Risk factors for complications in pediatric tissue expansion

Prediction model for haematoma after tissue expander placement: A retrospective cohort study of 7080 cases over 20 years

Haematoma is an early complication of tissue expander placement and can lead to infection, capsule contracture and various complications, hindering successful reconstruction. However, no scientific models can accurately predict the risk of haematoma following tissue expansion. Therefore, this study aimed to develop and validate a prediction model for haematoma following tissue expander placement. The medical records of patients who underwent expander placement between 2001 and 2021 were obtained from the clinical database of the Department of Plastic Surgery at the Xijing Hospital. A total of 4579 consecutive patients with 7080 expanders and 179 expanded pocket haematomas were analysed. Multivariate logistic regression analysis identified adult age (P = 0.006), male sex (P < 0.001), scar reconstruction (P = 0.019), perioperative hypertension (P < 0.001), face and neck location (P = 0.002) and activated partial thromboplastin time above the normal range (P < 0.001) as risk factors for haematoma. Therefore, these were included in the prediction model, and a nomogram was constructed. The discrimination of the nomogram was robust (area under the curve: 0.78; 95% confidence interval: 0.72-0.83). Further, the prediction model had a strong fit (Hosmer-Lemeshow test, P = 0.066) and maintained similar discrimination after considering performance optimism (bootstrapped area under the curve: 0.79; 95% confidence interval: 0.73-0.84). This clinical prediction model was created using a generalisable dataset and can be utilised to obtain valid haematoma predictions after expander placement, assisting surgeons in implementing preventive measures or interventions to reduce the occurrence of haematoma.

Complications Following Tissue Expander-Based Reconstruction in Pediatric Burn Injuries: A Retrospective Analysis

BACKGROUND

Tissue expansion has been widely used to reconstruct soft tissue defects following burn injuries in pediatric patients, allowing for satisfactory cosmetic and functional outcomes. Factors impacting the success of tissue expander (TE)-based reconstruction in these patients are poorly understood. Herein, we aim to determine the risk factors for postoperative complications following TE-based reconstruction in pediatric burn patients.

METHODS

A retrospective review of pediatric patients who underwent TE placement for burn reconstruction from 2006 to 2019 was performed. Primary outcomes were major complications (TE explantation, extrusion, replacement, flap necrosis, unplanned reoperation, readmission) and wound complications (surgical site infection and wound dehiscence). Descriptive statistics were calculated. The association between primary outcomes, patient demographics, burn characteristics, and TE characteristics was assessed using the chi-squared, Fisher's exact, and Mann-Whitney U tests.

RESULTS

Of 28 patients included in the study, the median [interquartile range (IQR)] age was 6.5 (3.3-11.8) years, with a follow-up of 12 (7-32) months. The majority were males [n = 20 (71%)], Black patients [n = 11 (39%)], and experienced burns due to flames [n = 78 (29%)]. Eleven (39%) patients experienced major complications, most commonly TE premature explantation [n = 6 (21%)]. Patients who experienced major complications, compared to those who did not, had a significantly greater median (IQR) % total body surface area (TBSA) [38 (27-52), 10 (5-19), P = 0.002] and number of TEs inserted [2 (2-3), 1 (1-2), P = 0.01]. Ten (36%) patients experienced wound complications, most commonly surgical site infection following TE placement [n = 6 (21%)]. Patients who experienced wound complications, compared to those who did not, had a significantly greater median (IQR) %TBSA [35 (18-45), 19 (13-24), P = 0.02].

CONCLUSION

Pediatric burn injuries involving greater than 30% TBSA and necessitating an increasing number of TEs were associated with worse postoperative complications following TE-based reconstruction.

Serial excision surgery for giant dorsal congenital melanocytic nevus: Case report

INTRODUCTION AND IMPORTANCE

Giant congenital melanocytic nevus increases the risk of melanoma and seriously affects the aesthetics and psychology of patients, influencing the personality development of children.

