Intraoperative tissue expansion in rhytidectomy revisited

Intraoperative tissue expansion is an adjunct that has been used during rhytidectomy to rejuvenate the face and neck. This technique has been thought to allow for additional skin resection and, thus, increased skin tightening during rhytidectomy. The stretch of the skin by expansion should allow for additional skin resection before closure. Also, when the force of the underlying expander is removed, the expanded skin would recoil and the advancement of the flap should become tighter, with improved results. The technique achieved some popularity a few years ago but has received little recent attention. In this study, the authors attempted to compare face-lift results of adjunctive intraoperative tissue expansion during rhytidectomy with similar techniques without intraoperative expansion. The results of 50 female patients who underwent rhytidectomy for midface rejuvenation by a single operating surgeon composed the study group. Twenty-five of the patients had undergone rhytidectomy that addressed the cheek, chin, and neck areas without expansion (nonexpanded rhytidectomy group). The other 25 patients (expanded rhytidectomy group) had adjunctive intraoperative tissue expansion performed with the rhytidectomy. A tissue expander was temporarily placed beneath the rhytidectomy flaps on each side and expanded in a standard manner before final skin resection and closure. Frontal and lateral photographs were evaluated by 54 examiners. Preoperative and postoperative photographs of the 50 patients were viewed side-by-side by the examiners. The patients were presented in blind fashion and random order. The examiners graded the results of each patient on a scale of improvement from 1 to 10, with 10 being the maximum level of improvement. The scores were recorded and statistically evaluated by using the two-sample test. Evaluation of the examiners' scores showed that the mean rating given to patients in the expanded rhytidectomy group was 5.07 (SD = 1.12). The mean rating for the nonexpanded rhytidectomy group was 5.27 (SD = 1.57). When the two groups were compared using the two-sample test, the difference between the two was not statistically significant (p = 0.6127). Intraoperative tissue expansion as an adjunct to rhytidectomy did not result in improved facial rejuvenation in this patient series. The authors' impression is that the benefits of tissue expansion do not justify the added expense, time, and risks associated with using tissue expansion during rhytidectomy.     

The biomechanical effects of deep tissue support as related to brow and facelift procedures

The adverse effects of increased tension across a healing wound are well known. However, the effect of closing a wound in layers in order to decrease tension on the epidermis has been a source of controversy. It is hypothesized that deep tissue support decreases skin tension upon wound closure. In order to clarify this issue, a two-part study was designed to address the immediate effects of deep tissue support in vitro using fresh-frozen cadavers and in vivo on patients undergoing scheduled surgery. Closing skin tension was measured at standard reference points in coronal brow lift and rhytidectomy procedures performed with and without galeal closure and superficial musculoaponeurotic system (SMAS) procedures, respectively. Deep tissue support was found to significantly (p less than 0.05) decrease skin tension at the time of skin closure at standard reference points in coronal brow lift and rhytidectomy procedures performed on fresh-frozen cadavers. Similar significant (p less than 0.05) decreases in closing skin tension also were found in vivo in patients undergoing similar surgical procedures. Stress relaxation was not found to play a significant role in contributing to this immediate decrease in closing skin tension. It would appear, therefore, that deep tissue support, in the form of galeal closure and an SMAS procedure in coronal brow lift and rhytidectomy procedures, respectively, provides increased viscoelastic support, producing immediate significant decreases in closing skin tension in these procedures. The beneficial effects on wound healing, scar formation, tension-related trophic skin changes, and possible improved long-term results are discussed.     

