The Journal of Craniofacial Surgery
Volume 26, Number 4, June 2015
Avoiding Extended Scar in Skin Expansion: Alagoz Technique Murat ahin Alago¨z, MD, Sinan O¨ksu¨z, MD,y Mustafa Keskin, MD,z Emrah Kag˘an Yas¸ar, MD, Fikret Eren, MD,y Mustafa Hasdemir, MD, and Ersin U¨lku¨r, MDy Abstract: The principal aim of skin expansion is to provide additional donor tissue without extra donor-site morbidity. Most of the reports about tissue expansion are focused on the properties of expander. Donor-site decision is usually underestimated. Here, we offer to use the defect area and surrounding healthy tissue as the donor site. In 4 cases, expanders were placed just under the defect in a fashion to extend 1 to 2 cm more laterally toward the encircling healthy tissue. The expanded tissue was not mobilized for longer distances; thus, there was no loss in flap gain. The resulting final scar was linear or crescentic. In the Alagoz technique, tissue gain similar in size to the defect is sufficient for reconstruction. The simpler the flap, the best the resulting scar. Key Words: Short scar expansion, skin expansion, subdefect expansion
Brief Clinical Studies
expander was equal or shorter than the defect to enable the resection of the extra defect length with the dog-ear resulting due to the expansion. In the Alagoz technique, actual expanded flap gain can be formulated as the difference between inflated tissue dome length and expanded defect width (Fig. 1).
Surgical Technique The expanders were placed through a short incision on the defect area perpendicular to the direction of the expansion. In 1 case, a previous incision scar on the defect, parallel to the expansion direction, was used for this purpose. On the face, a pouch over the superficial musculo-aponeurotic system was dissected for the expanders. On the temporoparietal region, the expander was located over the temporal muscle. The expanders were placed just under the defect area in a fashion to extend 1 to 2 cm more laterally under the encircling healthy tissue. Lateral extension of the expander under the defect ensures expansion of healthy tissue. The longer axes of both the rectangular expander and the defect were oriented parallel to each other. The ports were placed subcutaneously except for 1 case. Drains were kept in place up to 3 days postoperatively. The expansion was continued until the actual expanded flap gain size was similar to the initial defect width. After excising the expanded defect, encircling healthy tissue was primarily sutured.
RESULTS
T
he principal aim of skin expansion is to provide an additional donor tissue adjacent to the defect for reconstruction without extra donor-site morbidity.1 –3 Tissue expansion is closely associated with the parameters, namely, size, shape, volume, and location of the expander.4 For a better reconstruction, numerous reports are concentrated on expander properties and the flap gain or the flap mobilization techniques, but not many are focused on the location of expansion. Here, we offer to use the defect area and surrounding healthy tissue as the donor-expansion site.
MATERIALS AND METHODS Four patients were treated with the Alagoz subdefect tissue expansion technique (Table 1). The height of the expanders (MENTOR Tissue Expander) was equal or longer than the half width of the defect to provide sufficient tissue gain. Thus, defect width up to twice larger than the expanded height of the flap could be easily covered. A wider expander width (1–2 cm) than the defect was preferred, whereas the length of the From the Department of Plastic and Reconstructive Surgery, Kocaeli University Medical Faculty, Kocaeli, Turkey; yDepartment of Plastic and Reconstructive Surgery, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey; and zDepartment of Plastic and Reconstructive Surgery, Medipol University Medical Faculty, Istanbul, Turkey. Received July 26, 2014. Accepted for publication January 20, 2015. ¨ ksu¨z, MD, Gulhane Address correspondence and reprint requests to Sinan O Askeri Tip Akademisi, Haydarpasa Egitim Hastanesi, Plastik Rekonstruktif ve Estetik Cerrahi Servisi, Tibbiye Cad. Uskudar, Istanbul, Turkey; E-mail: [email protected] The authors report no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001591 #
2015 Mutaz B. Habal, MD
Expansion of the defect with encircling healthy skin provided enough tissue gain to resurface the defect. In 1 case with an incision parallel to expansion direction, the expander was partially exposed. Nevertheless, the expansion could be completed as intended. No infection or flap problems were encountered. Expander insertion scars could be removed through the excision of the defect. The defects were successfully resurfaced. The expanded tissue was not mobilized for longer distances; thus, there was no loss in the flap gain. The resulting final scar was linear or crescentic (Fig. 2).
