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Annals of Burns and Fire Disasters - vol. XXI - n.
1 - March 2008 TREATMENT OF POST-BURN SCAR DEFORMATIONS USING TISSUE EXPANSION AND ENDOSCOPY Sharobaro V.I.1, Moroz V.Y.1, Starkov Y.G.2, Yudenich A.A.1 A.V. Vishnevsky Institute of Surgery, Moscow, Russia 1 Division of Reconstructive and Plastic Surgery 2 Division of Endoscopic Surgery SUMMARY. Background. The essential drawbacks of conventional tissue expansion, a technique widely used in reconstructive surgery, are its significant duration and the high complications rate. The experience of our clinic covers 329 patients treated with this method from 1987 to 2006. The mean time of expansion was previously 72 ± 2 days (± SD) and the rate of local complications was 38.6%. We applied effective new approaches to this method in order to reduce its drawbacks, i.e. the endoscopic implantation of expanders, intensive expansion, and a modified technique of elevation of an expanded flap. Methods. Twenty-seven patients treated in the A.V. Vishnevsky Institute of Surgery between 2001 and 2006 for post-burn scar deformities underwent endoscopic implantations of 46 silicone expanders in various anatomical areas. High-grade tissue expansion was initiated immediately after implantation. The elevation of the reconstructed flap was performed, including defective tissues in the flap, after which the expander was removed and the expanded tissues were transposed. Results. With the help of the techniques developed, it was possible to reduce the mean expansion time from 72 days to 34 (less than half) and to reduce the complications rate from 38.6% to 6.5%. Conclusions. Endoscopic expander implantation, the accelerated technique of tissue expansion, and modified elevation of the expanded flap enabled us to considerably improve results in the treatment of post-burn scar deformities, using the tissue expansion method. Introduction In the last decade there has been a marked and steady growth in the number of patients suffering from post-burn and post-traumatic soft tissue deformities and scar contractures causing functional and cosmetic defects. Such “defects” of appearance promote alterations in the patients’ psychoemotional conditions, generate feelings of hopelessness, inferiority, and uncertainty, and reduce a person’s mental and working capacity, frequently leading to the development of concomitant diseases of psychosomatic origin such as neurosis, angina pectoris, and hypertension. Surgical treatment is frequently limited by the scarcity of adequate soft tissues available for reconstruction. Over the last 25 years tissue expansion has become a technique for overcoming such soft-tissue limitations.1-4 This method possesses the unique ability of generating skin with an almost perfect match of colour, texture, and sensation required for reconstruction in a specific area. Compared with other methods of plastic surgery, tissue expansion facilitates the closing of extensive soft-tissue defects without additional scars in donor areas. In the period from 1987 to 2006 tissue expansion was used in the treatment of 329 patients with postburn and post-traumatic cicatricial deformations in the A.V. Vishnevsky Institute of Surgery. A total of 780 expanders were implanted in various anatomical areas. However, the method presented some essential drawbacks, i.e. its significant duration (72 ± 2 days (± SD) and the high complications rate (up to 38.6%). Our data are consistent with those in the literature, according to which the expansion lasts 23 months and the complications rate ranges from 5% to 70%.4, 6-12 This considerably limits the possibilities of wide clinical usage of tissue expansion.
Fig. Patients and methods We used an endoscopic implantation of 46 expanders in 27 patients with post-burn scar deformities between December 2001 and December 2006. Moscow) in hemispherical. and the incision line for the creation of a pocket were selected and marked on the skin. the expander sizes. The incision was made within the defect area that it was planned to excise. abdominal wall.Scheme of orientation of tension vectors in relation to post-operative wounds in traditional and tissue expander implantation. We used an endoscopic expander implantation. 2). making use of expanded tissues.Plastis-M silicone expander. face. Fig. and its direction was parallel to that of the tissue expansion tension vectors (Fig. intensive expansion. 1). scapular. Expanders Silicone expanders (Plastis-M. sites for tissue expansion. Endoscopic technique of expander implantation In the early days. Expanders were implanted in the head. it was 10 mm long (in relation to the size of the endoscopic instrument). oblong.6) (± SE). and a modified technique for elevation of the expanded flap. and forearm and calf areas. 18 patients were female and 9 male. 25. . or cylindrical form were used (Fig. Their base size ranged from 80 õ 35 to 130 õ 50 mm and their volume from 50 to 500 ml. neck.1 yr ± 0. 1 .The above considerations led us to seek effective new approaches to this method that would enable us to considerably reduce the duration of treatment and the complications rate. chest. The patients’ ages varied from 15 to 44 yr (mean. The incision was as remote as possible from the expander pocket. 2 . shoulder.
