Repeated expansion in burn sequela

Burns 28 (2002) 494–499

Repeated expansion in burn sequela Ivo Pitanguy a,∗ , Natale Ferreira Gontijo de Amorim b , Henrique N. Radwanski b , José Eduardo Lintz c a

Department of the Pontifical, Institute of Post-Graduate Medical Studies, Catholic University of Rio de Janeiro, Rio de Janeiro 22280-020, Brazil b Department of the Pontifical, Catholic University of Rio de Janeiro, Rio de Janeiro 22280-020, Brazil c Institute of Post-Graduate Medical Studies, Catholic University of Rio de Janeiro, Rio de Janeiro 22280-020, Brazil Accepted 22 February 2002

Abstract This paper presents a retrospective study of the use of 346 expanders in 132 patients operated at the Ivo Pitanguy Clinic, between the period of 1985 and 2000. The expanders were used in the treatment of burn sequela. In the majority of cases, more than one expander was used at the same time. In 42 patients, repeated tissue expansion was done. The re-expanded flaps demonstrated good distension and viability. With the increase in area at each new expansion, larger volume expanders were employed, achieving an adequate advancement of the flaps to remove the injured tissue. The great advantage of using tissue re-expansion in the burned patient is the reconstruction of extensive areas with the same color and texture of neighboring tissues, without the addition of new scars. © 2002 Elsevier Science Ltd and ISBI. All rights reserved. Keywords: Tissue expander; Burn sequela; Reconstructive surgery

1. Introduction The ability of tissues to distend is based on the observation that all living tissues respond dynamically to mechanical stress. This may be noted in physiologic conditions such as during pregnancy, where the abdomen is progressively distended, the fetus’ skin stretches to accommodate the skeletal growth and the breast volume increases during lactation [1]. Tissue expansion can also be seen in pathologic process such as the growth of benign skin tumors, for instance, hemangiomas, cysts and large lipomas. Brazilian Indian’s were pioneers in the application of these principles, having a tradition in which objects of progressively increased size are placed in the ears and lips for the enhancement of physical beauty [2]. Many authors have indirectly supported this phenomenon by observing that soft tissues accommodate to the lengthening of limbs by bony distraction [3–6]. Plastic surgery relies on skin elasticity to accomplish simple resection of skin injuries, successive partial resection of sizeable lesions and design of flaps with rotation and advancement. This tissue elasticity is specially demonstrated in cases of multiple partial resection. The use of a tissue expander was first reported by Newmann in 1957 [7]. Radovan [8,9], Austad and ∗ Corresponding author. Present address: Ivo Pitanguy Clinic, Rua Dona Mariana 65, Rio de Janeiro 22280-020, Brazil. Fax: +55-21-2286-4991. E-mail address: [email protected] (I. Pitanguy).

Rose [10] and others contributed to the study of cutaneous expanders [11–27]. Manders et al. [28] described their experience, demonstrating the concepts, the complications of skin expansion and the importance of careful planning for a good outcome, mainly in scalp defects. Pitanguy et al. [29] recommended the maintenance of the fibrous capsule and proposed that performing incisions of this capsule would result in gaining additional length of the expanded flap. The same author analyzed the use of the expanders and the repeated expansion of the skin [30,31], concluding that, when correctly indicated, this leads to a good outcome, shortening the total time for the reconstruction of the deformity. In the authors’ experience, the flaps created in cutaneous re-expansion have demonstrated good distension and viability. With the increase in the area at each new expansion, expanders of larger volume can be employed, achieving an adequate advancement of the flaps to remove scar tissue (Fig. 1). The great advantage of using tissue re-expansion in the burned patient is the reconstruction of extensive areas with the same color and texture of the regional tissues, without the addition of new scars. 2. Patients and methods This study is a retrospective analysis on the use of 346 expanders in 132 patients operated at the Ivo Pitanguy Clinic between the period of 1985 and 2000. All expanders were

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I. Pitanguy et al. / Burns 28 (2002) 494–499

Fig. 1. The deformity that results from an inflatable implant is considerable, but is temporary. Patients accept this drawback when made aware of the possibility of removing a large amount of cutaneous deformity, as compared to conventional techniques. This 21-year-old patient is completing his fifth expansion in the cervical area.