DISCUSSION Pioneers in tissue expansion indicate that the base of the expander should have at least similar or larger diameter as that of the defect for reconstruction.2,5 Other reports recommend the base of the expander to be twice as large than the defect size or more.1,6 However, tissue expansion can also be associated with the height of the expander rather than the base size.4,6 The increase in expanded surface area is usually overestimated.6,7 Thus, different approaches such as using multiple expanders, modifying the transposition pattern of the expanded flap or different incision patterns increasing the mobility, and using flaps to extend the gain have been described.6,8 There is a discrepancy in the reported series about the right size and shape of the expander to be used in reconstruction.6 However, donor sites in the literature are constantly the healthy tissue regions other than the defect area.2,3,7,8 Expander location is crucial because as the distance between the donor and recipient site increases the transfer of the flap results in more scars due to rotation or transposition.6,9 When the developed flap is advanced, the resulting scar is U-shaped, and if rotated, the scar is lazy S.2 Advancement of classically expanded flap to minimize potential scarring restricts reconstructive capabilities of gained tissue, whereas transposition of flap results in more scars.8
e291
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Brief Clinical Studies
Volume 26, Number 4, June 2015
TABLE 1. Patient Characteristics Age, y
Sex
Defect Size, cm2
Defect Location
Defect Etiology
Expander Volume, mL
Expander Shape
Complication
21 22 25 20
Male Male Female Male
25 96 63 72
Face Head Face Face
Nevus Lymphatic malformation Vascular malformation Scar
100 250 250 250
Rectangular Rectangular Rectangular Rectangular
Minimal exposition None None None
1 2 3 4
replacement. Minimum flap motion yields less flap area loss and results in less scar tissue. The simpler the flap, the best the resulting scar. In the Alagoz technique, the final suture line can be linear or crescentic. In selected cases, round expanders can be used and central defect can be closed with a purse string suture. The limitations for this technique can be the absence of skin to expand at the site of the defect and the anatomic obstacles. FIGURE 1. Schematic placement of the expander under the defect and tissue gain correlation with the markings around the defect.
When the expander is classically placed under the healthy tissue next to the defect, the final flap size developed should theoretically be at least twice the defect size for a successful reconstruction. Thus, half of the flap can be used for the coverage of the defect and the other half for the donor site.2,3 In the classic approach, total expanded surface area required for reconstruction should be better estimated as the sum of the defect and donor-site areas as well as 20% to 30% more. This additional area is necessary owing to the loss in rotation or advancement as well as dog-ear and tissue retraction.10 However, the burden of the final incision scars or the shortage in the expected actual gain of the expanded flap can be handled by a smart donor-site selection. The Alagoz technique offers to place the expander right under the desired final reconstruction site, namely, under the defect as far as the anatomic structures allow. Thus, the defect is resurfaced with the most convenient contiguous tissue. In this technique, tissue gain similar in size to the defect is sufficient for reconstruction. After removing the defect located at the top of the expander, encircling flap can easily cover the defect. Because expanded donor area simultaneously contains the defect site, in contrast to the classic concept, there is no need for larger donor-site expansion to cover both donor and defect area separately. Rotation or transposition of the flap is usually not necessary. Reconstruction can be accomplished with less flap
