Rapid Intraoperative
Tissue Closure of Facial Defects Tamara K. Ehlert, MD, J.
for
Regan Thomas, MD
\s=b\Rapid intraoperative tissue expansion (RITE) has been shown to have definite applicability to reconstruction in the head and neck. However, widespread use of this modality has yet to be adopted by the otolaryngologic community. Believing that RITE might offer some advantages in the
reconstruction of soft-tissue facial defects following Mohs micrographic surgery for cutaneous malignant neoplasms, we evaluated 30 consecutive patients referred for cosmetic reconstruction after Mohs micrographic surgery for the use of RITE. Eight patients were selected and underwent reconstruction using a total of 10 tissue expanders. Herein, we describe our experithis initial series as well as some encewith background and future applications of RITE. (Arch Otolaryngol Head Neck Surg.
1991;117:1043-1049)
local availability of sufficient skin of adequate quality is certain¬ ly one of the most critical factors in cosmetic reconstruction of facial softtissue defects. As facial plastic sur-
The
Accepted for publication February 13,1991. From The Facial Plastic Surgery Center, St Louis, Mo.
Expansion
Presented at the annual meeting ofthe American Academy of Facial Plastic and Reconstructive Surgery, New Orleans, La, September 21,1989. Reprints not available.
we are taught that the simplest procedure to repair a defect is general¬ ly the best and that adjacent tissue is superior when used as the basis of an
geons,
aesthetic reconstructive effort. To this end, primary closure is preferred over local flaps, and full-thickness skin grafts from head and neck sites are more desirable than skin from a distant source. It is also with these principles in mind that tissue expansion has come to be a valuable and well-accepted modality in reconstruction of defects in the head and neck. The routine use of conventional methods of tissue expan¬ sion, however, are associated with cer¬ tain drawbacks that make rapid intra¬ operative tissue expansion (RITE) highly desirable. Soft-tissue expansion at the time of initial repair eliminates the need for multiple surgical proce¬ dures and the cosmetic deformities in¬ herent in the use of conventional, de¬ layed tissue expansion. It also eliminates the risk of infection posed by the 6- to 8-week presence of a foreign body necessary with conven¬ tional tissue expansion. We have ob¬ served, in the course of the reconstruc¬ tion of facial defects following Mohs micrographie surgery for cutaneous malignant neoplasms, that in many in¬ stances a small amount of additional laxity or soft-tissue availability might
a good cosmetic repair to become excellent one. We, therefore, won¬ dered whether this advantage might not be gained by the use of RITE. Some historical background, our expe¬ rience with RITE, and an evaluation of
allow an
the
modality are presented herein. HISTORY
The elastic property of skin was appreciated and exploited long before any medical application of this princi¬ ple was undertaken. The expansion of lips, earlobes, and other facial struc¬ tures for the purpose of appearance enhancement has been practiced for centuries in certain Eastern cultures, and the results can be quite impressive
(National Geographic. 1956;110:257; National Geographic. 1945;88:124; and National Geographic. 1989;175:105).
Similarly, the enlarged abdomen of a
pregnant woman or the neck of a pa¬ tient suffering from a massive goiter attest to the fact that skin and subcu¬ taneous tissues are capable of expan¬
sion. Using this concept for the first time in medicine was Charles Neu¬ mann1 who, in 1956, implanted a "col¬ lapsed rubber balloon" beneath the periauricular skin of a man who had sustained a traumatic amputation of the upper portion of the ear. During the course of 2 months, Neumann ex-
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panded this skin to
1.5 times its origi¬ nal surface area and successfully used this as the basis for a two-staged re¬ construction. Despite this early re¬ port, little attention was focused on the applications of tissue expansion until Radovan23 reintroduced the con¬ cept in 1976 and began using it suc¬ cessfully in breast reconstruction. Austad and Rose4 pioneered adapta¬ tions of conventional tissue expanders, and the effects of expansion on tissue were described in detail by several investigators. Until 1984, however, most reports and most of the applica¬ tions of tissue expansion employed standard models that required two op¬ erative procedures and an inflation time ranging from 6 to 10 weeks. In the mid-1980s, Marks et al5 intro¬ duced the technique of rapid tissue expansion using a porcine model and expansion times of 5 to 8 days. They extrapolated their success in pigs to possible use in humans; however, it was the work of Sasaki6 that demon¬ strated that intraoperative tissue ex¬ pansion was a viable alternative in humans. In more than 700 cases, using multiple body sites, he demonstrated that RITE "delivers added tissue in a
safe, reliable, uncomplicated manner long-term results."
with aesthetic
PURPOSE the efficacy of RITE has shown, it has still not been widely adopted, especially among facial plas¬ tic surgeons in the otolaryngologic community. Believing that RITE might offer the facial plastic surgeon an opportunity to utilize local tissues in a safe and expedient manner, we adopted RITE in our practice for aes¬ thetic reconstruction of certain facial soft-tissue defects secondary to Mohs
Although
been
micrographie surgery.
PATIENTS AND METHODS Patients Between December 1, 1988, and May 1, 1989, eight of 30 patients referred for cos¬ metic reconstruction of facial defects follow¬ ing Mohs chemosurgery for cutaneous malig¬ nant neoplasms were selected to undergo RITE. Suitable candidates were considered to be those persons with defects that would not be amenable to primary closure, simple advancement, or local flap reconstruction without either undue tension or marked dis-
Fig 1. —Photograph showing 1.0-, 1.5-, and 5.0tortion of surrounding mobile facial units. All of the patients could have undergone recon¬ struction without the use of RITE, but it was believed that in these patients, RITE would decrease tension at the time of wound clo¬ sure. Each patient was told by the investiga¬ tor of the possible use of an intraoperative tissue expander and the purpose for it, but as this was not considered to be an experimen¬ tal treatment, specific consent for RITE was not obtained. All tissue expanders used in this study were INTRAVENT Intraoperative Tissue Expanders obtained from Cox-Uphoff Inter¬ national, Santa Barbara, Calif (Fig 1).
