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PubMed1998

Breast reconstruction in previously irradiated patients using tissue expanders and implants: a potentially unfavorable result.

There exists a paucity of definitive information on the suitability of implant reconstructions in previously irradiated breast cancer patients. This controversial topic prompted a review of our prosthetic reconstructions in this select group of patients. A retrospective study of patients treated between 1976 and 1993 with lumpectomy and radiation therapy for early breast cancer revealed 67 patients with local recurrences. Nine of these patients (10 breasts) underwent a two-stage prosthetic reconstruction following a salvage mastectomy. The average age was 47.9 years. The mean dose of irradiation was 6,070 cGy. The average interval from radiation therapy to placement of a tissue expander was 4.6 years. In one patient (10%) the tissue expander extruded. The average follow-up for 8 patients (9 breasts) who underwent exchange to a permanent prosthesis was 5.1 years. In four reconstructions (40%) there was an uneventful postoperative course. Two cases (20%) were difficult to expand and the final result lacked projection. One patient (10%) developed an infection requiring removal of the permanent prosthesis. Two patients (20%) developed Baker class III or IV capsular contractures. Overall, in our group of 10 implant reconstructions, 60% of the patients resulted in either a complication or an unfavorable result.

Breast Implantation↗
PubMed1998

The combined use of the TRAM and expanders/implants in breast reconstruction.

The transverse rectus abdominis musculocutaneous (TRAM) flap has replaced the prosthetic implant as the first choice for breast reconstruction. However, we have found several incidences when the volume of autogenous tissue cannot fulfill the requirements for symmetry, especially in those patients with limited abdominal tissue and large ptotic breasts. The TRAM flap can be combined with tissue expanders and implants to obtain symmetry in these difficult reconstructive situations. Here we present our experience with the use of the TRAM flap in conjunction with expanders and saline implants. Between June 1993 and November 1996, 4 patients underwent immediate TRAM reconstruction in conjunction with saline implants or tissue expanders. In 3 patients a tissue expander was placed beneath the pectoralis muscle following the microanastomoses and prior to insetting the flap. Expansion was initiated 2 to 6 weeks postoperatively and continued over a period of 1 to 3 months. Permanent implants were placed at 3 to 4 months following the initial procedure. The final patient underwent a bilateral free TRAM with the placement of bilateral saline implants at the time of the initial reconstruction. One implant was placed beneath the pectoralis whereas the other was placed beneath the TRAM flap. Saline implants were used in all patients. The decision to use the combination of implants and TRAM flap was multifactorial and included position of donor scar in all patients, large ptotic breasts in 2 patients, request for contralateral augmentation in 2 patients, and an absence of adequate abdominal tissue in all patients. In addition, large skin deficits were present in 3 patients following mastectomy requiring the skin coverage provided by the TRAM flap. The average age of the patients was 41 years. Expanders were left in place for an average of 16 weeks. Average final implant volume was 210 cc. The average follow-up was 24 months, during which time there were no episodes of flap compromise, partial flap loss, or fat necrosis. The TRAM flap in combination with tissue expansion and implants provides an additional alternative in postmastectomy reconstruction. This technique is particularly useful in those patients in whom the need for TRAM skin coverage is combined with inadequate autogenous tissue and the patient request for large ptotic breasts.

Adult↗
PubMed1998

Versatility of tissue expansion in head and neck burn reconstruction.

Tissue expansion has enjoyed a wide range of applications since the technique was popularized by Radovan in 1978. A useful application of tissue expansion is in the reconstruction of the head and neck following burn injury. From July 1986 to March 1990, 25 patients underwent head and neck reconstruction for burn injury using tissue expanders. A retrospective chart review was undertaken. The average age was 24 years, and the age range was 9 months to 46 years. Fourteen males and 11 females were treated. A total of 51 expanders were placed, and the most common locations of the expanders were the cheeks, neck, and scalp. The time period from burn injury to reconstruction averaged 22.7 months. Operative time for placement of the expanders ranged from 40 to 180 minutes. The average time for full expansion was 86 days. Major complications were those that required an additional operative procedure, and included one dehiscence, one infection, and one port failure. The major complication rate was 12%. Minor complications were those that did not interrupt the expansion process or require any operative intervention. The minor complication rate was 32%, and included three cases of exposure, three cases of wound dehiscence, one seroma, and one ruptured implant. Minor complications were frequent, although when managed conservatively they did not compromise the overall outcome. Despite a major complication rate of 12%, final reconstruction was achieved in all patients. This retrospective review demonstrates that tissue expansion is a versatile adjunct in the treatment of burn injuries to the head and neck, and reconstruction in this area can be accomplished with excellent cosmetic results.

