Skin expansion in head and neck reconstructive surgery

Full-Thickness Skin Grafting for Local Defect Coverage Following Scalp Adjacent Tissue Transfer in the Setting of Cranioplasty

INTRODUCTION

Numerous techniques have been described to overcome scalp deficiency and high-tension closure at time of cranioplasty. However, there is an existing controversy, over when and if a free flap is needed during complex skull reconstruction (ie, cranioplasty). As such the authors present here our experience using full-thickness skin grafts (FTSGs) to cover local defects following scalp adjacent tissue transfer in the setting of cranioplasty.

METHODS

By way of an institutional review board-approved database, the authors identified patients treated over a 3-year period spanning January 2015 to December 2017, who underwent scalp reconstruction using the technique presented here. Patient demographics, clinical characteristics, technical details, outcomes, and long-term follow up were statistically analyzed for the purpose of this study.

RESULTS

Thirty-three patients, who underwent combined cranioplasty and scalp reconstruction using an FTSG for local donor site coverage, were identified. Twenty-five (75%) patients were considered to have "high complexity" scalp defects prior to reconstruction. Of them, 12 patients (36%) were large-sized and 20 (60%) medium-sized; 21 (64%) grafts were inset over vascularized muscle or pericranium while the remaining grafts were placed over bare calvarial bone. In total, the authors found 94% (31/33) success for all FTSGs in this cohort. Two of the skin grafts failed due to unsuccessful take. Owing to the high rate of success in this series, none of the patient's risk factors were found to correlate with graft failure. In addition, the success rate did not differ whether the graft was placed over bone verses over vascularized muscle/pericranium.

CONCLUSION

In contrary to previous studies that have reported inconsistent success with full-thickness skin grafting in this setting, the authors present a simple technique with consistent results-as compared to other more complex reconstructive methods-even in the setting of highly complex scalp reconstruction and simultaneous cranioplasty.

Soft tissue expansion and cranioplasty: For which indications?

PURPOSE

The aim of this study was to better define indications for scalp tissue expansion before cranioplasty, and to describe our methodology for calculate the surface of tissue needed, by combining a preoperative analysis of both the size of the defect and the quality of skin above.

MATERIAL AND METHODS

A retrospective analysis of patients who underwent expansion before cranioplasty between 2009 and 2015 was conducted. Information was collected on the etiology, size and location of the defect, and reasons of skin contracture. Data concerning expansion and cranioplasty were reviewed.

RESULTS

Among 47 patients who underwent operation for cranioplasty, five (10.6%) required previous scalp tissue expansion. The etiology of the bone defect was tumoral in three cases, posttraumatic in one case, and a decompressive craniectomy in one case. The mean surface of the bone defect was 69.6 ± 18.7 cm(2). The locations of the defects were fronto-temporo-parietal, frontal, temporo-frontal, on the vertex, and occipital. The cause associated with the skin contracture was an infection in four cases and a delayed cranioplasty in one case. A round-profile expander and a custom-made porous hydroxyapatite implant were used for all patients.

CONCLUSIONS

The accurate assessment of tissue needed before cranioplasty is as essential as the choice of the material used for bone reconstruction. After previous infected cranioplasty or delayed reconstruction of large defects, scalp tissue expansion should be proposed.

Tissue expanders in reconstruction of maxillofacial defects

Tissue expansion in its natural ways had fascinated man from prehistoric times itself. But tissue expansion for medical purposes was first tried and reported only in the early half of twentieth century. Presently the principle of tissue expansion is being used in reconstruction of many hard and soft tissue defects of larger dimension, which were previously regarded as great challenge for maxillofacial and plastic surgeons. Making use of the viscoelastic nature of the skin, considerable amount of tissue expansion based tissue engineering is possible in the maxillofacial region. Here we present a case of a facial scar of large dimension with a central oro cutaneous fistula developed as a result of facial artery blow out in a 24 year old female for which esthetic correction was done using the excess tissue obtained from tissue expansion. In this case where other methods of reconstruction such as local flaps, free flaps and normal tissue grafts were assessed to be non viable, tissue expansion was found to be an apt solution for esthetic reconstruction.

