Our Experience With Tissue Expansion In The Reconstruction of Burned Children

INTRODUCTION

In many ways burns are one of the worst types of injuries, often entailing life-long stigma. To achieve optimal results it is often necessary to perform reconstructive surgery in repeated stages. Burn trauma is caused by direct or indirect impact of thermal energy, electric energy, radiation or chemicals. The severity of the burn trauma depends not only on the mechanism of the injury but also on its extent, depth and location, as well as the age of the injured person (1). The course of severe burn trauma can be divided into three phases which are closely associated and mutually interdependent. The first phase is burn shock, which is followed by acute illness from burn injury. Finally, the third phase includes rehabilitation and reconstruction. Both of these are very important for the proper re-integration of an individual into society. Particularly good aesthetic and functional result can significantly reduce the risk of social death (2). This period is associated with long-standing, difficult treatment, and failure can leads to serious depression of a physical but predominantly psychological nature. The success of rehabilitation and reconstruction depends not only on a multidisciplinary approach, involving medical staff from the burns, plastic surgery, psychology and rehabilitation sectors, but also on the cooperation of the patient and the patient’s family.

Scars and contractures can be influenced by conservative methods, such as pressure treatment, splinting and rehabilitation exercise, as well as reconstructive surgery, to achieve good functional and aesthetic results. The spectrum of surgical interventions available is very wide, ranging from simple excisions to free flaps and tissue expanders (3). Nowadays tissue expanders are used more in burn, plastic and pediatric surgery. Tissue expanders are temporary silicone implants inserted into a surgically preformed cavity under the skin, muscle or other tissue (4) (Fig. 1, 2).

Gradual filling the expander with a physiological solution produces tissue expansion over a period of several months. The tissue can cover defects that are results of excision of scarred terrain. Neumann first described the use of tissue expansion in 1957. He reconstructed auricle by an inflated balloon placed retroauriculary (5). In 1975 Radovan (6) used silicone implant, and the first expansion of free flaps transferred into defects was described in 1988 by Leighton (7). The technique of tissue expansion can be used wherever there is a need for soft-tissue reconstruction. The most common indication for the use of tissue expanders is burn deformity and contracture, as already mentioned. However, it can also be used for reconstruction after excision of large pigmented nevi and to treat congenital and traumatic alopecia. (8) The expanders are frequently used in area of highly potential tissue where there is a skeletal base under the expander (sternum or scapula). Tissue expanders can therefore be used to reconstruct the scalp, face, neck, trunk, breast and extremities (9). At our workplace tissue expanders are most frequently used to reconstruct burn deformities. Because of the cost of tissue expanders, the active cooperation of the patient and also the patient’s family is important.

MATERIAL AND METHOD

This study involved 19 patients (15 girls and 4 boys) ages 0–19 who were hospitalized at the Department of Burns and Reconstructive Surgery, University Hospital Brno, between the years 2005 and 2009. These patients underwent 34 tissue expansions. Basic epidemiology data adhered to parameters that were set in advance, such as volume of the expanders used, localization of the expanded area, length of hospitalization due to the implantation and explantation of the expander. Retrospectively we also evaluate complications associated with this method.