Growing skin: tissue expansion in pediatric forehead reconstruction

Tissue expansion is a common surgical procedure to grow extra skin through controlled mechanical over-stretch. It creates skin that matches the color, texture, and thickness of the surrounding tissue, while minimizing scars and risk of rejection. Despite intense research in tissue expansion and skin growth, there is a clear knowledge gap between heuristic observation and mechanistic understanding of the key phenomena that drive the growth process. Here, we show that a continuum mechanics approach, embedded in a custom-designed finite element model, informed by medical imaging, provides valuable insight into the biomechanics of skin growth. In particular, we model skin growth using the concept of an incompatible growth configuration. We characterize its evolution in time using a second-order growth tensor parameterized in terms of a scalar-valued internal variable, the in-plane area growth. When stretched beyond the physiological level, new skin is created, and the in-plane area growth increases. For the first time, we simulate tissue expansion on a patient-specific geometric model, and predict stress, strain, and area gain at three expanded locations in a pediatric skull: in the scalp, in the forehead, and in the cheek. Our results may help the surgeon to prevent tissue over-stretch and make informed decisions about expander geometry, size, placement, and inflation. We anticipate our study to open new avenues in reconstructive surgery and enhance treatment for patients with birth defects, burn injuries, or breast tumor removal.     

Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin

Controlled clinical tissue expansion, a new technique of providing donor tissue, results in an increase in surface area of expanded skin. The aim of the present study was to determine the effect of controlled tissue expansion on the surviving lengths of random-pattern skin flaps elevated in expanded tissue. In five pigs the surviving lengths of flaps raised in skin expanded for 5 weeks using a 250-cc rectangular Radovan-type tissue expander were compared with the survival lengths of flaps elevated in tissue in which a similar prosthesis was not expanded, bipedicle flaps delayed for 5 weeks, and control acutely raised random-pattern flaps. The expanded flaps had a mean increase in surviving length of 117 percent over control flaps, which was statistically significant. The delay flaps had an increase in survival of 73 percent over control flaps, which was also statistically significant. There was no significant difference in survival between expanded flaps and delayed flaps. Morphologic studies using radiographic techniques on one pig demonstrated increased vascularity with tissue expansion. The results of this work demonstrate that in addition to providing increased surface area with controlled expansion, flaps raised in expanded skin have a significantly augmented surviving length. The mechanism for this increased vascularity with expansion is not known at this time, but it may be due to physical forces associated with expansion acting as a stimulus for angiogenesis.     

The double-eyelid operation without supratarsal fixation

Among the considerations in the formation of the double eyelid, two factors are considered to be important. They are the levator insertion into the skin and the amount of soft tissue between the levator aponeurosis and the skin. The author assumes that the amount of soft tissue may be more importantly related to forming the double eyelid than the levator expansion. Based on this assumption, the author undertook a modified operation to create the double eyelid by removing excessive soft tissue without any fixation to the levator aponeurosis or the tarsal plate.     

Repair of scalp defects using a tissue expander and Marlex mesh.

A simple technique using Marlex mesh and a tissue expander to cover scalp defects is described and two patients are presented. This technique is suitable for medium-sized defects that cannot be closed primarily. Marlex mesh is sutured to the wound edges in lieu of a temporary skin graft and to prevent enlargement of the defect during tissue expansion. The tissue expander is placed under adjacent normal scalp in a subgaleal pocket developed through the scalp defect. The scalp defect is closed secondarily using the expanded scalp flap. This technique was performed in two patients with satisfactory results. Marlex mesh obviates the need for a temporary skin graft to cover the scalp defect.     

Breast reconstruction using tissue expanders and implants in Hodgkin's patients with prior mantle irradiation.

