Complications Of Tissue Expansion Research Articles

Establishment of a Novel Mouse Model for Soft Tissue Expansion

BackgroundDespite its increasing use, not much is known about tissue expansion, and its complication rates are significantly high. Thus, there is an urgent need to establish a stable animal model to overcome the limitations and complications of tissue expansion. Although the mouse model has shown several advantages in the in-depth studies, an appropriate mouse expansion model has rarely been reported, likely because of its loose skin. Materials and methodsA micro expander was designed and implanted under the scalp of a mouse (expanded group); sterilized saline was regularly injected into the expander. In sham-operated mice (control group), a silicone sheet was implanted under the scalp. Skin samples were collected 5 wk after surgery. Histologic changes including epidermal and dermal thickness and collagen fiber arrangement were analyzed. In addition, vascular density and cell proliferation ratio were determined. An ultrastructural analysis was also performed. ResultsWith the application of the expansion device, the skin became tight and showed area enlargement. The epidermal thickness of the expanded skin increased significantly (P < 0.01), whereas the thickness of the dermis decreased significantly (P < 0.05) as compared with the control skin. Masson staining demonstrated that collagen bundles were arranged more compactly in the expanded skin (P < 0.05) than in the controls. Furthermore, more proliferating cells (P < 0.05) and blood vessels (P < 0.01) were observed. Transmission electron microscopy showed that the fibers of expanded skin were stretched and broken into bundles of various diameters, with abundant active fibroblasts. ConclusionsA reliable mouse model of scalp skin expansion was successfully established, which may be a promising tool for in-depth studies on skin soft tissue expansion.

Complications in tissue expansion: A logistic regression analysis for risk factors

BackgroundTissue expansion is frequently used in reconstructive surgery. Although the surgical procedure is typically considered simple, reported complication rates of tissue expansions exceed 40%. There is little evidence concerning risk factors for complications in tissue expansion in body regions other than breast. The aim was to determine risk factors for complications in non-breast tissue expansion. Methods34 patients treated with subcutaneous tissue expanders between 2005 and 2014 were analyzed. Demographic data, body-mass index (BMI), mean arterial blood pressure (MAP), treatment indications, expansion site, previous expansion therapies in the same body region, smoking history, as well as expander characteristics (shape, volume, and filling mechanism) were ascertained. Complications were assessed and ranked according to severity based on the Clavien–Dindo classification. Binary logistic regression analysis adjusted for clinical characteristics was used. A p<0.05 was considered as statistically significant. ResultsComplications were observed in 26 out of 71 expanders analyzed (36.6%), of whom 10 led to therapy failure. Expanders used in the limbs, female gender, and high expander volume turned out as significant risk factors. Patients with both a high MAP and low BMI developed tissue necrosis significantly more often (p=0.002). The use of tissue expansion after a burn was not associated with an increased risk for complications. ConclusionsThis is the first study revealing female gender and low BMI as risk factors in tissue expander surgery. Thus, careful patient selection is mandatory to avoid complications in tissue expansion. Burn patients do not develop complications more often.

Complications in Tissue Expansion: An Updated Retrospective Analysis of Risk Factors

The technique of tissue expansion has been widely applied in plastic surgery since the 1980 s. Implantation in the lower limb region, external port placement, and young patient age were known as risk factors for complications. Over the years, surgical experience has increased along with improved patient management and expander manufacturing. The aim of this study was to identify possible changes in risk factors regarding complications in tissue expansion. A retrospective, single-institution large sample observational study over a 5-year period (2006-2010) was performed involving 481 tissue expanders in 344 patients. Patients underwent surgical treatment for resurfacing scar tissue in the scalp, face, neck, nose, and limbs, but not breast. In addition, the results are discussed based on a comprehensive review of the literature published between 1995 and 2009. Statistical analysis showed significant correlations between cheek and hematoma (P=0.0133), scalp and dehiscence (P=0.0139), number of expanders per region and leakage (P=0.0379), number of expanders per region and overall complications (P=0.0252). Factors such as gender, age, tobacco use, and repeated expander implantation had no significant influence on the incidence of complications. The lower extremity region and young patient age ceased to show a statistical correlation with complications. The number of expanders per region was identified as a risk factor that has been disregarded so far. Evidence suggests a recent change in risk factors for tissue expansion-related complications. Consideration of updated risk factors may help to further improve outcomes in tissue expansion.

