The British Association of Plastic Surgeons (2004) 57, 336 341 CASE REPORTS Other ways to use tissue expanded flaps Donald A. Hudson* Department of Plastic and Reconstructive Surgery, University of Cape Town, Cape Town, South Africa Received 20 January 2003; accepted 17 February 2004 KEYWORDS Tissue expansion Summary Tissue expansion can arguably be regarded as one of the revolutions in reconstructive plastic surgery. Another three applications (illustrated by three case reports) for tissue expansion are presented. Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. Tissue expansion can arguably be considered one of the major advances in reconstructive plastic surgery. 1 7 The major advantage is supplying additional tissue to cover a defect. Another great advantage is aesthetic the tissue supplied is usually similar in colour and texture to the defect to be covered. The only sequelae of tissue expansion should be the scar. A further, but not well emphasised advantage of tissue expansion is the robustness of the expanded flap. Experimental work has demonstrated a 117% increase in vascularity compared to a random pattern flap. 8 Traditionally, tissue adjacent to a defect is expanded, e.g. the scalp is expanded to resurface burn alopecia. The expanded flap is then advanced to cover the defect. Another three ways in which tissue expanded flaps may be used is presented, illustrated by three case reports. *Address: Department of Plastic and Reconstructive Surgery, H53 OMB, Groote Schuur Hospital, Observatory, 7925 Cape Town, South Africa. Tel.: þ27-21-4043426; fax: þ27-21-4486461. E-mail address: hudsond@uctgsh1.uct.ac.za Case 1. Using the expanded skin as a distant-pedicle flap for nasal reconstruction Total nasal reconstruction in the burned patient is a difficult and challenging problem. The problem is aggravated when the forehead, the usual site of donor tissue, has been burnt. An expander is placed in the chest. After full expansion (gross over inflation is required), a pedicled flap passes across a normal tissue bridge (the neck and lips) and is applied to the nose. Later the pedicle is divided and returned. This is similar to a cross-leg flap, for example, except that in this situation the flap used for covering the defect has been expanded. The technique has also been described for cheek reconstruction. 9 The advantage of the technique is the ability to provide a large amount of skin. 9 Furthermore by supplying a pedicle, flap loss should be less than with a full thickness graft, especially when a large surface area (e.g. whole cheek) with multiple contour irregularities is to be resurfaced. The disadvantage of the technique is that three stages are required. S0007-1226/$ - see front matter Q 2004 The British Association of Plastic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2004.02.003
Other ways to use tissue expanded flaps 337 Figure 2 Lateral view. Pre-operative photograph of a patient who had sustained severe burns of her nose, forehead and scalp in which all the skin and subcutaneous tissue had been destroyed. Note that the nose and forehead (and most of the scalp) had had a split skin graft applied to the few muscle fibres above the periosteum. She previously had expanded flaps used to resurface her cheeks. She was also undergoing serial expansion of her scalp. Figure 1 Anterior view. Pre-operative photograph of a patient who had sustained severe burns of her nose, forehead and scalp in which all the skin and subcutaneous tissue had been destroyed. Note that the nose and forehead (and most of the scalp) had had a split skin graft applied to the few muscle fibres above the periosteum. She previously had expanded flaps used to resurface her cheeks. She was also undergoing serial expansion of her scalp. Clinical case. Patient 1, Figs. 1 6. This 11-year-old girl suffered very severe flame burns of her face and nose in which all the skin and subcutaneous tissue had been destroyed (Figs. 1 and 2). A split skin graft had been applied to the thin muscle layer of her nose (as well as her forehead). The lower lateral cartilages of her nose had also been destroyed. She previously had had expanded flaps used for cheek reconstruction and scalp reconstruction. She was also undergoing serial scalp expansion. She presented for nasal reconstruction. The usual sources for total nasal resurfacing such as forehead or scalping flap were not available. The upper chest was over expanded to 800 ml (using a 400 ml rectangular tissue expander) (Fig. 3) which was advanced across the neck and lips, to Figure 3 400 ml tissue expander inserted in chest and expanded to 800 ml.