Women treated for Hodgkin's disease with mantle irradiation have an increased risk for developing breast cancer. Typically, breast malignancy in Hodgkin's patients presents bilaterally in a younger age group. Skin flap ischemia, poor skin expansion, implant extrusion, capsular contracture, and poor cosmesis are common sequelae of tissue expander/implant breast reconstruction after breast irradiation for failed breast conservation therapy. This has led most surgeons to favor autologous tissue reconstruction in this setting. This study was performed to determine the efficacy of tissue expander/implant breast reconstruction in breast cancer patients who have been treated with prior mantle irradiation for Hodgkin's disease. A retrospective analysis of all breast cancer patients with a history of Hodgkin's disease and mantle irradiation treated with mastectomy and tissue expander/implant reconstruction between 1992 and 1999 was performed. There were seven patients, with a mean age of 35 years (range, 28 to 42 years). The average interval between mantle irradiation and breast cancer diagnosis was 16 years (range, 12 to 23 years). All patients underwent two-stage reconstruction. Textured surface tissue expanders were placed in a complete submuscular position at the time of mastectomy. Expansion was initiated 2 weeks after insertion and continued on a weekly basis until completion. Expanders were replaced with textured surface saline-filled implants as a second stage. Patients were evaluated for skin flap ischemia, infection, quality of skin expansion, implant extrusion, capsular contracture, rippling, symmetry, and final aesthetic outcome. Breast cancer was bilateral in five patients and unilateral in two. Two patients did not undergo simultaneous bilateral breast reconstruction because of metachronous cancer development. One of the patients had an initial transverse rectus abdominis muscle flap breast reconstruction, followed by a tissue expander/implant reconstruction of the opposite breast. The average follow-up was 3 years. Complications were limited to one case of cellulitis after implant placement that resolved with intravenous antibiotics. There were no cases of skin flap ischemia, poor skin expansion, or implant extrusion. Overall patient satisfaction was high and revisions were not requested or required. Symmetry was best achieved with bilateral implants. This study demonstrates the efficacy of tissue expander/implant breast reconstruction in patients treated with prior mantle irradiation. In this series, tissue expansion was reliable with low morbidity. Second-stage placement of permanent implants yielded good aesthetic results without significant capsular contracture. Mantle irradiation did not appear to compromise the prosthetic breast reconstruction. Tissue expander/implant breast reconstruction should remain a viable option in this category of irradiated patients.     

Breast reconstruction using modified tissue expansion

Inadequate chest-wall skin following mastectomy for carcinoma continues to be a problem in many breast reconstructions. To avoid extensive surgery, serial tissue expansion has been advocated. Since 1977, one of the authors has used a simple method of tissue expansion that we have termed "modified tissue expansion", defined as the creation of an adequate breast mound in one or two stages using a permanent prosthesis. Ninety percent of patients undergoing breast reconstruction between 1978 and 1983 were reconstructed using this method. A retrospective analysis of these 208 patients is presented. There were no mortalities, and only a 6.3 percent complication rate. Skin necroses related directly to the prosthesis occurred once, and there were no prosthetic deflations. Eighteen percent had first-step reconstruction only. The initial prosthesis averaged 400 cc in size. Selected Halsted radical mastectomy and postradiotherapy patients were successfully reconstructed. Seventy-eight percent felt their results were excellent at 1 year. Two percent were dissatisfied. Multiple office visits and the potential problems of serial expansion were avoided. Modified tissue expansion is a simple and viable method and should be considered among the options for breast reconstruction following mastectomy.     

Continuous versus intraoperative expansion in the pig model.

Continuous tissue expansion utilizing a continuous infusion device that maintains a constant expander pressure was previously demonstrated to be feasible and successful in obtaining rapid tissue expansion in a canine model. Intraoperative tissue expansion has been described and has gained some clinical acceptance as a method to gain rapid expansion. We compared the efficacy of continuous tissue expansion versus intraoperative tissue expansion in a piglet model. After completing a pilot study, continuous tissue expansion was performed in six pigs (14.5 to 20 kg) on one flank over a 3-day period utilizing an improved prototype device; at the termination of continuous tissue expansion, intraoperative tissue expansion was performed on the opposite flank. There were no complications or continuous tissue expansion device malfunctions. Intraoperative tissue expansion gave a true gain in area of 7.4 percent, while continuous tissue expansion produced a 22 percent gain (p < 0.02). When the effects of both recruitment and expansion were added, continuous tissue expansion gave a dividend of 286 percent versus 192 percent for intraoperative tissue expansion (p < 0.01). Biomechanically, intraoperative tissue expansion skin showed few differences from unexpanded skin, while continuous tissue expansion skin showed a significant increase in stress relaxation (47.78 versus 38.74) and decrease in breaking strength. Histologic analysis revealed some epidermal hyperplasia and inflammation surrounding the continuous tissue expansion expander and some vascular congestion over the intraoperative tissue expansion expander. We conclude that continuous tissue expansion is superior to intraoperative tissue expansion and that the prototype device may be useful clinically.     