Use of Scar and Capsule Flap for Preventing the Contour Deformity After Applying Tissue Expansion in Patients With Scar

Tissue expansion is a reconstruction method often used to repair the tissue loss that results after removing soft tissue lesions such as scars, tumors, and giant hairy nevi. However, because the pressure of a tissue expander applies in all directions almost equally, along with the desired expansion of skin and subcutaneous fat tissue, the muscle and bone underneath the expander become depressed simultaneously. Even with a successful expansion of the tissue itself, the conventional surgical procedure results to frequent aesthetically dissatisfying outcomes because of contour irregularities. However, no studies have been conducted regarding the correction of these secondary deformities. A surgical method to prevent secondary depression deformity was performed on a total of 80 patients who had undergone scar revision using tissue expansion between May 2002 and April 2012. First, the scar tissue was de-epithelized and transposed to fill the depressed area as a buried flap. Second, the capsule formed around a tissue expander was elevated as a flap and turned over to fill the depressed area. Lastly, the thickened capsule at the margins of the expander was used as a free capsule graft, which provides additional supports. Four plastic surgeons analyzed the postoperative aesthetic results after the surgery in an outpatient follow-up clinic. There were complications of tissue expansion in 7 patients: 5 had minor complications, which were successfully addressed with conservative treatments, and 2 had major complications, which required tissue expander removal during the course. In more than 85% of the patients, satisfactory postoperative aesthetic results were achieved without any perceivable depression or asymmetry. Secondary depression deformity induced by a tissue expander can be effectively prevented with a simple operative technique using capsule flaps, scar tissue flaps, and free capsule grafts.

Management of the complications of tissue expansion during a 5-year period (2005–2010)

We report our experience of using tissue expansion where we deal particularly with complications and their management. Forty patients had tissue expanded during a 5-year period (2005-2010). Indications included reconstruction of a scar (after a burn, after injury, or postoperative), congenital naevi, microtia, and breast reconstruction after mastecomy. Of the 50 expanders inserted, complications occurred in 12 (10 patients). Exposure and perforation of the expander were the most common complications, followed by infection, seroma, and local pain. In all cases, complications were managed successfully either by conservative treatment or by a single procedure. The reconstructive plan ended in an acceptable aesthetic result in 9 of the 10 complicated areas. The insertion of multiple expanders over extensive scar tissue and particularly over the lower limb, is associated with high morbidity. Selection of patients, identification of high-risk sites, and suggestions for treatment are important. When complications occur, immediate management usually results in a successful outcome.

Osteophyte-Induced Rupture of a Scalp Tissue Expander

Tissue expansion is in widespread use for the reconstruction of congenital and acquired defects. Complications of tissue expansion are well documented, the most common being infection or extrusion of the expander. Although the complications associated with scalp tissue expansion are similar to those experienced elsewhere in the body, site-specific complications can occur. These include bone thinning and erosion of the cranial vault. In this study, we report an unusual case of multiple osteophyte formation beneath a scalp tissue expander, resulting in its rupture and necessitating removal.

Rib Fracture as a Complication of Tissue Expansion in Breast Reconstruction

Rib Fracture as a Complication of Tissue Expansion in Breast Reconstruction

Delayed Development of Toxic Shock Syndrome Following Abdominal Tissue Expansion in a Pediatric Reconstruction Patient

Toxic shock syndrome (TSS) is a potentially fatal postoperative complication, and even more so if the diagnosis is delayed. We present the case of a 7-month-old male infant who developed TSS as a complication of tissue expansion using an external port device. There have been 5 documented cases of TSS after tissue expander or breast prosthesis placement occurring in the adult population, however, there has not been a reported case of TSS in an infant. The long interval to development of TSS like symptoms, 4 months in this case, should not exclude TSS from the differential diagnosis. In a pediatric patient, a diffuse macular rash without the severe systemic symptoms on initial presentation can present as a diagnostic challenge. New diagnosis techniques are discussed that can shorten the time to a diagnosis of TSS. In this case, because the local bacterial count was low, the expanded tissue was transferred without complication.

