Tissue Expander Insertion Research Articles

Incidence of Delayed Seromas and Related Risk of Bia-ALCL in a Cohort of 3521 Breast Cancer Women with Textured Implants Prospectively Followed Long Term

Incidence of Delayed Seromas and Related Risk of Bia-ALCL in a Cohort of 3521 Breast Cancer Women with Textured Implants Prospectively Followed Long Term

Unilateral Tissue Expander/Implant Two-Stage Breast Reconstruction with the Assistance of Three-Dimensional Surface Imaging.

In China, traditional preoperative planning of unilateral breast reconstruction mainly depends on anthropometric measurement and visual assessment. Thus, the lack of objective assessment of breast volume and shape would likely result in suboptimal reconstruction outcomes. Three-dimensional surface imaging (3D-SI), which could provide objective measurement data of the breast, may be a promising solution to this problem. A retrospective review of patients undergoing tissue expander (TE)/implant breast reconstruction without any mammoplasty surgery on the contralateral sides in our hospital from August 2013 to May 2018 was performed. All the patients underwent unilateral mastectomy with immediate or delayed insertion of TE, followed by an exchange of a silicone gel implant without contralateral procedures. 3D images were obtained at the time of preoperation, the routine expansion visit, and post-exchange of implant. The breast volume measured by 3D-SI served as a guide to conduct the surgery management, such as in deciding the total volume of expansion and guiding the final implant size selection. 3D-SI also provided objective data to evaluate the final outcomes of the reconstruction. Fifty-one patients were included in this study, in which eighteen patients underwent immediate TE insertion and thirty-three patients underwent delayed TE insertion. The ptosis degree of contralateral breasts was assessed as follows: forty-four were normal, and seven showed mild ptosis. The average expansion degree was controlled at 161.6% ± 14.1% compared to the contralateral breasts. The volume of implants exchanged had a strong linear correlation with the 3D volume of the contralateral breasts at the end of expansion (P < 0.01). The mean time of follow-up was 9.1 ± 6.6months. There was only one patient who experienced TE leakage with secondary infection and received TE exchange. For the immediate reconstruction group, the overall breast symmetry improved at the completion of implant exchange (P < 0.01), with an average asymmetry of 5.3% ± 4.0% compared with 10.6% ± 6.1% initially. For the delayed reconstruction group, the reconstructed side achieved good volume symmetry to the contralateral side (P > 0.05). There was no significant difference in breast basal width between bilateral breasts post-reconstruction (P > 0.05). 3D-SI serves as a valuable adjunct by providing accurate 3D volume of breasts within TE/implant breast reconstruction in Chinese patients without obvious breast ptosis, which could facilitate surgeons to achieve good reconstructive outcomes. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Characteristics of adhesion areas between the tissue expander and capsule in implant-based breast reconstruction.

BackgroundThe use of anatomic implants has improved the aesthetic results of breast surgery; however, implant malrotation is an uncommon, but serious complication of these procedures. Nevertheless, little research has explored implant adhesion. In this study, we investigated adhesion between the expander and the capsule.MethodsSeventy-nine cases of immediate breast reconstruction via two-stage implantbased reconstruction performed between September 2016 and November 2017 were evaluated. Mentor CPX4 expanders were used in 14 breasts, and Natrelle expanders in 65. We analyzed areas of adhesion on the surfaces of the tissue expanders when they were exchanged with permanent implants. We investigated whether adhesions occurred on the cephalic, caudal, anterior, and/or posterior surfaces of the expanders.ResultsTotal adhesion occurred in 18 cases, non-adhesion in 15 cases, and partial adhesion in 46 cases. Of the non-adhesion cases, 80% (n=12) were with Mentor CPX4 expanders, while 94.4% (n=17) of the total adhesion cases were with Natrelle expanders. Of the partial adhesion cases, 90.7% involved the anterior-cephalic surface. The type of tissue expander showed a statistically significant relationship with the number of attachments in both univariate and multivariate logistic regression analyses (P<0.001) and with total drainage only in the univariate analysis (P=0.015).ConclusionsWe sought to identify the location(s) of adhesion after tissue expander insertion. The texture of the implant was a significant predictor of the success of adhesion, and partial adhesion was common. The anterior-cephalic surface showed the highest adhesion rate. Nevertheless, partial adhesion suffices to prevent unwanted rotation of the expander.