Densitometric evaluation of DNA contents in expanded human skin

We studied 18 patients who underwent skin expansion. In 3 patients the prostheses had been inserted in anatomical areas previously expanded: in 3 other patients scarring tissue had been involved in the expansion. The DNA content of sections of epidermis, before and after the implantation of expanders, were analysed using an image analyzer (IBAS 2000). The preliminary data demonstrate that, at the end of the expansion, epidermis enters a phase of quiescency and is not affected by dysplastic processes.     

Stretching and tissue expansion for rhytidectomy: an improved approach

Intraoperative expansion of the skin of the face supplies additional tissue that permits closure of the face lift incision with minimal tension. This paper presents the findings in rhytidectomy patients over the last 3 years using both intraoperative stretching and intraoperative stretching combined with tissue expansion utilizing the Man face lift expander. Sixty-seven patients underwent rhytidectomy surgery, of whom 50 were treated with stretching techniques alone and 17 were treated with the combined stretching and expansion method. The patients' ages ranged from 28 to 78 years. Results indicate that the patients treated with combined stretching and expansion had significantly more skin removed. This new technique appears to offer significant clinical advantages over usual face lifts.     

An Axisymmetric Computational Model of Skin Expansion and Growth

Skin expansion is the principal technique used in plastic surgery to repair large cutaneous defects, typically after tumour removal, burn care, craniofacial surgery and post-mastectomy breast reconstruction. It allows a gain of new tissue by means of gradual expansion of a prosthesis, surgically implanted beneath the patient’s skin. Nevertheless, wide clinical use is not supported by a deep quantitative knowledge of the phenomena occurring during the expansion. A finite element model of the skin expansion was developed to evaluate the stresses and the strains of the skin due to the expander inflation and validated by proper in vitro experiments; furthermore, a growth model based on the mechanical stimulus was implemented to estimate the skin area gain. The developed computational approach, composed of the skin expansion model interaction and the growth law, proved its validity to investigate skin expansion phenomena: its use suggests a new predictive tool to optimize clinical procedures and the expander devices’ design.     

Subfascial expansion and expanded two-flap method for microtia reconstruction

This article presents an improved two-flap method for microtia reconstruction. In the first stage of this method, a tissue expander is inserted in the mastoid region through a subfascial pocket, after which the overlying fascia and skin are expanded simultaneously with saline infusion for about 5 months. In the second stage, the expanded fascial and skin layers are split and prepared as anteriorly based skin and fascial flaps defined by their vascularity. An erect, three-dimensional, contour-accentuated ear framework fabricated with autogenous rib cartilage is inserted between the two flaps. The anteroauricular surface of the framework is draped with the thin, expanded skin, and the postauricular surface is draped with the thin, expanded fascia and overlying grafted skin. In the third stage, remnant auricular cartilage is removed and the crus helicis, tragus, intertragic notch, conchal floor, and a hollow mimicking the external auditory meatus are shaped. In this study, 146 microtias were reconstructed consecutively using the improved two-flap method. The final results were promising--major complications were minimal and most patients showed consistently favorable aesthetic results. This method married a two-flap procedure with a gradual tissue expansion, conveniently exploiting the advantages of both methods, but without the disadvantages.     

Giant congenital nevi: a 20-year experience and an algorithm for their management.