CASE PRESENTATION

A 7-year-old female child presented with a giant congenital melanocytic nevus on the back, which extended from the right anterior abdominal wall to the left flank Taking advantage of the elasticity of children's skin, we performed serial excision and obtained favourable results. The procedure included seven surgeries, and the average interval between the surgeries was 7 months. The nevus was partially resected from the periphery to the centre, and the direction of excision of the nevus depended on the mobilisation of the surrounding normal skin, including from the shoulder downward, lateral to medial, and from the bottom upward. After the seventh surgery at 11 years of age, the nevus was completely removed, and there were no complications.

CLINICAL DISCUSSION

Serial excision is a simple and less invasive surgical technique that can achieve both complete excision and a satisfactory aesthetic result for giant congenital melanocytic nevus. The giant nevus of the back can be removed completely after several procedures due to the very good elasticity of the skin and the great ability of natural expansion of healthy skin under a considerable stretching force in children.

CONCLUSION

Serial excision is an effective method for treating dorsal giant congenital melanocytic nevus in children because of excellent natural skin elasticity.

Pediatric Tissue Expansion: Analysis of the National Surgical Quality Improvement Program-Pediatric

INTRODUCTION

Tissue expansion (TE) in pediatric surgery provides vascularized tissue to attain functional and esthetic goals in a broad range of reconstructive procedures. Our study evaluates the demographic, operative, and short-term outcomes of TE in pediatric patients utilizing the American College of Surgeons National Surgical Quality Improvement Program-Pediatric (NSQIP-P) database and highlights factors associated with postoperative complications.

MATERIALS AND METHODS

Retrospective review of a large multicenter database of 402 pediatric patients that underwent TE within the NSQIP-P database from 2013 to 2020 at freestanding general acute care children's hospitals, children's hospitals within a larger hospital, specialty children's hospitals, or general acute care hospitals with a pediatric wing. Patient demographics, clinical risk factors, operative information, and postoperative outcomes were collected with an odds ratio analysis of risk factors.

RESULTS

Patients were majority female (55.5%), White (63.2%), and non-Hispanic (67.4%). The minority were born prematurely (11.9%) and had congenital malformations (16.7%). Complications occurred in 5.7%, unplanned readmission in 4.5%, and unplanned operation in 6.5% of patients. Complications lead to readmission in 2.5% and return to the operating room in 3.2% of patients. American Society of Anesthesiology (ASA) score III-IV, congenital malformations, >1-day hospital stay, and pulmonary, neurologic, and hematologic comorbidities were associated with the greatest increase in odds of complication.

CONCLUSION

This study utilizes the NSQIP-P to provide a comprehensive multicenter view of pediatric patients undergoing TE. Increased understanding of risk factors for complications allows for guidance in patient selection and helps in achieving favorable surgical outcomes.

What Is the Impact of Postoperative Antibiotic Prophylaxis on Tissue Expander Infection Rates in Pediatric Patients?

BACKGROUND

Tissue expansion in the pediatric population can be complicated by high rates of infection and extrusion. The aim of this study was to examine the impact of postoperative antibiotic prophylaxis on infectious complications.

METHODS

A retrospective study of all pediatric patients who underwent tissue expander insertion at a children's hospital over a 12-year period was performed. Predictor variables included age, sex, race, indication, anatomical location, number of expanders inserted, serial expansion, history of infection or extrusion, and postoperative antibiotics. Outcome variables included infection and extrusion. Bivariate and multivariate analyses were performed to identify factors associated with infection and/or extrusion.

RESULTS

A total of 180 patients who underwent 317 operations for tissue expander insertion were included in this study. Postoperative infection and/or extrusion occurred after 73 operations (23 percent). Postoperative prophylactic antibiotics were prescribed after 232 operations (75 percent), and only perioperative (≤24 hours) antibiotics were administered in 85 cases (25 percent). There were no significant differences in the rate of infection (12.1 percent versus 8.9 percent; p = 0.46), extrusion (16.8 percent versus 17.7 percent; p = 0.88), or infection and/or extrusion (23.7 percent versus 24.1 percent; p = 0.95) between these two groups. Multivariate analysis revealed that postoperative antibiotics did not have a significant association with infection and/or extrusion (OR, 0.84; 95 percent CI, 0.44 to 1.63; p = 0.61).