Predictors for Prolonged Drainage following Tissue Expander-Based Breast Reconstruction.

A closed-suction drain is usually inserted during tissue expander-based breast reconstruction. Prolonged duration of drain retention can disturb patients' daily lives and affect overall sociomedical costs. This study aimed to investigate factors that may influence the drainage and to identify predictors of unusually prolonged drain duration. Patients who underwent delayed-immediate, two-stage breast reconstruction using a tissue expander between January of 2013 and July of 2017 were reviewed. Prolonged drain duration was defined as drain duration for longer than the 75th percentile of that for the entire cohort. Effects of patient- and operation-related variables on drainage and prolonged drain duration were evaluated. A total of 1056 cases (1002 patients) were analyzed. The median drain duration was 10 days. Drain placement for more than 12 postoperative days was observed in 256 cases (24.2 percent), classified as prolonged drain duration. Multivariate analyses demonstrated that old age, high body mass index, neoadjuvant chemotherapy, insertion of large Siltex textured tissue expanders, and greater volume of initial inflation were independent risk factors of prolonged drain duration. The size and texture of the tissue expanders and initial inflation volume retained their influence, regardless of mastectomy specimen weight. Use of acellular dermal matrix had contradictory effects according to breast size, being protective against prolonged drain duration in cases with mastectomy specimen weight greater than 400 g, and being a significant predictor for it in cases with mastectomy specimen weight less than or equal to 400 g. Several factors, including reconstructive operation-related factors, might influence drain duration following tissue expander-based breast reconstruction. Risk, III.

Abstract 122: Depression and Anti-depressant Therapy Effects on Quality of Life and Patient Satisfaction Outcome Measures in Breast Cancer Using the BREAST-Q

PURPOSE: Depression prior to breast cancer and its effect on post-diagnosis quality of life in women undergoing breast reconstruction is relatively unknown. The BREAST-Q has become widely used to assess pre- and post-operative patient-reported outcomes. There are no studies evaluating the impact of a pre-cancer diagnosis of depression or anti-depressant use on BREST-Q scores. We investigated if depression or anti-depressant use may alter the results of the BREAST-Q. METHODS: This study is a single-center, retrospective analysis of 300 patients with completed BREAST-Q data who underwent breast reconstruction from November 2013 to 2016 following a diagnosis of breast cancer. Patients completed the BREAST-Q at four time points: pre-operatively, 6-weeks following tissue expander insertion, and 6- and 12-months following final reconstruction. We reviewed medical records to identify patients who had a pre-cancer diagnosis of clinical depression and anti-depressant medication use. Patients were stratified into a depression and no depression group. The depression group was defined as a pre-cancer diagnosis of depression. The no depression group was defined as no pre-cancer clinical diagnosis of depression and no anti-depressant use. BREAST-Q scores were compared between depression (n=50) and no depression (n=250) patients; the depression group was further stratified by anti-depressant (n=36) and no anti-depressant (n=14) use. The Mann-Whitney U test was used for continuous variables, based on the non-parametric distribution of the data. The same statistical guidelines were used for the sub-group analysis. RESULTS: Sexual well-being scores at the 6-week tissue expander follow up for patients in the depression group (median=37, IQR = 25–47) were significantly lower (p<0.01) than scores for patients in the no depression group (median=47, IQR = 39–60). Patients in both groups showed a decrease from baseline in BREAST-Q scores across all domains at the 6-week tissue expander follow-up. However, the scores after final reconstruction (6 and 12-month follow-ups) were higher than baseline for both groups of patients. There were no statistically significant differences in BREAST-Q scores in other domains. The sub-group analysis comparing the depression group on anti-depressant medication (n=36, 72%) to those on no anti-depressant medication (n=14, 28%) did not show any statistically significant differences in BREAST-Q scores across all domains. Six (17%) of the 36 patients with a prior diagnosis of depression were currently taking either bupropion or mirtazapine, two medications that have shown to have minimal effects on sexual function. These patients had clinically higher sexual well-being BREAST-Q scores at baseline (median=61) compared to patients taking anti-depressants that cause sexual dysfunction (median=53). CONCLUSION: Patients with a diagnosis of depression prior to breast cancer had lower BREAST-Q sexual well-being scores at the 6-week tissue expander follow-up, regardless of anti-depressant medication use. While at 6-weeks there is a difference in scores between the patients with depression and no depression, by 12 months no other differences are noted.