Use of scar and capsule flap for preventing the contour deformity after applying tissue expansion in patients with scar

BACKGROUND

Tissue expansion is a reconstruction method often used to repair the tissue loss that results after removing soft tissue lesions such as scars, tumors, and giant hairy nevi. However, because the pressure of a tissue expander applies in all directions almost equally, along with the desired expansion of skin and subcutaneous fat tissue, the muscle and bone underneath the expander become depressed simultaneously. Even with a successful expansion of the tissue itself, the conventional surgical procedure results to frequent aesthetically dissatisfying outcomes because of contour irregularities. However, no studies have been conducted regarding the correction of these secondary deformities.

METHODS

A surgical method to prevent secondary depression deformity was performed on a total of 80 patients who had undergone scar revision using tissue expansion between May 2002 and April 2012. First, the scar tissue was de-epithelized and transposed to fill the depressed area as a buried flap. Second, the capsule formed around a tissue expander was elevated as a flap and turned over to fill the depressed area. Lastly, the thickened capsule at the margins of the expander was used as a free capsule graft, which provides additional supports. Four plastic surgeons analyzed the postoperative aesthetic results after the surgery in an outpatient follow-up clinic.

RESULTS

There were complications of tissue expansion in 7 patients: 5 had minor complications, which were successfully addressed with conservative treatments, and 2 had major complications, which required tissue expander removal during the course. In more than 85% of the patients, satisfactory postoperative aesthetic results were achieved without any perceivable depression or asymmetry.

CONCLUSIONS

Secondary depression deformity induced by a tissue expander can be effectively prevented with a simple operative technique using capsule flaps, scar tissue flaps, and free capsule grafts.

Psycho-oncological aspect of surgery in palliative care: our satisfactory experience using a V-Y island flap

CONCLUSIONS

Our reconstruction method using a V-Y island flap was minimally invasive and yielded a satisfactory esthetic result without impairing the patient's postoperative quality of life (QOL).

OBJECTIVE

Malignant skin tumors of the head and neck often affect the patient's appearance and QOL. Therefore, surgery for terminally staged patients with malignant skin tumors may be a treatment of choice for surgeons in a palliative care team to improve and sustain the patient's QOL.

METHODS

We describe our experience of surgical treatment of a large primary malignant skin tumor in the head performed as part of palliative care in a 38-year-old woman in the terminal stage. We developed a V-Y island flap that did not result in postoperative alopecia.

RESULTS

After surgery, the patient did not have alopecia and her hair hid the scar. The patient and her family were greatly satisfied with the result. Although the surgery did not extend her life, it alleviated her depressed condition caused by the uncomfortable primary tumor.

Staged scalp soft tissue expansion before delayed allograft cranioplasty: a technical report

BACKGROUND

Hemicraniectomy is an established neurosurgical procedure. However, before cranial vault reconstruction, it is imperative that sufficient scalp soft tissue is available for coverage of the reconstructed skull.

OBJECTIVE

To present 2 complex cases of posttraumatic patients requiring soft tissue expansion of the scalp before definite cranioplasty with use of a synthetic polyethylene graft.

METHODS

Two patients underwent decompressive hemicraniectomy for trauma and required delayed cranioplasty. Both patients had developed significant scalp contraction and presented with a paucity of soft tissue. These patients underwent a staged cranioplasty in which we first achieved scalp-tissue expansion adjacent to the craniectomy site over a prolonged interval. In a second stage, the patient underwent definite reconstructive surgery in which the subgaleal expanders were removed and polyethylene allograft cranioplasty was performed.

RESULTS

Cutaneous coverage of the underlying defect could be achieved in this setting without causing tension on the incision line secondary to the now available excess scalp tissue.