Adult↗
PubMed1999

The use of tissue expanders in staged abdominal wall reconstruction.

Reconstruction of large abdominal wall defects not amenable to primary closure remains a challenging problem. Various reconstructive techniques have been described in the surgical literature each with its advantages and disadvantages. In this report the authors describe their experience in treating 11 patients with large abdominal wall defects utilizing prosthetic mesh in conjunction with tissue expanders. Between 1986 and 1997 there were 6 pediatric and 5 adult patients treated with this method. The etiology included three congenital omphaloceles, five cases of necrotizing fasciitis, and three gunshot wounds. All patients initially required insertion of prosthetic mesh to bridge their large abdominal wall defects. This was followed by staged abdominal wall reconstruction with tissue expanders and prosthetic mesh. None of the patients had mesh infection or extrusion, and none developed enteric fistula or recurrent hernia. The tissue expansion process was well tolerated by all patients. One patient had partial exposure of the tissue expander due to thinning of the expanded skin. Our results suggest that the use of tissue expanders provides reliable, well-vascularized soft-tissue coverage and minimizes potential mesh-related complications in abdominal wall reconstruction.

Abdominal Muscles↗
PubMed2000

Skeletal deformities due to tissue expanders: report of two patients.

Two patients, burned at ages 2 and 5, developed scars that required multiple reconstructive operations over a period of several years. Tissue expanders were used as part of their reconstructive procedures. After the expanders were removed, skeletal deformity was encountered in the area underlying the expander in each patient. Patient 1 had deformity of the rib cage, and Patient 2 had deformity of the outer table of the skull. No treatment was felt to be indicated. Surgeons should be aware of the possibility of the development of this problem.

Burns↗
PubMed2001

Results of immediate breast reconstruction after skin-sparing mastectomy.

Skin sparing mastectomy (SSM) removes the breast, nipple-areolar complex, previous biopsy incisions, and skin overlying superficial tumors. Preservation of the native skin envelope facilitates immediate breast reconstruction. The procedure has been adopted for the treatment of breast cancer. All cases of SSM and immediate breast reconstruction performed by the senior author (G.W.C.) from January 1, 1993, through December 12, 1997, were reviewed. Patient demographics, cancer staging, treatment, types of surgery performed, and postoperative outcomes were examined. Aesthetic outcomes were measured using four 3-point subscales. A total of 100 patients underwent 118 SSMs during the study period. The American Joint Committee on Cancer staging was as follows: stage 0, 27 patients; stage I, 25 patients; stage II, 39 patients; stage III, 7 patients; stage IV, 3 patients; recurrent, 2 patients; and cystosarcoma phylloides, 1 patient. The mean follow-up was 42.7 months. Local recurrence occurred in 2 patients (2.7%). Reconstructive methods included the transverse rectus abdominis musculocutaneous flap (N = 82; pedicled, 73; free, 9), the latissimus flap (N = 18), and tissue expansion (N = 20). Two patients underwent contralateral delayed reconstruction. The aesthetic results achievable with the three methods were similar. The failure rate was higher for expander reconstruction (10%) than those observed for transverse rectus abdominis musculocutaneous (4.9%) and latissimus (5.6%) flaps. SSM can be used in the treatment of invasive breast cancer without compromising local control. The aesthetic results of the three methods were similar, but tissue expander reconstruction had a higher failure rate.

Adult↗
PubMed2001

Skin-sparing mastectomy with staged tissue expander reconstruction using a silicone gel prosthesis and contralateral endoscopic breast augmentation.

