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A simple practical model for planning tissue-expanded flaps
Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 686e695
SHORT REPORTS AND CORRESPONDENCE
A simple practical model for planning tissue-expanded flaps We were interested to read the recent communication by Cenk et al.1 Tissue expansion is part of the modern reconstructive repertoire that has many advantages making the prolonged multi-staged process with its risks and complications worthwhile in selected cases. There have been many attempts to determine the influence of expander shape, size and volume on the subsequent amount and configuration of new skin available for reconstruction. Various published formulae can be useful as guides when combined with clinical judgement and assessment of the individual case, however, the pragmatic approach is often to use the largest expander that can be inserted and to expand as much as possible.2 The efficient use of the expanded skin requires good planning; making the first cut can be daunting for the inexperienced. Familiarity with the technical and practical aspects of tissue expansion comes only from clinical experience.3 The conversion of a three-dimensional area of skin to provide two-dimensional skin coverage can be challenging. Recent papers have provided practical advice4 on the use of expanded skin: some advocate the use of transposition flaps,5,6 or rotation flaps7 whilst others recommend advancement flaps.1,7,8 Traditional advancement flaps represented a compromise e a narrow flap increases the tissue mobility allowing it to be advanced further but ‘wastes’ expanded tissue either side of the flap. An important conceptual advance has been to view the skin created by an expander (particularly rectangular expanders) as a cube that can be unfolded. These ‘unfolded-cube’ advancement flaps allow good tissue movement (theoretically twice the height) combined with efficient use of almost all the expanded skin through the inclusion of ‘lateral flaps’ and, most significantly, are much more intuitive to visualise. Kiyokawa unfolded the ‘cube’ with the lateral flaps on the distal segment whilst Hudson included them with the middle segment. Cenk et al. reiterate the safe use of the lateral flaps on the distal segment; the increased vascularity of expanded skin may reduce the incidence of tissue necrosis. Earlier this year, we were involved in organising the First Hong Kong Wound Healing Symposium, and from the focus meetings, many doctors expressed an interest in a ‘handson’ workshop into the practical aspects of tissue expansion. We found no reports of workshops or practice models for
tissue expander applications and so developed a simple model using basic equipment. Feedback was extremely favourable and we report the model here. The equipment required includes:
magnetic object, e.g. fridge magnet; metal object e preferably a flat plate; plaster of Paris (POP); two plastic sheets; adhesive tape; tissue expander and equipment for expansion. 1. One plastic sheet (sheet 1) is placed on a large work surface and the magnetic object (a fridge magnet is ideal) is placed on top, marking the position of the ‘lesion’ that requires excision. The magnet is held in place by placing the flat metal object underneath, below sheet 1. This is covered by the second plastic sheet (sheet 2). 2. The incision for the insertion of the tissue expander is planned and marked out on sheet 2. The cut is then made with a pair of scissors and the tissue expander is placed under sheet 2 through this opening, which is then sealed again with adhesive tape.
Figure 1 The tissue expander has been filled and the plastic sheet (sheet 2) over it made to conform to its contours using tape. The position of the lesion is marked. Sheets of POP have been cut.
Short reports and correspondence
Figure 2 The dried POP sheet has retained the shape of the inflated tissue expander which has been removed from underneath the POP sheet. The ‘lesion’ (dotted line) can be cut out and the extra ‘skin’ used in various ways to reconstruct the defect.
3. The filling port, which can be internal or external, is used to fill the expander in the normal manner. 4. As the expander fills, sheet 2 will tend to be ‘tented’ up, thus adhesive tape is used liberally to conform the sheet to the contours of the expander. 5. Single layers of POP are cut to a good length (Fig. 1). These are soaked one at a time, and placed in single layers (with minimal overlap) over the sheet that covers the expander and the ‘lesion’. The POP is moulded around the contours of the expander. 6. The POP then is allowed to dry producing the equivalent of expanded skin (Fig. 2). 7. The POP over the ‘lesion’ is cut out to create the defect. The expander can be removed through incisions or simply by lifting up the POP. 8. The incisions for the mobilisation of expanded skin are planned and made accordingly. The POP ‘flap’ is advanced, rotated or transposed into the defect according to the patterns described in the recent literature. This model is extremely cheap and easy to use, allowing frequent practice/‘trial and error’ in the use of tissueexpanded skin which we hope will translate to effective and efficient use in clinical situations. Refinements are planned in future models. Single layers of POP were used in this model e this is somewhat stiffer than skin but would replicate the physical effect of a fibrous capsule to a certain extent. POP was chosen for the workshop because it would be ready in a very short time. We envisage that without similar time constraints we could use a latex foam or similar model that would approximate the properties of skin more closely. In addition, in future workshops, we do plan to use mannequins instead of a flat work surface.
References 1. Cenk S, Cigdem U, Tonguc I, et al. Lateral wing flaps for increasing the gain in surface area of rectangular expanders. Br J Plast Surg 2006;59:896e8.
