ORIGINAL ARTICLES IMAJ • VOL 19 • february 2017 complications of post-burn tissue expansion reconstruction: 9 years experience with 42 pediatric and 26 Adult patients Alexander Margulis MD1,2,3, Allan Billig MD1, Jhonatan Elia MD1, Yair Shachar MD1 and Neta Adler MD1,3 1Department of Plastic and Reconstructive Surgery and 2Center for Pediatric and Craniofacial Surgery, Hadassah Medical Center and 3Hadassah-Hebrew University Medical School Jerusalem, Israel For Editorial see page 119 ABSTRACT: background: Burn scar reconstruction is extremely challenging, even for the most proficient reconstructive surgeon. Within issue expansion is a recognized surgical technique used the arsenal of tools at the plastic surgeon’s disposal, tissue for reconstruction of a wide variety of skin and soft tis- expansion provides an efficient modality for reconstruction T sue conditions and defects. Since first reported in 1957 [1], despite the reported complication rates. its application has allowed plastic surgeons worldwide to objectives: To critically review our experience with tissue expa- nsion for burn scar reconstruction, comparing particularly the achieve functional and esthetic results previously unattain- adult and pediatric populations. able. However, tissue expansion is not without a myriad of Methods: We conducted a retrospective study of the outcomes associated risks, and complication rates as high as 40% in of patients who underwent burn scar reconstruction with tissue infants and children have been reported [2]. The risks for expansion at Hadassah Medical Center between January 2003 such complications have been described in numerous stud- and July 2012. The data included patient age, anatomical site ies and have been categorized by patient age, wound type, of expansion, number of procedures, and associated complica- surgeon experience, and socioeconomic class. Recent series tions. The outcomes of the above-mentioned populations were report overall complication rates ranging from 15% to 43.1% also compared with those in a control group of patients under- [3–6]. Despite the available literature on complications of tis- going reconstruction with tissue expansion for indications other sue expansion, it is difficult to interpret the data in an impar- than burn scars. tial manner, mainly because the studies are retrospective and results: Sixty-seven tissue expansion procedures were ca- because different authors have different definitions of the term rried out in patients, in the pediatric population (< 50 42 16 'complication'. years of age) and 25 in the adult population. Complications Tissue expansion in burn patients justifies a separate and were observed in 10 of the 42 pediatric procedures (23.8%) and in 3 of the 25 adult procedures (12%). This difference perhaps more specific evaluation. Burn scar tissue may extend was statistically significant. When the complication rate for far deeper than the subcutis, requiring contracture release, and each population was compared to its control group (tissue may be more prone to breakdown and ischemia if the expansion expansion for indications other than burn scar reconstruction, process is carried out too close to the burn scar. such as reconstruction for motor vehicle accident scarring, In a search of the medical literature for information on congenital nevi, or vascular malformations), no statistically tissue expansion complications, we found that most studies significant difference was found between them (complication focus either on pediatric tissue expansion alone, or describe a rates 19.8% and 12.5%, respectively). furthermore, there was combined population of pediatric and adult patients (including no statistically significant difference in complication rates breast tissue expansion). Despite the convenience of incorporat- between the different anatomical areas of expansion within ing all ages in one group, pediatric and adult patients have differ- both populations undergoing burn scar reconstruction. Most ent characteristics that may affect the outcome of tissue expan- of the complicated cases completed successful reconstruction. sion and thus should be studied separately. For example, scar Tissue expansion is a useful surgical tool in post- conclusions: formation in a child’s arm may affect the rate of limb growth. burn scar reconstruction, both in the adult and pediatric pop- Furthermore, because young children are actively developing ulations and in all anatomic sites, despite consistently high compli- cation rates, especially in the pediatric population. This compli- their sense of self-awareness, severe burns can alter a child's cation rate is not higher than that in patients undergoing tissue sense of identity and place him or her at high risk for future expansion