Women with an A or B cup-size breast with no ptosis or glandular ptosis underwent a skin-sparing mastectomy through a periareolar incision. A submuscular tissue expander was placed for immediate reconstruction. The periareolar incision was closed using a modified pursestring technique. The reconstructed breast was expanded to a C cup size. The expander was removed and replaced with a silicone gel prosthesis. At the time of tissue expander removal, the contralateral breast underwent endoscopic augmentation. Nipple-areolar reconstruction was performed during a third stage to cover the mastectomy scar. Implant reconstruction of the breast frequently results in a breast mound that has greater upper breast fullness than the opposite breast. By augmenting the opposite breast, better symmetry is achieved. Burden WR. Skin-sparing mastectomy with staged tissue expander reconstruction using a silicone gel prosthesis and contralateral endoscopic breast augmentation.

Breast Implants↗
PubMed2002

Tragic case of a dog bite in a young child: the dog stands trial.

The authors present the tragic case of an 18-month-old child who was bitten by a dog, causing amputation of the forearm and substantial damage to the cutaneous muscle on his back, shoulder, thorax, and neck. A free latissimus dorsi flap was performed to preserve the humerus from which the periosteum had been torn away. A series of cutaneous expansions were then undertaken to graft skin back onto the back, the armpit, and the shoulder stump, to allow for a mechanical prosthesis. A study of the literature on this subject proves that dog bites are more frequent and serious (sometimes even fatal) in young children than in adults. In view of the current legislation, it would seem that the public health authorities are doing little to resolve this distressing problem.

Amputation, Traumatic↗
PubMed1990

Skin expansion--a sword that "stretches" two ways: scalp expansion and bone erosion.

Tissue expanders, which are used to enlarge the soft tissue of the scalp, eroded the outer table of the skull as well as a portion of the inner table. The patient in this case study is documented with photographs, and the entity of pressure due to skin expanders is discussed. A growing list of complications makes it important to be aware of the possible pitfalls of expanders and to discuss them with patients and/or their families, particularly when tissue expanders are used in children.

Dermatologic Surgical Procedures↗
PubMed2003

Pediatric tissue expansion: indications and complications.

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.

Adolescent↗
PubMed2004

Alopecia treatment with scalp expansion: some surgical fine points and a simple modification to improve the results.

In the current study, authors present their clinical experience with the esthetic reconstruction of alopecia by means of a tissue expansion technique in 74 consecutive patients who were treated between May 1986 and June 2002 in the Department of Plastic and Reconstructive Surgery. The principles of the conventional technique are mentioned briefly, but the authors essentially tried to explain a number of surgical fine points together with some simple modifications so as to get the maximum profit from the expanded tissue and to decrease the complication rate. In the first 39 patients of this study, who were treated with a conventional tissue expansion technique, the major complication rate was found to be 15.4%. In the last 35 patients, this rate was found to be decreased to 5.7%. The improvement in the major complication rate is attributed to the authors' surgical modifications compared with the conventional technique. The article provides a supplement to the existing literature, underscoring the importance of some surgical fine points and outlining a systematic way of planning expander placement and tissue expansion.

Adolescent↗
PubMed1991

Matrix engineering.

Matrix engineering is a technology that utilizes hyaluronan (HA, hyaluronic acid) based matrices to control, direct or augment tissue regenerative processes. Hyaluronan and the concept of matrix engineering have become established tools in ophthalmic and orthopaedic medicine. The clinical indications for HA are limited by the physical properties and short residence time of the natural HA molecule. To expand and improve upon its current medical applications, a family of HA derivatives was prepared by chemical modification and cross-linking. Relative to the non-modified HA molecule, the hylan family of polymers provides more versatile physical forms, improved mechanical properties and an extended residence time. Hylan can also be used as a surface coating to improve blood compatibility. The chemical, physical and biological properties of hylans will be reviewed, focusing on the specific therapeutic indications they enable.

Animals↗
PubMed1987

Eyelid reconstruction using temporary tissue expanders and cartilage grafts.

Temporary tissue expanders have been used in general plastic surgery to expand skin for breast reconstruction and for scar revision. A specifically designed eyelid tissue expander was used to reconstruct both upper and lower eyelids in a patient suffering a severe lye burn. The implant consists of an expander and a reservoir, connected by silicone tubing. The implants are inserted into the remnant of both eyelids and expanded slowly with multiple injections of saline into the reservoir. After full expansion is achieved the expanders are removed and ear cartilage grafts inserted into the eyelids. The newly created eyelids resemble normal eyelids. The technique of tissue expansion has had very limited use in oculoplastic surgery but new applications are waiting to be discovered.