CONCLUSION

Repair of a cranial defect requires detailed attention to the available scalp and its size relationship to the skull defect to achieve a successful outcome with an aesthetically pleasing, reliable, and lasting result. Preoperative scalp tissue expansion is a valuable step in taking care of patients presenting with scalp soft tissue defect. This technique reduces the morbidity associated with conventional rotational and free-flap techniques.

Scalp and forehead reconstruction

The treatment of scalp and forehead defects is challenging. There are few cases in which an untreated scalp defect can heal by secondary intention. However, lack of adequate treatment can also lead to fatal consequences. Adequate judgment and treatment of a defect on the scalp are therefore mandatory. There are many options to reconstruct a scalp defect. Each option has its role in the reconstruction repertoire. Various factors need to be considered when choosing the method to be used. These factors include etiology and the size of the defect, age and general health of the patient, as well as the situation at the hospital/unit where the treatment is performed. In this article, different reconstruction methods are presented, and guidelines for the selection of the various options are provided.

Management of postneurosurgical bone flap loss caused by infection

LEARNING OBJECTIVES

After studying this article, the participant should: 1. Be able to define indications and timing for secondary cranioplasty. 2. Understand the surgical options for reconstructing the cranium and overlying soft-tissue defect including their advantages and disadvantages. 3. Be able to apply this knowledge to the clinical setting of an infectious bone flap loss.

BACKGROUND

Infection after craniotomy occurs in approximately 1.1 to 8.1 percent of cases and often necessitates bone flap removal. For a secondary cranioplasty, there is an increased risk of recurrent infection, which influences the reconstructive plan. The soft tissue/scalp is frequently compromised by infection, sequelae of prior surgery, and/or adjuvant radiation therapy.

METHODS

A literature review was conducted to compile and summarize the indications for secondary cranioplasty after infectious bone flap loss, the timing of the procedure, and the surgical options for bone and soft-tissue reconstruction. In coordination with soft-tissue coverage, cranioplasty options include alloplastic reconstruction, allogeneic or autogenous bone grafts, and free tissue transfer.

RESULTS

The literature review identified the following factors that must be considered in the treatment plan for secondary cranioplasty after postneurosurgical bone flap loss: indications, timing of reconstruction, soft-tissue status and the need for soft-tissue reconstruction, and method of cranioplasty.

CONCLUSIONS

Treatment recommendations for cranioplasty in the clinical setting of infectious postneurosurgical bone flap loss are presented. These guidelines consider the risk factors for a recurrent infection, the condition of the soft-tissue coverage, and the concavity of the preoperative cranial deformity.

New flap for restoration of the temporal hair line

The authors have devised a novel method of designing a flap for coverage of posttraumatic temporal hairline alopecia. They have successfully performed restoration of temporal hairline alopecia as large as 18 x 4 cm resulting from a previous trauma treated with a primary grafting. The new method uses a simple flap designed preoperatively by Doppler based on the supraorbital vessels up to the flap's anastomosis with the occipital vessels. This flap is easy to design and elevate with sufficient blood flow. Alopecia resulting from scar formation at the suture line is not conspicuous. The donor site can be closed primarily, and no dog ear has resulted from its application.

Patient-controlled expansion: applying a new technique to breast reconstruction

Tissue expansion has been used as a technique to increase the amount of skin (and/or soft tissues) available for closing a defect or reconstructing an anatomic unit. Although the technique has undergone many modifications, the basic principles have remained more or less constant. The shortcomings of tissue expansion have remained unsolved for many years, namely, long periods of expansion with concomitant abnormal appearance with increased risk of complications over this extended period. Decreasing the expansion period would significantly contribute to patient convenience, decreased costs, and improved acceptance of the technique. This would need to be done within a background of safety without compromise to the reconstructive effort. With minor modification to the existing tissue expanders and their attachments together with modified patient-controlled infusion devices, a new method has been devised for tissue expansion in which the patient can control and expedite the entire process. As "proof of concept," 10 patients were selected for this trial. All had undergone mastectomies without concomitant radiotherapy. Successful full expansion, beginning the day after surgery, was achieved in all cases in approximately 3 weeks with minimal complications. Patent pending design modifications have been made that expedite the process, making it easier, more efficient, and cheaper to achieve full expansion. Although the numbers in this series were small, proof of concept was achieved, and trials are ongoing with increasing numbers expected. The concept is applicable to all forms of tissue expansion, including aesthetic indications such as hair restoration, tubular breast correction, and the like.