Germany) (Fig. a dissector. 4 .The second stage was the dissection of the expander pocket in the required anatomical stratum. The expanders were placed under a galea aponeurotica on the head and. tissue dissection. with meticulous haemostasis (Fig. and coagulation. since it was fitted with a camera. providing the opportunity of cutting tissues in conditions of haemostasis. 4).Endoscopic dissection of expander pocket via distant small incision with good visualization and precise haemostasis. A primary tunnel (approximate length. A coagulation hook. Fig. if possible. 15-17 mm Hg) was insufflated through the ESDO channel in order to maintain an optical cavity in the soft tissues and to simplify the endoscopic manipulations. Wolf. Fig. . This provided uniform tissue expansion and prevented pressure sores and excessive thinning of subdermal fat. 2 cm) was created bluntly from the incision to the planned expander site. This instrument made it possible to implant the expander through one remote incision. Wolf. a gas insufflator. making it easy to lift the dissected tissues mechanically and to create sufficient space for the dissection optical cavity. gas infusion. Carbonic gas (pressure. 3 . under a superficial fascia in all other areas.Endoscopic videosystem (R. and a channel for a working instrument. 3) was then inserted with a working tool. The instrument’s L-shaped form was very convenient. Germany) permitting simultaneous visualization. An ESDP endoscopic videosystem (R. The working tool was always in front of the camera at the centre of the field of vision. or scissors were used as a working tool. The expander pocket was created on the basis of the pre-operative markings.
filling the expanders in 3-4 weeks using expansion with a conventional implantation technique (up to 350 ml). with post-burn scar sequelae on left cheek and neck. straightened inside. depending on the diameter of the connecting tube). Filling was done daily or every other day with normal saline solution and was suspended on the appearance of signs of altered blood circulation in the expanded tissues (hyperaemia. pallor). Tissue expansion was performed until sufficient tissue gain for reconstruction had been achieved (Figs. ranging from 15 to 60 ml in one tissue expansion session. 17 years old. 5 .6). Ports were placed subdermally or externally through the small apertures (2 mm. The operative wound was closed in two layers with two single sutures. without taking any notice of post-operative wound dehiscence. 6 . Drainage was not used. Measuring oxygen pressure in the expanded tissues with a TCM 400 gas analyser (Radiometer. Fig.Patient N. Expanders were filled in such a way as not to interrupt the blood supply to the expanded tissues.Two endoscopically implanted expanders and sufficient tissue gain achieved by intensive expansion in 27 days. It was enough to change the antiseptic dressings once every two days to prevent infection. During filling the pressure should not go below 10 mm Hg (TcÐÎ2 of healthy intact skin is 55-60 mm Hg). Denmark) was an expedient method of objective control. . in view of the adequate haemostasis and the absence of free cavities in the tissues. 5. This eliminated any possible “dead spaces” between an expander and the surrounding tissues and thus made it possible to prevent seromas.. Intensive technique of tissue expansion High-grade tissue expansion was initiated at once on the operating table. haematomas and infection of the pocket. and filled with normal saline solution.An empty expander was implanted in the cavity created. Fig. Analgesic drugs were not used. The volume of the infusions depended on the anatomical area and the volume of the expander.
is the surface area of the defect. 7A . . with coagulation of bleeding vessels.. Twenty per cent of the gain achieved by expanded tissues was thus lost using this technique. fibroblasts. Fig. Planning of the defect area to be excised was done before . An endoscopic expander implantation enabled us to apply a new technique of elevation for expanded flap that permitted a more effective utilization of the flaps’ resources without any retraction. In the conventional technique. during which time retraction occurred. and myofibroblasts of derma and capsule. The implant was then taken out and the size of the expanded tissues was calculated.base is the surface area of the expander base. To avoid this deficit of expanded tissue on reconstruction. expanded tissues retracted by approximately 20% or 2-4 cm.14 The duration of tissue expansion was therefore prolonged.base = 1. = Sexp. Sexp. An expander pocket was opened with an incision on the edge of the pathological and expanded tissues that was practically an incision from the previous implantation (Fig. A traditional reconstruction by expanded tissues was performed as we shall now describe. on the basis of which defective tissues were excised. It was performed to prevent tissue deficit after reconstruction because. 7A).2 õ Sdef. the following formula was used: Snes. Sexp. after removal of the implant. is the surface area of tissues necessary for plastic surgery.Modified elevation of expanded tissues The anatomical blood supply of the expanded flaps was taken into the account during the planning and performance of reconstruction by expanded tissues. expansion was continued until the area of expanded tissues was 20% greater than the defective area. depending on expander size.Sexp. is the surface area of expanded skin above an expander.13. This procedure usually took from 30 to 60 min. and Sdef.Scheme of incisions for dissection and mobilization of expanded flap with conventional reconstruction. The modified technique became possible after study of endoscopic expander implantation allowed maximum use of expanded tissue resources. This retraction was caused by elastic and collagenic fibres. where Snes. The period of tissue expansion was therefore prolonged as it was necessary to reach Snes.