REFERENCES 1. Manders EK, Schenden MJ, Furrey JA, et al. Soft-tissue expansion: concepts and complications. Plast Reconstr Surg 1984;74:493–507 2. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg 1984;74:482–492 3. Neumann CG. The expansion of an area of skin by progressive distention of a subcutaneous balloon; use of the method for securing skin for subtotal reconstruction of the ear. Plast Reconstr Surg 1957;19:124–130 4. Duits EH, Molenaar J, van Rappard JH. The modeling of skin expanders. Plast Reconstr Surg 1989;83:362–367 5. Morgan RF, Edgerton MT. Tissue expansion in reconstructive hand surgery: case report. J Hand Surg Am 1985;10:754–757 6. van Rappard JH, Molenaar J, van Doorn K, et al. Surface-area increase in tissue expansion. Plast Reconstr Surg 1988;82:833–839 7. Zide BM, Karp NS. Maximizing gain from rectangular tissue expanders. Plast Reconstr Surg 1992;90:500–504 8. Bauer BS, Margulis A. The expanded transposition flap: shifting paradigms based on experience gained from two decades of pediatric tissue expansion. Plast Reconstr Surg 2004;114:98–106 9. Antonyshyn O, Gruss JS, Zuker R, et al. Tissue expansion in head and neck reconstruction. Plast Reconstr Surg 1988;82:58–68 10. Bhandari PS. Mathematical calculations in a spherical tissue expander. Ann Plast Surg 2009;62:200–204
Peripheral Facial Nerve Paralysis Triggered by Alveolar Osteitis Melek Ramoglu, DDS, PhD, Mehmet Demirkol, DDS, PhD, Mutan Hamdi Aras, DDS, PhD, and Bilal Ege, DDS, PhDy
FIGURE 2. Upper row, Scar view before expansion. Middle row, Scar view during the expansion and partial exposure of the expander. Lower row, Final scar after the expansion.
e292
Abstract: Peripheral facial nerve paralysis is the most common cranial nerve disorder; it is determined by the branches of the seventh cranial nerve and results in a characteristic facial distortion that is determined in part by the nerve branches involved. Peripheral facial nerve paralysis during dental treatment is very rare; when it does occur, it can be associated with the injection of local anesthetic, prolonged attempts to remove a mandibular third molar, and subsequent infection. Our article presents the case of a patient admitted with unilateral peripheral facial nerve paralysis occurring simultaneously with alveolar osteitis. #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Volume 26, Number 4, June 2015
Avoiding Extended Scar in Skin Expansion: Alagoz Technique Murat ahin Alago¨z, MD, Sinan O¨ksu¨z, MD,y Mustafa Keskin, MD,z Emrah Kag˘an Yas¸ar, MD, Fikret Eren, MD,y Mustafa Hasdemir, MD, and Ersin U¨lku¨r, MDy Abstract: The principal aim of skin expansion is to provide additional donor tissue without extra donor-site morbidity. Most of the reports about tissue expansion are focused on the properties of expander. Donor-site decision is usually underestimated. Here, we offer to use the defect area and surrounding healthy tissue as the donor site. In 4 cases, expanders were placed just under the defect in a fashion to extend 1 to 2 cm more laterally toward the encircling healthy tissue. The expanded tissue was not mobilized for longer distances; thus, there was no loss in flap gain. The resulting final scar was linear or crescentic. In the Alagoz technique, tissue gain similar in size to the defect is sufficient for reconstruction. The simpler the flap, the best the resulting scar. Key Words: Short scar expansion, skin expansion, subdefect expansion
Brief Clinical Studies
expander was equal or shorter than the defect to enable the resection of the extra defect length with the dog-ear resulting due to the expansion. In the Alagoz technique, actual expanded flap gain can be formulated as the difference between inflated tissue dome length and expanded defect width (Fig. 1).
Surgical Technique The expanders were placed through a short incision on the defect area perpendicular to the direction of the expansion. In 1 case, a previous incision scar on the defect, parallel to the expansion direction, was used for this purpose. On the face, a pouch over the superficial musculo-aponeurotic system was dissected for the expanders. On the temporoparietal region, the expander was located over the temporal muscle. The expanders were placed just under the defect area in a fashion to extend 1 to 2 cm more laterally under the encircling healthy tissue. Lateral extension of the expander under the defect ensures expansion of healthy tissue. The longer axes of both the rectangular expander and the defect were oriented parallel to each other. The ports were placed subcutaneously except for 1 case. Drains were kept in place up to 3 days postoperatively. The expansion was continued until the actual expanded flap gain size was similar to the initial defect width. After excising the expanded defect, encircling healthy tissue was primarily sutured.
