Acute Intraoperative Sustained Expansion (AISE) With or Without Fat Grafting Versus Local Flaps or Skin Grafts in Managing Facial Disfigurements

INTRODUCTION
Face is the keystone in perception of selfidentity
which has a direct involvement in social
and emotional communication, and poses a great
importance both from functional and aesthetic
point of view in a human life [1,2]. Patients suffering
from facial disfigurements usually seek the plastic
surgery clinic to restore function, comfort and
appearance. The magnitude of the problem my
varied from minimal dispersant scar to a debilitation
condition. By the time, the plastic surgeon needs
a wide verity of reconstructive tools, plenty of
techniques and multiple surgical procedures. Even
though, neither of these can be used as a single
fully satisfactory solution [3].
The main potential issue in managing these
cases is the lack of the skin with the same characteristics,
anatomical and functional features [4].
For example, limited nearby donor skin in reconstruction
of a post-burn disfigured scar may obligate
the plastic surgeon to seek a suboptimal donor
tissue as a full-thickness skin graft, local, or distant
flaps which are common practices in managing
these cases [5], as a result, incomplete color, nature
and tissue texture matching between the donor and
recipient site results in an obvious difference and
less satisfactory results in a wide variety of patients
[6].
Chronic tissue expansion had become a common
practice in plastic surgery to compensate this tissue
deficit with sound match [7]. This permits the
surgeon to achieve generation of local tissue; to
cover the cutaneous defect with a skin has the same
color, texture and characters where the face needs
this match [8]. At the same time, donor site morbidity
can be minimized, sensate and highly specialized
areas having hair or adnexal structures
can be generated by the expansion process to be
used [9,10].
Another type of expansion which was initially
pioneered by Sasaki in 1987, it was repeated cycles
of an acute intermittent expansion, it could stretch
the skin beyond its natural limit, lessened the
tension of wound closure and achieved an immediate
reconstruction [11].
In this work, we aimed to evaluate AISE as an
uncommon reconstructive tool in management of
facial disfigurements, which are requiring skin add
with or without subcutaneous volume add versus
the commonly used local flaps and grafts.
The other target of this work was to delineate
the concepts and the mechanism of action, and to
differentiate between skin dissection and skin
stretch and expansion adding role, and if providing
a suitable benefit for contour add if associated with
fat grafting g as an additional touch up in managing
associated contour defects.
PATIENTS AND METHODS
The present study was interventional study
(pre-post), included twenty-seven (n=27) patients,
(11 males and 16 females) between July 2014 and
May 2017, Patients were suffering from facial
disfigurements; post-burn scar, post traumatic scar,
post-inflammatory residual scar, residual deformity
after infantile hemangioma and post-surgical tumor
excision defects measuring (2 to 4cm) in diameter
and located on nose, cheek, temple, or forehead
skin, they were divided in in two groups.
Group A: (Expansion group) included 13 patients
(age: 17-55 years, mean 34.4), they were
treated with (AISE) by using totally 21 Foley
catheters. One to three sites of expansion were
applied in each case according to the tissue need
and the suitability of surrounding areas. Five patients
of this group were managed with additional
multi-planar subcutaneous fat injection when associated
with contour defects.
376 Vol. 42, No. 2 /Acute Intraoperative Sustained Expansion (AISE)
Group B: (Flap/Graft group): Included 14 patients
(age 19-56 years, mean 36.9), they were
managed by local random skin flaps (7 patients),
and local pedicled skin flaps (5 patients), and skin
grafts (3 patients).
After discussion of the procedures with all
patients, and obtaining detailed informed consents
from them, Pre-emptive antibiotics and general
anaesthesia were routinely applied. Regarding the
(Expansion group) patients, the operative and
mathematical parameters of AISE we have measured
and evaluated.
Operative procedure of (AISE) in group A:
For each expansion site, through 0.4cm length
incision made within the scar periphery or using
the defect itself (post lesion excision) in the face,
adequate blunt dissection by mosquito artery forceps
for 3-4cm were done. Then the silicone Foley
catheter 14-16 Fr was probed in the dissected tract
taking care to insert it with the balloon of the
catheter become completely in the tract when
inflated.
The balloon of the catheter was mildly filled
and the dimensions just when we feel the edges
of the balloon under the skin were firstly determined
by the ruler and marked on the skin, this
was considered the surface area of basic balloon
dissection or basic skin stretch (BSS). Secondly,
after emptying and removal of the balloon for the
first time, the surface area of basic relaxing skin
(BRS) was calculated from these dimensions on
the skin.
Then the dissected area undergone 4 repeated
cycles (C 1-4) of expansion with relaxing intervals
for 3 minutes in-between cycles, in each cycle the
balloon(s) of the catheter(s) synchronously were
gradually inflated with 20 cc saline then increased
until the overlying skin was blanched and waiting
for 5 minutes with expanded balloon and the dimensions
the skin of maximal catheter dissection
(MCD) were reported, then the balloon(s) were
deflated and the generated skin after expansion
(GSE) was measured. These dimensional measurements
were determined and reported for the repeated
4cycles, then by comparing (BSS) to skin of
C4 (MCD) to measure skin surface area gain by
dissection & stretch, and by comparing (BRS) to
C4 (GSE) to measure skin surface area generated
by expansion, and to calculate total skin surface
area gain by dissection, stretch & expansion. Then
the generated skin was used in wound closure,
combined with multi-planar injection of autologous
Egypt, J. Plast. Reconstr. Surg., July 2018 377
fat harvested by the conventional techniques as in
Figs. (1,2).
Operative procedure in group B:
They were managed by local flaps in (11 patients)
such as conventional forehead flap in Fig. (3), or birhomboid
flap as in Fig. (4) and full thickness skin
graft was done in (3 patients).
