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Use of tissue expanders and pre-operative external beam radiotherapy in the treatment of retroperitoneal sarcoma.
INTRODUCTION: We report our experience of treating retroperitoneal sarcoma (RPS) using pre-operative external beam radiotherapy (EBRT) in combination with radical resectional surgery from 1990 to 2005. METHODS: Twenty-eight primary and 10 recurrent tumors were identified from a prospective database. RESULTS: The resection rate was 71% overall; 82% in primary (23/28) and 40% (4/10) in recurrent cases. EBRT was administered preoperatively in 25 patients, postoperatively in 1, and palliatively in 11. In 33 patients a saline-filled tissue expander was inserted into the abdomen before radiotherapy to displace small bowel from the radiation field. 4,500-5,000 cGy was administered in fractions of 180-200 cGy over a 5-week period; surgery followed 6-8 weeks later. Expander insertion was associated with minimal morbidity; 31/37 patients received a dose of 4,000 cGy or more (median 4,650 cGy). Median resected tumor diameter was 13 cm, and a median of three adjacent organs was resected per patient. Complete macroscopic resection was achieved in 25/27 patients (93%); R0 in 9 (33%) and R1 in 13 (48%) (microscopic margins unclear in 5). There was no postoperative mortality. Tumors were high-grade in 20 patients, low-grade in 14 and ungraded in 4. Actuarial 5- and 10-year survival for all patients was 74 and 60%. For operable primary tumors, the 5-year survival and disease-free rates were 90 and 80%. In four patients with operable recurrent tumors, median disease-free interval was 91 months (27-160). In the 11 inoperable cases, median survival after radiotherapy was 48 months (9-77). CONCLUSIONS: We conclude that a combination of pre-operative tissue expander placement, high-dose EBRT and radical resectional surgery can achieve acceptable morbidity, extended survival and low long-term recurrence in patients with RPS. STATISTICS: Median (interquartile range).
Magnetic resonance imaging of soft tissue expanders used in the management of musculoskeletal sarcomas.
A soft tissue expander is surgically inserted into the body to displace radiosensitive organs from the treatment field in a small number of patients receiving radiotherapy for musculoskeletal sarcoma. MRI is routinely used to monitor the response to the radiotherapy, local recurrence and complications of treatment. This study retrospectively reviews MRI of soft tissue expanders in seven patients with musculoskeletal sarcomas; six arising in the pelvis and one in the retroperitoneum. In the absence of an appropriate clinical history, the soft tissue expander may be mistaken for a pathological fluid collection such as abscess, post-operative seroma or even recurrent tumour. MRI of the soft tissue expanders and potential errors in image interpretation are illustrated.
Nasal reconstruction with the rapidly expanded forehead flap.
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Clinical applications of tissue expansion in head and neck surgery.
Tissue expansion offers a new frontier in head and neck reconstruction in that it provides the capability of creating additional new skin for restoration of defects with skin of identical color, thickness, and appendages. The applicability of tissue expansion is only beginning to be appreciated as it is used in various aspects of head and neck surgery. Currently, the technique is most frequently used in scalp surgery for correction of male pattern baldness. Other uses of tissue expansion are in cranial facial surgery and expansion of distant, regional, or microsurgical flaps. Perhaps its greatest value from a reconstructive perspective, however, is in providing new skin for reconstruction of various facial defects through the use of primary wound closure or a multitude of local flaps.
The use of tissue expanders in the correction of ectropion in an animal model.
The use of tissue expanders in eyelid reconstruction has seen limited application. To determine the efficacy of tissue expanders in the correction of cicatricial ectropion, an animal model was developed. Lower-eyelid blepharoplasty with overcorrection was performed on 18 New Zealand white rabbits. After 1 month, if significant ectropion was present, tissue expanders (1.8-cm3 Cylindrical/Microdome [CUI Corporation, Carpinteria, Calif.]) were inserted on one side, the other eye being the control. These were inflated in the following weeks to a total volume of 2 cm3. The tissue expanders were then removed, and the animals were followed for 1 month. Although the early results were encouraging, the ectropion progressed toward its preoperative severity. It appears that lower-eyelid ectropion remains a therapeutic problem that is only partially corrected with tissue expansion alone.
Implantation of a soft-tissue expander before operation for club foot in children.
Primary skin closure after surgery for club foot in children can be difficult especially in revision operations. Between 1990 and 1996 a soft-tissue expander was implanted in 13 feet before such procedures. Two were primary operations and 11 were revisions. A standard technique was used for implantation of the expander. Skin augmentation was successful in 11 cases. There was failure of one expander and one case of wound infection. Sufficient stable skin could be gained at an average of five weeks. Primary skin closure after surgery was achieved in 12 cases. We conclude that soft-tissue expansion can be used successfully before extensive surgery for club foot. The method should be reserved for revision procedures and for older children. The technique is not very demanding, but requires experience to achieve successful results.
[Possibilities and problems in the use of skin expanders].
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Palatal mucoperiosteal expansion as an adjunct to palatal fistula repair: case report and review of the literature.
Case report of conventional palatal soft-tissue expansion in an attempt at cleft palate fistula closure with a standard tissue expander. This technique may be an alternative to a tongue flap to promote closure of persistent oronasal fistula.