338 D.A. Hudson the nose, with the distal end of the flap having to reach the root of the nose. Inadequate length places tension on the flap and led to dehiscence of the corner of the flap in this patient. This technique has not been described previously for nasal reconstruction. Case 2. Combining two cutaneous flaps: an expanded flap as an extension of a random flap Figure 4 Flap passed across neck and lips and inset into the nose. Dehiscence of superior corner occurred. The cartilage framework was only inset at the time of pedicle division. cover the nose (Fig. 4). Flexion of the neck shortens the distance required for the flap based in the chest to reach the nose (Fig. 4). There was dehiscence of 15% of the flap at the superior corner. For this reasons, a preliminary surgical delay was performed at two weeks, prior to definitive pedicle division at 3 weeks. No further problems occurred. The only sequelae of the expander on her chest are scars (Fig. 6). At the time of flap inset, a cartilage framework was also applied to the tip. She has subsequently had a contouring procedure performed. This technique provided this girl with skin appropriate in colour and texture (Fig. 5). An alternative, a radial forearm free flap (or any other free flap) would have provided a bulky flap with a marked colour difference. The colour missmatch seems to be particularly obvious in pigmented skin. It requires emphasis that a large amount of tissue is required for a flap based on the chest, to pass to A tissue expanded flap is usually used as a transposition or advancement flap. 10,11 These methods have the disadvantage of increasing the scar burden as these flaps have three edges. A rotation flap is another alternative as it has got one edge, but rotation flaps need to be very large if used to cover anything other than small defects. Orticochea 12 states that the length of the flap should be about five times as large as the defect. A large expander is probably required to create such a large flap. However, inserting a large expander, which has a large base, may not be possible in the neck, due to anatomical constraints, particularly in a child. Another alternative to creating a large flap is by adding a tissue expanded flap to a conventional flap. Clinical case. Patient 2, Figs. 7 and 8. This 12-year-old boy required resurfacing of his lower face following a 25% flame burn (Fig. 7). A Juri 13 type cervicofacial rotation advancement flap alone would have not been adequate to resurface the burnt cheek. A 150 ml rectangular tissue expander (6 5 cm) was inserted subcutaneously into the neck and inflated to 210 ml (Fig. 7). If this expanded flap were advanced, probably insufficient tissue would have been obtained for full cheek reconstruction. Furthermore, the scars from such an expanded flap would have transgressed the mandibular border and neck which would have been unaesthetic, particularly in black skin. Additionally, lower eyelid ectropion after transposition from the neck to the cheek is not uncommon By adding the expanded flap to the cervicofacial rotation flap, a number of advantages accrued (Fig. 8). 1. A larger flap was available for resurfacing. 2. The vascularity of the cervicofacial flap was not compromised by having another subcutaneous flap attached. 3. A rotation flap could be used but without the need for a very large round tissue expander. 4. Had transposition or advancement flaps been
Other ways to use tissue expanded flaps 339 Figure 5 (A) Front view, child at 12 months after division of flap, (B) right lateral and (C) left lateral. used there would be two scars which would have crossed the mandibular border. 5. The scars could be hidden more effectively (Fig. 8). 6. Ectropion of the lower eyelid was avoided by using a rotation flap. This is a relatively unusual application, which is probably only possible in head and neck reconstruction. Case 3. Repositioning of displaced cutaneous structure Certain cutaneous structures, e.g. eyebrows, ear, Figure 6 View of chest (donor site of tissue expander) The only sequelae are scars. Figure 7 Patient with rectangular expander in situ in neck for resurfacing of burnt cheek. (Patient also has tissue expander in the scalp).
340 D.A. Hudson Figure 8 Patient 6 weeks after subcutaneous cervicofacial rotation flap combined with a subcutaneous tissue expanded flap. There are no scars crossing the mandibular border and no ectropion of the lower eyelid. Note site of scar. nipple areola complex (NAC) may become displaced by trauma or disease. A tissue expander can be placed beneath these structures. Once expansion is complete, the cutaneous structure can be transposed, as part of the expanded flap, (if it displaced in two planes, either superiorly\inferiorly and medially\laterally) or, advanced (if displaced in only one plane see example below) back to its original position. Tissue expanded flaps are very robust, hence if the cutaneous structure is displaced in two planes (e.g. both superiorly and laterally) by more than a few cm, a large amount of transposition would be possible to achieve by placing the cutaneous structure under the (distal) end of a large rectangular tissue expander. This technique is used, for example, in the tuberose breast deformity 14 where an expander helps to reposition the breast tissue and inframammary fold. Figure 10 A 500 ml tissue expander inserted and overinflated (as this patient only required a 225 ml prosthesis) to 420 ml so that some excision could be effected. Hence, the left breast is larger than the right. Clinical case. Patient 3, Figs. 9 11. A 62-year-old lady underwent an immediate one stage breast reconstruction 15 with a prosthesis on the left (skin sparing mastectomy) and a contralateral reduction using an inverted T pattern). A local skin flap had been used for immediate nipple reconstruction. Her NAC had been retained as a full thickness graft, which had been applied to a local flap 15 to effect one stage NAC reconstruction. However, she was on high dose steroids (prednisone 60 mg per day) for a sudden deterioration in her asthma. This, combined with a large post-op seroma led to mastectomy flap necrosis with prosthetic extrusion. She still desired reconstruction, which was undertaken 6 months later. Pre-op it can be seen that the left NAC had been displaced superiorly almost 2 cm above (Fig. 9), the other normally Figure 9 Patient pre-op, prior to insertion of tissue expander. Note that the left NAC is displaced superiorly by almost 2 cm but remains in the midaxillary line. Figure 11 Patient after insertion of a permanent 225 ml textured gel prosthesis, and excision of 2 cm of the superior flap, which was performed to lower the NAC by 2 cm. Much better symmetry obtained.