Free Flap Reconstruction of the Scalp and Calvaria of Major Neurosurgical Resections in Cancer Patients: Lessons Learned Closing Large, Difficult Wounds of the Dura and Skull

BACKGROUND

Reconstruction of major neurosurgical resections can present a significant challenge because of the morbidity of radiation therapy, cerebrospinal fluid leaks, bacterial contamination from sinus exposure, and functional and cosmetic deformity from the size and location of the defect. The authors present their experience with free tissue reconstruction of scalp and calvarial defects. In particular, the authors examine their results in relation to major comorbidities, such as preoperative cerebrospinal fluid leak, history of smoking, and perioperative radiation therapy.

METHODS

From 1997 to 2004, 22 patients requiring neurosurgical or head and neck resection for cancer from a single institution who underwent reconstruction with 24 flaps were examined retrospectively. Factors examined included patient demographics, indication for surgery, type of flap used, exposed critical structures, comorbidity, complications, and outcomes.

RESULTS

Of the 22 patients, seven had a cerebrospinal fluid leak present at the time of their reconstructive surgery. Of the seven, one patient died as a result of a stroke postoperatively. Of the remaining six patients, two had partial flap necrosis (33 percent). However, all six flaps survived, with resolution of cerebrospinal fluid leak. In comparison, of the 15 patients (17 flaps) without a cerebrospinal fluid leak, three had partial flap necrosis (18 percent; not significant). With regard to smoking status, the partial flap necrosis rate was 30 percent in smokers versus a rate of 14 percent in nonsmokers, although this was not statistically significant. Only one patient who received perioperative radiation (11 of 22 patients) developed partial flap necrosis.

CONCLUSIONS

The authors' data support the concept that free tissue transfer is a viable option in reconstruction of cranial defects. Although complications can occur in this high-risk population, successful reconstruction with free flaps was possible. Difficult problems, such as recurrent cerebrospinal fluid leaks and large irradiated wounds, can be managed and resolved successfully using this technique.

Nevus Sebaceus of Jadassohn

The nevus sebaceus of Jadassohn (SNJ) is a hamartomatous disorder of the skin and its adnexa pertaining to the group of "organoid nevi,'' most frequently involving the face and scalp. During adulthood, patients with SNJ have a 10% to 20% risk of the development of cutaneous or adnexal neoplasia, so that prophylactic excision before puberty is recommended by most authors, and tissue expansion is considered to be the best method of reconstruction. It has been largely demonstrated in literature that most of the lesions that have been interpreted as basal cell carcinoma (BCC) are actually examples of primitive follicular induction or trichoblastomas, not authentic BCCs. A literature review on histopathologic findings associated with SNJ and a retrospective chart review of two cases occurring in young females are presented. In one case, the lesion was treated by intraoperative expander-assisted reduction and scalp graft (Case 1); in the other one, a primary closure with adjacent tissue was performed (Case 2). No signs of malignant degeneration or residual pathology have been found. For treatment of the biggest lesions, when preoperative tissue expansion cannot be performed, intraoperative one, transfer of a scalp graft has been shown to be a good reconstructive method. For the smallest lesions, a primary closure with adjacent tissue is sufficient.

Reconstruction of acquired scalp defects: an algorithmic approach

LEARNING OBJECTIVES

After studying this article, the participant should: 1. Understand scalp anatomy, hair physiology, and skin viscoelastic properties as they relate to scalp reconstruction. 2. Understand the principles that allow for aesthetic reconstruction of scalp defects. 3. Understand the use of local tissue rearrangement for reconstruction of specific areas of the scalp. 4. Understand the use of tissue expansion and free tissue transfer for scalp reconstruction.

