Management of burn deformities using tissue expanders: a retrospective comparative analysis between tissue expansion in limb and non-limb sites

The tissue expansion technique is in the armamentaria in reconstructive surgery. It provides donor skin that is an optimal match in terms of skin color, texture, sensation and hair-bearing characteristics. Literature shows its applications in all regions from the head to the feet. Tissue expansion in extremities, however, carries a high rate of complications. Fortunately, not every complication in tissue expansion means failure.

Objective

A retrospective comparative analysis between tissue expansion in limb and non-limb sites in burn deformities.

Materials and methods

Sixty expanders in 53 patients were included. These constitute the experience of a single surgeon. Forty expanders (66.6%) were applied to non-limb sites and 20 expanders (33.3%) to limb sites. Indications of tissue expansion were burn alopecia, scarring and contracture. Complications and failures were recorded.

Results

Non-limb expanders had 10% rate of complications and 2.5% of failure. Limb expanders showed 30% complications and 15% failure. Statistical analysis showed that the difference was non-significant at this statistical power.

Conclusion

The non-significant difference regarding complication and failure rates between limb and non-limb expanders in this study encourages the use of tissue expanders in extremities. Close follow-up of patients will prevent many expanders that develop complications from becoming failures.     

Tissue expansion of the lower limb: complications in a cohort of 103 cases.

Over 10 years we performed 103 skin-expansion procedures and placed 207 prostheses on lower limbs, using the same surgical protocol. In 83 cases (80.6%) the expansion was achieved without complications. We recorded 20 complications in all (19.4%). Major complications included sepsis, damage due to undermining, exposure of the prosthesis and necrosis of the flap in 16 cases (15.5%), resulting in complete failure of the method in five cases (4.9%). In all, nine patients had septic complications (8.7% of the patients and 45% of the complications), five had exposure of the prosthesis and two had skin necrosis after expansion. Infection and skin necrosis, which are the main causes of failure of this method, can be prevented by a strict surgical protocolcovering all stages of the procedure. Atraumatic undermining, remote and external valves, suction drains in the cavities, advancement flaps and plaster casts after surgery can help to prevent skin necrosis. A separate and remote approach for each prosthesis can prevent infection of all the prostheses and complete failure of the expansion procedure.     

Tissue expansion in the lower limbs of children and young adults

We report the successful use of tissue expansion in the lower limbs of five children and one young adult. It was possible to replace dense adherent skin grafts by expanded skin and subcutaneous tissue. Such expansion needs to be undertaken slowly, but expanded tissue matches the normal local tissue and has normal sensation. These qualities were particularly important in three amputations which were revised.     

Tissue expansion of the lower limb: Retrospective study of 141 procedures in burn sequelae

Introduction

Skin expansion in the lower limb is a difficult procedure with a significant rate of complications. We propose, in this retrospective mono centric study, a systematic review of our skin expansion procedures on the lower limb in burn sequelae with a 30-years follow-up. The objective was to evaluate the overall result of our procedure and present its technical specificities.

Tissue expansion in perspective.

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.     

Tissue expansion: a unit review of non-scalp, non-breast expansion

The results in 76 tissue expansions of sites other than the breast and scalp in 56 patients are presented. The overall failure rate was 12%, being particularly high in the arm (31%) and low in the leg (0%). Details of the technique used and their relevance to success are discussed.     

Tissue defects in the limbs: replacement with free vascularized tissue transfers.

The use of free vascularized tissue transfers in reconstructive surgery is an exciting new development. Such procedures require careful planning and meticulous attention to detail. Illustrative cases are described to indicate the value and scope of this concept, which has been made possible by the development of microsurgery.     

Tissue expansion 1984-1999: a 15-year review.

We assessed all patients who underwent tissue expansion, excluding breast reconstructions, between 1984 and 1999. A total of 237 patients had 257 expansions, normally for distorted scars, 202 of 257 cases (79%). Their mean age was 27 (range 7-67) years, most being women, 149 of 237 (63%). The mean duration of expansion was 16 weeks (range 0.4-118). The most common site was the skull (61/257). Prophylactic antibiotics were used in 224 of 257 (86%) at the time of expander insertion and 147 of 257 (56%) at the removal of the expander. Sixty-two patients (24%) had minor complications and 34 (13%) had major complications. Tissue expansion can be used with a currently acceptable failure rate though we continue to strive to lower this further.     

Tissue expansion in a patient with extensive nevus comedonicus.

Nevus comedonicus is a rare developmental abnormality of the pilosebaceous apparatus that presents as an aggregation of dilated follicular orifices filled with pigmented keratinous material. Occurrence of extensive or giant lesions is even more rare. Indications for treatment include recurrent infections and cosmetic reasons. Therapeutic approaches include topical keratolytic agents, manual extraction of comedones, dermabrasion, and excision of smaller lesions. Increasing clinical experience with tissue expansion has suggested that it might be used effectively in the definitive treatment of an extensive nevus comedonicus previously considered too large to excise without the use of a skin graft, despite the potential risk of infection within the lesion during the course of expansion. We report the first patient with giant nevus comedonicus to be treated using tissue expansion. This patient demonstrates that prompt treatment of cellulitis and abscesses within the lesion will keep this process isolated from the adjacent expanders and will not compromise a planned excision and reconstruction.     