Tissue expanders; review of indications, results and outcome during 15 years’ experience

BackgroundTissue expanders (TE) are frequently used worldwide.In this study we surveyed outcome of our patients retrospectively during 15 years. Materials and MethodsWe had 1105 patients for whom 3059 TEs have been used. Demographic data, age, sex, indications, type of tissue expander devices, volume of devices, site of scar and site TE insertion, our technique for tissue expander insertion and flap design, complications and outcome were gathered. A complete and through technical points and tips will be discussed. ResultsIn 91% of patients overexpansion was done. (Expansion ratio=2.1–4.5). Re-expansion has been done in about 12% of patients. Complications were perforation of skin of pocket (11%) or exposure, infection (6%), dehiscence of the wound (1.5%), perforation of the port or disconnection of the tubes (2.1%), expansion of the scar itself (1%), saggy flap (3%), dog ear (5%), lack of adhesions of flap to its new site (4%). OutcomeIn 93% of the patients we could totally remove the scar. Around 9.1% of our patients had two sessions of expansion in the same area and 2.9% had three sessions of expansion. 51% of our patients were highly satisfied and 42% were satisfied of the results of expansion. ConclusionOur patients were satisfied with the results. In 12% cases we have done re-expansion. Re-expansion is possible as long as you have enough thickness of dermis in the skin. More than 50% of our patients were optimistic for 2nd or 3rd session of re-expansion.

Early Rehabilitation after Total Mastectomy and Immediate Reconstruction with Tissue Expander Insertion in Breast Cancer Patients: A Retrospective Case-control Study.

PurposeTo prevent surgical site complications, many plastic surgeons use the so-called “conventional protocol,” which immobilizes the shoulder and upper arm for 1 month after reconstruction. In an effort to improve the shoulder mobility of patients who received immediate breast reconstruction with tissue expander insertion (TEI), we introduced an early rehabilitation protocol with a short-term immobilization period of 2 weeks. This study aims to compare this early rehabilitation exercise program with the conventional protocol and to determine factors affecting shoulder mobility and quality of life of patients after immediate breast reconstruction.MethodsA total of 115 patients with breast cancer who underwent reconstructive surgery were retrospectively reviewed. For patients who underwent reconstruction before January 2017, the conventional protocol was followed with immobilization of their shoulder for over 4 weeks. Patients who underwent reconstruction after January 2017 were educated to undergo a self-exercise program after a short-term immobilization period of 2 weeks. We compared shoulder mobility, pain, quality of life, and complications at postoperative 1 and 2 months between the groups.ResultsPatients who received early rehabilitation showed greater shoulder flexion and abduction range at postoperative 1 month than those who received the conventional protocol. This increased shoulder abduction range continued until postoperative 2 months. There were no significant surgical site problems in both groups during the 2 months of follow-up.ConclusionTo enhance the recovery of shoulder mobility, early rehabilitation with a shorter immobilization period should be recommended to patients with breast cancer undergoing reconstruction surgery with TEI.Trial RegistrationClinicalTrials.gov Identifier: NCT03541161

RETRACTED: An erector spinae plane block for chronic pain management after tissue expander insertion

This article has been retracted: please see Elsevier Policy on Article Withdrawal (http://www.elsevier.com/locate/withdrawalpolicy). This article has been retracted at the request of the Editor-in-Chief as it contains fabricated/falsified data. The Editor-in-Chief decision was based on the investigation by the Japanese Society of Anesthesiologists which concluded that no research was conducted and all the data including patient backgrounds were fabricated. The society also concluded that the corresponding author, Dr. Ueshima presented the names of the individuals not involved or only partially involved in research as lead authors, presented the names of the individuals not involved in research as co-authors and submitted papers without the agreement of the co-authors. The investigation report can be found here.

Simple-safe-sure Fluid Drainage Just above Breast Tissue Expander using 18-Gauge Blunt Cannula.