Operative Technique With the exception of patient 1, all proce¬ dures in which RITE was performed em¬ ployed local anesthesia, often with continu¬ ously monitored intravenous analgesia and sedation. Electrocardiography and oxygen saturation monitoring were used along with continuous administration of oxygen. After any necessary wound débridement, the planned reconstruction was outlined with a fine surgical marker. A pocket for the expan¬ der was created in the subdermal plane by sharp undermining, an appropriately sized tissue expander was then placed in the pock¬ et, and its egress was sealed either with sub¬ cutaneous sutures or manual pressure at the pocket opening. With use of a low-profile injection port, the expander was then filled with sterile saline solution until the overlying skin was seen to lightly blanch. The initial filling volume was generally one third to one half the listed volume of the expander. This saline solution was retained in the expander for 2.5 to 3 minutes and then withdrawn. A 3to 4-minute rest period then ensued to allow
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mL tissue expanders.
over the expander, and the expander was then once again filled until a blanch appeared. After another 3- to 4-minute rest period, the expander was inflated a
capillary refill
third time for 2.5 to 3 minutes. This last expansion usually allowed the full volume of the expander to be employed, and overexpansion was often possible. After the third inflation, the expander was removed from the wound. The amount of tissue gained was then measured directly, if possible, or esti¬ mated, and the planned reconstruction was performed. Patients were treated with oral antibiotics (cephalosporins) for 5 days post¬ operatively and were asked to return in 5 to 7 days for suture removal. Patients were in¬ structed to cleanse the suture lines with hy¬ drogen peroxide twice daily and to apply an antibiotic ointment immediately after. (Pa¬ tient 1 was the only exception to these in¬
structions, as a two-stage procedure was em¬ ployed.) Following reconstruction, the use of RITE was evaluated on an arbitrary 10-point scale relative to the advantage it offered, or did not offer, over conventional reconstruc¬
tive efforts.
REPORT OF CASES Patient 1. —A 62-year-old white man had squamous cell carcinoma of the nose that had been resected and treated with radio¬ therapy 1 year before reconstruction. He had a
been using a prosthesis until his primary sur¬ geon was satisfied that recurrence was un¬ likely. Due to the large size of the defect (Fig 2), a midline forehead flap was chosen for reconstruction. With the patient under gen¬ eral anesthesia, a midline musculocutaneous forehead flap was outlined and one limb was incised. A subgaleal pocket was created across the entire mid-forehead, and a 100-mL
Fig 2. —Patient 1. defect.
Preoperative oblique
view of
Fig 3. —Patient 1. Midline forehead with expander fully inflated.
flap outlined
Fig 4. —Patient 1. Forehead closure achieved without tension.
expander was placed and inflated ac¬ cording to protocol to a final volume of 100 mL (Fig 3). Following removal of the tissue expander, the remainder of the midline forehead flap was incised, the flap was raised, and recon¬ struction of the nasal defect was performed (Fig 4). By direct measurement, at least 2 cm of expanded tissue was obtained. Even though a wide midline forehead flap was re¬ quired for reconstruction of this large nasal defect, the tissue afforded by expansion was tissue
sufficient to allow closure of the forehead donor site without tension, a circumstance that could not have been achieved without expansion. There was some concern at the time of the procedure relating to the transpo¬ sition of an expanded flap to an irradiated bed, but the flap remained viable and healed without complication. The patient was seen at weekly intervals following this procedure, and at 19 days the flap was divided, allowing final-stage reconstruction and replacement of a portion of the flap to the donor site (Fig 5). Because of the large amount of tissue gained and the lack of tension on closure of the forehead donor site, RITE in this patient earned a score of 10. Patient 2.—A 51-year-old white woman had a recurrent basal cell carcinoma of the left nasal aladateral nose. One day before reconstruction, the tumor had been excised via Mohs micrographie surgery, leaving a 16 13-mm defect that extended to the perichondrium of the upper lateral cartilage of the nose. Although this was not a huge defect, re¬ construction was complicated by the fact that
Fig
5. —Patient 1. Photograph obtained 6 months postoperatively.
Fig 6. —Patient 2. Nasal defect with tissue pander in place in subcutaneous pocket.
the patient had a tiny nose with a flat nasal dorsum and very little laxity of the nasal skin. Use of a local flap was thought to be the best option for a cosmetic reconstruction; however, it was feared that excessive ten¬ sion on closure of the donor site could compli¬ cate this effort. Expansion, therefore, was performed over the nasal dorsum to the root of the nose with a 1.5-mL cylindrical expan¬ der, with a final volume on third inflation of 5
construct the defect. About 1 cm of tissue
mL(Fig6).
A cheek transposition flap was used to re-
ex¬
obtained, and closure of the flap and donor site was performed without tension (Figs 7 and 8). It was believed, following the procedure, that this reconstruction would have been quite difficult without RITE and that tension on the wound could have result¬ ed in a widened scar or wound separation. On our relative value scale, this effort was rated at 7.5. PATIENTS 3, 4, AND 5.—Patients 3, 4, and 5 all had defects of the right temple/forehead was
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8. —Patient 2. Photograph obtained 7 months postoperatively.
Fig 7. —Patient 2. Intraoperative photograph showing final wound closure.
Fig
junction extending through full-thickness skin and, in one case, the frontalis muscle. The patients ranged in age from 25 to 38 years. All tumors were basal cell carcinoma, one recurrent, excised 1 to 24 hours previ¬ ously via Mohs micrographie surgery. The defects measured 10 12-mm, 19 x I-min,
rhomboid flap without tension or eyebrow distortion. In fact, there was redundant skin at the lateral orbital margin following closure that was not resected. Patient 5, with a 19 x 17-mm defect, had considerable skin laxity, which, however, was not sufficient to effect primary closure. Thus, as in patient 4, two 1.0-mL spherical expanders were placed, one above and one below the defect, and inflated to final vol¬ umes of 3.0 and 2.8 mL (Fig 11). Closure was accomplished with a limited, superiorly based rotation flap (Fig 12). Again, this was achieved without tension on the wound or eyebrow distortion. In each of these three patients, the value of RITE was rated as 4 to 5 on our 10-point scale. There was some migration of the ex¬ panders toward the brow with the third infla¬ tion in these cases, and it was believed that if this migration could have been avoided, greater efficacy of RITE might have resulted. Patient 6. —A 66-year-old white woman had a recurrent basal cell carcinoma of the nose/lip junction excised 1 day before recon¬ struction via Mohs micrographie surgery. The resultant defect measured 35 x 25 x 10 mm and, at its deepest, extended to the peri¬ osteum of the maxilla (Fig 13). An inferiorly based nasolabial flap was chosen for recon¬ struction, with a portion of the nasal floor to be left to granulate without flap coverage. As the required flap was quite wide, RITE was employed in an attempt to decrease ten¬ sion on the wound closure following transpo¬ sition. The area of the flap was undermined, as was a portion of the adjacent cheek. A 5.0-
and 29 21 mm. Although all three patients were quite young, the laxity of skin in this area varied markedly from patient to patient, and, given the different configuration of each defect, three different reconstructions were
performed. In patient 3, with the largest defect and moderate skin laxity, the lower portion of the defect was closed primarily (Fig 9). Superior to the upper portion of the defect, a 1.5-mL cylindrical expander was placed under the area of a proposed rotation-advancement flap. Expansion was performed over three inflations to a final volume of 3 mL, and a flap of roughly the same size as would have been used without expansion was then utilized. Closure of the defect and donor site, howev¬ er, was accomplished without tension and without brow distortion (Fig 10). Patient 4, with the smallest defect, had very little skin laxity, and a rhomboid flap was selected for reconstruction. This was outlined, and two tissue expanders were placed in subcutaneous pockets—one above the defect and one below. A 1.0-mL spherical expander was placed above the defect and inflated to a final volume of 1.5 mL. A 1.5-mL cylindrical expander was placed below and inflated to a final volume of 2.2 mL. Closure of the defect was achieved with the outlined
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Fig 9. —Patient 3. Defect of forehead.