used in the treatment of burn sequela. In the majority of cases, more than one expander was used at the same time. In 42 patients, repeated expansion (i.e. the use of an expander in the same site that was previously expanded) was performed. The basic principles of multiple expanders are the same as for a single expander and depend on degree of cutaneous elasticity, anatomical region, trophic conditions of skin and subcutaneous tissue. When planning the placement of one or more expanders, specific factors regarding the reconstruction should be considered, such as the dimension of the expanded flap and the direction of advancement or rotation of the future flap after completion of expansion. The expanded skin is clinically well vascularized, thus allowing for a variable design of the flap. In repeated expansions the design of the flaps that have previously been rotated or advanced should be especially observed. Insertion of the expander is done via an incision placed on the border between healthy and scar tissue and should not jeopardize the blood supply of the flap, or future flaps, in repeated expansions. The expander is placed into a pocket that is designed according to the plan of rotation or advancement of the flap, observing the local conditions of the skin and the suitability of the skin near the region that will be expanded. Dissection should be ample enough to comfortably contain the implant without tension. Sharp edges, formed by folding of the implant in a tight pocket, may cause skin erosion and subsequent extrusion. Undermining is performed by sharp dissection and is usually subcutaneous. In the scalp and in the frontal region, the expander is placed under the galea. For breast reconstruc-

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tion, when the pectoralis muscle has been preserved, the implant can be positioned under the muscle. When treating defects of the upper or lower limbs, fasciocutaneous flaps may be created by placing the expander under the fascia. In re-expansion it is often noticed that dissection is easier due to the presence of a capsule which varies in thickness according to the region and the time elapsed since the last expander was removed. The filling valve is positioned in a small, separate pocket, distant from the implant, so as to avoid accidental perforation during infiltration. The valve should be placed in a higher position because the weight of the expander will cause blunt dissection downwards, and, whenever possible, over a hard undersurface, such as bone, which will aid in immobilization of the valve during infiltrations. Choosing the position of the valve should take in consideration different pressure areas that may be uncomfortable for the patient during resting. When the expander is removed, the pocket of the valve should be enlarged by undermining laterally to the expander to obtain greater advancement of the flap. Hemostasis must be meticulously reviewed. Before closure of the incision, which is always done in two planes, a suction drain is left in the pocket and removed within 24–48 h. The first infiltration may be carried out before the dressing is placed and is usually 10–20% of total expander volume. This maneuver will fill the pocket and prevent accumulation of serosanguineous fluid. In the post-operative period, the infiltration begins, on the average, on the seventh post-operative day. This period is extended to 10–15 days when the expanders are located on the scalp and in the limbs. Infiltration should be accomplished under sterile conditions and always under monitor of a surgeon. Usually, the volume of infiltration per session is approximately 10% of the total volume of the expander, yet variability is dependent on local criteria such as decrease in capillary filling and excessive tension that causes local pain. A slight sensation of discomfort and pressure is expected and well tolerated by the patients. If the patient complains of local pain, this is a sign that the expander has been over-expanded and the excess saline solution should be removed. An interval of 3 or 4 days between each session is recommended and completion of the expansion is expected around 8 weeks. The patient is warned that any incident may interrupt the rate of expansion. It has been noted that in cases of re-expansion, the patient is more stimulated and collaborative, because of satisfaction with the previous procedure. Special attention must be taken with expansion of the lower extremities. The patient should refrain from walking for about 15 days and after this, the leg should be kept up at rest and movement restricted. Depending on the site, a plaster cast is used to ensure greater comfort and curtail movement. The second surgical procedure consists in the removal of the implant, with advancement or rotation of the flap. The incision is usually the same as was employed in the placement

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Table 1 Age group

Table 5 Repeated expansions

Age group (years)

Number of cases

01–09 10–19 20–29 30–39 40–49 50–59 60 or ≥60

14 50 36 21 4 4 3

Total

132

% 10.6 37.8 27.3 16.0 3.0 3.0 2.3

Number of expanders

Head Neck Thorax Lower limbs Upper limbs Abdomen

112 98 58 40 20 18

Total

346

32.4 28.3 16.8 11.5 5.8 5.2

Neck

17 6 5 2 1

1 2 3 5 7

4 1 1

1 3 5

Abdomen

3

1

Upper limbs

2 1

1 2

Lower limbs

2 1

1 7

100

Shape

Number of expanders

Oval Croissant Rectangular

120 118 108

Total

346

% 34.7 34.1 31.2 100

of the implant, with excision of the previous scar. Scoring of the capsule is performed by careful parallel incisions and helps to avoid excessive tension on the flap. The capsule should not be removed, as this might jeopardize the extracapsular vessels (subcutaneous vascular plexus) responsible for the increased perfusion of the expanded flap. The flap is advanced over the burn sequela, and fixed with strong sutures. Only after the flap has been fully stretched and positioned is scar tissue demarcated resected and substituted for healthy skin. Repeated expansions in the same area requires an interval of 6 months to 1 year, depending on the anatomical region Table 4 Ratio of expanders to patients