BACKGROUND

Reconstruction of scalp defects is required for acute trauma, tumor extirpation, radiation necrosis, and the repair of traumatic alopecia or cosmetically displeasing scars.

METHODS

The proper choice of a reconstructive technique is affected by several factors-the size and location of the defect, the presence or absence of periosteum, the quality of surrounding scalp tissue, the presence or absence of hair, location of the hairline, and patient comorbidities. Successful reconstruction of these defects requires a detailed knowledge of scalp anatomy, hair physiology, skin biomechanics, and the variety of possible local tissue rearrangements. In nearly total defects, local tissues may be inadequate and tissue expansion or free tissue transfer may be the only alternatives.

RESULTS

Plastic surgeons are now able to obtain coverage over the calvaria after the most devastating of defects; however, the challenge to the reconstructive surgeon today is to do so with excellent cosmetic results. Cosmetic scalp reconstruction requires restoration and preservation of normal hair patterns and hair lines.

CONCLUSIONS

Successful reconstruction of the scalp requires careful preoperative planning and precise intraoperative execution. Detailed knowledge of scalp anatomy, skin biomechanics, hair physiology, and the variety of available local tissue rearrangements allows for excellent aesthetic reconstruction.

Facial reconstruction after mucormycosis in an immunocompetent host

Cutaneous mucormycosis in the immunocompetent patient is exceedingly rare. However, if the infection is not rapidly identified and aggressively treated, its progression is fast, fulminate, and characteristically fatal. This case report describes the treatment and surgical reconstruction of a previously healthy, immunocompetent girl after pervasive mucormycosis of the right face. The patient's diagnosis was established by tissue biopsy. She was promptly started on 1.5 mg/kg per day intravenous amphotericin B and underwent numerous surgical debridements resulting in a large defect of the right face. After 2 xenograft procedures the defect was covered with an autologous split thickness skin graft. During this procedure a submandibular 4 x 7-cm tissue expander with a remote occipital port was placed superficial to the platysma. Serial tissue expansion took place over 8 weeks without complication. The tissue expander was removed and the expanded flap was advanced over the freshly de-epithelialized defect. Revisional surgeries may yet be performed; notwithstanding, the patient and her parents are pleased with the current results. Although the management of cutaneous mucormycosis often involves disfiguring tissue resection, the current wealth of reconstructive modalities can greatly improve the aesthetic and functional outcomes of requisite therapy.

A Novel Procedure Using a Tissue Expander for Management of Persistent Alveolar Fistula After Lobectomy

We treated a patient with postlobectomy persistent alveolar fistula using a tissue expander, which is a prosthesis widely used in plastic surgery. The patient had thoracic empyema develop after right bilobectomy for lung cancer, and consequently underwent drainage of empyema followed by muscle flap closure for alveolar fistula. A residual space remained, and air leak persisted. However, implanting and expanding a tissue expander enabled us to tightly fix the flap on the raw pulmonary surface, which eventually solved the air leak. The tissue expander greatly contributed to muscle flap closure for a persistent alveolar-pleural fistula with a large remaining thoracic space.

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.

Aesthetic reconstruction of large scalp defects by sequential tissue expansion without interval

Tissue expansion is indicated in the reconstruction of various scalp defects when there is inadequate adjacent tissue to allow either primary closure of the defect or repair with a local flap. It is the most important armamentarium for aesthetic hair-bearing scalp reconstruction in cases of congenital or required defects. This technique was used sequentially without interval to achieve scalp reconstruction for 12 patients with a defect ranging from 30% to 75% of the scalp (average, 55%). For 12 patients, 32 expansion treatments were undertaken between September 1997 and January 2002. The 12 patients included 3 women, 4 men, and 5 children with a mean age of 20 years (range, 45 days to 36 years). All patients had more than one period of treatment. The most common conditions treated were burns (n=7), trauma (n=1), congenital naevi (n=2), and male pattern baldness (n=2). Reconstruction of 12 large scalp defects has been performed with a 3.1% rate of major complications. Results show that tissue expansion is a safe and efficient but time-consuming technique for aesthetic scalp reconstruction, especially in the case of "sideburn" scenario or large defects. There was no significant alteration in ratio of complications although tissue expansions were made sequentially.

