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Tissue expansion has become a popular method of reconstructive surgery over the last few years and is used to reconstruct a wide range of defects. This article aims to outline the technique and results of tissue expansion on the plastic surgery unit in Bradford.
Tissue expansion has now achieved an important place in reconstructive surgery, since the first experiments about 10-15 years ago. Expanded tissue used in reconstruction is usually excellently matched for colour, thickness, elasticity and other physical properties. This is particularly important in reconstructions in the head and neck region. Tissue expansion is also used increasingly for breast reconstruction all over the world. It is now the most common procedure for breast reconstruction in USA. Various options using either a temporary or a permanent expander are discussed.
Tissue expansion in dermatologic surgery has gained wide acceptance. We report the case of a patient with basal cell carcinoma in whom a Foley catheter was used for immediate intraoperative tissue expansion. Wound tension was decreased significantly and primary closure obtained. This technique is appropriate for office surgical procedures and provides an alternative approach to wound closure with flaps and grafts. The Foley catheter is an inexpensive and disposable tissue expander.
Tissue expansion is used to facilitate reconstruction procedures following trauma and cosmetic breast augmentation. This article describes tissue expansion, reviews intraoperative expansion techniques, and discusses the nurse's role in the procedure.
Tissue expansion is a recent advance in skin cover technique. Its empirical use has enabled many previously difficult reconstructions to be completed without recourse to distant flaps. Its high complication rate and lack of basic scientific understanding at present restrict its use to selected cases, but the quality of repairs possible by this method encourage further serious scientific study.
The tissue extension method was applied in 13 patients with cicatricial alopecia of the scalp. Eighteen Soviet-made tissue expanders were used. Clinical experience showed that the sequelae of burns of the scalp attended by alopecia should be treated by tissue extension. The growth of hair can be restored on up to half of the scalp surface by expansion of the local tissues by their direct transfer and by additional formation of grafts for contour plastics. Plastics by expanded tissues is indicated for closure of naked bones of the vault of the skull.
Soft-tissue expansion in the lower extremities is typically well tolerated. The more proximal one is--that is, the closer to the thigh and buttocks--the easier and less complication prone the expansion will be. It is another valuable technique for resurfacing the lower extremity and for reconstructing defects in contour and in skin character. There are limitations to this technique, which generally is most useful in late reconstructions. Intraoperative expansion has no place in lower extremity reconstruction. Soft-tissue expansion may be limited by an unsuitable geometry or the sheer size of defects. It should not be used next to open wounds. Soft-tissue expansion offers significant advantage in that the coverage of a defect will be replaced with tissue like that lost. Seldom does one see necrosis of advanced flaps, so that there is little risk of tissue loss in using this modality. There is an excellent vascularity to the flaps and an excellent character to the skin. In addition, in this cost-conscious era, soft-tissue expansion is quite cost effective, and in many cases the procedures can be conducted on an outpatient basis with a minimum of hospitalization, if any. With care to select patients properly, design carefully, and conduct expansion in a leisurely fashion, soft-tissue expansion offers a valuable means of reconstructing both large and small lower extremity defects.
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.
Historically, tissue expansion is a prolonged process, typically requiring at least 6 weeks to complete. Recently, interest has increased in shortening this time period. In the current study, a continuous infusion device maintaining constant expander pressure less than capillary filling pressure was used in a canine model in seven dogs to minimize the time period needed to achieve significant expansion. There were no complications, except one device malfunction, corrected by changes in design. The process was shown to be a safe and effective means of producing amounts of expansion similar to traditional methods in approximately 72 hours, with expansion of 28 percent (n = 6) for continuous tissue expansion (CTE) versus 34 percent (n = 6) for a 2-week rapid expansion protocol. This expansion was derived from either stretch of preexisting tissue (46 percent for CTE, 35 percent for 2-week expansion) or recruitment of adjacent tissue. The clinical application of continuous tissue expansion could permit the advantages of tissue expansion to be obtained in many more situations than are currently available to traditional tissue expansion techniques.
Tissue expansion alters the function of skin cells. We studied the effects of expansion on the contractile function of dermal fibroblasts using an in vitro model, the fibroblast-populated collagen lattice (FPCL). Spherical expanders were placed dorsally in 30 Sprague-Dawley rats; one-half were serially inflated. One, 2, and 4 weeks later, 5 rats from each group were killed. Fibroblasts were cultured from dermis overlying the expanders and mixed with collagen, medium, and serum in petri dishes to form FPCL. Fibroblasts from 5 rats that had not undergone surgery were cultured to make control FPCL. Contraction was assessed by measuring the areas of the FPCL. At 48 hours, FPCL containing expanded fibroblasts had contracted significantly less than those containing unexpanded or control fibroblasts. Four weeks of expansion resulted in less contraction than 1 or 2 weeks. Tissue expansion inhibits the in vitro contractile function of dermal fibroblasts in the rat in a time-related fashion.