An Alternative Method of Using an Interpositional Silicone Sheet in Tissue Expansion

To reduce the rate of complications in tissue expansion, we placed a silicone sheet between the expander and the tissue above it in a rat model. In the rats in group 1 (n = 10), the expanders were placed under the dorsal skin. The expanders were inflated with up to 45 mL of saline solution. In group 2 (n = 10), a silicone sheet was inserted between the tissue expander and the skin, after which the procedure used in group 1 was performed. The blood flow was reduced at the dome (center [C]) of the expanders in groups 1C and 2C to a degree greater than that in the expanded skin in groups 1 and 2 far periphery. However, the flow was significantly better in group 2C than in group 1C. Histologic analysis showed that the dermal and capsular tissues were significantly thicker in group 2C than in group 1C. In our opinion, placing a silicone sheet between the expander and the tissue above it seems to be beneficial. This may reduce the incidence of complications, especially the expander extrusion in this model.

Investigation of the Expansion Properties of Osmotic Expanders with and without Silicone Shell in Animals

Particularly in clinical studies, it has been found that rapid swelling of tissue expanders leads to high-pressure peaks that can cause hypoxia in the tissue and thus also skin damage. For this reason, the present study in animals investigated whether an osmotic expander with silicone shell is capable of expanding in tissue and bringing about useful tissue expansion without complications. It was also examined whether and what quantitative and qualitative differences there are between conventional osmotic expanders and the new expanders with silicone shell. The expansion of osmotic expanders with silicone shell was compared with that of osmotic expanders without silicone shell in four mini pigs. The expander type used was an M1 rectangle with an initial volume of 6 ml. Five expanders were implanted in each pig, meaning that 20 expanders were measured. The volume of the expanders was measured directly after explantation. Indirect volume determination was performed by producing plaster casts for subsequent laser optical measurement. Comparison of the two curve profiles showed a much flatter profile for the expanders with silicone shell. The absolute values for the volumes of the expanders with silicone shell were likewise substantially lower. Controlled skin expansion is a technique of providing localized donor tissue for reconstructive surgery. The new expanders could be in a position to lower the rate of complications in tissue expansion.

Repeated Tissue Expansions on Split-Thickness Skin Graft in a Patient With Neurocutaneous Syndrome

Soft tissue expansion is a mechanical process that increases the surface area of local tissue available for reconstructive procedures. In most cases, adjacent tissue that matches the recipient site in color, texture, and hair-bearing quality is preferred for tissue expansion. In this particular case with neurocutaneous syndrome, the defects that resulted from removal of parts of a giant hairy nevus overlying the latissimus dorsi muscle bilaterally were grafted with a split-thickness skin graft. Two expanders were then placed under the latissimus dorsi muscles. After full expansion of the grafted area, some part of the remaining nevus surrounding the grafted area was removed and the defects were covered with the expanded skin graft obtained after deflation of the expanders. The expanders placed under the latissimus dorsi muscle in the first operation were reused in the second operation to obtain a second expansion of the skin graft. After the second expansion of the skin graft, the expanders were deflated and another portion of the remaining nevus surrounding the grafted area was removed. The resulting defects were again covered with the excess expanded skin graft. Although repeated expansion of the skin graft is a time-consuming and laborious process, it eliminates the need for taking repeated skin grafts; it decreases skin graft donor site morbidity; it decreases possible infectious complications of tissue expansion by decreasing the number of surgical interventions to the expander pocket; and it increases the aesthetic outcome by keeping all the surgical scars around the grafted area without extending them into healthy surrounding skin.

Preexpanded distant “super-thin” intercostal perforator flaps for facial reconstruction without the need for microsurgery

Concept of the 'super-thin perforator flap' was introduced in 1994 by authors. Since then, various types of 'super-thin perforator flaps' were applied successfully especially for contour sensitive reconstruction such as face and neck. Eleven patients requiring large flaps who presented with extensive disfiguring facial scar (male: seven cases, female: four cases). On the consideration of flaps' colour, texture and thickness requirements, the authors selected 'super-thin' anterior intercostal perforator flaps (AICP, range from 4 x 14 cm to 25 cm x 9 cm) for reconstruction purpose. First, tissue expanders (volume range from 800 cc to 1200 cc) were carefully inserted under the AICP. After the flaps were expanded for 2 months, distant scars were removed and the covering super-thinned flaps were transferred into recipient site. Two weeks later, pedicles in the anterior chest were cut down and flaps were transferred to replace all the left scars. Flap were survived without any complications. The colour, texture and thickness of the transferred flap were satisfactory, shrink of flaps were not observed after long term follow-up. The authors present a method of facial reconstruction that has the advantages of creating a large amount of thin tissue of both good colour and texture, without the need of microsurgery and few disadvantages of donor-site morbidity. The disadvantages are three-staged procedures, complications of tissue expansion and uncomfortable compulsory posture for patients. In our opinion, this is an alternative method of choice for reconstructing all large defects in the lower two-thirds of the face.

