Use of overinflated tissue expanders in the surgical repair of head and neck scars

[Forehead burns]

Severe burns on the forehead are rare; well-conducted initial surgical treatment also limits the occurrence of sequelae. Therefore, indications for repairing the forehead arise from complex burns often extending to adjacent units. Repair techniques depend on the location and size of the lesions, associated nearby damage, and the patient's ability to withstand the burden of treatment. Management at the acute stage determines the sequelae; excision-grafting is the standard treatment, but it yields good results only if the fundamental principles of repair are respected: intervention within the 10th and 15th days post-burn, graft harvesting from the cephalic extremity or the upper part of the thorax and arms, and respect for the frontal unit. Sequelae management follows the same imperatives and typically requires skin expansion: front expansion for skin flaps if enough frontal skin is still available, upper thorax expansion for full thickness skin grafts if the frontal scar is too extensive. However, the excellent results obtained should not conceal the significant constraints associated with skin expansion.

The Efficacy of Anterior Capsulotomy and Basal Capsulectomy Adherent to Expanded Scalp Flap During Alopecia Reconstruction in Pediatric Burned Patients

BACKGROUND

Scalp expansion is an optimal treatment for alopecia resulting from burn injuries, especially in the pediatric population through providing highly vascularized adjacent local tissues with optimal hair density, color matching, texture, and hair-bearing characteristics. The aim of this study was to evaluate the efficacy of anterior capsulotomy and basal capsulectomy adherent to expanded scalp flap during alopecia reconstruction with scalp expansion in pediatric burned patients.

METHODS

The study was conducted on 127 patients with an age range of 5 to 19 years who presented with postburn alopecia accompanied by hairline loss. The patients were divided into 2 groups: group I consisted of 58 patients who were operated on using conventional technique, and group II consisted of 69 patients who were operated using modified technique including basal capsulectomy on the skull side and anterior capsulotomy on the expanded scalp flap.

RESULTS

The Hairdex, a validated questionnaire of Hair-Specific Health-Related Quality of Life measures, showed that percentage of satisfaction concerning outcomes was 91.50%, psychological well-being was 95%, and self-confidence was 84.30% in group II, compared with 63%, 55.70%, and 66.20%, respectively, in group I. This significant values had a great positive effect on patient satisfaction, changing child's behavior and self-confidence.

CONCLUSION

Although physiological background of tissue expansion is the same, proper flap design with anterior capsulotomy on flap undersurface and basal capsulectomy on the skull side improve results of the traditional method significantly and minimize the complication rate. These surgical modifications provide maximum benefits from expanded tissue, with restoration of the hairline and a uniform hair direction.

LEVEL OF EVIDENCE

Level III, case-control study.

Transcriptomic analysis reveals dynamic molecular changes in skin induced by mechanical forces secondary to tissue expansion

Tissue expansion procedures (TE) utilize mechanical forces to induce skin growth and regeneration. While the impact of quick mechanical stimulation on molecular changes in cells has been studied extensively, there is a clear gap in knowledge about sequential biological processes activated during long-term stimulation of skin in vivo. Here, we present the first genome-wide study of transcriptional changes in skin during TE, starting from 1 h to 7 days of expansion. Our results indicate that mechanical forces from a tissue expander induce broad molecular changes in gene expression, and that these changes are time-dependent. We revealed hierarchical changes in skin cell biology, including activation of an immune response, a switch in cell metabolism and processes related to muscle contraction and cytoskeleton organization. In addition to known mechanoresponsive genes (TNC, MMPs), we have identified novel candidate genes (SFRP2, SPP1, CCR1, C2, MSR1, C4A, PLA2G2F, HBB), which might play crucial roles in stretched-induced skin growth. Understanding which biological processes are affected by mechanical forces in TE is important for the development of skin treatments to maximize the efficacy and minimize the risk of complications during expansion procedures.

Complications of tissue expansion in the head and neck

BACKGROUND

The authors aim to present a comprehensive review detailing the present state of evidence with regard to complications following tissue expansion in the head and neck.

METHODS

A systematic literature search was conducted to identify all studies reporting complications of tissue expansion in the head and neck between 2000 and 2019. Subgroup comparisons based on expander locations and planes were conducted.

RESULTS

A total of 7058 patients were included. Tissue expansion was associated with an overall complication rate of 8.73% (616/7058). The most common complications were extrusion (207/7009; 3.0%) and hematoma (200/7009; 2.9%). Overall complications were highest in the scalp (65/238; 27.3%) and lowest in the mastoid (347/5688; 6.1%). Complications were more common with expansion in the non-subcutaneous plane (63/590; 10.7%).

CONCLUSION

In the absence of large clinical trials, systematic reviews such as these can help inform clinical guidelines and provide practitioners with an evidence-based reference to improve informed consent.

Cellular and Molecular Responses to Mechanical Expansion of Tissue

The increased use of tissue expander in the past decades and its potential market values in near future give enough reasons to sum up the consequences of tissue expansion. Furthermore, the patients have the right to know underlying mechanisms of adaptation of inserted biomimetic, its bioinspired materials and probable complications. The mechanical strains during tissue expansion are related to several biological phenomena. Tissue remodeling during the expansion is highly regulated and depends on the signal transduction. Any alteration may lead to tumor formation, necrosis and/or apoptosis. In this review, stretch induced cell proliferation, apoptosis, the roles of growth factors, stretch induced ion channels, and roles of second messengers are organized. It is expected that readers from any background can understand and make a decision about tissue expansion.

