FIGURE 1 - uploaded by Erik M Wolfswinkel
Content may be subject to copyright.
Case 1: A 1-year-old girl with nevus to the left periorbital area, nasal bridge, and cheek (A). She underwent initial placement of 2 tissue expanders to the left forehead, cheek with 95 and 75 mL, respectively. She then underwent tissue rearrangement, including a cervicofacial flap (B). She later underwent resection of residual lower lid nevus with full-thickness skin graft and canthoplasty (C). She developed postoperative ectropion (D), requiring a second full-thickness skin graft for correction (E, F).
Source publication
Background:
Despite advances in the field of tissue expansion, the face is especially difficult to reconstruct using this technique due to its dynamic nature and high incidence of distortional scarring. This article aimed to review complications seen in pediatric facial tissue expansion, specifically ectropion, as well as its restorative treatment...
Context in source publication
Context 1
... total incidence of ectropion in our series was 11.3%. Of the 10 cases of ectropion, 9 were treated with canthoplasty, whereas 1 was managed satisfactorily with conservative therapy. Canthoplasty yielded satisfactory results in 5 patients, but 4 went on for additional procedures including a redo canthoplasty in 1, full-thickness skin graft in 1 ( Fig. 1), Z-plasty in 1, and lid switch procedure in 2 (Figs. 2 and 3). Of note, canthoplasty was also used in 2 cases of medial canthal ...
Citations
... Scars, traumatic scars, burn scars, atrophic scars, revision of the scars, scar contractures, treatment of hypertrophic scars and keloids [7,33,37,38,34,39,19,20,40-45, 17,46,35,47-51,21-23,52,24, 53,25,54,55,26,56-64,72, 73,65,66,67,36,68,31,69-74 Complications of the insertion of the TE during different stages of operations, are presented in Table 5 [30,31,84,85,[87][88][89][90]. ...
... Total rate of complications has been reported among 10%-33% in different studies and in our study rate of complication were 11.6%. We believe that proper technique and good design for flaps are the key factors that decreased the rate of complications in our cases [90,87,49,21,22,7,81,29,30,88,89,95,84,31,85,96,97,74]. There is a report from Sweden that they had 24% minor complications and 13% major complications for which they had to do a corrective surgery [21]. ...
... In our experience we have not seen any retraction of the flap after the second surgery. Besides after insertion of the flap there is no risk for recurrence of scar and we have seen no rejection of the flap [9,98,28,105,84,106,31,71,90]. ...
Background:
Tissue expanders (TE) are frequently used worldwide. In this study we surveyed outcome of our patients retrospectively during 15 years.
Materials and methods:
We 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.
Results:
In 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%).
Outcome:
In 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.
Conclusion:
Our 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.
... Another concern is risk of complications or psychologic distress, especially with large facial lesions where multiple tissue expansions may be required or when expansion occurs in an anatomically sensitive area. [31][32][33] Surgeons managing these patients have also found that serial excision with primary closure may often provide better aesthetic outcome with less complication in some patients. [34][35][36] Local flaps or autologous skin grafts are other options commonly performed to achieve surgical wound closure after removal of CMN in suitable patients. ...
Background:
Congenital melanocytic nevi (CMN) have a 1% to 5% lifetime risk for malignant transformation, with 50% of transformations occurring before the age of 5 years.The aim of this study is to assess the risk of melanoma development in pediatric patients with facial CMN involving the eyebrows, eyelid margins, and nasal alae where a margin of CMN was not excised to preserve these structures.
Methods:
A retrospective chart review of all pediatric patients with CMN from 1986 to 2014 was performed to review demographic information, diagnosis, and number of surgeries. Patients' clinical photographs were evaluated for residual nevi after completion of the treatment.
Results:
More than 950 medical charts of patients with CMN of the face area were reviewed. We identified 32 patients (13; 41% male) that met the study criteria with pathology-confirmed diagnosis of facial CMN with an average age of 4.4 years (3.3 months-15.8 years) at the time of initial surgery. The CMNs were classified into small (1; 3%), medium (14; 44%), large (14; 44%), and giant (3; 9%) based on their projected adult sizes. No patients developed melanoma within the small residual lesions left over the eyebrows and eyelids and inside nostrils at an average follow-up time of 5.6 (1.0-14.4) years and average age of 9.6 (1.8-19.2) years at the time of last follow-up.
Conclusions:
Although a lifelong risk of malignant transformation of the residual CMN cannot be concluded, our results found no transformation in follow-up visits at an average age beyond the highest risk of melanoma development in childhood. We feel that leaving residual lesions on the face in areas of important anatomic structures for better cosmetic outcome is an acceptable risk.