The presence of seroma after breast tissue expander (TE) insertion for a long duration can cause infection and purulency; thus, obvious fluid collection around TEs should be drained as early as possible. However, due to the risk of puncture, it may not be possible to completely drain the fluid if it is located above the TE. To manage such cases, we used an 18-gauge blunt cannula and achieved good results. Among 98 cases in which breast reconstruction was performed with a TE, 5 patients had symptoms of infection with fluid collection just above the TE. In all 5 cases, resolution of the infection was observed in an outpatient setting without the removal or puncture of the inserted TE, by performing a drainage technique using an 18-gauge blunt cannula. An 18-gauge blunt cannula minimized the risk of expander rupture during drainage and enabled the complete aspiration of fluid, even when it was located just above the TE; thus, the resolution of infection with the preservation of the expander was possible in cases that would otherwise have been impossible to treat without the removal of the TE. This drainage procedure using an 18-gauge blunt cannula is considered to be simple, safe, and sure, with benefits that exceed the risk; thus, there should be no reason to hesitate in performing this drainage procedure, even in cases involving slight fluid collection around the TE.

Impact of hormonal therapy and other adjuvant therapies on contralateral breast volume change after implant-based breast reconstruction.

BackgroundAdjuvant therapy after breast surgery, including tamoxifen or aromatase inhibitors, improves the postoperative outcomes and long-term survival of breast cancer patients. The aim of this study was to determine whether volume changes occurred in the contralateral breast during hormonal or other adjuvant therapies.MethodsThis study reviewed 90 patients who underwent unilateral breast reconstruction between September 2012 and April 2018 using tissue expanders and a permanent implant after the surgical removal of breast cancer. The volume of the contralateral breast was measured using a cast before the first (tissue expander insertion) and second (permanent implant change) stages of surgery. Changes in breast volume were evaluated to determine whether adjuvant therapy such as hormonal therapy, chemotherapy, and radiation therapy influenced the volume of the contralateral breast.ResultsThe group receiving tamoxifen therapy demonstrated a significant decrease in volume compared with the group without tamoxifen (−7.8% vs. 1.0%; P=0.028). The aromatase inhibitor–treated group showed a significant increase in volume compared with those who did not receive therapy (−6.2% vs. 4.5%; P=0.023). There were no significant differences between groups treated with other hormonal therapy, chemotherapy, or radiation therapy. ConclusionsPatients who received tamoxifen therapy showed a significant decrease in volume in the contralateral breast, while no significant change in weight or body mass index was found. Our findings suggest that we should choose smaller implants for premenopausal patients, who have a high likelihood of receiving tamoxifen therapy.

Effectiveness and Safety of Tissue Expander for Adjuvant Helical Tomotherapy in Curatively Resected Retroperitoneal Sarcoma.

We investigated the effectiveness and safety of using a tissue expander (TE) for adjuvant helical tomotherapy (HT) for curatively resected retroperitoneal sarcoma (RPS). This study was conducted with 60 RPS patients who underwent curative resection with or without TE insertion followed by HT from June 2009 to December 2016. Among the patients, TE was inserted in 37 (61.7%). The quality of TE insertion was evaluated. Median follow-up after surgery was 19.4 months (range=4.5-93.2 months). A higher biologically-equivalent dose (α/β=10) was used with patients who had TE insertion (median, 72.0 gray [Gy] vs. 67.1 Gy, p=0.02). The quality of TE insertion was excellent in 18 patients (48.6%), good in 10 (27.0%), fair in seven (18.9%), and poor in two (5.4%). Toxicity was not significantly different according to TE insertion. Local recurrence-free survival (LRFS) was 78.2%, and overall survival was 95.6% at 3 years. TE insertion was not a significant factor for LRFS (91.1% in TE vs. 62.9% in non-TE group at 3 years, p=0.62). In the subgroup of patients with R1 or unknown tumor margin status, however, LRFS was marginally higher in the TE insertion group (100.0% in TE vs. 62.9% non-TE group at 3 years, p=0.05). HT with TE insertion as adjuvant RT for curatively resected RPS was feasible with acceptable toxicity. In the patients with R1 or unknown tumor margin status, LRFS was marginally higher in the TE insertion group after HT.

