ. : expanded transposition flap from back / shoulder Circumf. :expanded free TRAM flap

Mid-forearm

Large/circumf. : expanded flank flap (pedicled flap)

Use expanded FTG from abdomen / groin

Hands, web-space, fingers

Complications
Major :

Infection Implant exposure Flap ischemia

Transient pain Seroma Dog ear at donor site Widening of scar

Minor :

Thank you

TABLE 1. Tissue expansion by site.

Scalp 27 (21%) Face 9 (7%) Neck 14 (11%) Trunk (including breast) 16 (12.5%) Upper extremity 26 (20.3%) Lower extremity 36 (28.2%)