CONCLUSIONS

The rates of infection/extrusion were similar between pediatric patients who received only perioperative antibiotics (≤24 hours) and those who were prescribed a course of postoperative antibiotics. Based on these results, a course of postoperative prophylactic antibiotics may be unnecessary after insertion of tissue expanders in pediatric patients.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

[Complications of head and neck expansion: Acting on modifiable factors. A study of 98 prothesis]

BACKGROUND

Tissue expansion is a key tool in the therapeutic arsenal that is proposed for repairing soft tissue losses of the head and neck. This technique, however interesting it may be, is not without its risks. The aim of this work is to identify the different steps of this procedure, determine the complications risk factors inherent to each step of the expansion and propose recommendations to improve functional and aesthetic results.

PATIENTS AND METHODS

We carried out a retrospective study on tissue expansion of the head and neck over a period of 10 years extending from January 2009 to December 2018, with at least one year follow-up for each patient. Our study counted 63 patients with the placement of 98 prostheses. We considered the various variables involved in the expansion process in order to determine those that increase the risk of complications.

RESULTS

In our series we counted 66.3 % of complications and 22.4 % of failures. We found that a young age increased the risk of skin suffering and that smoking increased the risk of hematoma occurrence. Neck expansion was found to be the riskiest site of expansion followed by the scalp that increased the risk of exposure (especially the parietal section of the scalp). The face is considered as an interesting site for expansion. We found that the use of multiple expanders is an attractive alternative to iterative expansions and to the choice of large expanders.

CONCLUSION

Tissue expansion of the head and neck requires careful planning that takes into account each step of the process.

Complications using tissue expanders in burn sequelae treatment at a reference university hospital: a retrospective study

BACKGROUND

tissue expanders have high relevance in plastic surgery and among indications it is worth mentioning their use in the treatment of burn reconstruction. Although it shows good results, its use requires special care because some complications can interrupt the reconstruction process. The objective of this study was to report the experience of the Clinics Hospital (University of Sao Paulo) with the use of tissue expanders to treat burn sequelae, establishing the incidence of complications, and identifying risk factors for their occurrence.

METHODS

a retrospective, observational, and analytical study, evaluating the use of expanders in burns sequelae treatment from 2009 to 2018.

RESULTS

245 expanders were placed in 84 patients, 215 were female, with a mean age of 19.96 years, being 40% in the trunk and 20% in the scalp, with a predominance of rectangular shape in 76.7% of cases. Complications were classified as major and minor.Complications occurred in 17.95% of cases, and extrusion and infection were the most common. There was a higher incidence of complications in expanders used in the upper and lower limbs as well as in those who did not undergo concomitant expansion (p <0.05), with an even higher chance of major complications in patients submitted to additional expansion. From 2009 to 2018, we observed a decrease in the incidence of complications.

CONCLUSION

the complication rate (17.95%) is similar to other studies of the literature, there was a higher rate of complication with expanders placed in the limbs and a higher rate of major complications when additional expansion was done.

[Tissue expansion in child's burn reconstruction. Management principles and eleven years retrospective study of 42 patients]

PURPOSE

With constraints and a risk of complication, tissue expansion in child's burn sequelae need a controlled surgical procedure, and a therapeutic plan appropriate to the specific pediatric healing, growth, and development.

MATERIAL AND METHODS

Our principles of management and technical points are described. A retrospective study of tissue expansion in child's burn sequelae between 2005 and 2016 is submitted.

RESULTS

There are 185 expanders, 98 protocols in 41 children, over half of sequelae concerning scalp, neck and chest. Mean age at the first expansion was 10.3 years old (5.8 years after burn). There are in average 2,4 (1-8) protocols by patient, with 1.9 (1-4) expanders by procedure. Surgical repair was a flap (78.8%), a full-thickness skin graft (13.3%) or both. Fifteen patients (30 expanders (14.6%) and 22 protocols (22.4%)), had expansion's complications, mostly infections and expositions. Eight patients (14 expanders (7.6%) and 10 protocols (10.2%)) had reconstructive's complications. An increase of burn area was a risk factor of complication (significant). Complicated expanders rate by location was 7.9% (scalp), 12.5% (neck), 9.8% (supraclavicular), 10.5% (chest), 19.4% (abdomen), 30% (buttock), 29.4% (lower limb), 1/2 (face).