Radiographic and histologic assessment of calcium sulfate in experimental animal models and clinical use as a resorbable bone-graft substitute, a bone-graft expander, and a method for local antibiotic delivery. One institution's experience.
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A system for three-dimensional shape measurement and its application in microtia ear reconstruction.
Microtia is one form of ear anomalies representing the defect of a partial or total loss of external ear. This paper describes new method of total auricular reconstruction which combines the use of tissue expander and the non-contact, 3-dimensional (3-D) shape measurement system. The anterolateral and posterior surface of the both sides of the ear of the patients were measured with the 3-D shape measurement system. The data from normal side was mirror-imaged electronically and transferred to the computer-controlled milling machine to create the life-sized, mirror-image wax model. These models were sterilized and used as a template or an aid during assembling procedure of the autologous cartilage framework in order to reproduce the 3-D configuration of the wax model. Seven cases were treated with this method and 5 cases (72%) were graded as excellent (superior to that result obtainable from conventional methodology), one each (14%) was good (better result) and fair (the same level). There are no poor evaluations. In two cases, the exposure of the expander, one of the major complications, developed. Although additional surgery was needed, excellent and fair result was obtained in these cases. It was concluded that the method presented here was evaluated as an overall good method and its application should be further extended.
Endothelial cell seeding of polymeric vascular grafts.
Pioneers in the field of small diameter graft development sought to promote graft endothelialization and, thereby, increase patency by transplanting a varying degree of autologous endothelial cells onto vascular grafts prior to implantation. This process has become known as endothelial cell seeding. The underlying hypothesis is quite simple; that is, by promoting the establishment of the patient's own endothelial cells on the blood contacting surface of a vascular prosthesis, a "normal" endothelial cell lining and associated basement membrane, together known as the neointima, will form on the graft and counteract the rheologic, physiologic, and biomaterial forces working synergistically to promote graft failure. After 30 years of research in this area, this simple hypothesis has proven to be deceptively naive. The purpose of this review is to summarize the historic context and current base of knowledge regarding many of the technical issues relevant to the endothelial cell seeding process. Special attention is given to electrostatic endothelial cell seeding, the latest research methodology designed specifically to accelerate endothelial cell adhesion and morphological maturation onto expanded poly(tetrafluoroethylene) (e-PTFE) small diameter vascular grafts.
Salvage of exposed implants.
With increased use of tissue-expanders the incidence of exposed implants is expected to rise. Eight cases with salvage of an exposed implant are presented. At repair great care was taken to prevent tension on the suture lines either by reducing the volume of the implant or by using a skin flap. Seven patients healed without further complications. In one patient the implant had to be removed due to reexposure. We find that salvage of implants should be tried in suitable cases. If this procedure is not successful a traditional surgical procedure with removal of the implant only has to be delayed for a short time.
Treatment of severe developmental asymmetry of the female breast.
In a material of 49 female patients with severe developmental breast asymmetry, Poland's syndrome and isolated unilateral hypoplasia were the most frequent etiological factors (69%). Prosthetic augmentation alone, transfer of the de-epithelialized latissimus dorsi musculocutaneous flap to fill up the infraclavicular hollow, combined with an expander prosthesis for the breast, or augmentation with tissue from the contralateral "healthy" hypertrophic breast were found to be the methods of choice in selected cases. In order to achieve optimum symmetry the contralateral ptotic/hypertrophic breast should be corrected in most patients.
Tissue expansion in functional and aesthetic reconstruction of the trunk and extremities. Case report.
To illustrate how the technique of tissue expansion may be adapted for different types of reconstruction, the following cases are described: a 10-year-old girl with a circumferential naevus from shoulder (at the back) and umbilicus (at the front) to the knees; a 3-year-old boy with a severe injury to the left arm; a 36-year-old man with an amputation injury of the left hip; and an 18-year-old girl with scars from a complicated fracture of the left lower leg. In all cases function and/or appearance were considerably improved.
The effects of venous blood, silicone gel and prilocaine on capsular contraction around silicone implants studied with a new method in the rat.
The pressure exerted by wound tissue on a subcutaneously implanted silicone expander was studied in rats. A significant increase in pressure was noted four and eight weeks postoperatively when venous blood was instilled into the cavity around the expander, but this increase was significantly reduced at eight weeks if 1.0 ml of prilocaine 5 mg/ml with adrenaline 4 micrograms/ml was instilled at the same time as the blood. Instillation of silicone gel outside the expander tended to increase the pressure eight weeks postoperatively, but there was no increase when silicone gel was given together with prilocaine and adrenaline. The next step is to investigate whether prilocaine with adrenaline instilled around an implanted mammary prosthesis in humans is not only capable of reducing pain and bleeding but can also inhibit capsular contracture.
Reconstruction of ischial pressure ulcers by skin expansion.
Ten patients, eight of whom were paraplegic, have had ischial pressure ulcers treated by skin expansion. Skin expanders 680 ml in size were inserted subcutaneously on the posterior aspect of the thigh. They were filled during a short period without complications, the filling being monitored with a cutaneous tonometer. At a second operation the ulcers were repaired easily with the expanded flaps. After a few weeks the patients were able to undergo a programme of rehabilitation that included sitting with the expanded flaps. No ulcers recurred during a median follow-up of 12 months (range 8-34).