right
lateral
part of
Fig 10. —Patient 3. Intraoperative photograph showing final wound closure.
mL cylindrical expander was placed in a sub¬ cutaneous pocket overlying the malar emi¬ nence and inflated to a final volume of 7.0 mL. Reconstruction with use of the nasolabial flap was then accomplished, and the donor site was closed. In this elderly woman with skin laxity, tissue obtained by the use of RITE was difficult to assess. There was very little tension on the closure despite the use of a large flap and no distortion of the lower eye¬ lid, but the relative contribution of RITE vs aged tissue was hard to determine (Fig 14). The value of RITE in this case was rated 3.5. Two other cases in which RITE was em¬ ployed are summarized with the six de¬ scribed above in the Table. As can be seen from the comments, complications were few and minor. There were no infections in ex¬ panded wounds, contracture of expanded skin was not encountered, all flaps remained viable, and morbidity was confined to the
Patient Data Defect
Patient/
Age,
Tumor
Type
1/64
SCC
Site Nose
2/51
RBCC
Nose
3/25 4/38
y
RBCC
BCC
Expander Value
,-
Size, 60
16 X 13
mm
40
Temple
29X21
Temple
12 X 10
Site Forehead
Size, mL 100, cylindrical
Nasal dorsum
1.5,
Lateral forehead Lateral
1.5,
forehead
Temple 5/29
BCC
Temple
19 X 17
Lateral forehead
Temple
mL 100
%
Reconstruction Midline forehead
100
spherical 1.5, cylindrical 1.0, spherical 1.0,
Comments
_flap_ 5
330
Cheek
7.5
transposition flap
cylindrical cylindrical
Rating
3
200
Rotation
_advancement flap 1.5
150
Rhomboid flap
4
3.0
300
Rotation advancement flap
5
Discomfort on third inflation Partial primary closure achieved Discomfort on third inflation
Migration on
of
expanders
third inflation
_
spherical 6/66
RBCC
Upper lip,
35
25X 10
cheek,
Malar
prominence
5.0, cylindrical
7
140
Nasolabial
100
Advancement
flap
nose
7/85
RBCC
Junction
14X10
nose/
8/61
RBCC
cheek Nose
11 X 10
Buccal cheek Nasal dorsum
SCC indicates squamous cell carcinoma; RBCC, recurrent
5.0,
flap
Poor
cylindrical 5 330 5.0, Bilobed flap cylindrical basal cell carcinoma; and BCC, basal cell carcinoma.
7.5
Expansion
Fig 13. —Patient 6. defect.
11 Patient 5. Mohs' defect with upper and lower expanders In place.
Fig 12. —Patient 5. Final closure. migration of expander toward brow.
complaint by two patients of uncomfortable sensations during the third
sion have shown that epidermal thick¬ is less after expansion and that the change is almost immediate. The number of intercellular spaces is re¬ duced, and tonofibrils in the basal lami¬ na are oriented in a less undulating fashion than before expansion. More substantial, however, are the changes that take place in the dermis.
Fig
—
.
pressure
inflation.
COMMENT Histopathologic Examination of Tissue Expansion
Quantitative analyses of porcine' and human7,8 skin following tissue expan-
expansion
over
buccal fat pad on
of defect
either side
might be better
Preoperative photograph
of
Dots outline
ness
'
Fig 14. —Patient 6. Intraoperative photograph showing final closure.
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Here, the thinning is quite pro¬ nounced, with collagen fibers assuming a position parallel to the skin surface.
Skin appendages, such as hair follicles and glands, are distracted from one another but are not structurally al¬ tered and continue to function.8 Muscle thinning also occurs, but, again, active function is maintained. Only fat seems to be permanently af¬ fected. Fat layers are reduced in thick¬ ness following expansion, and fatty tissues do not seem to regrow over time. Distention of small capillaries occurs immediately on expansion, and blood flow increases to expanded tissue very rapidly.7,9 It has been hypothesized that daily expansion in a porcine model results in a hypoxic gradient between adjacent and expanded tissue that serves as a stimulus for angiogenesis. Whether this actually occurs or wheth¬ er mechanical pressure forces open ex¬ isting capillary beds to increase flow has not been resolved.9 What has been found, however, is that "rapidly" expanded flaps (two in¬ jections per week in a conventional expander) are better vascularized than are slowly expanded tissues1" and that flaps expanded over as few as 8 days survive to be greater in flap length than do flaps that are not expanded or are
delayed.5,11,12
How all of the above findings relate to rapid expansion of tissues intraoper¬ atively is uncertain. Skin creep defi¬ nitely plays an important role in the ability to harvest "extra" skin with rapid expansion. Load cycling of the skin, such as is accomplished when placing skin hooks on the edges of undermined tissue and serially pulling and relaxing the skin, causes an incre¬ mental increase in the length of the loaded skin.6,13 The viscoelasticity of skin is the reason extra length can be obtained and is based on the concept of skin creep, which is thought to be due in part to the extrusion of tissue fluid from between collagen fibers in the dermis. This extrusion allows the colla¬ gen fibers to realign in the direction of the stretching force, parallel to the skin, rather than to maintain their usual convoluted position.13 This stretching and realignment of collagen fibers alone, however, cannot
account for all of the "excess" tissue obtained with RITE. Sasaki6 has spec¬ ulated that at least three other sources
of tissue might contribute: (1) circum¬ ferential migration of skin toward the apex of the expander occurring with inflation, (2) tissue compression above and below the expander "creating" more tissue, and (3) relative dehydra¬ tion of tissue by the force of mechani¬ cal pressure pushing fluid out and "cre¬ ating" more skin.6 Biologic creep, the increase in cell mitosis and collagen synthesis seen with long-term expan¬ sion, is not thought to contribute, as RITE is too short in duration to stimu¬ late such changes.