Contrary to prior pediatric burn treatment philosophies, we now know that early burn excision and grafting for non life-threatening burns can compromise future reconstruction. Extensive scar excision should be minimized and scar rehabilitation maximized, as secondary iatrogenic deformities can become even more difficult to fix. Scar remodeling with local tissue rearrangement can relieve tension and soften scars over time. The majority of facial burns often only involve skin and can be adequately treated without the need for complex flap reconstruction. Facial burn scars are a different problem than facial burn scar contracture. The former needs scar rehabilitation, whereas the latter needs the addition of skin. Laser therapy has transformed the treatment of burn scars and is an incredibly valuable adjunct to local tissue rearrangement and grafting. The most favorable functional, aesthetic, and psychological outcomes require a long-term multidisciplinary effort and customized protocol utilizing the vast armamentarium of reconstructive tools described below.
Background:
This study aims to observe and investigate the clinical value of scar loosening and tissue-expansive autologous skin grafting in the treatment of postburn scars and independent risk characteristics for surgery-related complications.
Methods:
We retrospectively analyzed 94 cases with postburn scars, and all patients were treated with scar loosening and autologous skin grafting. Overall therapeutic effects were evaluated using the standard of cure and improvement of clinical diseases. Burn Specific Health Scale-brief was used to analyze patients' quality of life. The visual analog scale scores were used to analyze esthetic satisfaction. Surgery-related complications were recorded, and logistic regression model was used to analyze independent factors affecting surgery-related complications.
Results:
As for overall efficacy evaluation, 50 cases were cured, 19 cases were markedly improved, 17 cases improved, and 8 cases were detected and tested, and the overall effective rate was 91.4%. The Burn Specific Health Scale-brief and visual analog scale score showed a trend of increasing gradually. It indicated that the patients were satisfied with the operation and their quality of life was improved. The logistic regression model showed that history of skin disease (OR=1.53 (1.08-2.16), P=0.02) and skin area (OR=2.50 (1.22-4.50), P<0.01) were significantly associated with surgery-related complications.
Conclusions:
Scar loosening and autologous skin grafting is a safe and effective treatment. The history of skin disease and skin area was the independent factors for surgery-related complications.
Background:
Tissue expansion is a key tool in the therapeutic arsenal that is proposed for repairing soft tissue losses of the head and neck. This technique, however interesting it may be, is not without its risks. The aim of this work is to identify the different steps of this procedure, determine the complications risk factors inherent to each step of the expansion and propose recommendations to improve functional and aesthetic results.
Patients and methods:
We carried out a retrospective study on tissue expansion of the head and neck over a period of 10 years extending from January 2009 to December 2018, with at least one year follow-up for each patient. Our study counted 63 patients with the placement of 98 prostheses. We considered the various variables involved in the expansion process in order to determine those that increase the risk of complications.
Results:
In our series we counted 66.3 % of complications and 22.4 % of failures. We found that a young age increased the risk of skin suffering and that smoking increased the risk of hematoma occurrence. Neck expansion was found to be the riskiest site of expansion followed by the scalp that increased the risk of exposure (especially the parietal section of the scalp). The face is considered as an interesting site for expansion. We found that the use of multiple expanders is an attractive alternative to iterative expansions and to the choice of large expanders.
Conclusion:
Tissue expansion of the head and neck requires careful planning that takes into account each step of the process.
The treatment of sequelae for burns or other loss of perioral tissues is complex due to the site where they occur, its functional importance, and social and esthetic aspects. Functional consequences of burns to this area are cutaneous retraction and a lack of skin that can lead to an inability to close the oral aperture, compromising the provision of dental hygiene and intubation procedures. The aim of the present publication was to evaluate the efficacy of chin, labial and jugal cutaneous expansions for the treatment of perioral lesions and lesions of the lower half of the face in our retrospective series of patients. We collected data and photography from digital files for each patient. Proportion of scarred skin that could be treated by one or several expansion procedures was evaluated. The main outcome was the resection of 50% or more initial lesions. Side effects were assessed. Out of a total of 33 expanders, 28 were at the jugal level, 5 were chin expanders, and none were labial expanders. This equated to the inclusion of fourteen patients. The average percentage of the lesion that was removed after the perioral expansion protocol was 68.9% (40%-100%). 85% of patients had a positive outcome. 12% of procedures were complicated by hematoma, infection or prosthesis exposure. Each time that the lesional area could be fully (i.e. 100%) treated, only a single expansion was used. Head and neck expansion is the technique of choice for reconstruction of the lower half of the face and the horizontal part of the neck in terms of efficiency and safety.
