Tissue Expansion for Trunk Defects



Tissue Expansion for Trunk Defects


Ibrahim Khansa

Jeffrey E. Janis





ANATOMY



  • In the trunk, the tissues most commonly expanded for wound coverage are the skin and subcutaneous tissue.


PATHOGENESIS



  • As the skin and subcutaneous tissue are expanded, all layers get thinner, except for the epidermis, which undergoes cellular hyperplasia via mitosis.1


  • After removal of the tissue expander, all layers return to normal thickness, except the adipose layer, which permanently thins.


  • Expanded skin has improved vascularity compared to nonexpanded skin.


  • Around the tissue expander, a capsule forms, consisting of collagen and fibroblasts. The zone between the native tissue and the capsule is highly vascular.


PATIENT HISTORY AND PHYSICAL FINDINGS



  • Tissue expansion is indicated when there is a local deficiency of soft tissue coverage over a wound, with healthy tissue in the surrounding zone that is able to be expanded.


  • Ask about history of radiation, because this makes radiated tissues much more stiff and difficult to expand and increases the risk of tissue expander exposure, infection, and/or loss.


  • On physical examination, look for infection/contamination, as this increases risk of complications with tissue expansion.


  • In the lower abdominal wall, regional transfer of tissues from the anterolateral thigh may be a better option for soft tissue coverage than tissue expansion. However, in the epigastric region, those flaps may not have sufficient reach. In addition, the epigastric region often has a scarcity of soft tissue, which increases the usefulness of tissue expansion in this area.


IMAGING



  • No imaging is required specifically for tissue expansion.


SURGICAL MANAGEMENT


Preoperative Planning



  • Control contamination



    • Mupirocin nasal ointment and chlorhexidine baths for 5 days preoperatively in patients at risk for methicillinresistant Staphylococcus aureus (MRSA) or who are known MRSA carriers.



      • This protocol has been shown to reduce surgical site infections in total joint arthroplasties.2


  • Optimize the patient to lower complication rates:



    • Glucose control: Hemoglobin A1c should be ≤7.4%.3


    • Nutrition: Albumin should be 3.25 g/dL or higher, and prealbumin should be 15 mg/dL or higher.3,4


    • Obesity: BMI should be 42 or lower and preferably below 40.3


    • Tobacco usage: Patients should quit all tobacco products for 4 weeks preoperatively and 4 weeks postoperatively.3


  • Tissue expander selection



    • Choose largest tissue expander that can be placed in the pocket.


    • Length of the expander should be at least as long as the defect.


    • Crescentic and rectangular tissue expanders tend to be best suited for abdominal wall defects. Rectangular expanders tend to have the highest yield.5


    • Remote port tissue expanders are preferred.


Positioning



  • Supine with arms abducted 90 degrees, with all pressure points padded


Approach



  • The planned flap movement should be designed before tissue expansion is begun. The incision to insert a tissue expander is usually made very close to the border of the soft tissue defect. This helps minimize the amount of tissue between the leading border of the flap and the wound, which will be discarded, and provide for expansion of uninjured/unscarred tissue to transpose later directly to the defect.


Dec 6, 2019 | Posted by in Reconstructive microsurgery | Comments Off on Tissue Expansion for Trunk Defects
Premium Wordpress Themes by UFO Themes