Other ways to use tissue expanded flaps 341 situated right NAC. The displaced left NAC was still in the midaxillary line and only required advancement (i.e. it was displaced in only one plane and did not require transposition either laterally or medially.) A 500 ml round tissue expander was inserted (using the transverse incision of the previous inverted T) and (over) inflated to 420 ml (Fig. 10). Overinflation (the patient only required a 225 ml prosthesis) was undertaken (Fig. 9) so that for some tissue could be excised from the advancing skin flap containing the NAC. Pre-op second stage, prior to expander removal, it can be seen that the left breast is larger than the right (Fig. 10). At operation, 2 cm of the leading (inferior edge) of the superior flap was excised in order to achieve 2 cm of advancement and lower the displaced NAC (Fig. 11). A permanent 225 ml textured gel prosthesis was then also inserted. While other techniques, e.g. z-plasty may be able to transpose tissue, in this patient these technique would have added additional scars to the breast. Also, in this patient, a z-plasty may have created narrow flaps and skin bridges with possible skin necrosis. Similarly, transferring the NAC as a free nipple graft would have also created additional scars and there are also the potential complications of grafts viz pigmentary changes etc. Tissue expansion should always be considered as an option when confronted by a reconstructive problem. It is a staged procedure and complications do occur, although these can be largely reduced as experience with expanders occurs. 16 References 1. Argenta LC, Austad ED. Principles and techniques of tissue expansion. In: McCarthy J, editor. Plastic surgery, vol. 1. Philadelphia: WB Saunders; 1990. p. 475 507. 2. Masser MR. Tissue expansion: a reconstructive revolution or a cornucopia of complications? Br J Plast Surg 1990;43: 344 8. 3. Argenta LE, Marks MW, Pasyk KA. Advances in tissue expansion. Clin Plast Surg 1985;12:159 71. 4. Manders EK, Schenden MJ, Furrey JA, Hetzler PT, Davis TS, Graham WP. Soft-tissue expansion: concepts and complications. Plast Reconstr Surg 1984;74:493 507. 5. Zoltie N, Chapman P, Joss G. Tissue expansion: a unit review of non-scalp, non-breast expansion. Br J Plast Surg 1990;43: 325 7. 6. Chun JT, Rohrich RJ. Versatility of tissue expansion in head and neck burn reconstruction. Ann Plast Surg 1998;41: 11 16. 7. Manders E. Reconstruction using soft tissue expansion. In: Cohen M, editor. Mastery of plastic and reconstructive surgery. Boston: Little Brown Co; 1994. p. 201 15. 8. Cherry GW, Austad E, Pasyk K, McClatchey K, Rohrich RJ. Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin. Plast Reconstr Surg 1983;72:680 7. 9. Hoekstra K, Hudson DA, Smith AW. The use of pedicled expanded flaps for aesthetic resurfacing of the face. Ann Plast Surg 2000;45:1 6. 10. Zide BM, Karp NS. Maximising gain from rectangular tissue expanders. Plast Reconstr Surg 1992;90:500 7. 11. Joss GS, Zoltie N, Chapman P. Tissue expansion flap and the transposition flap. Br J Plast Surg 1990;43:328 33. 12. Orticochea M. Flaps of the cutaneous coating of the skull. In: Grabb WE, Myes MB, editors. Skin flaps. Boston: Little Brown Co; 1975. p. 155 83. 13. Juri J, Juri C. Cheek reconstruction with advancement rotation flaps. Clin Plast Surg 1981;8:223 6. 14. Scheepers JH, Quaba AA. Tissue expansion in the treatment of tubular breast deformity. Br J Plast Surg 1992;45:529 32. 15. Hudson DA, Skoll PJ. Complete one stage immediate breast construction with prosthetic material in patients with large or ptotic breasts. Plast Reconstr Surg 2002;110: 487 96. 16. Pisaki GP, Mertens D, Warden GD, Neale HW. Tissue expander complications in the pediatric burn patient. Plast Reconstr Surg 1998;102:1008 12.