In view of the possibility of tissue deficit due to complete excision of all extensive defects. Incisions were made on the basis of this plan (Fig. the superficial fascia were included in the flap in order to save the blood supply in distal parts (Fig. . 7B . The wound was closed with two layers of sutures. Fig.the operation on the basis of the tissue gain due to the expansion. Fig.Mobilization of cutaneous or fasciocutaneous layer (under defect) towards expander pocket with subsequent haemostasis. with subsequent haemostasis. arrow shows direction of mobilization). Fig. 9). The expanded flap was placed on the defect. 8). and tissues scheduled for removal excised from flap. and tissues scheduled for removal were cut from the flap (Fig. if possible. Using this technique. there was no time for the retraction of expanded tissues.Expanded flap transferred to defect. final fitting was done. the defective tissues had already been cut from subjacent tissues and haemostasis had been achieved on the wound surface. 8 . final fitting performed. was left in the distal part of the flap. 9 . Subdermal fat and if possible the superficial fascia is included in the flap in order to maintain blood supply to distal parts. the strip of pathologic tissues. The subdermal fat and. When during mobilization an expander pocket was reached. 7B). After that the expander pocket was opened and the implant was removed. where the blood supply was not interrupted by the incision for implantation of the expander. after which mobilization of a cutaneous or fasciocutaneous layer (under the defect!) towards an expander pocket was carried out.Scheme of incisions for dissection and mobilization of expanded flap with modified reconstruction and inclusion of defective tissue in flap (wide continuous lines show incisions.
The complications had a negative influence on tissue expansion. haematomas (6.0 was used for statistical analysis.5 * p < 0.6 ± 2.3%).0%).2 Infection 14. Statistical analysis The licensed program Statistica 6.The advantage of this modified technique of reconstruction was thus the reduction in expansion time. Wound dehiscence and pressure sores were associated with seromas.6 0 Total* 38. and the results of treatment: in 24 cases (5. This testified to the important role of these in the development of trophic alterations in expanded tissues. the hypothesis of equality of average (frequencies) in two groups was rejected at a significance value of p < 0.0 0 Pressure sore 15.05 Table I .5%). haematomas. and Student’s t-test. tissue expansion failed because of complications such as infection (2.Comparison of techniques of implantation and tissue expansion .7 (± SE) 33. The most frequent complications with the conventional technique were seromas (11.6% of cases. pressure sores (1. using the following parameters: mean value (M). Criteria of comparison Conventional implantation and expansion Endoscopic implantation and intensive expansion Mean expansion time (days) 71. dehiscence of post-operative wounds (8.6%). or infections of the expander pocket in respectively 63. without losing up to 20% of the gain because of retraction and without the risk of tissue deficit for plastic surgery. Results For the comparison of techniques we considered the results. average standard deviation.8 3. and pressure sores (15. the terms of treatment. and wound dehiscence (1.6 6. its duration. infections (14. and the complications rates.3 (± SE) Complications (percentage of expansions) Seroma 11.8 ± 1.6% and 47.8%).6 0 Wound dehiscence 8.4%) using the conventional technique. due to maximum use of expanded tissues.05 for quantitative attributes and the c2 criterion for qualitative attributes.4%).4 0 Haematoma 6.6%).3%) (Table I).2 Failure of expansion due to complications 5.3 3.