Purpose:
With constraints and a risk of complication, tissue expansion in child's burn sequelae need a controlled surgical procedure, and a therapeutic plan appropriate to the specific pediatric healing, growth, and development.
Material and methods:
Our principles of management and technical points are described. A retrospective study of tissue expansion in child's burn sequelae between 2005 and 2016 is submitted.
Results:
There are 185 expanders, 98 protocols in 41 children, over half of sequelae concerning scalp, neck and chest. Mean age at the first expansion was 10.3 years old (5.8 years after burn). There are in average 2,4 (1-8) protocols by patient, with 1.9 (1-4) expanders by procedure. Surgical repair was a flap (78.8%), a full-thickness skin graft (13.3%) or both. Fifteen patients (30 expanders (14.6%) and 22 protocols (22.4%)), had expansion's complications, mostly infections and expositions. Eight patients (14 expanders (7.6%) and 10 protocols (10.2%)) had reconstructive's complications. An increase of burn area was a risk factor of complication (significant). Complicated expanders rate by location was 7.9% (scalp), 12.5% (neck), 9.8% (supraclavicular), 10.5% (chest), 19.4% (abdomen), 30% (buttock), 29.4% (lower limb), 1/2 (face).
Conclusion:
Tissue expansion in child's burn sequelae is ideal in scalp, good in neck, chest and proximal upper limb, and to do carefully in lower limb and face.
Background:
The authors aim to present a comprehensive review detailing the present state of evidence with regard to complications following tissue expansion in the head and neck.
Methods:
A systematic literature search was conducted to identify all studies reporting complications of tissue expansion in the head and neck between 2000 and 2019. Subgroup comparisons based on expander locations and planes were conducted.
Results:
A total of 7058 patients were included. Tissue expansion was associated with an overall complication rate of 8.73% (616/7058). The most common complications were extrusion (207/7009; 3.0%) and hematoma (200/7009; 2.9%). Overall complications were highest in the scalp (65/238; 27.3%) and lowest in the mastoid (347/5688; 6.1%). Complications were more common with expansion in the non-subcutaneous plane (63/590; 10.7%).
Conclusion:
In the absence of large clinical trials, systematic reviews such as these can help inform clinical guidelines and provide practitioners with an evidence-based reference to improve informed consent.
Background:
Congenital giant melanocytic nevus on the face is a challenging condition, especially in the pediatric population. It can produce significant cosmetic deformity with negative psychosocial effects in pediatric patients even after treatment. The objective of this study was to report aesthetic and psychosocial results in the management of congenital melanocytic nevus on the face using multiple reexpansion.
Methods:
Data of 6 patients with congenital melanocytic nevus on the face who underwent excision and multiple reexpansion at our center from September 2004 to August 2017, were retrospectively reviewed. To evaluate aesthetic outcomes, preoperative and final photographs of each patient were reviewed by 3 other plastic surgeons and 4 laypersons. For comparison, 6 other patients who were treated with conventional surgery during the same period were reviewed. After final reconstruction surgery, the authors surveyed patients' satisfaction via telephone.
Results:
Six patients were followed up for an average of 87.66 months (range, 55-123 months). The mean number of tissue expander insertions was 3.33 and the mean number of total expanders inserted was 4.83. Complication associated with expander exposure occurred in 1 patient during the fifth expansion. The average score of aesthetic outcome in the multiple reexpansion group was superior to that of the conventional group (2.60 versus 2.10, P = 0.03). During the telephone survey, patients did not rate their appearance as positive, although they were comparatively satisfied with the surgical procedure.
Conclusion:
Considering the low rate of malignancy involving congenital melanocytic nevus in childhood, multiple reexpansion is an attractive option to obtain better results compared with other reconstructive methods.
Tissue expansion reconstruction in clinical practice has existed for over half a century. The technique was initially used for breast reconstruction but later found its use in reconstruction of excisional defects resulting from a variety of causes including surgery for post-burn/post-traumatic deformities, congenital giant naevi, skin cancer, etc. It offers an improved matching of skin colour and texture, and avoids the high infrastructure requirements of microsurgery for free flap transfers. We present a systematic literature review of 35 worldwide English language articles with representative cases of paediatric tissue expansion reconstruction of burn injuries of the head and neck. The review identified 68 children of an average age of 11.3 years. The most common burn aetiology was flame burn injury. The average area to be reconstructed was of 206 cm² and patients went through expansion processes for an average of 99.7 days. Three articles included cases in which patients had more than one expansion session. Supportive techniques provide examples of developments in the area of tissue expansion reconstruction such as self-inflating expanders and endoscopic approaches. Further studies focussing on particular indications, age groups and anatomical locations of tissues to be expanded are required in order to improve the understanding of this technique's limitations and continue its development.
