TISSUE EXPANSIONTISSUE EXPANSIONGrabb & Smith Plastic Surgery 2007Grabb & Smith Plastic Surgery 2007

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Hartono Kartawijaya (HKW)Hartono Kartawijaya (HKW)

TISSUE EXPANSIONTISSUE EXPANSION

Reliable method providing additional Reliable method providing additional cutaneous tissue cutaneous tissue match color & match color & contourcontour

BackgroundsBackgrounds

Distraction OsteogenesisDistraction Osteogenesis Mechanical stress on tissue could lead to Mechanical stress on tissue could lead to

lengtheninglengthening Neumann in 1957Neumann in 1957 Charles Rodovan 1976Charles Rodovan 1976 Eric Austad 1982Eric Austad 1982 11stst National Tissue Expansion 1982 National Tissue Expansion 1982

Regional siteRegional site Distant siteDistant site

PhysiologyPhysiologyConstant mechanical stress applied to skin over Constant mechanical stress applied to skin over

timetime

Mechanical CreepMechanical Creep

Cell is stretchedCell is stretched

Morphologic Morphologic change on cellular change on cellular levellevel

Biological CreepBiological Creep Gap junction Gap junction

disruption + disruption + tissue surface areatissue surface area

Cell proliferationCell proliferation Growth of the Growth of the

tissuetissue Resting tension Resting tension

restores to baselinerestores to baseline

Epidermis get thickerEpidermis get thicker Dermis get thinnerDermis get thinner Alignment of collagen fibrilsAlignment of collagen fibrils Improved vascularityImproved vascularity Molecular changes :Molecular changes :

Cytokines ( VEGF )Cytokines ( VEGF ) HormonesHormones Adhesion moleculesAdhesion molecules CytoskeletonCytoskeleton Signal transduction proteinSignal transduction protein

Similarity of Similarity of Expanded Flap Delay PhenomenExpanded Flap Delay Phenomen Delayed Flap Delayed Flap

Types of ProsthesesTypes of Prostheses

Shape : round, rectangular, crescentShape : round, rectangular, crescent Size : round 100 – 2000 ccSize : round 100 – 2000 cc

rectang. 100 – 1000 ccrectang. 100 – 1000 cc Type of filling portType of filling port

Integrated into prosthesisIntegrated into prosthesis Connected to the device by silicone Connected to the device by silicone

tubingtubing

Expanded Flap DesignExpanded Flap Design

Consider :Consider : IncisionsIncisions Expander placementExpander placement Flap movement in relation to defectFlap movement in relation to defect Post operative scarPost operative scar

Donor Site :Donor Site : Match color, texture, contourMatch color, texture, contour Free of infectionFree of infection Scar ( stable scar )Scar ( stable scar ) Free of traumaFree of trauma

Techniques of placementTechniques of placement

Incision within the lesion to be excisedIncision within the lesion to be excised Gentle tissue handlingGentle tissue handling Port placed over region with firm Port placed over region with firm

skeletal supportskeletal support Partial fill 10-20% with salinePartial fill 10-20% with saline Closed suction drainsClosed suction drains Closed watertight suturesClosed watertight sutures Dressing : non-adherent + soft paddingDressing : non-adherent + soft padding

Techniques of expansion Techniques of expansion

Serial within 8-12 weeksSerial within 8-12 weeks Start on 7-10 days post insertionStart on 7-10 days post insertion Remove drains in 3-10 daysRemove drains in 3-10 days Can be done on home expansion protocolCan be done on home expansion protocol Point : not until extremely painfulPoint : not until extremely painful

not until skin compromise not until skin compromise occurredoccurred

Movement of expanded flap :Movement of expanded flap :Advancement, transposition, rotationAdvancement, transposition, rotation

Scalp Scalp Indications : large congenital nevi, scar, skin Indications : large congenital nevi, scar, skin

graft alopecia, craniofacial reconstructiongraft alopecia, craniofacial reconstruction SAFE : no distortion on cranial suturesSAFE : no distortion on cranial sutures

temporary cranial moldingtemporary cranial molding Not induced proliferation of hair folliclesNot induced proliferation of hair follicles Can doubled size of scalp without obvious Can doubled size of scalp without obvious

alopeciaalopecia Pay attention to major arteries : Pay attention to major arteries :

superf.temporal, post.auricular, occipital, superf.temporal, post.auricular, occipital, supraorbitalsupraorbital

Placement on subgaleal above periosteumPlacement on subgaleal above periosteum Best port placement : pre-auricularBest port placement : pre-auricular

Forehead Forehead

Most challengingMost challenging Potential disfigurement of upper Potential disfigurement of upper

facial structures : brow asymmetry, facial structures : brow asymmetry, brow ptosis, altered hair direction, brow ptosis, altered hair direction, anterior hair line asymmetryanterior hair line asymmetry