The wounds healed uneventfully by primary intention. With the traditional technique a surgeon has to balance between insufficient filling (seroma and infection) and overfilling (post-operative wound dehiscence) in the first two weeks after an implantation. The mean duration of tissue expansion using an endoscopic expander implantation. and modified reconstruction was less than half than using the conventional technique. Discussion Tissue expansion is an effective method of reconstructive and plastic surgery.Same patient three months after reconstruction with expanded tissues. a haematoma was observed in one case (3. and all the transferred expanded flaps survived after reconstruction (Fig.5%.e. i. Conventional post-operative implantation wounds did not allow tissue expansion within 10-14 days before healing.6 ± 1.e.1% (p < 0. by 32.05) and to decrease expansion time by 38 days. The new techniques therefore enabled us to considerably reduce the complications rate from 38. intensive expansion. This fortnight’s delay promotes the development of a thicker capsule around the expanders that complicated tissue expansion16 and increased the retraction of expanded tissues.8 ± 2.14 .7 days (± SE) compared to 71.6% to 6. 10). as reported above. and to develop a reconstruction technique without retraction of the expanded tissues and therefore without the need to waste time on overexpansion up to 20%. Thus the commencement of tissue expansion immediately after implantation and the intensive filling technique did not increase the trophic alteration rate in the expanded tissues.15 However.3 days (± SE) (p < 0. Reduction of the length of the incision was limited by the need of good visual control and of adequate operative space for maintenance of haemostasis. its essential drawbacks of significant duration and a high local complications rate considerably limit its wide clinical application. A reliable technique was necessary to reduce the risk of complications to a minimum. Fig.2%) and a pressure sore (due to an accidental trauma in the expansion site) also in one patient (3. This time was completely inadequate for tissue expansion.05). We analysed factors that might consent a reduction of these limits of expansion: it was necessary “to exclude” the time required for healing of an implantation wound. thus reducing patient discomfort. 33. i. There were no failed expansions. 10 . This period was even longer in the event of complications.2%).With the new techniques. to prevent complications.
Even if an expansion process has no complications. served to prevent haematomas. Endoscopic techniques and instruments made it possible to create the required cavity for an expander in the selected anatomical layer of tissues. Patients should not therefore suppose they are going to be “switched off” from their usual lives for 3-4 months (2-3 months for expansion plus of 2-4 weeks after the reconstructive operation). High-grade tissue expansion is started immediately after expander implantation and is maintained until sufficient tissue gain for reconstruction has been achieved. wound dehiscence). plus precise haemostasis. with subsequent haemostasis that includes defective tissues on the flap.5 months). The new techniques effectively prevent complications. All patients want to get rid of their defect with minimal discomfort and within the shortest terms.). It should be emphasized that a surgeon cannot guarantee the final outcome. antibiotic therapy. especially if the expanders are located on exposed body sites. it considerably limits normal life and physical activity. In reconstruction by means of expanded tissues adjacent to the defect. such as the face or head. especially from the patient’s point of view. The new techniques have made it possible to reduce the risk of complications and to considerably reduce expansion time (from 2-3 to 1-1. daily bandagings. surgeons have to make several parallel incisions for capsular release that can impair damage the flap’s blood supply. Conclusions Tissue expansion is an effective method in the treatment of various extensive post-burn scar deformities that makes it possible to increase the area of normal tissues available for reconstruction having a colour and texture similar to those of the defect area. haematoma. If such complications occur (i. The commencement of tissue expansion immediately after implantation and the intensive filling technique did not cause any trophic alterations in the expanded tissues. in their turn. and minimize patient discomfort. A careful check of all the areas of a newly formed pocket. because of the elevated risk of complications. reduced the infections and pressure sore rates above the expanders. Some minor incisions (5-10 mm). In plastic surgery psychosocial aspects play an important role and should not be underestimated. reaching its maximum after approximately two months of expansion. To overcome this. Defects of appearance are not life-threatening.23 Endoscopic implantation of expanders appeared to effectively prevent complications. Endoscopic expander implantation is preferable because of the reduction of expansion time and in-patient stay. thus significantly diminishing patient discomfort.e. Some moments during tissue expansion are disappointing.22. repeated wound suturing. The prevention of seromas and haematomas. the thick capsule. reduce expansion time by over a half.Capsular thickness is proportional to expander pressure. . made parallel to tension forces. with conventional techniques.18-21 A high-grade expansion process was therefore immediately initiated immediately after implantation of the expander. limited the expanded tissues’ mobility. the expansion process lasts even longer and causes more discomfort (pain. infection. etc. after two or three months of expansion. enabled us to initiate a high-grade tissue expansion just after the expander implantation without taking care of a wound dehiscence that also prevented seromas. Pathological tissues are excised after removal of the expander and transposition of the expanded tissues on the defect. and the prevention of complications.17 Thus. seroma. with good haemostasis control through remote 5-10 mm incision(s) made parallel to the tension vectors.16. an incision is made on the opposite side and mobilization is effected towards an expander.