Expanded occipito-cervico-pectoral flap for reconstruction of burned cervical contracture

Postburn neck contracture and hypertrophic scarring can cause functional limitation and aesthetic disfigurement. Reconstruction of severe deformities and scar of neck following healing from burns confronts the surgeon with some of the most challenging problems in reconstructive surgery. Through knowledge of available reconstructive technique accurate diagnosis of tissue deficiency and secondary distortion, imaginative planning and definitive, careful execution of ones surgical plan are the bare minimum items for achieving improvement in a burned deformed neck. The aim of this article is to assess the role of expanded occipito-cervico-pectoral (o-c-p) flap for reconstruction in a series of four patients with severe burn scar of neck and involvement of shoulder back but intact anterior aspect of chest. This is an alternative method of reconstruction burn scar of neck area.

Algorithm of hair restoration surgery in children

Hair is an inseparable element of external appearance of every human being. Although various fashion trends come and go, the lack of hair is for many a major aesthetic and psychological problem. Even if men's balding can be accepted as a natural phenomenon, hair loss in children is considered to be a condition demanding correction. During an 18-year period, 8440 hair restoration operations were performed at the Hair Clinic Poznan, in Poznan, Poland. Most patients were men treated for androgenic alopecia. Among the patients were 57 children in whom hair loss resulted from hereditary factors, perinatal traumas, radiotherapy, and mechanical, thermal, and chemical damage. Methods of restoration were adjusted to type of hair loss, patient age, and ability to cooperate with the surgeon. In cases of single massive scars, skin flap correction was usually used. The flaps were prepared with the use of expanders. In cases of numerous scattered defects or considerable thinning of the scalp, the method of choice was hair transplantation. The "four-hand stick-and-place" technique developed by the authors enabled the surgeon to quickly and precisely carry out the procedure. Application of varied surgery techniques in scalp reconstruction procedures in children gave very good aesthetic results with a minimal complication rate.

Assessment of facial tissue expansion with three-dimensional digitizer scanning

This article reports a three-dimensional (3D) digital color scanning system used in the measurement of facial soft tissue expansion. This system consists of digital scanning equipment, software for stereolithographical (STL) forms and nonuniform rational B-spline (NURBS) surfaces, and a computer-aided design program. Accurate data for the area of scar excision and the expanded cervicofacial flap were obtained by using this measuring system in a young patient with scar contracture of the face. This technique can accurately model the reconstruction and make plastic surgery planning a truly interactive procedure.

The role of tissue expansion in the management of large congenital pigmented nevi of the forehead in the pediatric patient

The authors present a cohort of 21 consecutive patients who had congenital pigmented nevi covering 15 to 65 percent of the forehead and adjacent scalp and who were treated at their institution within the last 12 years. All patients were treated with an expansion of the adjacent texture- and color-matched skin as the primary modality of treatment. The median age at presentation was approximately 1 year; mean postoperative follow-up was 4 years. Nevi were classified according to the predominant anatomic areas they occupied (temporal, hemiforehead, and midforehead/central); some of the lesions involved more than one aesthetic subunit. The authors propose the following guidelines: (1) Midforehead nevi are best treated using an expansion of bilateral normal forehead segments and advancement of the flaps medially, with scars placed along the brow and at or posterior to the hairline. (2) Hemiforehead nevi often require serial expansion of the uninvolved half of the forehead to minimize the need for a back-cut to release the advancing flap. (3) Nevi of the supraorbital and temporal forehead are preferentially treated with a transposition of a portion of the expanded normal skin medial to the nevus. (4) When the temporal scalp is minimally involved with nevus, the parietal scalp can be expanded and advanced to create the new hairline. When the temporoparietal scalp is also involved with nevus, a transposition flap (actually a combined advancement and transposition flap because the base of the pedicle moves forward as well) provides the optimal hair direction for the temporal hairline and allows significantly greater movement of the expanded flap, thereby minimizing the need for serial expansion. (5) Once the brow is significantly elevated on either the ipsilateral or contralateral side from the reconstruction, it can only be returned to the preoperative position with the interposition of additional, non-hair-bearing forehead skin. Expansion of the deficient area alone will not reliably lower the brow once a skin deficiency exists. (6) In general, one should always use the largest expander possible beneath the uninvolved forehead skin, occasionally even carrying the expander under the lesion. Expanders are often overexpanded.