A variety of treatment options exists for the management of giant congenital nevi. Confusion over appropriate management is compounded because not all giant congenital nevi are pigmented, and malignant potential varies between different types. The present study sought to define factors in the presentation of giant congenital nevi that could provide an algorithm for their management, with respect to both the extent of resection and subsequent reconstructive options.A retrospective review of all patients who presented with a congenital nevus of 20 cm2 or greater since 1980 was performed, distinguishing among nevi involving the head and neck, the torso, and the extremities. Sixty-one patients with giant congenital nevi were evaluated (newborn to age 16 years), of which 60 nevi in 55 patients have been operated on.Giant congenital nevi having malignant potential were pigmented nevi (53 patients) and nevus sebaceus (four patients). Those not having malignant potential were verrucous epidermal nevi (three patients) and a woolly hair nevus (one patient). Of the 60 giant congenital nevi operated on, expanded flaps were used in 25, expanded full-thickness skin grafts were used in 10, split-thickness or nonexpanded full-thickness skin grafts were used in 13, and serial excision was used in 30. After 1989, operations tended to use multimodality treatment plans, with an increased use of expanded full-thickness grafts and immediate serial tissue expansion. The use of serial excision, particularly in the extremities, also increased after 1989. Serial excision was the treatment of choice when it could be completed in two procedures or less, which occurred in more than 80 percent of cases using serial excision alone. Expanded flaps were the most common mode of reconstruction in the head and neck region and were used in 49 percent of these procedures. Serial excision was the most common form of treatment in the extremities, used in 50 percent of procedures. Tissue expansion in the extremities was infrequently used to provide an expanded flap (8 percent of procedures), whereas it was frequently used to provide expanded full-thickness skin grafts harvested from the torso (used in 31 percent of procedures).On the basis of these data, algorithms for the extent of resection and subsequent reconstructive options for giant congenital nevi were developed. Their management should be formulated relative to pigmentation, malignant potential, and anatomic location of the respective lesions.     

An accelerated approach to tissue expansion for breast reconstruction: experience with intraoperative and rapid postoperative expansion in 370 reconstructions

Breast reconstruction with tissue expansion is a well-established technique that offers satisfactory aesthetic results with minimal patient morbidity. The traditional period of expansion, however, continues to be a significant source of patient inconvenience and dissatisfaction. The objective of this study was to develop and evaluate a protocol for rapid tissue expansion. A total of 370 breast reconstructions in 314 patients who underwent rapid tissue expansion were retrospectively reviewed. Contraindications to rapid expansion were considered to be previous radiation, mastectomy skin flaps of questionable viability, and an excessively tight skin envelope. All expanders were placed submuscularly and filled to 40 to 50 percent of tissue expander volume. Office expansion was undertaken within 10 to 14 days after the operation and continued on a weekly basis. Each expansion was limited by patient tolerance up to a maximal pressure of 40 mm of water or a volume of 120 cm3. Expansion was considered complete once the expanded breast was 30 to 50 percent larger than the contralateral breast. If required, postoperative chemotherapy was given during the expansion period. Mean patient age was 48 years (range, 23 to 73 years). Two hundred fifty-eight patients had unilateral reconstructions. Three hundred two patients had immediate reconstruction. Mean tissue expander size was 583 cm3 (SD, 108 cm3). Mean intraoperative expansion was 271 cm3, or 46 percent (SD, 9 percent) of the tissue expander size. The first expansion was started 12 days (SD, 3 days) after the operation. The mean volume of each expansion was 88 cm3 (SD, 23 cm3). Expansion was completed in 4.7 office visits (SD, one visit). Mean final expander volume was 672 cm3 (SD, 144 cm3). The expanders were overexpanded by 15.3 percent (SD, 8.4 percent). The mean time between expander placement and the final expansion was 6.6 weeks (SD, 3 weeks). The overall complication rate was 4 percent. Ten patients developed cellulitis, five patients had hematomas requiring drainage, and one expander became exposed. A total of eight expanders were removed: four for cellulitis, one for a hematoma, one because of locally recurrent disease, one because of expander exposure, and one at the patient's request for no medical reason. Intraoperative and rapid postoperative tissue expansion is a safe and reliable technique that offers a significant improvement over conventional techniques. In this accelerated protocol, expansion may be completed in less than 7 weeks. The result is decreased patient morbidity and delays in adjuvant therapy at no detriment to the final surgical outcome.     

Use of a calf prosthesis and tissue expansion in aesthetic reconstruction of the leg.