RESULTS
T
he principal aim of skin expansion is to provide an additional donor tissue adjacent to the defect for reconstruction without extra donor-site morbidity.1 –3 Tissue expansion is closely associated with the parameters, namely, size, shape, volume, and location of the expander.4 For a better reconstruction, numerous reports are concentrated on expander properties and the flap gain or the flap mobilization techniques, but not many are focused on the location of expansion. Here, we offer to use the defect area and surrounding healthy tissue as the donor-expansion site.
MATERIALS AND METHODS Four patients were treated with the Alagoz subdefect tissue expansion technique (Table 1). The height of the expanders (MENTOR Tissue Expander) was equal or longer than the half width of the defect to provide sufficient tissue gain. Thus, defect width up to twice larger than the expanded height of the flap could be easily covered. A wider expander width (1–2 cm) than the defect was preferred, whereas the length of the From the Department of Plastic and Reconstructive Surgery, Kocaeli University Medical Faculty, Kocaeli, Turkey; yDepartment of Plastic and Reconstructive Surgery, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Istanbul, Turkey; and zDepartment of Plastic and Reconstructive Surgery, Medipol University Medical Faculty, Istanbul, Turkey. Received July 26, 2014. Accepted for publication January 20, 2015. ¨ ksu¨z, MD, Gulhane Address correspondence and reprint requests to Sinan O Askeri Tip Akademisi, Haydarpasa Egitim Hastanesi, Plastik Rekonstruktif ve Estetik Cerrahi Servisi, Tibbiye Cad. Uskudar, Istanbul, Turkey; E-mail: [email protected] The authors report no conflict of interest. Copyright # 2015 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000001591 #
2015 Mutaz B. Habal, MD
Expansion of the defect with encircling healthy skin provided enough tissue gain to resurface the defect. In 1 case with an incision parallel to expansion direction, the expander was partially exposed. Nevertheless, the expansion could be completed as intended. No infection or flap problems were encountered. Expander insertion scars could be removed through the excision of the defect. The defects were successfully resurfaced. The expanded tissue was not mobilized for longer distances; thus, there was no loss in the flap gain. The resulting final scar was linear or crescentic (Fig. 2).
DISCUSSION Pioneers in tissue expansion indicate that the base of the expander should have at least similar or larger diameter as that of the defect for reconstruction.2,5 Other reports recommend the base of the expander to be twice as large than the defect size or more.1,6 However, tissue expansion can also be associated with the height of the expander rather than the base size.4,6 The increase in expanded surface area is usually overestimated.6,7 Thus, different approaches such as using multiple expanders, modifying the transposition pattern of the expanded flap or different incision patterns increasing the mobility, and using flaps to extend the gain have been described.6,8 There is a discrepancy in the reported series about the right size and shape of the expander to be used in reconstruction.6 However, donor sites in the literature are constantly the healthy tissue regions other than the defect area.2,3,7,8 Expander location is crucial because as the distance between the donor and recipient site increases the transfer of the flap results in more scars due to rotation or transposition.6,9 When the developed flap is advanced, the resulting scar is U-shaped, and if rotated, the scar is lazy S.2 Advancement of classically expanded flap to minimize potential scarring restricts reconstructive capabilities of gained tissue, whereas transposition of flap results in more scars.8
e291
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
Brief Clinical Studies
Volume 26, Number 4, June 2015
TABLE 1. Patient Characteristics Age, y
Sex
Defect Size, cm2
Defect Location
Defect Etiology
Expander Volume, mL
Expander Shape
Complication
21 22 25 20
Male Male Female Male
25 96 63 72
Face Head Face Face
Nevus Lymphatic malformation Vascular malformation Scar
100 250 250 250
Rectangular Rectangular Rectangular Rectangular
Minimal exposition None None None
1 2 3 4
replacement. Minimum flap motion yields less flap area loss and results in less scar tissue. The simpler the flap, the best the resulting scar. In the Alagoz technique, the final suture line can be linear or crescentic. In selected cases, round expanders can be used and central defect can be closed with a purse string suture. The limitations for this technique can be the absence of skin to expand at the site of the defect and the anatomic obstacles. FIGURE 1. Schematic placement of the expander under the defect and tissue gain correlation with the markings around the defect.