Reconstruction of scalp defects with free flaps in 30 cases

29 consecutive patients treated for reconstruction of various scalp defects with 30 free flaps were reviewed. The scalp defects resulted from accidents (13), electric burns (4), tumour excision (8), chronic osteomyelitis (1), and osteoradionecrosis (1). Secondary reconstructions for cosmetic improvement were performed in 2 patients. The defects involved scalp with bone exposure in 21 patients, and both scalp and calvarium in 8 patients. The average extent of the defects was 130 cm2 (23-420 cm2). Free flaps employed for reconstruction included radial forearm flaps (15), latissimus dorsi muscle flaps (10), medial arm flaps (2), juri flap (1), rectus abdominis muscle flap (1), and scapular flap (1). In 6 cases bone grafts were used for skull reconstruction. Three patients required dura repair. There were two flap failures. Donor-site morbidity was negligible. No local recurrence occurred in 7 tumour cases who are still alive. Secondary procedures (tissue expansion, debulking) were performed in 6 patients. The authors recommend selection of reconstructive options for scalp defects according to their aetiology, localisation, and duration of treatment, whereas the size of the defect dose not seem to be the most important determinant. They conclude that a free flap procedure is appropriate for scalp reconstruction in trauma, osteomylitis, and osteoradionecrosis cases, and following radical resection of malignant tumours.

The use of tissue expansion in children with burns of the head and neck

The outcome of 25 children who underwent reconstruction of the head and neck with tissue expanders is described. Fourteen boys and 11 girls with a mean age of 6.2 years (range 3-11 years) had 36 tissue expanders inserted. Five of the expanders extruded and five children suffered other expander-related complications. The best aesthetic results were achieved in the scalp and the poorest results occurred where expanded neck skin was transposed into the face. Tissue expansion is a useful method for reconstruction of the head and neck in burned children. However patients require careful selection in order to achieve optimal results. Meticulous attention to detail is required to reduce the incidence of complications.

Tissue expansion: clinical applications

In this second article, the authors outline the process of reconstructive surgery using the tissue expansion technique described in the January 1995 issue of JWC.

Tissue expansion: an overview

A review of a surgical technique which uses the skin's ability to stretch to obtain tissue for reconstruction

Clinical evaluation of techniques used in the surgical treatment of progressive hemifacial atrophy

We critically review 13 patients with progressive hemifacial atrophy treated with three basic surgical procedures (free flap transplantation, alloplastic implants, micro-fat injections 'lipofilling') and further ancillary techniques. In spite of the satisfactory results achieved with the procedures, with the exception of alloplasts, we feel that lipofilling may be considered an interesting solution for soft tissue augmentation of the face especially for moderate adipose defects, due to its repeatability, no donor site morbidity, no complications at the recipient site such as lesions resulting from dissection, bleeding, necrosis, etc. This technique can be performed in a day-hospital with short surgery time, at low cost and without a highly skilled team. For severe grades of adipose atrophy, because of the low blood supply to these tissues which interferes with take of any type of autograft, we think that free flaps actually represent one of the best solutions for soft tissue augmentation.