Advantages of RITE Whatever the biologic phenomena responsible for the "creation" of excess skin with RITE, the benefits of a fast, one-stage reconstruction utilizing local tissues are manifold. First, because local tissues are used, color match is necessarily better. Similarly, because expansion allows an adequate flap with tissue available for donor site closure, more options for reconstruc¬ tion are often produced, allowing pri¬ mary closure where a flap might other¬ wise have been necessary, or use of a more
flap designed
more
would have been
aesthetically than possible without
expansion. Second, when RITE is used instead of conventional expansion, as in pa¬
tient 1, the need for an additional procedure for placement of an expan¬ der is eliminated, as are weeks of office visits for inflation and the cosmetic deformity inherent to conventional ex¬ pansion. The risk of infection caused by the prolonged presence of a subcu¬ taneous foreign body is also elim¬ inated. Third, even when the general plan for reconstruction is not changed by the use of RITE, increased availability of tissue allows decreased wound ten¬ sion at closure, with the potential for better wound healing, improved scar¬ ring, and a reduced need for later revision. Finally, RITE is relatively inexpen¬ sive compared with additional proce¬ dures and the increased morbidity found with conventional expansion, adds only 15 minutes to the operative
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procedure, is easy to use, and causes no damage to underlying or overlying muscle, vascular structures, or ner¬ vous tissue.6 Unlike rapid expansion applied to the extremities, there is also little risk of flap loss or skin necrosis due to the highly vascular nature of facial tissues.
Applications of RITE We found RITE to be especially useful when a large flap was needed from an area with relatively inelastic
tissue, such as the forehead. In this circumstance, a substantial amount of tissue was obtained immediately. Without RITE, a conventional expan¬ der would have been used, adding an¬ other procedure to the reconstructive effort and weeks of cosmetic deformity as this was slowly inflated. Conven¬ tional expansion in this circumstance is certainly acceptable and well described in the literature14 but may, at times, be unnecessary with the advent of RITE. The RITE procedure would also seem to be useful in the younger pa¬ tient with less skin redundancy or in the patient whose defect is surrounded by tight skin (case 2). Similarly, recon¬ structive efforts near areas that toler¬ ate little, if any, distortion, such as the lower eyelid, brow, upper lip, or com¬ missure, may be areas in which RITE offers just enough extra tissue for re¬ construction without placing traction on vital structures. We also found, as would be ex¬ pected, that expansion of tissue over¬ lying a bony prominence was much more successful than in areas with two distensible surfaces (buccal cheek). If expansion in the cheek is desirable, application of counterpressure intraorally might afford better results. Aside from the usefulness of RITE in closing soft-tissue facial defects sec¬ ondary to cutaneous malignant neo¬ plasms, several other applications in the head and neck may prove to be of value. Limited areas of alopecia sec¬
ondary to burns, trauma,
or
congenital
factors may be eliminated in a single operation with rapid intraoperative ex¬ pansion of adjacent scalp. Sasaki6 found, in a limited series of scalp appli¬ cations, that the average gain of tissue was 1 to 1.5 cm, which could be dou¬ bled or tripled by placing expanders on
sides of a defect. In the use of RITE in serial excision of facial scars could decrease the number of procedures necessary to obtain an optimal result. two
or more
same
fashion,
CONCLUSION
Rapid intraoperative tissue expan¬ sion offers definite advantages in se¬
lected situations
(midline forehead
flap, tight-skinned individuals, and ar-
where feature distortion is intoler¬ a relative advantage in oth¬ ers (young patients or the highly appearance-conscious older patient). It is easy to use, is economical, and is associated with almost no morbidity. Patient selection is the most important factor to be considered in the use of RITE, as it could be said to be "gilding the lily" in the inappropriate candi¬ dates. It certainly deserves more ateas
able) and
tention and investigation, especially by those of us who work in the area of facial aesthetic surgery and head and neck reconstruction. We thank
George Hruza, MD, of the Washing¬ University Division of Cutaneous Surgery, St Louis, Mo, for referring the patients described
ton
herein for reconstruction. We also thank CoxUphoff International for providing the tissue ex¬ panders used in this study.
References 1. Neumann CG. The expansion of an area of skin by progressive distention of a subcutaneous balloon. Plast Reconstr Surg. 1957;19:124-130. 2. Radovan C. Development of adjacent flaps using a temporary expander. Plast Surg Forum.
1979; 2:62.
3. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg. 1984;74:482\x=req-\ 490. 4. Austad DE, Rose GL. A self-inflating tissue expander. Plast Reconstr Surg. 1982;70:588-593. 5. Marks MW, MacKenzie JR, Burney RE, Knight PR, Anderson SH. Response of random skin flaps to rapid expansion. J Trauma.
1985;25:947-952.
6. Sasaki GH.
Intraoperative sustained limited
expansion (ISLE)
as an
immediate reconstructive
technique. Clin Plast Surg. 1975;14:563-573. 7. Argenta LC, Marks MW, Pasyk KA. Advances in tissue expansion. Clin Plastic Surg. 1985;12:159-171. 8. Pasyk KA, Argenta LC, Austad ED. Histopathology of human expanded skin. Clin Plast Surg. 1987;14:435-445.
9. Marks MW, Burney RE, Mackenzie JR, Knight PR. Enhanced capillary blood flow in rapidly expanded random pattern flaps. J Trauma.
1986;26:913-915.
MW, Argenta LC, Thornton JW. Rapid expansion: experimental and clinical experience. Clin Plast Surg. 1987;14:445-463. 11. Marks MW, MacKenzie JR, Burney RE, 10. Marks
Knight PR, Anderson SH. Response of random flaps to rapid expansion. J Trauma.
skin
1985;25:947-952.
12. 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.
constr Surg.
1986;7:316-319.
13. Hirshowitz B, Kaufman T, Ullman J. Reconstruction of the tip of the nose by load cycling of the nasal skin and harnessing of extra skin. Plast Re14. Kroll SS. Forehead flap nasal reconstruction with tissue expansion and delayed pedicle separation. Laryngoscope. 1989;99:448-452.
Editorial Footnote The authors describe a new technique that are finding to be useful in solving clinical problems. They point out that RITE does not actually provide a means for closing defects that could not otherwise be repaired but that it does allow this to be accomplished more simply, more aesthetically, and with decreased wound tension. One reviewer con¬ tended that there was no proof that the exsurgeons
panded skin stays expanded with RITE. The authors responded that the fact that these repairs did not break down, produce widened or otherwise contract and result in cosmetic deformity would lead one to con¬ clude that it does stay expanded long enough and with sufficient size to accomplish the desired goal. This report was extensively reviewed after its initial receipt. Publication
scars,
delayed for revision, and, at one point, the authors mistook our request for revision to be a rejection notice. In any event, the report is now presented for your review, analysis, and interpretation. was
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ByronJ.
