بسم الله الرحمن الرحيم

1. بسم الله الرحمن الرحيم

2. Guidelines to improve the result of tissue expansion Mohamed Osama Kotb,M.D. The department of plastic surgery, Ahmed Maher Teaching Hospital, Cairo

3. Over the past 20 years,the mechanical tissue expansion has become a versatile and dependable technique for overcoming soft tissue limitations. There is a steep learning curve in tissue expansion and the complication rate early in surgeon’s experience may be high. Most surgeons who have performed a significant number of expansions have encountered complications and have learned how to deal with them,so that few cases are aborted because of complications.

4. Aim of Work The aim of this work is to find some guidelines in the procedure of tissue expansion to improve the results and to decrease the incidence of complications.

5. Material and Methods Twenty five patients with soft tissue limitations,treated by means of tissue expansion.The sites of expander insertion were as follows: Scalp______________15 cases Neck______________2 cases Supraclavicular______1 case Anterior trunk_______3 cases

6. Posterior trunk_____1 case Upper limb________1 case Lower limb________2 cases Sixteen patients were males and 9 were females with age ranging from 4 to 30 years.The smallest expander was 80cc and the largest one was 500cc. All expander were new(Eurosilicone Company).The defect surface area ranged from 70 to 250cm2

7. The Guidelines 1-Careful patient selection *The patient must understand -Two operations are required. -The temporary deformity may be inconvenient -The process must be afforded the time required to generate the tissue necessary. -All patients should be counseled that 2 operations may be required. -The possibility of complications.

8. 2-PREOPERATIVE PLANNING * Select the most appropriate tissue for expansion in the area surrounding the defect(textures-color-hair-aesthetic units) *The choice of particular expander depends on: -The surface area of the defect. -The surface area of the expander before and after expansion. -The longest limb of the defect -The diameter of the round expander

9. Operative Technique 1-Insertion of the expander *Incision:all the expanders were inserted through marginal incision at the edge of the defect.The incision must be made in stable tissue that is expected to heal.The expander was placed 1-2 cm from the defect in the normal tissue.The space between the incision and the expander must be closed by deep sutures.

10. *Pocket:it should be adequate to accommodate the expander. *The drain:suction drain was left for 2-4 days. *External reservoirs:were used in all cases through a separate stab 6 cm from the pocket.The tunnel for the filling tube must be narrow,sufficient only to take the bore of the tube. *Closure:the closure was done in 3 layers. -The first layer by vicryl(3/0) 2cm from the incision site -The second layer by vicryl(3/0) in the subcutaneous tissue. -The third layer by prolene(3/0) in the skin.

11. Advantages of external reservoirs: -No pain during injection. -Early detection of leakage. -Free drainage of fluid around the expander. -No possibility of puncturing the expander. -No dissection of separate pocket for placement of the reservoir.

12. All the expanders were inflated to 10% of their capacity intraoperatively to help in haemostasis and avoid wrinkles. All patients received intravenous antibiotics at the time of surgery and for a period of 48 hours post operatively.

13. Time of inflation:expansion was delayed until the incision was completely healed(3-4 weeks post operative). Initial inflation was performed once weekly,increasing to twice weekly towards the last 3 weeks of expansion. The amount of fluid injected was controlled by local pain and pallor of the overlying skin. The inflation was performed using a 23 butterfly needle after the valve was wiped with alcohol prior to injection.

14. Expander removal and flap coverage: Once maximum expansion was achieved,the expander was removed and the expanded skin was transferred as an advancement flap.The capsule formed around the expander was not excised. Advancement of the flap to determine that it will replace the defect was done before the defect itself is excised.Suction drain was left.

15. RESULTS No major complications occurred in the perioperative period necessitated removal of the implant. Four delayed minor complications(16%)occurred late the course of expansion,2 implant exposure(scalp-neck) and 2 infections (scalp-supraclavicular region). Only 2 patients had partial reconstruction(8%).

25. CONCLUSION It is concluded that by careful patient selection,proper pre-operative planning and meticulous surgical technique,tissue expansion can be considered an extremely useful tool in reconstructive surgery.

26. THANK YOU