RESULTS

Between the years 2005 and 2009 we hospitalized a total of 385 pediatric patients for reconstruction after burn injury. In 19 patients we completed 34 (i.e. 8.8% of the total amount of reconstruction surgeries) tissue expansions (Graph 1). Graph 2 shows the gender ratio of patients with tissue expanders. The average age of patients in this group was 12.8 years (5–19 years); average length of hospitalization associated with implantation of an expander was 6.8 days (4–12 days); and average length of hospitalization associated with explantation of an expander was 6.3 days (3–10 days). The average time between the thermal trauma and the first implantation of an expander was 5.5 years (2–9 years). In 12 patients we expanded only one area; in others we performed multiple expansions. We implanted four tissue expanders in three patients (Fig. 3, 4). The average volume of the tissue expanders used was 510 ml (68–1640 ml). The average time of filling was 4.7 weeks (3–11 weeks). None of the patients had complications with filling the expander. The most common area for expansion was the trunk (Fig. 5, 6), the ventral side (a total of 15 expansions), and the dorsal side (a total of 11 expansions). In 8 cases the tissue expanders were used for reconstruction in the area of the head and neck (Fig. 7, 8a, 8b, 8c). The most common complications were dehiscence in the area of suture of the expander in four cases (i.e. 11.8%) without its dislocation. In one patient we observed dehiscence of the suture above the port. In one patient surgical revision due to a hematoma was necessary. Due to the antibiotic prophylaxis during implantation there were no infection complications associated with this procedure. Total frequency of complications associated with tissue expansions was therefore established at 17.7%.

DISCUSSION

The introduction of tissue expansion into clinical practice and its use in the reconstructive phase of burn injury allows for better quality of care as well as improvement of esthetic and functional result of therapy in severe burn trauma. The advantage of tissue expansion is the acquisition of skin with appropriate pigmentation and quality, such as can be found in the surrounding area. Moreover, it is not necessary to traumatize the patient by creating yet another harvest area and more scar tissue. Complications are relatively infrequent and are primarily influenced by the process of expansion, the quality and availability of tissue; they may also depend on the surgical procedure. The main complications associated with implantation or explantation that are described in literature include hematoma, seroma, infections, prolapse or dislocation of the expander, necrosis of the tissue above the expander or failure of the expander to fill (10, 11). Formation of the hematoma and dehiscence are described as the most common complications. This was also confirmed in our study. In none of the patients were we obliged to explant the tissue expander sooner than originally planned. The disadvantage is the fact that tissue expanders cannot be used in areas where there is atrophy or in areas treated previously by radiation. Another disadvantage is the length of treatment and its financial cost.

Tissue expansion is a very useful method in cases of post-traumatic alopetia and other cosmetic defects. When used in the area of reconstructive surgery after severe thermal injuries (scarring) the use of this method requires considerable attention to surgical technique in order to minimize the negative consequences. Nowadays the use of tissue expanders makes it possible to attend simultaneously to several areas, such as the eyebrow, face and beard.

Bozkurt et al. (12) in his study retrospectively analyzes the use of tissue expanders in 57 patients after burn trauma. Over 8 years they used a total of 102 expanders for correction of post-traumatic deformities. In their work they did not confirm any correlation between factors such as age, gender and number of expanded areas and failure of this method above the level of statistical significance.

The method of tissue expansion in patients after burn injuries requires careful and thorough planning, and a time-line for procedures should be set in order to prevent complications associated with this method. In his works Lasheen et al. (13) presents the results of the so-called external tissue expanders. Expansion of the chosen area is achieved by the use of negative pressure on the external expander. As a conclusion he evaluates this method in reconstruction in the area of head and neck as safe, with good results and few undesirable effects. In the new millennium the possibility of using endoscopic technique for implantation of tissue expanders is developing. Sharobaro (14) published his experience with endoscopic implantation of tissue expanders in 9 patients. In total he completed expansion in 20 areas (head, neck, shoulder blade, chest). Iconomou et al. (15) focused on risks associated with the use of implants in particular groups. His conclusion was that tissue expansion in children after burns does not bring higher risk of complications when compared with children where tissue expansions were completed for other indications than burn deformities.

CONCLUSION

In the complex care of burned patients, the quality of life after discharge home from primary hospitalization represents a very important period which has recently received more attention. Methods of tissue expansion are associated with excellent functional results while also being aesthetically more impressive than conventional reconstructive methods. Therefore the possibility of tissue expansion should be routinely offered for all patients with indications after burns.

Address for correspondence:

B. Lipový, M.D.

Department of Burns and Reconstructive Surgery

University Hospital Brno

Jihlavská 20

625 00 Brno

Czech Republic

E-mail: b.lipovy@seznam.cz