We present a technique for reconstruction of the legs in patients with soft-tissue loss and formation of large scars with retraction of this tissue in the pretibial region. In such patients, a subcutaneous tissue expander is placed in the region adjacent to the scar tissue. With expansion, we obtained sufficient skin for use in the reconstruction, and the resulting asymmetry in leg diameter was compensated for by means of one or two calf prostheses, depending on the patient.     

胸三角皮瓣并自体脂肪移植修复颌面部大面积缺损畸形

目的：探讨颌面部皮肤软组织大面积缺损凹陷的理想修复方法。方法：本组6例均为爆炸伤后颌面部皮肤软组织缺损及严重凹陷畸形,采用胸三角皮肤扩张形成带蒂皮瓣修复上述皮肤缺损及自体脂肪移植纠正残存凹陷畸形。手术分五步进行：1．胸三角深筋膜浅层埋植500mL-800mL皮肤扩张器并注水扩张3个月。2井艮据面颈部预计皮肤缺损大小及形状作皮瓣预制并面部局部皮瓣纠正器官移位。3．带蒂皮瓣转移修复颌面部缺损。4．蒂部延迟及断蒂微整形。5．自体脂肪移植。结果：所有皮瓣成活良好,皮瓣色质接近面颈部周围正常皮肤,缺损畸形修复,外观形态好,供区直接缝合无需植皮,取得了较好的面部改观效果。结论：对于面部大面积皮肤软组织缺损,合并面部凹陷、面部器官缺损及移位,采取胸三角扩张延迟预制皮瓣并自体脂肪移植修复可取得良好的整复效果,为颌面部战创伤畸形提供了理想的修复方法。     

Alterations in skin properties during rapid and slow tissue expansion for breast reconstruction.

This study comprises 23 women who had had mastectomies because of breast cancer. They were randomly divided into two groups when they were admitted for breast reconstruction by tissue expansion. The first group was expanded rapidly, i.e., every day, and the other group was expanded slowly, i.e., every week. There were no other differences in the treatment between the two groups. Three months after completion of expansion, the expander was replaced by a permanent prosthesis. The follow-up time was up to 6 months after the second operation. Three different parameters--distensibility, elasticity, and hysteresis--were measured noninvasively on the breast skin and at a control site on several occasions throughout the treatment. During the treatment period there were no differences in skin properties between rapidly and slowly expanded patients. Of the three parameters, distensibility showed the most prominent changes: decreasing during the expansion period, increasing after the expander had been replaced by a permanent prosthesis, and decreasing during the following 6 months. Elasticity did not change significantly, except decreasing after insertion of the permanent prosthesis, and the hysteresis increased at the same time. These findings indicate that tissue expansion alters breast skin only to a small extent and that the mechanical resistance sometimes encountered during tissue expansion is due to deeper structures such as underlying muscles or capsule formation.     

Tissue expansion in the reconstruction of Tessier craniofacial clefts: a series of 17 patients

Tessier craniofacial clefts are among the most surgically challenging examples of craniofacial dysmorphology. These clefts are characterized by hypoplasia of soft-tissue and skeletal elements throughout the three-dimensional extent of the cleft. Whereas bone grafting and craniofacial osteotomies have been successful toward correcting the underlying skeletal abnormalities, the ultimate success of these reconstructions has been limited by the deficiency of skin and soft tissue. This deficiency demands reconstruction ideally with tissue of like texture, consistency, and, especially in the face, color. Craniofacial tissue expansion was used toward reconstructing these facial clefts with like-quality tissue, allowing for tension-free reconstruction after osteotomy and bone grafting. Seventeen patients with Tessier craniofacial clefts underwent preoperative craniofacial soft-tissue expansion in the surgical management of their clefts. Tissue expansion was used in the primary correction of facial clefts in eight patients, with nine patients undergoing expansion before secondary surgery. In this series, tissue expansion has evolved as an important element in overcoming the skin and soft-tissue deficiency associated with these clefts, allowing for tension-free closure and improved aesthetic results in these surgically challenging patients.