Adult↗
PubMed1991

A modified tissue expander for socket enlargement in clinical anophthalmos.

Early and rapid expansion of the tiny socket is desirable in clinical anophthalmos. This paper reports three cases utilizing an expandable conformer made of silicone. Socket enlargement adequate for fitting of a satisfactory cosmetic prosthesis was attained rapidly in each case. The design of the conformer allows the greatest expansion toward the fornices.

Anophthalmos↗
PubMed1992

Stimulation of orbital growth by the use of expandable implants in the anophthalmic cat orbit.

We evaluated the efficacy of expandable orbital implants to stimulate bone growth in the anophthalmic cat orbit. Eighteen cats unilaterally enucleated at 2 weeks of age received either expandable orbital implants (groups A1 and A2), solid silicone sphere implants of 12 mm or 8 mm (groups B1 and B2), or no implant (group C). Those cats with expandable implants (group A) had the implant size increased by 0.5 ml injections of saline at 2-week intervals starting at 8 weeks of age until a final volume of 4 cc was reached. Four of the expandable implants were found to be only partially inflated at 20 weeks and were subgrouped A2. At 20 weeks of age, the anophthalmic orbits with fully inflated expanders showed no significant difference in either orbital volume or orbital entrance area when compared with control orbits: volume (91.2%), area (95.7%) (p = 0.01). These same orbits also showed a significant increase in both orbital volume and orbital entrance area when compared with the growth obtained by any other group. These other groups showed growth, expressed as a percentage of normal growth, as follows: partially inflated implant: volume (63.0%), area (69.0%); 12-mm sphere implant: volume (57.0%), area (54.5%); 8-mm sphere implant: volume (46.5%), area (44.6%); no implant: volume (47.6%), area (43.6%) (p = 0.01). This study suggests that the use of expandable orbital implants stimulates bony growth in the immature cat orbit. Bony stimulation was proportional to volume implanted, and expandable orbital implants achieved maximum bony stimulation in the groups studied.

Animals↗
PubMed1997

The effect of maturation on the ability to stimulate orbital growth using tissue expanders in the anophthalmic cat orbit.

Tissue expanders were used to stimulate orbital growth at different stages of maturity in the immature anophthalmic cat orbit. Twelve cats had the right globe enucleated at 2 weeks of age and tissue expanders implanted in the orbit. The cats were randomized into four groups (A, B, C, and D). The tissue expanders remained in the nonexpanded state for a preassigned length of time. Orbital volume was determined on each cat using computed tomography (CT) immediately prior to expansion of the implant. Expansion began at age 10 weeks for group A, 15 weeks for group B, and 25 weeks for group C and involved 0.7 cc injections of saline at 2-week intervals until a final volume of 4.5 cc was obtained. Group D remained as a nonexpansion control group. Four to 5 weeks after expansion was completed, a second orbital volume CT was obtained on each animal and compared with the pre-expansion CT. The right orbits of group A, had pre-expansion (week 10) orbital hypoplasia with a volume 26.2% smaller than the left control orbits. Postexpansion (week 25), the right orbital hypoplasia had decreased to a volume 10.3% less than the left control orbits. The right orbits of group B had pre-expansion (week 15) orbital hypoplasia with a volume 35.6% smaller than the left control orbits. Postexpansion (week 31), the right orbital hypoplasia had decreased to a volume 25.9% less than the left control orbits. The right orbits of group C had a preexpansion (week 25) orbital hypoplasia with a volume 39.8% smaller than the left control orbits. Postexpansion (week 41), the right orbital hypoplasia had decreased to a volume 29.3% less than the left control orbit. Tissue expanders, expanded in the hypoplastic immature cat orbit stimulated orbital growth and reversed orbital bony hypoplasia to varying degrees. The amount of growth stimulated was inversely proportional to the age at which expansion began. Orbital growth, stimulated by tissue expander expansion, was also demonstrated after the normal age of cat orbit maturation (weeks 28-30).

Animals↗