The history of tissue expansion, technique, indications, and complications are reviewed. A detailed review of delayed tissue expansion's histologic, biochemical, biomechanical, and physiologic changes in the skin is given. There is a net gain in epidermal tissue during delayed expansion. Recent experimental and clinical experience suggests that expansion for 1 to 2 weeks is just as effective as longer delayed expansion for 6 to 8 weeks. A new deviation from standard technique, intraoperative tissue expansion, may have significant implications for dermatologic surgery. Intraoperative tissue expansion is explored in relation to other commonly used techniques of intraoperative load cycling.
A quantitative comparison of the effects on tissues is performed between chronic tissue expansion, intraoperative expansion, and load cycling in a guinea pig model. Intra-operative expansion, which was developed by Sasaki as a method of immediate tissue expansion for small- to medium-sized defects, and load cycling, which was described by Gibson as a method using intraoperative pull, are compared with chronic tissue expansion on the basis of the following four parameters: amount of skin produced, flap viability, intraoperative tissue pressures, and histological changes. The chronically expanded group, which included booster and nonbooster expansions, produced a 137% increase in surface area, or a 52% increase in flap arc length, whereas intraoperative expansion resulted in a 31% increase in surface area, or a 15% increase in flap arc length. The load-cycled group, however, resulted in an almost negligible amount of skin increase. All three techniques exhibit immediate postexpansion stretchback. Flap viability is not impaired by any of the three techniques, in spite of the elevated pressures observed during expansion. Therefore, intraoperative expansion is effective primarily for limited expansion of small defects, whereas chronic tissue expansion still provides the greatest amount of skin increase when compared with other techniques.
We report a modification of the controlled tissue expansion technique, that is, immediate intraoperative tissue expansion. The procedure is performed by placing tissue expanders at the time of surgery. After placement, three to four cycles of inflation/deflation of the expander for 3 to 5 minutes are performed. In a one-stage procedure the stretched skin is then immediately used to close the surgical defect. Three case reports demonstrating the immediate intraoperative tissue expansion technique, in which the Foley catheter balloon was used as the tissue expander, are presented. These cases illustrate that this technique may allow the surgeon to cover defects more easily with less tension and with a better cosmetic result than with other closure techniques.
Tissue expansion is indicated in the reconstruction of various defects of the head and neck in instances where there is inadequate adjacent tissue to allow either primary closure of the defect or repair with a local flap. It may also be indicated in instances where repair of a defect by an alternative method such as a local, regional, or distant flap will result in an unacceptable donor or recipient site deformity. Although tissue expansion is simplistic in concept, it does require judgment and indepth preoperative planning to ensure optimal results. The complication rate is high for tissue expansion in the head and neck, particularly in the cheek and neck area. Despite the frequency of complications, in the vast majority of cases the intended reconstruction is successful.
To assess the advantages of tissue expansion as a method of breast reconstruction, a prospective, consecutive study was carried out in 41 women who had undergone mastectomy. The expander was positioned in the submuscular plane and expanded weekly to double the volume of the calculated permanent implant. A permanent gel implant was inserted after 10 weeks. Two examiners judged the rate of capsular contracture after 15 and 32 months according to the Breast Augmentation Classification. The rate of capsular contracture was 28% at the second follow-up. Major complications were rare--7%. The patients were pleased with the overall result in 82% of cases. We conclude that tissue expansion is safe, produces a good result and causes few complications with only minor discomfort to the patient.
Intraoperative tissue expansion is advocated as a technique to facilitate closure of soft-tissue wounds with less tension than if they were closed primarily without expansion or, presumably, simple undermining. Few objective studies have been done, however, to validate the technique. We specifically questioned the relative effects of intraoperative tissue expansion and undermining on wound closing tensions in an animal model. Our data showed statistically significant reduction in the force required to close a wound after acute intraoperative tissue expansion when compared with baseline. However, when the degree of undermining achieved by the expander was matched in an equivalent defect, no difference in the resultant wound closing tensions could be discerned between techniques. This study should be viewed as an initial effort to understand the role of intraoperative tissue expansion in reconstructive surgery.
A rodent model was used to study tissue expansion. Three chemical agents--hyaluronidase, prostaglandin E2, and colchicine--were administered and their effects on tissue expansion studied. Hyaluronidase and colchicine both enhanced the rate of expansion when compared with results in control animals (p less than 0.05). Although prostaglandin E2 had less effect on expansion rate, it did significantly enhance tissue oxygen tension of expanded skin when compared with controls (p less than 0.05). Clinical implications include the possibility of pretreating patients with these agents to increase the rate of expansion and to improve the safety of current methods of expansion.
A prolonged tissue expansion has the advantage of creating large amounts of additional skin for reconstructing cutaneous defects that might not be possible without the use of multiple, regional, distant, or microsurgical flaps. In spite of this, there are disadvantages, many of which can be circumvented by the use of rapid intraoperative tissue expansion instead. Although rapid expansion does not increase skin surface area as much as prolonged expansion, it may be helpful in assisting with closure of defects that might otherwise be problematic.