CONCLUSION

Tissue expansion in child's burn sequelae is ideal in scalp, good in neck, chest and proximal upper limb, and to do carefully in lower limb and face.

Management of Congenital Melanocytic Nevus on Face Using Multiple Re-expansion Method: Aesthetic and Psychosocial Results

BACKGROUND

Congenital giant melanocytic nevus on the face is a challenging condition, especially in the pediatric population. It can produce significant cosmetic deformity with negative psychosocial effects in pediatric patients even after treatment. The objective of this study was to report aesthetic and psychosocial results in the management of congenital melanocytic nevus on the face using multiple reexpansion.

METHODS

Data of 6 patients with congenital melanocytic nevus on the face who underwent excision and multiple reexpansion at our center from September 2004 to August 2017, were retrospectively reviewed. To evaluate aesthetic outcomes, preoperative and final photographs of each patient were reviewed by 3 other plastic surgeons and 4 laypersons. For comparison, 6 other patients who were treated with conventional surgery during the same period were reviewed. After final reconstruction surgery, the authors surveyed patients' satisfaction via telephone.

RESULTS

Six patients were followed up for an average of 87.66 months (range, 55-123 months). The mean number of tissue expander insertions was 3.33 and the mean number of total expanders inserted was 4.83. Complication associated with expander exposure occurred in 1 patient during the fifth expansion. The average score of aesthetic outcome in the multiple reexpansion group was superior to that of the conventional group (2.60 versus 2.10, P = 0.03). During the telephone survey, patients did not rate their appearance as positive, although they were comparatively satisfied with the surgical procedure.

CONCLUSION

Considering the low rate of malignancy involving congenital melanocytic nevus in childhood, multiple reexpansion is an attractive option to obtain better results compared with other reconstructive methods.

Tissue expansion in pediatric patients: a 10-year review

BACKGROUND/PURPOSE

Tissue expansion complication rates up to 40% have been reported in the pediatric population. This study aims to review one Canadian pediatric plastic surgeon's experience with tissue expansion by examining tissue expander and flap complication rates, and discussing important aspects of the tissue expansion experience.

METHODS

This is a retrospective chart review of the medical records of all tissue expansion patients treated by the senior author during a ten-year period. Data were collected on patient demographics, tissue expansion details, complications, and outcomes, and were analyzed descriptively. The relationship between tissue expander complications and flap complications was analyzed with odds ratio.

RESULTS

Ninety-three expanders were placed in 24 patients during 49 sessions. Complications occurred in 19 expanders (10 patients; 16 sessions), resulting in premature removal of nine. Only one session was unsuccessful; the expander became exposed and was removed after 1 month. The odds of having a flap complication were three times greater with preceding tissue expander complication (not statistically significant).

CONCLUSIONS

Our study identifies a 20% expander complication rate in the pediatric population. Patients with tissue expander complications subsequently experienced more flap complications than those without tissue expander complications. Complications do not preclude successful reconstruction.

TYPE OF STUDY

Prognostic.

LEVEL OF EVIDENCE

II.

Tissue expansion reconstruction of head and neck burn injuries in paediatric patients - A systematic review

Tissue expansion reconstruction in clinical practice has existed for over half a century. The technique was initially used for breast reconstruction but later found its use in reconstruction of excisional defects resulting from a variety of causes including surgery for post-burn/post-traumatic deformities, congenital giant naevi, skin cancer, etc. It offers an improved matching of skin colour and texture, and avoids the high infrastructure requirements of microsurgery for free flap transfers. We present a systematic literature review of 35 worldwide English language articles with representative cases of paediatric tissue expansion reconstruction of burn injuries of the head and neck. The review identified 68 children of an average age of 11.3 years. The most common burn aetiology was flame burn injury. The average area to be reconstructed was of 206 cm2 and patients went through expansion processes for an average of 99.7 days. Three articles included cases in which patients had more than one expansion session. Supportive techniques provide examples of developments in the area of tissue expansion reconstruction such as self-inflating expanders and endoscopic approaches. Further studies focussing on particular indications, age groups and anatomical locations of tissues to be expanded are required in order to improve the understanding of this technique's limitations and continue its development.