Select..R. Kerem H. Vadodaria S.. Magalon G. 1995. Plast. Antonyshyn O. 1989. le temps moyen de l’expansion était de 72 ± 2 jours (± DS) et le taux de complications locales était de 38. 2000. L’expansion tissulaire à niveau élevé a été commencée immédiatement après l’implantation. Read.. Surg.P.. Gibstein L. Bilkay U.S. a été effectuée et ensuite l’expanseur a été enlevé et les tissus expansés ont été transposés. Surg. Grishkevich V. Kayser M. Conclusions.. Moroz V.: A method of expansion of soft tissues in plastic and reconstruction surgery (review of the literature).S.. Plast. Plast. il a été possible de réduire le temps moyen de l’expansion de 72 jours jusqu’à 34 (moins que la moitié) et de réduire le taux de complications de 38. Plast. In: Georgiade G. 57: 93-7.. Br. Fac.. Herson M. avec l’emploi de la méthode de l’expansion tissulaire. J.. Ann. J.C. 42: 396-401. Surg. Hosp. Faes J. Vishnevsky entre 2001 et 2006 pour des séquelles cicatricielles post-brûlures ont reçu l’implantation endoscopique de 46 expanseurs de silicone dans diverses zones anatomiques du corps. Coleman D.. c’est-à-dire l’implantation endoscopique des expanseurs. 1999.C. Karp N. y compris les tissus déficients du lambeau. Songur E.: Tissue expansion in the limbs: A comparative analysis of limb and non-limb sites. 2004.ont permis aux Auteurs d’améliorer notamment les résultats du traitement des séquelles cicatricielles post-brûlure. Legre R. Clin. la technique accélérée de l’expansion tissulaire et l’élévation modifiée du lambeau expansé . Ann.R. une technique fréquemment utilisée dans la chirurgie reconstructive. Ozek C. Plast. 41: 239-50. Trois techniques l’implantation endoscopique de l’expanseur. Surg. Rev.L. 2002. Mackinnon S. Med. Ferreira M.C.RÉSUMÉ. J. J. 114: 98-106... Plast. Bartlett R. 15: 758-65. Sao Paulo.. Surg. 54: 310-6. sont la durée significative et le taux élevé des complications.. Ganzha P. Méthodes.. (eds): “Plastic. Mulliken J.. 8: 7-58...: Tissue expander complications in plastic surgery: A 10-year experience. Hodges P.M. Sharobaro V. 6: 42-6. l’expansion intensive et une technique modifiée pour l’élévation d’un lambeau expansé..V. Les désavantages de l’expansion tissulaire conventionnelle. Maxillofacial and Reconstructive Surgery”.: Complications of soft tissue expansion. Plast..S.. Cunha M.5%..Y.S.. 38: 358-64. Bardot J.. Levin L. Khirurgiia (Mosk. Craniofac... Riefkohl R. Williams & Wilkins.. Résultats. Les Auteurs décrivent leur expérience du traitement en clinique de 329 patients traités avec cette méthode pendant la période 1987-2006...: Tissue expansion. Margulis A. Youm T.: Tissue expansion of the lower limb: Complications in a cohort of 103 cases. 2001. L’élévation du lambeau reconstruit.A.: Tissue expansion in children: A retrospective study of complications. Erdem O. Madazimov M. 1997. Br. Br. Vingt-sept patients traités à l’Institut de Chirurgie A. Orgill D. Utilisant ces techniques qui ont été perfectionnées. 1988. 55: 302-6..: Alopecia treatment with scalp expansion: Some surgical fine points and a simple modification to improve the results. Bauer B.F. Nakamoto H.A. Gruss J. Surg. Khirurgii. Surg...S. Pandya A.B.C. 8: 140-3. Bibliography Argenta L.. Kasabian A.A. Reconstr. Ann.I.M.. Données générales. Baltimore. 87-98. Gemperli R. Abramson D. Surg.: Principles of flaps (overview).E.6%. Moroz V. 2004. Bali D.: Complications of tissue expansion in a public hospital.L.J.6% à 6. Avec la méthode ancienne. 2002... Upton J. Les Auteurs ont appliqué une nouvelle approche à cette méthode afin de réduire ses désavantages. Margiotta M.Y.N.....). .. Casanova D.: The expanded transposition flap: Shifting paradigms based on experience gained from two decades of pediatric tissue expansion. 1997.: Prevention of complications of tissue expansion.
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