When the expander is classically placed under the healthy tissue next to the defect, the final flap size developed should theoretically be at least twice the defect size for a successful reconstruction. Thus, half of the flap can be used for the coverage of the defect and the other half for the donor site.2,3 In the classic approach, total expanded surface area required for reconstruction should be better estimated as the sum of the defect and donor-site areas as well as 20% to 30% more. This additional area is necessary owing to the loss in rotation or advancement as well as dog-ear and tissue retraction.10 However, the burden of the final incision scars or the shortage in the expected actual gain of the expanded flap can be handled by a smart donor-site selection. The Alagoz technique offers to place the expander right under the desired final reconstruction site, namely, under the defect as far as the anatomic structures allow. Thus, the defect is resurfaced with the most convenient contiguous tissue. In this technique, tissue gain similar in size to the defect is sufficient for reconstruction. After removing the defect located at the top of the expander, encircling flap can easily cover the defect. Because expanded donor area simultaneously contains the defect site, in contrast to the classic concept, there is no need for larger donor-site expansion to cover both donor and defect area separately. Rotation or transposition of the flap is usually not necessary. Reconstruction can be accomplished with less flap
REFERENCES 1. Manders EK, Schenden MJ, Furrey JA, et al. Soft-tissue expansion: concepts and complications. Plast Reconstr Surg 1984;74:493–507 2. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg 1984;74:482–492 3. Neumann CG. The expansion of an area of skin by progressive distention of a subcutaneous balloon; use of the method for securing skin for subtotal reconstruction of the ear. Plast Reconstr Surg 1957;19:124–130 4. Duits EH, Molenaar J, van Rappard JH. The modeling of skin expanders. Plast Reconstr Surg 1989;83:362–367 5. Morgan RF, Edgerton MT. Tissue expansion in reconstructive hand surgery: case report. J Hand Surg Am 1985;10:754–757 6. van Rappard JH, Molenaar J, van Doorn K, et al. Surface-area increase in tissue expansion. Plast Reconstr Surg 1988;82:833–839 7. Zide BM, Karp NS. Maximizing gain from rectangular tissue expanders. Plast Reconstr Surg 1992;90:500–504 8. Bauer BS, Margulis A. The expanded transposition flap: shifting paradigms based on experience gained from two decades of pediatric tissue expansion. Plast Reconstr Surg 2004;114:98–106 9. Antonyshyn O, Gruss JS, Zuker R, et al. Tissue expansion in head and neck reconstruction. Plast Reconstr Surg 1988;82:58–68 10. Bhandari PS. Mathematical calculations in a spherical tissue expander. Ann Plast Surg 2009;62:200–204
Peripheral Facial Nerve Paralysis Triggered by Alveolar Osteitis Melek Ramoglu, DDS, PhD, Mehmet Demirkol, DDS, PhD, Mutan Hamdi Aras, DDS, PhD, and Bilal Ege, DDS, PhDy
FIGURE 2. Upper row, Scar view before expansion. Middle row, Scar view during the expansion and partial exposure of the expander. Lower row, Final scar after the expansion.
e292
Abstract: Peripheral facial nerve paralysis is the most common cranial nerve disorder; it is determined by the branches of the seventh cranial nerve and results in a characteristic facial distortion that is determined in part by the nerve branches involved. Peripheral facial nerve paralysis during dental treatment is very rare; when it does occur, it can be associated with the injection of local anesthetic, prolonged attempts to remove a mandibular third molar, and subsequent infection. Our article presents the case of a patient admitted with unilateral peripheral facial nerve paralysis occurring simultaneously with alveolar osteitis. #
2015 Mutaz B. Habal, MD
Copyright © 2015 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