687 2. Hudson DA. Maximising the use of tissue expanded flaps. Br J Plast Surg 2003;56:784e90. 3. Shively RE. Discussion: surface-area increase in tissue expansion. Plast Reconstr Surg 1988;82:838e9. 4. Zide BM, Karp NS. Maximizing gain from rectangular tissue expanders. Plast Reconstr Surg 1992;90:500e6. 5. Bauer BS, Margulis A. The expanded transposition flap: shifting paradigms based on experience gained from two decades of pediatric tissue expansion. Plast Reconstr Surg 2004;114:98e106. 6. Vendroux J, Ascherman JA, Lacroix P, et al. Obtaining maximal use of expanded scalp rotation flaps via an experimental model. Plast Reconstr Surg 1997;99:1000e5. 7. Hudson DA, Grob M. Optimising results with tissue expansion: 10 simple rules for successful tissue expander insertion. Burns 2005;31:1e4. 8. Kiyokawa K, Rikimaru H, Inoue Y, et al. A new concept and technique for reconstructing skin defects in the cheek region: an unfolded cube advancement flap. Plast Reconstr Surg 2004; 113:985e91.
Tor Wo Chiu C.K. Lam S.Y. Wong Y.K. Lau S.Y. Ying Andrew Burd Chinese University of Hong Kong, Department of Surgery, Division of Plastic and Reconstructive Surgery, 4th Floor, Clinical Sciences Building, Prince of Wales Hospital, Shatin, New Territories, Hong Kong E-mail address: [email protected] ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.11.029
Pinnaplasty trends in Scottish children A recent feature in a leading national newspaper1 raised concerns that increasing numbers of children and teenagers were undergoing cosmetic procedures at public expense in National Health Service (NHS) institutions. The authors expressed concerns about the appropriateness of such surgery in vulnerable children and implied that the surgery was being offered inappropriately. Of concern to us, in particular, was the statement that ‘by far the most common cosmetic operation carried out on children was pinnaplasty’1 under the NHS. Does this statement reflect the current trend in NHS hospital pinnaplasties? An independent website lists pinnaplasties or otoplasties as costing between £1100 and £2800 in the private sector.2 Psychologists tell us that prominent ears may lead to significant psychosocial dysfunction for children and adolescents and impact on the education of young children as a result of teasing and truancy. Although essentially a cosmetic procedure, national guidelines3,4 have been drawn up recently to stipulate criteria as to how
SHORT REPORTS AND CORRESPONDENCE
A simple practical model for planning tissue-expanded flaps We were interested to read the recent communication by Cenk et al.1 Tissue expansion is part of the modern reconstructive repertoire that has many advantages making the prolonged multi-staged process with its risks and complications worthwhile in selected cases. There have been many attempts to determine the influence of expander shape, size and volume on the subsequent amount and configuration of new skin available for reconstruction. Various published formulae can be useful as guides when combined with clinical judgement and assessment of the individual case, however, the pragmatic approach is often to use the largest expander that can be inserted and to expand as much as possible.2 The efficient use of the expanded skin requires good planning; making the first cut can be daunting for the inexperienced. Familiarity with the technical and practical aspects of tissue expansion comes only from clinical experience.3 The conversion of a three-dimensional area of skin to provide two-dimensional skin coverage can be challenging. Recent papers have provided practical advice4 on the use of expanded skin: some advocate the use of transposition flaps,5,6 or rotation flaps7 whilst others recommend advancement flaps.1,7,8 Traditional advancement flaps represented a compromise e a narrow flap increases the tissue mobility allowing it to be advanced further but ‘wastes’ expanded tissue either side of the flap. An important conceptual advance has been to view the skin created by an expander (particularly rectangular expanders) as a cube that can be unfolded. These ‘unfolded-cube’ advancement flaps allow good tissue movement (theoretically twice the height) combined with efficient use of almost all the expanded skin through the inclusion of ‘lateral flaps’ and, most significantly, are much more intuitive to visualise. Kiyokawa unfolded the ‘cube’ with the lateral flaps on the distal segment whilst Hudson included them with the middle segment. Cenk et al. reiterate the safe use of the lateral flaps on the distal segment; the increased vascularity of expanded skin may reduce the incidence of tissue necrosis. Earlier this year, we were involved in organising the First Hong Kong Wound Healing Symposium, and from the focus meetings, many doctors expressed an interest in a ‘handson’ workshop into the practical aspects of tissue expansion. We found no reports of workshops or practice models for
tissue expander applications and so developed a simple model using basic equipment. Feedback was extremely favourable and we report the model here. The equipment required includes:
magnetic object, e.g. fridge magnet; metal object e preferably a flat plate; plaster of Paris (POP); two plastic sheets; adhesive tape; tissue expander and equipment for expansion. 1. One plastic sheet (sheet 1) is placed on a large work surface and the magnetic object (a fridge magnet is ideal) is placed on top, marking the position of the ‘lesion’ that requires excision. The magnet is held in place by placing the flat metal object underneath, below sheet 1. This is covered by the second plastic sheet (sheet 2). 2. The incision for the insertion of the tissue expander is planned and marked out on sheet 2. The cut is then made with a pair of scissors and the tissue expander is placed under sheet 2 through this opening, which is then sealed again with adhesive tape.