Bailey, MD Galveston, Tex
Tissue Closure of Facial Defects Tamara K. Ehlert, MD, J.
for
Regan Thomas, MD
\s=b\Rapid intraoperative tissue expansion (RITE) has been shown to have definite applicability to reconstruction in the head and neck. However, widespread use of this modality has yet to be adopted by the otolaryngologic community. Believing that RITE might offer some advantages in the
reconstruction of soft-tissue facial defects following Mohs micrographic surgery for cutaneous malignant neoplasms, we evaluated 30 consecutive patients referred for cosmetic reconstruction after Mohs micrographic surgery for the use of RITE. Eight patients were selected and underwent reconstruction using a total of 10 tissue expanders. Herein, we describe our experithis initial series as well as some encewith background and future applications of RITE. (Arch Otolaryngol Head Neck Surg.
1991;117:1043-1049)
local availability of sufficient skin of adequate quality is certain¬ ly one of the most critical factors in cosmetic reconstruction of facial softtissue defects. As facial plastic sur-
The
Accepted for publication February 13,1991. From The Facial Plastic Surgery Center, St Louis, Mo.
Expansion
Presented at the annual meeting ofthe American Academy of Facial Plastic and Reconstructive Surgery, New Orleans, La, September 21,1989. Reprints not available.
we are taught that the simplest procedure to repair a defect is general¬ ly the best and that adjacent tissue is superior when used as the basis of an
geons,
aesthetic reconstructive effort. To this end, primary closure is preferred over local flaps, and full-thickness skin grafts from head and neck sites are more desirable than skin from a distant source. It is also with these principles in mind that tissue expansion has come to be a valuable and well-accepted modality in reconstruction of defects in the head and neck. The routine use of conventional methods of tissue expan¬ sion, however, are associated with cer¬ tain drawbacks that make rapid intra¬ operative tissue expansion (RITE) highly desirable. Soft-tissue expansion at the time of initial repair eliminates the need for multiple surgical proce¬ dures and the cosmetic deformities in¬ herent in the use of conventional, de¬ layed tissue expansion. It also eliminates the risk of infection posed by the 6- to 8-week presence of a foreign body necessary with conven¬ tional tissue expansion. We have ob¬ served, in the course of the reconstruc¬ tion of facial defects following Mohs micrographie surgery for cutaneous malignant neoplasms, that in many in¬ stances a small amount of additional laxity or soft-tissue availability might
a good cosmetic repair to become excellent one. We, therefore, won¬ dered whether this advantage might not be gained by the use of RITE. Some historical background, our expe¬ rience with RITE, and an evaluation of
allow an
the
modality are presented herein. HISTORY
The elastic property of skin was appreciated and exploited long before any medical application of this princi¬ ple was undertaken. The expansion of lips, earlobes, and other facial struc¬ tures for the purpose of appearance enhancement has been practiced for centuries in certain Eastern cultures, and the results can be quite impressive
(National Geographic. 1956;110:257; National Geographic. 1945;88:124; and National Geographic. 1989;175:105).
Similarly, the enlarged abdomen of a
pregnant woman or the neck of a pa¬ tient suffering from a massive goiter attest to the fact that skin and subcu¬ taneous tissues are capable of expan¬
sion. Using this concept for the first time in medicine was Charles Neu¬ mann1 who, in 1956, implanted a "col¬ lapsed rubber balloon" beneath the periauricular skin of a man who had sustained a traumatic amputation of the upper portion of the ear. During the course of 2 months, Neumann ex-
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panded this skin to
1.5 times its origi¬ nal surface area and successfully used this as the basis for a two-staged re¬ construction. Despite this early re¬ port, little attention was focused on the applications of tissue expansion until Radovan23 reintroduced the con¬ cept in 1976 and began using it suc¬ cessfully in breast reconstruction. Austad and Rose4 pioneered adapta¬ tions of conventional tissue expanders, and the effects of expansion on tissue were described in detail by several investigators. Until 1984, however, most reports and most of the applica¬ tions of tissue expansion employed standard models that required two op¬ erative procedures and an inflation time ranging from 6 to 10 weeks. In the mid-1980s, Marks et al5 intro¬ duced the technique of rapid tissue expansion using a porcine model and expansion times of 5 to 8 days. They extrapolated their success in pigs to possible use in humans; however, it was the work of Sasaki6 that demon¬ strated that intraoperative tissue ex¬ pansion was a viable alternative in humans. In more than 700 cases, using multiple body sites, he demonstrated that RITE "delivers added tissue in a
safe, reliable, uncomplicated manner long-term results."
with aesthetic
PURPOSE the efficacy of RITE has shown, it has still not been widely adopted, especially among facial plas¬ tic surgeons in the otolaryngologic community. Believing that RITE might offer the facial plastic surgeon an opportunity to utilize local tissues in a safe and expedient manner, we adopted RITE in our practice for aes¬ thetic reconstruction of certain facial soft-tissue defects secondary to Mohs
Although
been
micrographie surgery.
PATIENTS AND METHODS Patients Between December 1, 1988, and May 1, 1989, eight of 30 patients referred for cos¬ metic reconstruction of facial defects follow¬ ing Mohs chemosurgery for cutaneous malig¬ nant neoplasms were selected to undergo RITE. Suitable candidates were considered to be those persons with defects that would not be amenable to primary closure, simple advancement, or local flap reconstruction without either undue tension or marked dis-
Fig 1. —Photograph showing 1.0-, 1.5-, and 5.0tortion of surrounding mobile facial units. All of the patients could have undergone recon¬ struction without the use of RITE, but it was believed that in these patients, RITE would decrease tension at the time of wound clo¬ sure. Each patient was told by the investiga¬ tor of the possible use of an intraoperative tissue expander and the purpose for it, but as this was not considered to be an experimen¬ tal treatment, specific consent for RITE was not obtained. All tissue expanders used in this study were INTRAVENT Intraoperative Tissue Expanders obtained from Cox-Uphoff Inter¬ national, Santa Barbara, Calif (Fig 1).