Total

1 2 3

%

Table 3 Shape of the expanders

1 2 3 4 5 6 7

Number of repeated expansion

6 1 1

Thorax

Location

Number of cases

Scalp

100

Table 2 Anatomical location

Number of expanders

Anatomical area

and the aspect of the skin and subcutaneous tissues. When re-expansion is indicated, it is recommended that the area be prepared with endermology or dermotony [32,33], which is a mechanical massage method consisting of positive pressure rolling in conjunction with applied negative pressure (suction) to both the skin and subcutaneous tissues. In our service, this method has been noted to clinically increase the vascularization and the elasticity of the skin that is to be re-expanded.

3. Results A total of 346 expanders were used in 132 patients, operated at Ivo Pitanguy Clinic, between the period of 1985 and 2000, for the correction of burn sequela. In the majority of cases, more than one expander was used at the same time. In 42 patients, repeated expansion was indicated.

Table 6 Complications Complications

Number of cases 20 57 27 16 6 5 1 132

100

%

Minor

Hematoma Seroma

9 6

2.6 1.7

Major

Wound dehiscence Partial flap necrosis Epidermolisis Implant rupture Infection Plugging of the valve Disconnection of the valve

4 2 2 1 1 1 0

1.1 0.6 0.6 0.3 0.3 0.3 0

26

7.5

% 15.2 43.2 20.5 12.1 4.5 3.8 0.7

Number of cases

Total

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Fig. 2. (A and B) A male patient, 32-year-old, with facial burn sequela, submitted to three cutaneous expansions. (C and D) Pre-operative aspect during the third expansion process. (E and F) Post-operative aspect after the third expansion, showing the complete resection of the burned area.

The age group with the greatest number of cases was the second decade (37.8%; Table 1). The most frequent anatomical locations for tissue expansion was the head (32.4%) and the neck (28.3%; Table 2) and the shape of the implant was oval (34.7%), “croissant” (34.1%) or rectangular (31.2%; Table 3) in equal proportion. The ratio of expanders to patients was 2.6 (Table 4). Repeated expansion included different anatomical areas (Table 5). The low rate of complications did not interfere with the procedure (Table 6). According to Manders et al. [28], complications were divided between minor and major. The

post-operative results were satisfactory in the great majority of patients (see surgical cases, Figs. 2 and 3).

4. Discussion The use of expanders has brought new perspectives to reconstructive plastic surgery. Results that were of difficult resolution with conventional techniques, such as multiple partial resections and autografting, are currently treated by tissue expansion. The great advantage of using tissue

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Fig. 3. (A) The 21-year-old patient with scar tissue over the thorax was submitted to four cutaneous expansions. (B) Pre-operative aspect during the second expansion. (C) Post-operative aspect after four expansions.

re-expansion in the burned patient is the reconstruction of extensive areas with tissue of the same color and texture, without the addition of new scars. However, the use of inflatable implants does not preclude partial excisions and they can even be associated. The success or failure of insertion, expansion and advancement of the flap will be determined by correct planning, execution and post-operative care, beginning in the first surgical procedure of the initial expansion. The indication of placing expanders in burn sequela is limited by the suitability of the skin near the region that will be expanded. When nearby tissues are unsuitable, either conventional procedures, such as partial resections, or more complex procedures, such as microsurgical flap transfer, are considered. Despite the decreased capacity of tissue elasticity in repeated expansion, as noted in our clinical experience, the re-expanded flaps in re-expansion have nevertheless demonstrated good distension and viability. There is also an extra gain in skin due to the increase in the area of healthy skin obtained from the previous procedure. It is recommended that in re-expansion, larger expanders be utilized so as to take advantage of the greater reliability of the flap, since it is more vascular than a previously non-expanded flap. In our protocol, the time interval between removal of the expanders and a new expansion was between 6 months and 1 year. A few days before the re-expansion, the area is prepared with mechanical massage (i.e. endermology or dermotony), to increase the vascularization and the elasticity of the skin. Various histologic studies have been performed in expanded skin aiming to understand the different alterations in its structures [2,34,35]. A fibrous capsule, composed by