Tissue expander-stimulated lengthening of arteries for the treatment of midaortic syndrome in children

BackgroundMidaortic syndrome (MAS) is a rare condition characterized by stenosis of the abdominal aorta. Patients with disease refractory to medical management will usually require either endovascular therapy or surgery with use of prosthetic graft material for bypass or patch angioplasty. We report our early experience with a novel approach using a tissue expander (TE) to lengthen the normal native arteries in children with MAS, allowing primary aortic repair without the need for prosthetic graft material. MethodsWe conducted a retrospective review of patients with MAS undergoing the TE-stimulated lengthening of arteries (TESLA) procedure at our institution from 2010 to 2014. Data are presented as mean (range). ResultsFive patients aged 4.8 years (3-8 years) underwent the TESLA procedure. Stages of this procedure include the following: stage I, insertion of retroaortic TE; stage II, serial TE injections; and stage III, final repair with excision of aortic stenosis and primary end-to-end aortic anastomosis. Stage II was completed in 4 months (1-9 months) with 12 (7-20) TE injections. Goal lengthening was achieved in all patients. Stage III could not be completed in one patient because of extreme aortic inflammation, which precluded safe excision of the aortic stenosis and required use of a prosthetic bypass graft. The other four patients completed stage III with two (one to three) additional vessels also requiring reconstruction (renal or mesenteric arteries). At 3.2 years (1-6 years) of follow-up, all patients are doing well. ConclusionsThe TESLA procedure allows surgical correction of MAS without the need for prosthetic grafts in young children who are still growing.

Mucosal Perfusion Preservation by a Novel Shapeable Tissue Expander for Oral Reconstruction.

Background:There are few methods for expanding oral mucosa, and these often cause complications such as tissue necrosis and expander eruption. This study examines mucosal blood perfusion following insertion of a novel shapeable hydrogel tissue expander (HTE). The canine model used subgingival insertion of HTE following tooth extraction and alveolar bone reduction. The primary goal of this study was to gain understanding of epithelial perfusion and reparative responses of gingival mucosa during HTE expansion.Methods:Nine Beagle dogs underwent bilateral premolar maxillary and mandibular tooth extraction. Three to four months later, HTE-contoured inserts were implanted submucosally under the buccal surface of the alveolar ridge. After removal and following a 6- to 7-month period of healing, new HTE implants were inserted at the same sites. The area was assessed weekly for tissue perfusion and volume of expansion. Biopsies for histological analysis were performed at the time of expander removal.Results:Within 2 weeks following the second insertion, blood flow returned to baseline (defined as the values of perfusion measurements at the presurgery assessment) and remained normal until hydrogel full expansion and removal. Volume expansion analysis revealed that the hydrogel doubled in volume. Histological assessment showed no macrophage or inflammatory infiltration of the mucosa. No superficial fibrosis, decreased vascularity, or mucosal change was seen.Conclusion:Maintenance of adequate tissue perfusion is a clinically important aspect of tissue expander performance to reduce risk of device loss or injury to the patient, particularly for areas with a history of previous surgeries.

Catching and monitoring clinical innovation through performance indicators. The case of the breast-conserving surgery indicator

BackgroundThe evolution in the surgical and diagnostic procedures, the attention to women’s preferences, the case mix, and differences in professional practices may lead to a variability in the quality of breast cancer clinical pathway. To catch and manage this variability it is important to use valid measures. The aim of this paper is to examine the concurrent validity of the breast-conserving surgery (BCS) indicator and to provide evidence to guide the quality improvement process.MethodsThe BCS indicator was calculated using hospital discharge records (HDRs) and was validated against surgical registry (SR) data in a random sample of 336 women undergoing breast cancer surgery in 2012 in two Tuscan teaching hospitals. The concurrent validity of BCS was examined by cross-tabulating patients using the ICD-9 CM codes for breast surgery obtained from the two data sources.ResultsThe analysis, carried out involving breast cancer professionals, highlighted that the large majority of interventions coded as “mastectomies” in HDRs are in fact reconstructing procedures, including nipple-sparing, skin-sparing and skin-reducing mastectomies in SR. These results led us to refine the old algorithm, that calculates the proportion of breast-conserving surgery over the total number of breast interventions, and reclassify breast cancer surgical procedures into three categories: conservative, reconstructive and traditional mastectomy. Based on this new classification algorithm, the percentages of (I) reconstructive interventions were 16% at Florence TH and 38.3% at Pisa TH; (II) breast-conserving interventions were respectively 72.8 and 52.1%; and (III) mastectomies 11.2 and 9.6%. After adjusting for age in a logistic regression model, the percentages of reconstructive interventions at Florence and Pisa were respectively 22 and 34% and those of breast-conserving interventions 63 and 53%.ConclusionsOur results indicate that breast cancer care indicators should be refined by distinguishing reconstructive procedures (nipple/skin-sparing surgery with implant or breast tissue expander insertion) from traditional mastectomy. The involvement of breast care professionals in the choice of indicators proved to be crucial to capture the up-to-date breast cancer surgical practice and inform the quality improvement process.