Operative Technique With the exception of patient 1, all proce¬ dures in which RITE was performed em¬ ployed local anesthesia, often with continu¬ ously monitored intravenous analgesia and sedation. Electrocardiography and oxygen saturation monitoring were used along with continuous administration of oxygen. After any necessary wound débridement, the planned reconstruction was outlined with a fine surgical marker. A pocket for the expan¬ der was created in the subdermal plane by sharp undermining, an appropriately sized tissue expander was then placed in the pock¬ et, and its egress was sealed either with sub¬ cutaneous sutures or manual pressure at the pocket opening. With use of a low-profile injection port, the expander was then filled with sterile saline solution until the overlying skin was seen to lightly blanch. The initial filling volume was generally one third to one half the listed volume of the expander. This saline solution was retained in the expander for 2.5 to 3 minutes and then withdrawn. A 3to 4-minute rest period then ensued to allow
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mL tissue expanders.
over the expander, and the expander was then once again filled until a blanch appeared. After another 3- to 4-minute rest period, the expander was inflated a
capillary refill
third time for 2.5 to 3 minutes. This last expansion usually allowed the full volume of the expander to be employed, and overexpansion was often possible. After the third inflation, the expander was removed from the wound. The amount of tissue gained was then measured directly, if possible, or esti¬ mated, and the planned reconstruction was performed. Patients were treated with oral antibiotics (cephalosporins) for 5 days post¬ operatively and were asked to return in 5 to 7 days for suture removal. Patients were in¬ structed to cleanse the suture lines with hy¬ drogen peroxide twice daily and to apply an antibiotic ointment immediately after. (Pa¬ tient 1 was the only exception to these in¬
structions, as a two-stage procedure was em¬ ployed.) Following reconstruction, the use of RITE was evaluated on an arbitrary 10-point scale relative to the advantage it offered, or did not offer, over conventional reconstruc¬
tive efforts.
REPORT OF CASES Patient 1. —A 62-year-old white man had squamous cell carcinoma of the nose that had been resected and treated with radio¬ therapy 1 year before reconstruction. He had a
been using a prosthesis until his primary sur¬ geon was satisfied that recurrence was un¬ likely. Due to the large size of the defect (Fig 2), a midline forehead flap was chosen for reconstruction. With the patient under gen¬ eral anesthesia, a midline musculocutaneous forehead flap was outlined and one limb was incised. A subgaleal pocket was created across the entire mid-forehead, and a 100-mL
Fig 2. —Patient 1. defect.
Preoperative oblique
view of
Fig 3. —Patient 1. Midline forehead with expander fully inflated.
flap outlined
Fig 4. —Patient 1. Forehead closure achieved without tension.
expander was placed and inflated ac¬ cording to protocol to a final volume of 100 mL (Fig 3). Following removal of the tissue expander, the remainder of the midline forehead flap was incised, the flap was raised, and recon¬ struction of the nasal defect was performed (Fig 4). By direct measurement, at least 2 cm of expanded tissue was obtained. Even though a wide midline forehead flap was re¬ quired for reconstruction of this large nasal defect, the tissue afforded by expansion was tissue
sufficient to allow closure of the forehead donor site without tension, a circumstance that could not have been achieved without expansion. There was some concern at the time of the procedure relating to the transpo¬ sition of an expanded flap to an irradiated bed, but the flap remained viable and healed without complication. The patient was seen at weekly intervals following this procedure, and at 19 days the flap was divided, allowing final-stage reconstruction and replacement of a portion of the flap to the donor site (Fig 5). Because of the large amount of tissue gained and the lack of tension on closure of the forehead donor site, RITE in this patient earned a score of 10. Patient 2.—A 51-year-old white woman had a recurrent basal cell carcinoma of the left nasal aladateral nose. One day before reconstruction, the tumor had been excised via Mohs micrographie surgery, leaving a 16 13-mm defect that extended to the perichondrium of the upper lateral cartilage of the nose. Although this was not a huge defect, re¬ construction was complicated by the fact that
Fig
5. —Patient 1. Photograph obtained 6 months postoperatively.
Fig 6. —Patient 2. Nasal defect with tissue pander in place in subcutaneous pocket.
the patient had a tiny nose with a flat nasal dorsum and very little laxity of the nasal skin. Use of a local flap was thought to be the best option for a cosmetic reconstruction; however, it was feared that excessive ten¬ sion on closure of the donor site could compli¬ cate this effort. Expansion, therefore, was performed over the nasal dorsum to the root of the nose with a 1.5-mL cylindrical expan¬ der, with a final volume on third inflation of 5
construct the defect. About 1 cm of tissue
mL(Fig6).
A cheek transposition flap was used to re-
ex¬
obtained, and closure of the flap and donor site was performed without tension (Figs 7 and 8). It was believed, following the procedure, that this reconstruction would have been quite difficult without RITE and that tension on the wound could have result¬ ed in a widened scar or wound separation. On our relative value scale, this effort was rated at 7.5. PATIENTS 3, 4, AND 5.—Patients 3, 4, and 5 all had defects of the right temple/forehead was
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8. —Patient 2. Photograph obtained 7 months postoperatively.
Fig 7. —Patient 2. Intraoperative photograph showing final wound closure.
Fig
junction extending through full-thickness skin and, in one case, the frontalis muscle. The patients ranged in age from 25 to 38 years. All tumors were basal cell carcinoma, one recurrent, excised 1 to 24 hours previ¬ ously via Mohs micrographie surgery. The defects measured 10 12-mm, 19 x I-min,
rhomboid flap without tension or eyebrow distortion. In fact, there was redundant skin at the lateral orbital margin following closure that was not resected. Patient 5, with a 19 x 17-mm defect, had considerable skin laxity, which, however, was not sufficient to effect primary closure. Thus, as in patient 4, two 1.0-mL spherical expanders were placed, one above and one below the defect, and inflated to final vol¬ umes of 3.0 and 2.8 mL (Fig 11). Closure was accomplished with a limited, superiorly based rotation flap (Fig 12). Again, this was achieved without tension on the wound or eyebrow distortion. In each of these three patients, the value of RITE was rated as 4 to 5 on our 10-point scale. There was some migration of the ex¬ panders toward the brow with the third infla¬ tion in these cases, and it was believed that if this migration could have been avoided, greater efficacy of RITE might have resulted. Patient 6. —A 66-year-old white woman had a recurrent basal cell carcinoma of the nose/lip junction excised 1 day before recon¬ struction via Mohs micrographie surgery. The resultant defect measured 35 x 25 x 10 mm and, at its deepest, extended to the peri¬ osteum of the maxilla (Fig 13). An inferiorly based nasolabial flap was chosen for recon¬ struction, with a portion of the nasal floor to be left to granulate without flap coverage. As the required flap was quite wide, RITE was employed in an attempt to decrease ten¬ sion on the wound closure following transpo¬ sition. The area of the flap was undermined, as was a portion of the adjacent cheek. A 5.0-
and 29 21 mm. Although all three patients were quite young, the laxity of skin in this area varied markedly from patient to patient, and, given the different configuration of each defect, three different reconstructions were
performed. In patient 3, with the largest defect and moderate skin laxity, the lower portion of the defect was closed primarily (Fig 9). Superior to the upper portion of the defect, a 1.5-mL cylindrical expander was placed under the area of a proposed rotation-advancement flap. Expansion was performed over three inflations to a final volume of 3 mL, and a flap of roughly the same size as would have been used without expansion was then utilized. Closure of the defect and donor site, howev¬ er, was accomplished without tension and without brow distortion (Fig 10). Patient 4, with the smallest defect, had very little skin laxity, and a rhomboid flap was selected for reconstruction. This was outlined, and two tissue expanders were placed in subcutaneous pockets—one above the defect and one below. A 1.0-mL spherical expander was placed above the defect and inflated to a final volume of 1.5 mL. A 1.5-mL cylindrical expander was placed below and inflated to a final volume of 2.2 mL. Closure of the defect was achieved with the outlined
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Fig 9. —Patient 3. Defect of forehead.