A Randomized Controlled Trial Comparing Endoscopic-Assisted Versus Open Neck Tissue Expander Placement in Reconstruction of Post-Burn Facial Scar Deformities

BACKGROUND

Tissue expansion has evolved reconstruction surgery by providing a great source of additional tissue for large skin defects. Nevertheless, wide application of tissue expander reconstruction is challenging due to high complication rates and uncertainty about final outcomes. Recently, endoscopy has shown promise in reconstructive surgeries using tissue expander placement.

AIMS

This study aimed to compare outcomes between open and endoscopic-assisted neck tissue expander placement in reconstruction of post-burn facial scar deformities.

METHODS

Through a randomized clinical trial, 63 patients with facial burn scars were assigned to an open group or endoscopic group for placement of 81 tissue expanders. The complication rate, operative time, length of hospital stay, and time to full expansion were compared between the two groups.

RESULTS

Thirty-one patients were assigned to the open group and 32 patients to the endoscopic group. The average operative time was significantly reduced in the endoscopic group compared with the open group (42.2 ± 3.6, 56.5 ± 4.5 min, p < 0.05). The complication rate was significantly lower in the endoscopic group than the open group (6 vs. 16, p < 0.05). Hospital stay was also significantly diminished from 26.3 ± 7.7 h in open group to 7.4 ± 4.5 h in endoscopic group (p < 0.0001). There was a significant reduction in time to full expansion in the endoscopic group as compared with the open group (93.5 ± 10.2 vs. 112.1 ± 14.2 days, p = 0.002).

CONCLUSION

Endoscopic neck tissue expander placement significantly reduced operative time, the postoperative complication rate, length of hospital stay, and time to achieve full expansion and allowed early initiation of expansion and remote placement of the port in relation to the expander pocket.

LEVEL OF EVIDENCE I

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Reconstruction of post burn scalp alopecia by using expanded hair-bearing scalp flaps

Background and Objective:

Tissue expansion is a time-tested and frequently used procedure for utilizing local tissue to replace large defects. We aimed to assess the success & complications of tissue expansion in correction of post burn scalp alopecia.

Methods:

In this study, 30 patients of scalp burn alopecia of 5 to 35 years age group were treated with tissue expansion of the scalp at Bahawal-Victoria Hospital from January 2013 to December 2014. The area of the scalp loss was within 1/5 to 2/5. Our technique employed an insertion site distal to the area needed to be expanded, attempting to minimize complication like extrusion & wound dehiscence. The patients were followed-up weekly during first month and then fortnightly for next four months.

Result:

Our study involved 8 male (26.67%) and 22 female subjects (73.33%) with a mean age of 21years. Flame burn accounted for the mostly 53.3% (n=16) of scalp burns & parieto-temporal region was most commonly affected in 33.4% (n=10) of subjects. Desired aesthetic results were achieved in all the patients without any major complication. Minor complication included mild infection in 8 (26.67%), seroma in 4 (13.33%) & wound dehiscence in 2 (6.67%) patients.

Conclusion:

Tissue expansion is a simple, safe, & efficient technique for aesthetic scalp reconstruction. With a simple modification of distal incision and tunneling, we succeeded in minimizing complications. Versatile design of the expanded scalp flap can distribute the expanded hair-bearing scalp properly in the reconstructed recipient site.

Endoscopic-assisted neck tissue expansion in reconstruction of facial burn injuries

BACKGROUND

Endoscopic-assisted tissue expansion has been recently used in plastic surgery. However, there is limited evidence regarding its efficacy in reconstruction of facial burn injuries.

AIMS

Our study aimed to evaluate the utility of endoscopic-assisted neck tissue expansion in reconstruction of facial burn deformities.

METHODS

Through a prospective study, 42 consecutive patients with facial burn injuries attending a major referral center of plastic and reconstructive surgery in Iran underwent reconstruction of facial defects with endoscopic-assisted neck tissue expansion. Intraoperative events, expansion process, and postoperative outcomes were measured for this group of patients.

RESULTS

The mean ± SD injected volume for intraoperative expansion was 66 ± 3.7 mL (range, 35-80 mL). The mean ± SD operative time was 45.6 ± 3.5 minutes. Moreover, the mean ± SD distance between the main access incision and the expander pocket was 5.6 ± 1.2 cm. Time to achieve full expansion ranged between 12 and 16 weeks, and the expanded volume at the time of reconstruction ranged from 400 to 800 mL. All the patients had less than 24 hours of hospital stay after placement of tissue expanders. There were only 2 minor complications during the postoperative follow-up including 1 case of seroma and 1 case of severe pain, which were treated conservatively.

CONCLUSIONS

Endoscopic-assisted neck tissue expansion is associated with lower complication rate, shorter duration of hospitalization, reduced operative time, earlier initiation of expansion, and faster expansion process. It could be a feasible alternative to open technique in reconstructing facial burns, allowing smaller incision at port site, far placement of tissue expander, and excellent visualization of operation site.