Respect to aesthetic subunitsRespect to aesthetic subunits

ForeheadForehead

Techniques to minimize complication :Techniques to minimize complication : Bilateral expansionBilateral expansion Serial expansionSerial expansion Supra-orbital & temporal nevus Supra-orbital & temporal nevus use use

transposition from medial of the nevustransposition from medial of the nevus Temporal region Temporal region use parietal expanded use parietal expanded

skinskin Brow elevation Brow elevation use interposing with use interposing with

non-hair bearing forehead skinnon-hair bearing forehead skin

Face and NeckFace and Neck

Subunit principleSubunit principle Scar hidden in natural creasesScar hidden in natural creases Complication with tension on lower face : Complication with tension on lower face :

lower lip drooping, oral incompetence.lower lip drooping, oral incompetence. To minimize : use transposition & rotation To minimize : use transposition & rotation

from lateral cheek, neck, post.auricularfrom lateral cheek, neck, post.auricular Expansion useful in enlarging donor site Expansion useful in enlarging donor site

for FTG : perioral / periorbitalfor FTG : perioral / periorbital Above the claviculaAbove the clavicula Expanded = unexpandedExpanded = unexpanded

Trunk Trunk

Indications : giant nevi, vascular Indications : giant nevi, vascular malformations, contour defectsmalformations, contour defects

Anterior trunkAnterior trunk Lower abdomenLower abdomen

Most easilyMost easily For excision of adjacent lesionsFor excision of adjacent lesions Donor tissue for free TRAM flap Donor tissue for free TRAM flap to aid donor to aid donor

site closuresite closure Donor for FTGDonor for FTG Use anterior trunk limited in childrenUse anterior trunk limited in children

Trunk Trunk

Posterior trunkPosterior trunk Use commonly for giant nevi in Use commonly for giant nevi in

back /buttockback /buttock Reconstruction at age 6 months Reconstruction at age 6 months

BreastBreast

Post Mastectomy Reconstruction :Post Mastectomy Reconstruction : Autologous tissueAutologous tissue Expander – implantExpander – implant

Losken,et al :Fewer secondary procedure Losken,et al :Fewer secondary procedure with expander.with expander. Mastectomy + placement expander Mastectomy + placement expander

subpectoralsubpectoral Exchange with permanent prosthesis + nipple Exchange with permanent prosthesis + nipple

areola complex reconstruction + balancing areola complex reconstruction + balancing procedureprocedure

(Top) Preoperative and post-expansion, with full expanders in place.(Bottom) Permanent textured, shaped silicone gel implants in place.

Breast Breast

Congenital Breast AnomaliesCongenital Breast Anomalies Breast agenesis ( Poland Syndrome )Breast agenesis ( Poland Syndrome ) Idiopathic unilateral breast hypoplasiaIdiopathic unilateral breast hypoplasia Iatrogenic breast asymmetryIatrogenic breast asymmetry

Traditional : wait for maturityTraditional : wait for maturity Face problem : self-esteem, body-image, Face problem : self-esteem, body-image,

sexual identitysexual identity Solution : expanderSolution : expander Maturity Aged : replaced with permanent Maturity Aged : replaced with permanent

implant + balancing procedureimplant + balancing procedure

Extremities Extremities

Unfavorable donor for an expanded Unfavorable donor for an expanded flapflap

Complication rates higher ( 47% vs. Complication rates higher ( 47% vs. 23% )23% )

Cassanova : 19.4% of 200 casesCassanova : 19.4% of 200 cases ( 15.4% major complication, 4% ( 15.4% major complication, 4%

failure )failure )

Lower LimbLower Limb Expansion in lower limb is feasibleExpansion in lower limb is feasible Remote incision lead to lower Remote incision lead to lower

infection, extrusion & flap failure ratesinfection, extrusion & flap failure rates Contra-indication : unstable wound, Contra-indication : unstable wound,

infected woundinfected wound Large defect : expanded free flap Large defect : expanded free flap

(TRAM,Scapular)(TRAM,Scapular)

Upper LimbUpper Limb Proximal arm – elbowProximal arm – elbow

Non-circ. : expanded transposition flap Non-circ. : expanded transposition flap from back / shoulderfrom back / shoulder

Circumf. :expanded free TRAM flapCircumf. :expanded free TRAM flap Mid-forearmMid-forearm

Large/circumf. : expanded flank flap Large/circumf. : expanded flank flap (pedicled flap)(pedicled flap)

Hands, web-space, fingersHands, web-space, fingers Use expanded FTG from abdomen / Use expanded FTG from abdomen /

groin groin

Complications Complications

Major Major :: InfectionInfection Implant exposureImplant exposure Flap ischemiaFlap ischemia

MinorMinor : : Transient painTransient pain SeromaSeroma Dog ear at donor siteDog ear at donor site Widening of scarWidening of scar

Thank youThank you

TABLE 1. Tissue expansion by site.TABLE 1. Tissue expansion by site.

Scalp 27 (21%)Scalp 27 (21%)

Face 9 (7%)Face 9 (7%)

Neck 14 (11%)Neck 14 (11%)

Trunk (including breast) 16 (12.5%)Trunk (including breast) 16 (12.5%)

Upper extremity 26 (20.3%)Upper extremity 26 (20.3%)

Lower extremity 36 (28.2%)Lower extremity 36 (28.2%)