right
lateral
part of
Fig 10. —Patient 3. Intraoperative photograph showing final wound closure.
mL cylindrical expander was placed in a sub¬ cutaneous pocket overlying the malar emi¬ nence and inflated to a final volume of 7.0 mL. Reconstruction with use of the nasolabial flap was then accomplished, and the donor site was closed. In this elderly woman with skin laxity, tissue obtained by the use of RITE was difficult to assess. There was very little tension on the closure despite the use of a large flap and no distortion of the lower eye¬ lid, but the relative contribution of RITE vs aged tissue was hard to determine (Fig 14). The value of RITE in this case was rated 3.5. Two other cases in which RITE was em¬ ployed are summarized with the six de¬ scribed above in the Table. As can be seen from the comments, complications were few and minor. There were no infections in ex¬ panded wounds, contracture of expanded skin was not encountered, all flaps remained viable, and morbidity was confined to the
Patient Data Defect
Patient/
Age,
Tumor
Type
1/64
SCC
Site Nose
2/51
RBCC
Nose
3/25 4/38
y
RBCC
BCC
Expander Value
,-
Size, 60
16 X 13
mm
40
Temple
29X21
Temple
12 X 10
Site Forehead
Size, mL 100, cylindrical
Nasal dorsum
1.5,
Lateral forehead Lateral
1.5,
forehead
Temple 5/29
BCC
Temple
19 X 17
Lateral forehead
Temple
mL 100
%
Reconstruction Midline forehead
100
spherical 1.5, cylindrical 1.0, spherical 1.0,
Comments
_flap_ 5
330
Cheek
7.5
transposition flap
cylindrical cylindrical
Rating
3
200
Rotation
_advancement flap 1.5
150
Rhomboid flap
4
3.0
300
Rotation advancement flap
5
Discomfort on third inflation Partial primary closure achieved Discomfort on third inflation
Migration on
of
expanders
third inflation
_
spherical 6/66
RBCC
Upper lip,
35
25X 10
cheek,
Malar
prominence
5.0, cylindrical
7
140
Nasolabial
100
Advancement
flap
nose
7/85
RBCC
Junction
14X10
nose/
8/61
RBCC
cheek Nose
11 X 10
Buccal cheek Nasal dorsum
SCC indicates squamous cell carcinoma; RBCC, recurrent
5.0,
flap
Poor
cylindrical 5 330 5.0, Bilobed flap cylindrical basal cell carcinoma; and BCC, basal cell carcinoma.
7.5
Expansion
Fig 13. —Patient 6. defect.
11 Patient 5. Mohs' defect with upper and lower expanders In place.
Fig 12. —Patient 5. Final closure. migration of expander toward brow.
complaint by two patients of uncomfortable sensations during the third
sion have shown that epidermal thick¬ is less after expansion and that the change is almost immediate. The number of intercellular spaces is re¬ duced, and tonofibrils in the basal lami¬ na are oriented in a less undulating fashion than before expansion. More substantial, however, are the changes that take place in the dermis.
Fig
—
.
pressure
inflation.
COMMENT Histopathologic Examination of Tissue Expansion
Quantitative analyses of porcine' and human7,8 skin following tissue expan-
expansion
over
buccal fat pad on
of defect
either side
might be better
Preoperative photograph
of
Dots outline
ness
'
Fig 14. —Patient 6. Intraoperative photograph showing final closure.
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Here, the thinning is quite pro¬ nounced, with collagen fibers assuming a position parallel to the skin surface.
Skin appendages, such as hair follicles and glands, are distracted from one another but are not structurally al¬ tered and continue to function.8 Muscle thinning also occurs, but, again, active function is maintained. Only fat seems to be permanently af¬ fected. Fat layers are reduced in thick¬ ness following expansion, and fatty tissues do not seem to regrow over time. Distention of small capillaries occurs immediately on expansion, and blood flow increases to expanded tissue very rapidly.7,9 It has been hypothesized that daily expansion in a porcine model results in a hypoxic gradient between adjacent and expanded tissue that serves as a stimulus for angiogenesis. Whether this actually occurs or wheth¬ er mechanical pressure forces open ex¬ isting capillary beds to increase flow has not been resolved.9 What has been found, however, is that "rapidly" expanded flaps (two in¬ jections per week in a conventional expander) are better vascularized than are slowly expanded tissues1" and that flaps expanded over as few as 8 days survive to be greater in flap length than do flaps that are not expanded or are
delayed.5,11,12
How all of the above findings relate to rapid expansion of tissues intraoper¬ atively is uncertain. Skin creep defi¬ nitely plays an important role in the ability to harvest "extra" skin with rapid expansion. Load cycling of the skin, such as is accomplished when placing skin hooks on the edges of undermined tissue and serially pulling and relaxing the skin, causes an incre¬ mental increase in the length of the loaded skin.6,13 The viscoelasticity of skin is the reason extra length can be obtained and is based on the concept of skin creep, which is thought to be due in part to the extrusion of tissue fluid from between collagen fibers in the dermis. This extrusion allows the colla¬ gen fibers to realign in the direction of the stretching force, parallel to the skin, rather than to maintain their usual convoluted position.13 This stretching and realignment of collagen fibers alone, however, cannot
account for all of the "excess" tissue obtained with RITE. Sasaki6 has spec¬ ulated that at least three other sources
of tissue might contribute: (1) circum¬ ferential migration of skin toward the apex of the expander occurring with inflation, (2) tissue compression above and below the expander "creating" more tissue, and (3) relative dehydra¬ tion of tissue by the force of mechani¬ cal pressure pushing fluid out and "cre¬ ating" more skin.6 Biologic creep, the increase in cell mitosis and collagen synthesis seen with long-term expan¬ sion, is not thought to contribute, as RITE is too short in duration to stimu¬ late such changes.