Figure 1 The tissue expander has been filled and the plastic sheet (sheet 2) over it made to conform to its contours using tape. The position of the lesion is marked. Sheets of POP have been cut.
Short reports and correspondence
Figure 2 The dried POP sheet has retained the shape of the inflated tissue expander which has been removed from underneath the POP sheet. The ‘lesion’ (dotted line) can be cut out and the extra ‘skin’ used in various ways to reconstruct the defect.
3. The filling port, which can be internal or external, is used to fill the expander in the normal manner. 4. As the expander fills, sheet 2 will tend to be ‘tented’ up, thus adhesive tape is used liberally to conform the sheet to the contours of the expander. 5. Single layers of POP are cut to a good length (Fig. 1). These are soaked one at a time, and placed in single layers (with minimal overlap) over the sheet that covers the expander and the ‘lesion’. The POP is moulded around the contours of the expander. 6. The POP then is allowed to dry producing the equivalent of expanded skin (Fig. 2). 7. The POP over the ‘lesion’ is cut out to create the defect. The expander can be removed through incisions or simply by lifting up the POP. 8. The incisions for the mobilisation of expanded skin are planned and made accordingly. The POP ‘flap’ is advanced, rotated or transposed into the defect according to the patterns described in the recent literature. This model is extremely cheap and easy to use, allowing frequent practice/‘trial and error’ in the use of tissueexpanded skin which we hope will translate to effective and efficient use in clinical situations. Refinements are planned in future models. Single layers of POP were used in this model e this is somewhat stiffer than skin but would replicate the physical effect of a fibrous capsule to a certain extent. POP was chosen for the workshop because it would be ready in a very short time. We envisage that without similar time constraints we could use a latex foam or similar model that would approximate the properties of skin more closely. In addition, in future workshops, we do plan to use mannequins instead of a flat work surface.
References 1. Cenk S, Cigdem U, Tonguc I, et al. Lateral wing flaps for increasing the gain in surface area of rectangular expanders. Br J Plast Surg 2006;59:896e8.
687 2. Hudson DA. Maximising the use of tissue expanded flaps. Br J Plast Surg 2003;56:784e90. 3. Shively RE. Discussion: surface-area increase in tissue expansion. Plast Reconstr Surg 1988;82:838e9. 4. Zide BM, Karp NS. Maximizing gain from rectangular tissue expanders. Plast Reconstr Surg 1992;90:500e6. 5. Bauer BS, Margulis A. The expanded transposition flap: shifting paradigms based on experience gained from two decades of pediatric tissue expansion. Plast Reconstr Surg 2004;114:98e106. 6. Vendroux J, Ascherman JA, Lacroix P, et al. Obtaining maximal use of expanded scalp rotation flaps via an experimental model. Plast Reconstr Surg 1997;99:1000e5. 7. Hudson DA, Grob M. Optimising results with tissue expansion: 10 simple rules for successful tissue expander insertion. Burns 2005;31:1e4. 8. Kiyokawa K, Rikimaru H, Inoue Y, et al. A new concept and technique for reconstructing skin defects in the cheek region: an unfolded cube advancement flap. Plast Reconstr Surg 2004; 113:985e91.
Tor Wo Chiu C.K. Lam S.Y. Wong Y.K. Lau S.Y. Ying Andrew Burd Chinese University of Hong Kong, Department of Surgery, Division of Plastic and Reconstructive Surgery, 4th Floor, Clinical Sciences Building, Prince of Wales Hospital, Shatin, New Territories, Hong Kong E-mail address: [email protected] ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2006.11.029
Pinnaplasty trends in Scottish children A recent feature in a leading national newspaper1 raised concerns that increasing numbers of children and teenagers were undergoing cosmetic procedures at public expense in National Health Service (NHS) institutions. The authors expressed concerns about the appropriateness of such surgery in vulnerable children and implied that the surgery was being offered inappropriately. Of concern to us, in particular, was the statement that ‘by far the most common cosmetic operation carried out on children was pinnaplasty’1 under the NHS. Does this statement reflect the current trend in NHS hospital pinnaplasties? An independent website lists pinnaplasties or otoplasties as costing between £1100 and £2800 in the private sector.2 Psychologists tell us that prominent ears may lead to significant psychosocial dysfunction for children and adolescents and impact on the education of young children as a result of teasing and truancy. Although essentially a cosmetic procedure, national guidelines3,4 have been drawn up recently to stipulate criteria as to how