External Port Tissue Expansion in the Pediatric Population: Confirming Its Safety and Efficacy

BACKGROUND

External filling ports in tissue expander-based reconstruction have the advantages of being associated with less pain and emotional distress. However, among practicing surgeons using tissue expansion, a theoretical concern remains regarding higher risk of infection. The authors' goal was to evaluate external port safety in the pediatric population by looking at the complications and overall success rate of reconstruction.

METHODS

A retrospective review of all patients undergoing tissue expansion using external ports at Children's Hospital Los Angeles between January of 2008 and June of 2016 was conducted. Patient demographic and perioperative data were collected and analyzed.

RESULTS

Two hundred forty-one expanders were placed in 100 pediatric patients, resulting in 123 procedures for congenital and acquired conditions, with an average age at the time of surgery of 7.1 years (range, 1 month to 19.9 years) and average follow-up length of 2.5 years (range, 2.8 months to 8.8 years). The overall complication rate was 29.9 percent, and the infection rate was 17 percent. The majority of these cases were treated conservatively without additional need for surgery. Of 123 cases, 25 required premature expander removal because of complications. Despite early intervention, 21 of these cases underwent successful completion of their reconstruction according to the preoperative plan, resulting in an overall 96.7 percent success rate of tissue expander reconstruction.

CONCLUSIONS

In children, who are often less tolerant of the pain and distress associated with internal port expansion, the authors encourage the use of external ports. This study found a high success rate in terms of successful reconstruction, with the majority of complications being treated conservatively.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Selective Scalp Nerve Block: A Useful Technique With Tissue Expansion in Postburn Pediatric Alopecia

BACKGROUND

Scalp defects can be reconstructed either with skin graft, local flaps, free flaps, or tissue expansion. Tissue expanders have been proved to be fruitful in the pediatric population. Scalp expansion has proved to be useful in the reconstruction of posttraumatic and postburn alopecic defects. Selective nerve block can be added for attenuation of sympathetic stimulation and decrease surgical stress in cranial surgeries. In this study, a comparison was done between using selective nerve block and without selective nerve block in both stages of tissue expansion procedure.

PATIENTS AND METHODS

This study included 32 different children who underwent tissue expansions in the management of postburn alopecia. Pediatric patients presented with postburn alopecia of the scalp with mature scar were included in this work.

RESULTS

Postoperative analgesics were less in children who had received scalp block, whereas it was shorter in patients who did not receive any scalp block. Meperidine consumption was much more less in patients who received selective scalp nerve block. Pain score was markedly decreased in children who had received selective scalp nerve block in the immediate postoperative period. Children who received scalp block showed marked attenuation in the surgical stress responses with minimal changes in heart rate and mean arterial blood pressure after skin incision.

CONCLUSIONS

Scalp nerve block is considered an excellent choice for postoperative pain control with less need for opioid analgesia.

Tissue Expansion in Children

Tissue expansion is a well-established surgical method that has been creatively applied to the management of many congenital and acquired pediatric conditions, including the removal of giant congenital melanocytic nevi and the separation of conjoined twins. Careful preoperative planning and patient follow-up are required to achieve the proper results and minimize complications. Special considerations for pediatric patients are present during each step of the process, from patient selection to postoperative care. The complication rate in tissue expansion remains high, though measures can be taken to reduce and effectively manage these complications.