Individual difference in pectoralis major muscle thickness and its effect on single-stage breast reconstruction using a tissue expander.

In breast reconstruction using a tissue expander (TE), sufficient coverage of the TE with the pectoralis major (PM) muscle, particularly with a musculofascial flap, is highly important for avoiding postoperative complications. In patients in whom the PM is thin, intraoperative trauma often occurs, leading to troublesome repair. The present study aimed to investigate the usefulness of preoperative measurement of PM thickness in planning of breast reconstruction using a TE. In this case-control study, we identified 68 patients (70 breasts) with mammary carcinoma treated with simple mastectomy and TE insertion from April 2014 to December 2016. We measured average PM thickness at two specific points, sternocostal PM distance on the long axis and sternocostal PM area preoperatively using magnetic resonance imaging. Then, we analyzed the difference in PM thickness among individuals and its relationship to intraoperative trauma to the PM or surgical difficulty creating a muscular pocket (delicate PM). Average PM thickness was significantly larger in younger patients (p=0.046) and those with larger breasts (p<0.01). In addition, average PM thickness on the affected side was significantly smaller in patients with delicate PM (12 breasts) (p<0.01). PM thickness had a significant influence on delicate or firm PM (odds ratio 27.40; 95% confidence interval 2.01-372.00; p=0.013). These findings demonstrate the usefulness of preoperative measurement of PM thickness in planning of breast reconstruction using a TE. Dissection should be performed more carefully in patients with average PM thickness less than 2.9mm.

Breast Pocket Irrigation with Antibiotic Solution at Implant or Tissue Expander Insertion: A Systematic Review and Meta-Analysis

Breast Pocket Irrigation with Antibiotic Solution at Implant or Tissue Expander Insertion: A Systematic Review and Meta-Analysis

Abstract: Reverse Abdominoplasty, a Viable Option for Breast Reconstruction

INTRODUCTION: The reverse abdominoplasty was first described in the 1970’s, and since then, it has been described for reconstruction of thoracic wall defects, upper abdominal wall contouring, and augmentation mammaplasty.1 It has received little attention in the literature, it can however be a useful method of breast reconstruction in a select group of patients, such as those who are obese. We present a series of 3 patients who underwent post-mastectomy breast reconstruction with the reverse abdominoplasty flap after being found unsuitable for other methods of breast reconstruction. METHODS: Three patients underwent breast reconstruction with reverse abdominoplasty, and complication and Breast-Q data were obtained prospectively. Patient 1 is a 55-year-old lady with a body mass index (BMI) of 48.30, who underwent 2 stage bilateral breast reconstruction with reverse abdominoplasty and insertion of tissue expanders. Patient 2 is a 49-year-old lady with a BMI of 38.40, who underwent 2 stage bilateral breast reconstruction with reverse abdominoplasty and insertion of tissue expanders. Patient 3 is a 36-year-old lady with a BMI of 28.00, who underwent reverse abdominoplasty to correct a unilateral partial mastectomy defect. RESULTS: Patients 1 and 3 did not experience any post-operative complications, and Patient 2 experienced minor wound healing problems. All three patients were satisfied with their outcomes, everyone having significant improvements in the Breast-Q scores across various domains. CONCLUSION: Although not for everyone, we present a safe and satisfactory option for breast reconstruction, when other usual methods of breast reconstruction are not available, especially in the obese patient group. DISCLOSURE/FINANCIAL SUPPORT:Supported by Flinders University Postgraduate Research Scholarship (to Dr. Eugene Koh). None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. REFERENCES: 1. Halbesma GJ, van der Lei B. The reverse abdominoplasty: a report of seven cases and a review of English-language literature. Annals of plastic surgery. 2008;61(2):133–137.