for indications other than burn scar reconstruction. emotional and psychologic disturbances [7]. IMAJ 2017; 19: 100–104 In this study we present a critical review of our experience KEY WORDS: burn scar, tissue expansion, reconstruction, complications with tissue expansion for treatment of pediatric and adult burn- scars, and we compare the frequency and severity of complica- 100 IMAJ • VOL 19 • february 2017 ORIGINAL ARTICLES tions from different anatomic sites along with their effect on the Table 1. Indications for operation among patients with complications final reconstruction. Complications: Complications: adult procedures pediatric procedures Adult (% of total adult Pediatric (% of total pediatric PATIENTS AND METHODS Indication procedures procedures) procedures procedures) Burn scar We reviewed the medical charts and surgical reports of patients 25 3 (5.3%) 42 10 (4.9%) who underwent non-breast tissue expansion at Hadassah MVA scar 5 0 9 2 (1%) Medical Center between January 2003 and July 2012. Forty- Vascular malformation 3 1 (1.8%) 9 2 (1%) four adult and 119 pediatric patients (under 16 years of age) Tumor 3 1 (1.8%) 3 0 underwent 56 and 202 procedures, respectively. Of the 56 Scar 7 1 (1.8%) 1 0 adult and 202 pediatric tissue expander procedures, 25 and 42 Nevus 12 1 (1.8%) 135 26 (12.9%) respectively were for burn-scar reconstruction [Table 1]. The Alopecia 1 0 2 0 data collected included patient age, anatomical site of expan- Combined 0 0 1 0 sion, surgical indication, number of procedures performed, and Total presence of any complication (hematoma, exposure, infection, 56 7 (12.5%) 202 40 (19.8%) flap necrosis), and treatment regimen with either conservative MVA = motor vehicle accident management or premature expander removal. Complications were studied and analyzed using the Pearson chi-square test. sion. The time lapse between the final expansion and the second Review of the literature regarding post-burn scar recon- surgery varied, ranging from 1 week to 1 month depending on struction with tissue expansion, along with associated compli- scheduling and operating room availability. The total volume of cations, revealed an inconsistent cutoff age between children expansion ranged from 70 ml to 1000 ml. and adults [8]. Our decision to use 16 as the cutoff age between After expansion was completed and the patient was ready children and adults was made based on the classic tables of total for the second surgery, reconstruction via local expanded flaps body surface area estimation of burns by Lund and Browner was planned, with transposition flaps usually achieving more showing that only at around age 15 does the surface area of the coverage than pure advancement flaps. In serial cases when body reach that of the adult. After age 15, there are minimal more than one expansion cycle in the same anatomical area differences between body surface areas with regard to the head, was necessary, scars from the previous surgery limited our flap extremities, and torso [9]. design, and advancement flaps rather than transposition flaps were used. technIque Rectangular expanders with a soft bottom and remote injec- tion port (SoftspanTM Tissue Expander, Bauer Design, Special RESULTS Surgical Products, Victor, MT, USA) were used in all body A total of 67 tissue expansion procedures in 50 burn scar patients regions. All expanders with their accompanying remote ports were identified, 42 in the pediatric population (younger than were placed subcutaneously. The surgical incision through 16 years of age) and 25 in the adult population. Complications which the pocket was created was made parallel to the lesion [Table 1] were observed in 10 of the pediatric procedures (23.8%) or affected area. The incision was made approximately 1–2 cm and 3 of the adult procedures (12%). When the complication away from the scar and within healthy skin to minimize the rate for each population was compared with its control group risk of skin breakdown and eventual exposure of the expander. (tissue expansion for indications other than burn scar recon- At the end of surgery we inflated the expander (approximately struction, such as reconstruction for motor vehicle accident 20–30 ml of saline) through the port to check for any leaks scarring, congenital nevi, or vascular malformations), no sta- or mechanical obstruction. A surgical drain was always left in tistically significant difference was observed (23.8% vs. 19.8% place and subsequently removed when drainage volume was in pediatric and 12% vs. 12.5% in adult procedures). The com- less than 20–30 ml per day. plication rate within the pediatric burn group was significantly Starting 1–2 weeks post-surgery, expansions were performed higher than in the adult burn group (23.8% vs. 12%, P = 0.047).