[The complications of skin expansion in paediatrics: Diagnostic, taking over and prevention]

Skin expansion is a difficult and long process in which can occur more or less serious complications. Overall complications rates describe in the literature vary between 13 and 37%. We can categorize them in major complications, which can lead to a failure maybe even an aggravation of the anterior status, and in minor complications that do not compromise the expansion process but can alter it. The main major complications are infection, skin suffering and necrosis which can lead to prosthesis exposition, leaks and technical problems with equipment dysfunctions that may cause difficulties or a failure of the inflations. The main minor complications are hematomas, seromas, valve or tube exposition, pains with paraesthesias caused by neighbouring organs compression, pathologic and unsightly scares and can lead to an important psychological impact. These complications can be due to a precarious skin's state, a material dysfunction or unpredictable technical problems but also by an inappropriate preoperative indication or planning. The emerging of a complication, however, is not synonymous to a failure of the procedure; a satisfactory reconstruction may still be obtained in 75% of all cases. The purpose of this article is to help to identify the situations at risk of complications in order to prevent, detect and treat them early.

Complications of nonbreast tissue expansion: 9 Years experience with 44 adult patients and 119 pediatric patients

BACKGROUND

Tissue expansion is a common reconstructive technique that has been associated with significant complications since its inception. However, the existing literature mostly focuses on complications associated with pediatric tissue expansion only or describes a combined population of adult and pediatric patients, including breast tissue expansion; despite the fact that each of these groups of patients has different characteristics that may affect tissue expansion.

OBJECTIVE

In this study we present a critical review of our experience with complications of nonbreast tissue expansion in adult and pediatric patients and compare between these groups.

METHODS

The charts of patients who underwent nonbreast tissue expansion at Hadassah Medical Center between January 2003 and July 2012 were reviewed. Data were collected including the age of the patient, anatomical site of the expansion, indication and complications.

RESULTS

A total of 202 expansion procedures were performed on 119 pediatric patients (<16 years) and 56 expansion procedures on 44 adult patients. The overall complication rate was 18.2%, with 40 pediatric procedures having complications (19.8%) and 7 adult procedures (12.5%). The difference in complication rates between the two groups was not found to be statistically significant. There was no statistically significant difference in complication rate between the different anatomical areas of expansion in both adult and pediatric patients or between the indications for operation. Most (68%) of the cases with complications underwent subsequent successful reconstruction.

CONCLUSIONS

Despite the consistent high complication rate, tissue expansion can be used as a good reconstructive method in both adult and pediatric patients in all anatomic areas and for different indications.

Rapid intraoperative tissue expansion with Foley catheter in a challenging cripple Hypospadias

Failed hypospadiass cases may result in hypovascular, scarred penis with residual penile chordee and leave the patient with minimal residual skin for penile resurfacing and urethroplasty. Local tissue expansion has become a good alternative to provide skin for penis by using expanders however they require long periods of time for expansion. Besides, rapid tissue expansion was also described in different tissues.We used rapid intraoperative expansion technique by using a Foley catheter in a failed hypospadias case who had minimal residual skin secondary to infection and we concluded that rapid intraoperative tissue expansion with Foley catheter is an effective, feasible reconstructive method for easy dissection and penile resurfacing in failed hypospadiass cases.

Pre-augmentation soft tissue expansion: an overview

OBJECTIVES

The aim of this study was to explore the development of soft tissue expanders, their different types and their potential applications prior to bone augmentation and implant placement.

MATERIAL AND METHODS

A review of pertinent literature was performed using PubMed to comprehend the dynamics of soft tissue expanders and determine the current position of their pre-augmentation applications.

RESULTS

There is promising, albeit preliminary information regarding the benefits of pre-augmentation soft tissue expansion. Findings cannot be generalised due to relatively small sample size.

CONCLUSIONS

Further clinical trials with larger sample sizes and long-term follow-up are needed before soft tissue expanders can be confidently applied in everyday clinical practice.

Management of challenging congenital melanocytic nevi: outcomes study of serial excision

BACKGROUND

Large congenital melanocytic nevi (CMN) cause significant deformity and are at risk for malignant degeneration. Techniques used to remove difficult CMN include serial excision, skin grafting, or tissue expansion. Some authors prefer skin grafting or tissue expansion if several stages would be required to serially resect the CMN. The purpose of this study was to determine the efficacy of serial excision for CMN requiring ≥3 procedures.