Classification of the callus in limb lengthening. Radiographic study of 35 limbs.

35 calluses formed during limb lengthening were classified radiographically into 6 types: external, straight, attenuated, opposite, pillar, and agenetic. The healing indexes correlated well to the intrinsic periosteal and endosteal conditions of each type. This classification enabled us to estimate the intrinsic conditions, predict the healing index, control the daily lengthening speed, and decide to apply early augmentation of the callus.     

Tissue expansion in the extremities using external reservoirs.

Over a 24-month period, 18 patients had 33 expanders placed in the extremities. Twelve expansions were performed in the upper extremity, and 21 in the lower extremity. Indications for expansion include scarring, excision of skin grafts, tumor excision, burn scars, tattoos, or unacceptable incisional scars for revision. Of the 12 expansions performed in the upper extremity in seven patients, nine were successful. Nine expansions in the thigh and two expansions in the region of the knee were completed without complication. Three expansions were performed in the distal lower extremity following crush injury to remove scarring, and all three failed. Seven expansions were performed in the foot for removal of scarred tissue. There was one infection, two skin necroses on the dorsum of the foot, and one implant exposure. Seven complications in the lower extremity occurred in these areas with an infection rate of 20%. The remaining 23 expansions were performed for soft tissue defects in the upper extremity or in the lower extremity above the level of the mid-calf, with only two complications of implant exposure or infection. Therefore, the infection rate and complication rate in the upper extremity and above the knee was only 6%. Overall, 23 of the 33 expansions, or 70%, were taken to completion with a successful advancement of expanded flaps. Overall, complications occurred in 30% of patients, all eventually requiring removal of the expander.(ABSTRACT TRUNCATED AT 250 WORDS)     

Tissue expansion in the head and neck

Tissue expansion can be a valuable adjunct in reconstruction of large defects of the head and neck and is particularly useful in the scalp and forehead region. This article discusses the differences between conventional long-term expansion and rapid intraoperative expansion. Careful expander selection and application can allow extensive reconstructions with adjacent tissues that might otherwise be impossible. Complications are rare and usually avoidable with careful attention and technique.     

Tissue expansion in the treatment of tubular breast deformity.

Four cases of tubular breast deformity were treated using tissue expansion. The expanders were inserted through either an axillary or an infra-mammary approach in as low a position as possible. The expanders were then over-inflated and allowed to settle for a period of time before removal and insertion of a permanent implant. We present our experience using this technique and the complications and problems we had to deal with.     

Tissue expansion: a promising trend for reconstruction in urology

To evaluate the role of the tissue expansion concept in reconstructive urology, the contemporary literature was reviewed, together with our own results with tissue expansion. The principle of tissue expansion has been applied in cases of bladder augmentation, ureteral dilation for the generation of indigenous tissue and subsequent ureterocystoplasties, ureteral elongation, and dilation of the renal pelvis, producing native tissue for the reconstruction of defects or strictures of the upper ureter. Even though the exact mechanism of action of mechanical strain in different tissues is not known, tissue expansion is a well-accepted technique that can amplify the armamentarium of reconstructive urologists for the management of defects along the urinary tract.     

Tissue expansion in the upper extremity

The use of temporary inflatable implants to generate expanded skin flaps in the upper extremity is a useful reconstructive technique. Applications, technique, and complications are discussed and emphasized with case reports.     

威利坦消除四肢骨折后早期肿胀疗效的对照研究

目的对照研究威利坦(venostan)在消除四肢骨折后早期肢体肿胀中的临床疗效。方法自2011年1月至2011年10月,将200例四肢骨折后肢体肿胀患者随机分为实验组和对照组,每组100例。实验组给予威利坦片剂口服结合冷疗、肢体抬高等常规物理疗法,对照组仅给予冷疗、肢体抬高等常规物理疗法,两组均禁用其他消肿药物。于入院时、入院后第3、4、5、7、10、14天测量肿胀肢体周径并作记录,观察消肿程度、消肿时间、临床疗效及不良反应。结果实验组起效更快,第3天即开始起效,对照组第5天才能起效。受伤后7 d内,两组间消肿情况有统计学差异(P<0.05),但10 d后无统计学差异(P>0.05);两组间消肿的有效率无统计学差异(P>0.05)。结论威利坦片剂能在创伤后早期(7 d内)较快消除肢体肿胀,有助于手术早期进行和肢体康复。     

Tissue regeneration in the reconstruction of lost bone and soft tissue in the lower limbs: a preliminary report

Tissue regeneration obtained by using a limb lengthening apparatus has been used by the authors in five cases for the repair of traumatic loss of bone and soft tissue from the lower limbs. The principles of "regenerated tissue" introduced by Ilizarov for the lengthening of limbs were modified and applied to traumatological needs. Very encouraging results have been obtained.     

Tissue expansion in the treatment of alopecia

During the period December, 1983 to August, 1984, 14 patients were treated for alopecia of the scalp using tissue expansion in the Northern Ireland Plastic and Maxillo-Facial Service. Nine of the defects were due to burns. Representative case reports are presented and the planning of advancement and rotation flaps described. The management and prevention of complications are discussed, and the conclusion drawn that tissue expansion is a valuable technique in the treatment of alopecia, allowing reconstruction of defects previously beyond adequate surgical repair.