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 650 cm 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=25 cm × 13 cm) was excised after serial clinic saline injection. The preexpanded free flap (size=29 cm × 15 cm) 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° (preoperative 74° to postoperative 88°); and an increase in lateral flexion of 10° (preoperative 30° to postoperative 40°). 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.

Tissue expansion and serial excision in scar revision.

Scars in the head and neck caused by trauma or extirpative surgery can present a significant problem to the patient and may require revision. A variety of techniques, both surgical and nonsurgical, exists for treatment of unsightly scars. Surgical excision of scars relies upon recruitment of local tissue for closure of the ensuing defect. Tissue expansion and serial scar excision may be used to provide more tissue for advancement or local flap coverage of revised scars. Herein we review the history, technique, and complications of tissue expansion and serial excision as well as the basic scientific principles underlying these techniques.

Tissue Expansion: King Khalid University Experience

Tissue expansion is a means of mechanically generating excess soft tissue adjacent to a defect. The advantage of this technique is that it enables replacement of missing tissue with similar tissue of matching color, texture and other inherent local characteristics. The mechanism of generating skin by this technique and the physiologic changes occurring in the skin during the process of expansion have been well studied in animal models. 1-3 However, meticulous attention to detail is required to reduce the incidence of complications associated with the technique and to achieve optimum results. We present here our experience with 128 tissue expanders in 97 patients in an Arab population. The treatment was carried out at King Khalid University Hospital from 1989-1996. The aim of the study is to evaluate the outcomes of tissue expansion, with a view to identifying the factors that could contribute to minimizing complications.

Some Useful Techniques for Avoiding Complications of Tissue Expansion

Some Useful Techniques for Avoiding Complications of Tissue Expansion

Complications of tissue expansion.

he previous articles in this issue have dealt in depth with the technique of tissue expansion and its unique and remarkable advantages for T soft tissue reconstruction. However, as with all aspects of cutaneous surgery, tissue expansion does have its share of disadvantages and potential complications (Table 1). The disadvantages of tissue expansion are relatively few. The procedure does require at least two operations and multiple visits to the physician are required during the 6 to 8 weeks of expansion. Up to 20 sterile injections may be required.' Some authors have advocated inflation in the home setting, but this is not typically recommended. Tissue expansion may necessitate time away from work or school dependent in part upon how well the patient tolerates the cosmetic deformity and body image distortion that occurs with the procedure. Indeed, patient selection is extremely important prior to undertaking tissue expansion. The patient needs to be well informed, motivated, mentally competent, and fully understand the nature of the procedure. Patients invariably will respond to the obvious distortion in body image in a number of ways with negative reactions ranging from depression, to withdrawal, to even exhibitionist behavior. Some patients may simply be unable to tolerate tissue expansion because of unacceptable body image distortion and/or psychologic instability. Children can be an additional challenge although most are able to continue with their normal activities, including school. Successful expansion in the pediatric population is widely reported. Complications of tissue expansion are more numerous and varied than are the simple disadvantages. Fortunately, most complications are minor and can be resolved without interruption of the expansion procedure. Reported rates of complications vary widely from 5 to 60%.2-5 The discrepancy of this rate is multifactorial, owing in part to the experience and expertise of the surgeon, the anatomic site of the expanded tissue, the health

Elias, D. L., Baird, W. L., and Zubowicz, V. N. Applications and complications of tissue expansion in pediatric patients

Elias, D. L., Baird, W. L., and Zubowicz, V. N. Applications and complications of tissue expansion in pediatric patients

Applications and complications of tissue expansion in pediatric patients

We have reviewed our experience with 61 tissue expansions in 49 pediatric patients. Indications for expansion included traumatic alopecia or soft tissue loss, myelomeningocele, congenital hairy nevi, burn scars, and other less common defects. The complication rate, necessitating interruption of expansion, was 25%. This occurred more frequently with scalp and burn reconstruction. Nevertheless, 86% of patients ultimately achieved good to excellent results.

Contraindications and complications in tissue expansion.

Contraindications and complications in tissue expansion.