Advantages of RITE Whatever the biologic phenomena responsible for the "creation" of excess skin with RITE, the benefits of a fast, one-stage reconstruction utilizing local tissues are manifold. First, because local tissues are used, color match is necessarily better. Similarly, because expansion allows an adequate flap with tissue available for donor site closure, more options for reconstruc¬ tion are often produced, allowing pri¬ mary closure where a flap might other¬ wise have been necessary, or use of a more
flap designed
more
would have been
aesthetically than possible without
expansion. Second, when RITE is used instead of conventional expansion, as in pa¬
tient 1, the need for an additional procedure for placement of an expan¬ der is eliminated, as are weeks of office visits for inflation and the cosmetic deformity inherent to conventional ex¬ pansion. The risk of infection caused by the prolonged presence of a subcu¬ taneous foreign body is also elim¬ inated. Third, even when the general plan for reconstruction is not changed by the use of RITE, increased availability of tissue allows decreased wound ten¬ sion at closure, with the potential for better wound healing, improved scar¬ ring, and a reduced need for later revision. Finally, RITE is relatively inexpen¬ sive compared with additional proce¬ dures and the increased morbidity found with conventional expansion, adds only 15 minutes to the operative
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procedure, is easy to use, and causes no damage to underlying or overlying muscle, vascular structures, or ner¬ vous tissue.6 Unlike rapid expansion applied to the extremities, there is also little risk of flap loss or skin necrosis due to the highly vascular nature of facial tissues.
Applications of RITE We found RITE to be especially useful when a large flap was needed from an area with relatively inelastic
tissue, such as the forehead. In this circumstance, a substantial amount of tissue was obtained immediately. Without RITE, a conventional expan¬ der would have been used, adding an¬ other procedure to the reconstructive effort and weeks of cosmetic deformity as this was slowly inflated. Conven¬ tional expansion in this circumstance is certainly acceptable and well described in the literature14 but may, at times, be unnecessary with the advent of RITE. The RITE procedure would also seem to be useful in the younger pa¬ tient with less skin redundancy or in the patient whose defect is surrounded by tight skin (case 2). Similarly, recon¬ structive efforts near areas that toler¬ ate little, if any, distortion, such as the lower eyelid, brow, upper lip, or com¬ missure, may be areas in which RITE offers just enough extra tissue for re¬ construction without placing traction on vital structures. We also found, as would be ex¬ pected, that expansion of tissue over¬ lying a bony prominence was much more successful than in areas with two distensible surfaces (buccal cheek). If expansion in the cheek is desirable, application of counterpressure intraorally might afford better results. Aside from the usefulness of RITE in closing soft-tissue facial defects sec¬ ondary to cutaneous malignant neo¬ plasms, several other applications in the head and neck may prove to be of value. Limited areas of alopecia sec¬
ondary to burns, trauma,
or
congenital
factors may be eliminated in a single operation with rapid intraoperative ex¬ pansion of adjacent scalp. Sasaki6 found, in a limited series of scalp appli¬ cations, that the average gain of tissue was 1 to 1.5 cm, which could be dou¬ bled or tripled by placing expanders on
sides of a defect. In the use of RITE in serial excision of facial scars could decrease the number of procedures necessary to obtain an optimal result. two
or more
same
fashion,
CONCLUSION
Rapid intraoperative tissue expan¬ sion offers definite advantages in se¬
lected situations
(midline forehead
flap, tight-skinned individuals, and ar-
where feature distortion is intoler¬ a relative advantage in oth¬ ers (young patients or the highly appearance-conscious older patient). It is easy to use, is economical, and is associated with almost no morbidity. Patient selection is the most important factor to be considered in the use of RITE, as it could be said to be "gilding the lily" in the inappropriate candi¬ dates. It certainly deserves more ateas
able) and
tention and investigation, especially by those of us who work in the area of facial aesthetic surgery and head and neck reconstruction. We thank
George Hruza, MD, of the Washing¬ University Division of Cutaneous Surgery, St Louis, Mo, for referring the patients described
ton
herein for reconstruction. We also thank CoxUphoff International for providing the tissue ex¬ panders used in this study.
References 1. Neumann CG. The expansion of an area of skin by progressive distention of a subcutaneous balloon. Plast Reconstr Surg. 1957;19:124-130. 2. Radovan C. Development of adjacent flaps using a temporary expander. Plast Surg Forum.
1979; 2:62.
3. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg. 1984;74:482\x=req-\ 490. 4. Austad DE, Rose GL. A self-inflating tissue expander. Plast Reconstr Surg. 1982;70:588-593. 5. Marks MW, MacKenzie JR, Burney RE, Knight PR, Anderson SH. Response of random skin flaps to rapid expansion. J Trauma.
1985;25:947-952.
6. Sasaki GH.
Intraoperative sustained limited
expansion (ISLE)
as an
immediate reconstructive
technique. Clin Plast Surg. 1975;14:563-573. 7. Argenta LC, Marks MW, Pasyk KA. Advances in tissue expansion. Clin Plastic Surg. 1985;12:159-171. 8. Pasyk KA, Argenta LC, Austad ED. Histopathology of human expanded skin. Clin Plast Surg. 1987;14:435-445.
9. Marks MW, Burney RE, Mackenzie JR, Knight PR. Enhanced capillary blood flow in rapidly expanded random pattern flaps. J Trauma.
1986;26:913-915.
MW, Argenta LC, Thornton JW. Rapid expansion: experimental and clinical experience. Clin Plast Surg. 1987;14:445-463. 11. Marks MW, MacKenzie JR, Burney RE, 10. Marks
Knight PR, Anderson SH. Response of random flaps to rapid expansion. J Trauma.
skin
1985;25:947-952.
12. 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.
constr Surg.
1986;7:316-319.
13. Hirshowitz B, Kaufman T, Ullman J. Reconstruction of the tip of the nose by load cycling of the nasal skin and harnessing of extra skin. Plast Re14. Kroll SS. Forehead flap nasal reconstruction with tissue expansion and delayed pedicle separation. Laryngoscope. 1989;99:448-452.
Editorial Footnote The authors describe a new technique that are finding to be useful in solving clinical problems. They point out that RITE does not actually provide a means for closing defects that could not otherwise be repaired but that it does allow this to be accomplished more simply, more aesthetically, and with decreased wound tension. One reviewer con¬ tended that there was no proof that the exsurgeons
panded skin stays expanded with RITE. The authors responded that the fact that these repairs did not break down, produce widened or otherwise contract and result in cosmetic deformity would lead one to con¬ clude that it does stay expanded long enough and with sufficient size to accomplish the desired goal. This report was extensively reviewed after its initial receipt. Publication
scars,
delayed for revision, and, at one point, the authors mistook our request for revision to be a rejection notice. In any event, the report is now presented for your review, analysis, and interpretation. was
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ByronJ.
Bailey, MD Galveston, Tex