METHODS

Medical records and clinical images of patients with CMN treated between 2007 and 2013 were reviewed. Inclusion criteria were: (1) lesions that required ≥3 serial excisions to remove and (2) CMN that could have been treated reasonably with skin grafting or tissue expansion. Patient age, gender, location of the lesion, size of the CMN, number of serial excisions, and complications were recorded.

RESULTS

The study included 21 patients. Lesions were located on the lower extremity (38.1%), head/neck (33.3%), upper extremity (14.3%), or trunk (14.3%). Nevus size was 2.2%±1.2% total body surface area. The age during the first operation was 4.3 years (range 3 months to 15 years). The number of excisions was 3.5±0.7, spaced 8.2±4.3 months apart. Partial suture line dehiscence occurred after 2/72 operations and seroma resulted after 1/72 operations; there were no infections.

CONCLUSION

Challenging CMN amenable to serial excision can be removed effectively and safely using this technique. Children are left with a favorable linear scar, do not have donor or recipient site morbidity from skin grafting, and are not subjected to potential tissue expander complications and injections required for expansion.

Tissue expander complications in the pediatric burn patient: a 10-year follow-up

BACKGROUND

This study is a 10-year follow-up to our previous publication reviewing the complication rates of tissue expansion in the pediatric burn population. The purpose of this study was to determine if our institutional experience with tissue expanders had remained stable during the subsequent 10 years.

METHODS

There were 240 patients who were identified at a major pediatric burn center who underwent reconstruction with a tissue expander (256 tissue expanders) from 1996 to 2006. Data were obtained retrospectively by reviewing patient medical records. Complications were categorized into absolute and relative complications.

RESULTS

Absolute complications occurred in 36 (14.1%) of 256 expanders placed and relative complications occurred in 26 (10.2%) of 256 expanders placed. There was no statistical difference between this study and our previous study for overall complication rates and complications for all sites. The highest complication rate occurred when the scalp was a surgical site. Betadine skin preparation was associated with a 10% reduction in infection-related complications compared to other skin preparations. The operating surgeon or age of patient was not found to be associated with increased complication rates.

CONCLUSIONS

After changing our tissue expander protocol, the complication rates at our institution have remained stable during the 10-year follow-up period. Tissue expansion in the pediatric burn population continues to be a safe and effective reconstructive option with acceptable complication rates.

[Complications of head and neck skin expansion]

INTRODUCTION

Skin expansion is a good solution for the reconstruction of head and neck defects. We assessed the complications of cervico-facial skin expansion technique to draft recommendations so as to minimize risks.

METHODS

We made a retrospective study from 1990 to 2005. Complications were analyzed according to age, sex, etiology, area to reconstruct, location of the expander, expander volume and number, simultaneous single or repeated technique, type of expander, duration of expansion, and type of flap used for reconstruction.

RESULTS

One hundred and thirty-nine tissue expanders were placed in 114 patients. The rate of complications was 60.4%. Age was not a risk factor (P=0.21; Fisher's exact test). The early complications were not related to the expander volume (P=0.32; Fisher's exact test). Infection was the most frequent complication (51.3%). Hypertrophic or large scars, retraction, or cording accounted for 32.4% of sequels. A rate of 6.5% of total and 6.5% of partial failure were recorded. Infection was the cause of 77.8% of total or partial failure.

DISCUSSION

The complications of head and neck soft tissue expansion are often minor. The rate of reconstruction failure remains acceptable.

Osteophyte-induced rupture of a scalp tissue expander

Tissue expansion is in widespread use for the reconstruction of congenital and acquired defects. Complications of tissue expansion are well documented, the most common being infection or extrusion of the expander. Although the complications associated with scalp tissue expansion are similar to those experienced elsewhere in the body, site-specific complications can occur. These include bone thinning and erosion of the cranial vault. In this study, we report an unusual case of multiple osteophyte formation beneath a scalp tissue expander, resulting in its rupture and necessitating removal.

Giant congenital melanocytic nevi

BACKGROUND

: Giant congenital melanocytic nevi are rare lesions with the potential to regress into malignant melanoma and/or neurocutaneous melanosis. Appropriate investigations include a screening magnetic resonance imaging scan, neurologic evaluation, and serial clinical observations looking for the development of these complications. Numerous excisional and nonexcisional options have been described for the management of giant congenital melanocytic nevi.