Distant blunt forceps dissection in tissue expander insertion: a novel technique

Tissue expansion using implantable expanders is a useful means of generating surplus tissue for reconstruction of defects such as scarring following burns. The authors describe their technique of incisions distant to the desired location of expander placement, and remote dissection of the expander pocket with hydrodissection and blunt forceps. A total of 81 expanders were placed in 30 consecutive patients, 81% of whom had burn scars due for reconstruction. During preparation, no complications, such as bleeding, were encountered, except one case with severe subdermal fibrosis, in which bleeding was stopped through brief application of pressure. Postoperatively, no complications were encountered in 76% of patients; however, 16.6% exhibited surgical site infection, which was managed conservatively and was correlated with a high number of expanders implanted at once. One patient experienced hematoma formation that resolved spontaneously, and one instance of expander extrusion and subsequent removal occurred. Receiving ≥2 expanders at the same time was statistically associated with higher risk for complication(s). The authors' complication rates were moderate and comparable with open or endoscopic approaches. Time of expansion is reduced compared with the open approach due to distant incision placement and immediate usability. Cost effectiveness appeared to be better using only inexpensive forceps, rather than elaborate and costly endoscopic equipment.

Expanded Cheek-Shaped Flap for Aesthetic Cheek Reconstruction in the Cervicoperiauricular Area.

The cervical area is well acknowledged as an ideal donor site for aesthetic reconstruction of the cheek, and tissue expansion may play an important role for maximally achieving such a purpose. However, the conventional design of the expanded cervical flap generally results in unsightly morbidity of the donor site. The aim of this study is to evaluate the results of using an improvised cervical expanded flap in aesthetic reconstruction of the cheek. From July 2004 to October 2012, a total of 23 burn sequelae patients (30 cheeks) underwent cheek reconstruction with an expanded flap that originated from the cervicoperiauricular area. The procedures were initially carried out with the insertion of a round tissue expander in the cervicoperiauricular area, followed by serial inflation of the expander, and finally, transplantation of the expanded flap to the cheek in a rotation advancement fashion. The donor site closure was along the auricular sulcus. The average area of the harvested flaps was 9.7 × 8.1 cm. All the flaps completely survived, only one major complication occur-a dome exposure of the tissue expander after the expansion was completed. The flap was salvaged, and the transfer stage was done without intact. Minor complications after flap transfer include: widened scar at the donor site, a "dog-ear" needing additional minor surgery, distal part of the flap transient congestion. The patients achieved very satisfactory results functionally and aesthetically. Using the expanded cheek-shaped flap technique can provide a safe, thin, and color-matched flap in aesthetic reconstruction of the cheek with minimal donor site morbidity.

Clinical outcomes of tissue expanders on adjuvant radiotherapy of resected retroperitoneal sarcoma.

We investigated the efficacy and safety of a tissue expander (TE) for adjuvant radiotherapy (RT) of resected retroperitoneal sarcoma (RPS).This study was conducted with 37 patients with RPS who received resection with or without TE insertion followed by RT from August 2006 to June 2012 at Samsung Medical Center. Among the 37 patients, TE was inserted in 19. The quality of TE insertion was evaluated according to the correlation of clinical target volume and retroperitoneal surface volume covered by TE and was defined as follows: excellent, ≥85%; good, 70% to 85%; fair, 50% to 70%; and poor, <50%. The median follow-up period after surgery was 47.9 months (range, 5.5–85.5 months).The quality of TE insertion was excellent in 7 (36.8%), good in 5 (26.3%), fair in 4 (21.0%), and poor in 3 (16.7%) patients. A significantly higher biologically equivalent dose (BED, α/β = 10) was used in patients who had TE insertion (median, 64.8 vs. 60.0 Gy, P = 0.01). Local control was 39.7%, and overall survival was 76.4% at 5 years. Local control was significantly higher in patients who received ≥65 Gy of BED, 100.0% in contrast to 22.8% (P = 0.01). One patient with a history of multiple tumor resections showed abdominal infection with duodenal perforation of uncertain cause but had the potential of being related to TE and/or RT. Otherwise there were no ≥grade III acute or late toxicities.TE for adjuvant RT in RPS is feasible for delivering a higher RT dose with acceptable toxicity.