myofibroblast and collagen fibers, is formed around the implant. A large number of new vessels are formed in the area adjacent to the capsule, which in turn serves to increase flap survival. The capsule formed around the expander may limit the extension of the flap, so multiple parallel incisions may be made down to the subcutaneous cellular tissue (capsulotomies) to further extend the flap. For best results, the surgeon should design an optimal flap. Each case demands an individualized planning, considering factors such as position of previous scar, amount of scar to be resected, and total gain from expansion. The great majority of expanded flaps in our study have been used as simple advancement flaps. Rotation of flaps may be performed, so long as an extra incision is not placed and healthy tissue is not sacrificed in the area bridging scar tissue and expanded flap. The pedicle of a rotation flap should, of course, be free of scars to allow for viability. In our community, an important factor to be considered in the indication of tissue expansion is the patient’s background. Patients that live away from our institution are often unable to remain for the average of 8 weeks that are necessary for completion of the procedure, having to return at least once a week for infiltration. Expansion at home has not been adopted at our service, as we believe that it is the surgeon’s responsibility to evaluate the local conditions and volume of each infiltration, besides being an additional factor for contamination. In general, the process of tissue expansion is well tolerated by emotionally stable patients of all ages, but its use is avoided in children less than 4-year-old. Non-compliant and mentally impaired patients are obviously poor candidates for expansion. In our experience, patients usually accept this

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technique willingly and, because of the good result of a previous process, many patients request further expansions. It is essential to appraise the patient’s psychological status during expansion. According to our experience, the re-expanded flaps demonstrated good distensibility and survival and the incidence of complications has been low. Other authors refer similar decrease in complication rates due to the large experience acquired with this method [36–43]. References [1] Austad ED, Thomas SB, Pasyk K. Tissue expansion: dividend or loan. Plast Reconstr Surg 1986;78:63–7. [2] Pitanguy I, Muller PM, Piccolo N. Expansores cutˆaneos e ressecções parciais múltiplas. (Tissue expanders and multiple partial resections). Rev Bras Cir 1987;777(1):41–58. [3] Codvilla A. On the means of lengthening in the lower limbs, the muscle and tissues which are shortened through deformity. Am J Orthop Surg 1905;2:353–405. [4] Magnuson PS. Lengthening shortened bones of the leg by operation. Univ Penn Med Bull 1908;103. [5] Petti V. The operative lengthening of the femur. JAMA 1921;77:934. [6] Matev I. Thumb reconstruction after amputation of the metacarpophalangeal joint with bone lengthening. J Bone Joint Surg 1970;52: P.957. [7] Newmann CG. The expansion of an area of skin by progressive distention of a subcutaneoous balloon. Plast Reconstr Surg 1957;19:124–30. [8] Radovan C. Adjacent flap development using expandable silastic implants. In: Proceedings of the Annual Meeting of American Society of Plastic and Reconstructive Surgeons. Boston, MA, 30 September 1976. [9] Radovan C. Tissue expansion in soft tissue reconstruction. Plast Recontr Surg 1984;74:482–92. [10] Austad ED, Rose GL. A self-inflating tissue expander. Plast Reconstr Surg 1982;70:107–11. [11] Pasyk KA. Electron microscopic evaluation of guinea pig skin and soft tissue expansion with a self-inflating silicone implant. Plast Reconstr Surg 1982;70:37–41. [12] Austad ED, Pasyk KA, McClatchey KD, Cherry GW. Histomorphologic evaluation of guinea pig skin flaps elevated in controlled expanded skin. Plast Reconstr Surg 1982;70:704–10. [13] Cherry GW. Increased survival and vascularity of random-pattern skin flaps elevated in controlled expanded skin. Plast Reconstr Surg 1983;72:680–7. [14] Sasaki GH, Pang CY. Pathophysiology and skin flaps raised on expanded pig skin. Plast Reconstr Surg 1984;74:59–65. [15] Brobman CF, Huber J. Effects of different shaped tissue expanders on transluminal pressure, oxygen tension, histopathologic changes and skin expansion in pigs. Plast Reconstr Surg 1985;76:731– 6. [16] Chrétien-Marquet B, Bennaceur S, Fernandez R. Surgical treatment of large cutaneous lesions of the back in children by concentric cutaneous mobilization. Plast Reconstr Surg 1997;100:926–36. [17] Hallock GG. Safety of clinical over inflation of tissue expanders. Plast Reconstr Surg 1995;96:153–7. [18] Hardestry JM. Something for nothing. Plast Reconstr Forum 1988;11:40. [19] Lantieri LA, Martin-Garcia N, Wechsler J, Mitrofanoff M, Raulo Y, Baruch JP. Vascular endothelial growth factor expression in expanded tissue: a possible mechanism of angiogenesis in tissue expansion. Plast Reconstr Surg 1998;101:392–8.

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