METHODS

: A MEDLINE search was performed to obtain all relevant citations.

CONCLUSIONS

: To successfully treat these complex lesions, the plastic surgeon must understand the disease process, the natural history and complications, and the options for treatment.

A comparative analysis of tissue expander reconstruction of burned and unburned chest and breasts using endoscopic and open techniques

BACKGROUND

Tissue expansion is not widely accepted for reconstruction of breast and chest burn deformities because of concerns about the capacity of compromised skin to stretch without complications. The authors hypothesized that tissue expander reconstruction of breast and chest burn deformities is reliable and has outcomes similar to those of expansion of similar nonburned tissues. The authors used congenital breast anomalies as a control because they share similar reconstructive challenges: constricted skin envelope and gross malformation of the parenchyma and nipple-areola complex. The authors also hypothesized that endoscopic techniques may improve outcomes for breast and chest burn reconstruction.

METHODS

A retrospective review was completed of tissue expander reconstructions of burn and congenital breast deformities. All reconstructions used an endoscopic or open tissue expander placement and subsequent local tissue rearrangements. Data were analyzed using parametric and nonparametric methods.

RESULTS

For reconstruction of burn deformities, 15 women had 37 expanders placed. Within the congenital breast cohort, 20 patients had 22 tissue expanders placed. There were no statistical differences in follow-up time, body mass index, or comorbidities between burn and congenital patients. There was no statistical difference in major complications (p = 0.72) between these groups. Within the burn deformity cohort, endoscopic reconstructions had fewer major complications (p = 0.04), required less operative time per expander (p < 0.001), and required less time to expand (p = 0.021).

CONCLUSIONS

The authors believe that breast and chest burn deformities can be safely reconstructed with tissue expanders without increased complications over expander reconstruction of the congenital breast. Furthermore, endoscopic techniques may be superior for burn deformities because of improved visualization and remote incisions.

Tissue expansion for correction of baldness in aplasia cutis congenita

Aplasia cutis is a congenital absence of the skin, usually presenting on the scalp. In 20% of all cases, part of the skull is also absent. A residual area of baldness may still be present some years after surgical or conservative treatment. It is possible to excise the scarred hairless region and cover that area with expanded hair-bearing skin from the rest of the skull. We present three patients who underwent tissue expansion and discuss the indications and pitfalls of this procedure.

CONCLUSION

Tissue expansion can be used to cover a residual alopecia defect in young children with aplasia cutis congenita and associated bone abnormalities. The quality of the bone appears to be normal in our three patients. We demonstrate that even in young children with aplasia cutis and an underlying bony defect, tissue expansion is a safe and effective modality as a second stage reconstruction procedure.

Pediatric facial burns

Despite major advances in the area of burn management, burn injury continues to be a leading cause of pediatric mortality and morbidity. Facial burns in particular are devastating to the affected child and result in numerous physical and psychosocial sequelae. Although many of the principles of adult burn management can be applied to a pediatric patient with facial burns, the surgeon must be cognizant of several important differences. Facial burns and subsequent scar formation can drastically affect the growth potential of a child's face. Structures such as the nose and teeth may become deformed due to abnormal external forces caused by contractures. Serious complications such as occlusion amblyopia and microstomia must be anticipated and urgently addressed to avert permanent consequences, whereas other reconstructive procedures can be delayed until scar maturation occurs. Furthermore, because young children are actively developing the concept of self, severe facial burns can alter a child's sense of identity and place the child at high risk for future emotional and psychologic disturbances. Surgical reconstruction of burn wounds should proceed only after thorough planning and may involve a variety of skin graft, flap, and tissue expansion techniques. The most favorable outcome is achieved when facial resurfacing is performed with respect to the aesthetic units of the face. Children with facial burns remain a considerable challenge to their caregivers, and these patients require long-term care by a multidisciplinary team of physicians and therapists to optimize functional, cosmetic, and psychosocial outcomes.