The data of the two groups were collected regarding
aetiology, operative time, common donor and
recipient site complications: Early and late (two
months) post-operative, tissue matching, patients'
satisfaction, incidence of the need of secondary
procedure. These determined data of both groups
were compared and analyzed.
Fig. (1): Pre (A,C,E,G) and post-operative (B,D,F,H) views of 18 years old female with previously treated infantile haemangioma
with marked fibrosis and lower lid ectropion, intraoperative views for the procedure of AISE for deficient skin and
contracture (I,J,K) associated with fat injection to correct contour irregularity.
378 Vol. 42, No. 2 /Acute Intraoperative Sustained Expansion (AISE)
Fig. (2): Intra-operative views for the procedure of AISE (A,B,C,D,E,F), Preoperative (G,I,L) and post-operative (H,K,L) views
of 15 years old female for correction perioral and cheek post burn contracture.
Fig. (3): A case of 65 years old female with nasal basal cell carcinoma. Post excision cutaneous defect (3cm x 2,5) was
reconstructed by pedicled forehead flap with grafting of the donor site. Preoperative (A), operative (B,C) and early
post-operative views (D,E) before pedicle separation and late post-operative view (F) after flap pedicle separation.
Fig. (4): A case of 61 years old man with basal cell carcinoma in the temple area, post excision cutaneous defect (3x3,5cm)
was reconstructed by bi-rhomboid flap. Preoperative (A), operative flap design and excision, flap insitting (B,C,D)
and early post-operative views (E) and late post-operative view (F) (note the distortion of hair bearing area).
A
B D
C E
F
A C E F
B D
D E F j L
i K
A B C
G H
Egypt, J. Plast. Reconstr. Surg., July 2018 379
RESULTS
Regarding the (Expansion group), the 13 patients
were treated by 21 Foley catheter expansion,
by Comparing the mean operative time between
the two groups, the expansion group (Group A)
had more lengthy operation 140 minutes versus
75 minutes when treated with local flaps or grafts
(Group B).
There were two cases of haematoma formation,
2 cases of closure under tension (one resulted in
partial wound dehiscence) and 3 cases of patient
dissatisfaction with the results. These complications
were early in study and were a motive for us to
refine the technique. However, the AISE showed
success in closure of all defects or gaining skin in
cases of contractures up to 3cm length gap or 7
cm total surface area with each expansion site
which is very precious skin in the face. Also, AISE
was aesthetically reliable if associated with fat
grafting in cases with contour defects.
Dimensional measurements were intraoperatively
reported from all managed cases by AISE
(Group A), the tissue response was obtained as
follow Fig. (5): Percentage of skin surface area
gained by dissection & stretch ranged between 8.3-
17.6% with the mean 14.2%, percentage of skin
surface area generated by expansion 10.1-19.3%
with the mean 16.5%, and Percentage of total skin
gain (total skin surface area gain by dissection,
stretch & expansion) ranged between 17.7-34.3%
with the mean 30.7%.
The most common complications in (Group B)
were donor site unsatisfactory imaging in 80% of
cases, wound dehiscence 22%, need for second procedure
28%, partial graft loss 20%, unnatural distortion
65%, poor color and texture matching to the
surrounding area 25% in local flap cases and 100%
in cases reconstructed by skin grafts, flap viability
problems 12%, additional facial scars 100% in cases
of local flaps.
DISCUSSION
It is a great challenge to achieve a good or even
accepted aesthetic outcome in patients with facial
disfigurement.
Reconstruction either by flaps; local or distant,
or by skin grafts was the common source of skin
in facial resurfacing. However, the reconstruction
by grafts usually results in undesirable results
being non-sensate, with poor color, texture and
characteristics matching [12], and it might be complicated
by partial loss or contracture. On the other
hand, flaps still have its own hazards regarding
flap viability and the necessity to do another incision
or more in the face with additional scars.
On the other hand, reconstruction by local tissue
chronic expansion was described in literatures as
having the privilege of generating a well color and
characteristics matching skin. It is also having the
advantages of obtaining a sensate skin and safer
vascularity avoiding the complications of tissue
transfer rendering it a good source of facial skin
when needed [12,17,18].
In spite of three decades of worldwide research
work in acute intraoperative immediate tissue
expansion since its first description, its use in
clinical work is still uncommon and relatively a
rare procedure beside the chronic tissue expansion
in literature all over the body. It may be due to that
many surgeons tend to stick to the common practice
[15,19.20].
The use of chronic tissue expansion is commoner
than the immediate one. However, several complications
were reported with chronic expansion
like potential infection risk which was described
by some authors as non-significant problem [18].
Many other obstacles related to the implant itself
like implant puncture, and port technical complications
should be considered. Other drawbacks
were including difficult to use in children, being
two stages procedure having long period use with
multiple follow-up clinic visits, producing soft
tissue capsule in the bed and having a prolonged
period of distortion annoying the patients. Compli-
Fig. (5): Minimum, mean and maximum percentages of acute
intraoperative sustained expansion (AISE) versus
basic relaxing skin (BRS).
100
90
80
70
60
50
40
30
20
10
0
(BRS) (L) Total skin
surface area
gain by
dissection &
stretch
(M) Total skin
surface area
generated by
expansion
(N) Total skin
surface area
gain by
dissection,
strech &
expansion
Acute intraoperative sustained expansion (AISE)
percentages versus basic relaxing skin (BRS)
Min. % Mean % Max. %
380 Vol. 42, No. 2 /Acute Intraoperative Sustained Expansion (AISE)
cations like erosion, hematoma and producing a
significant pain were also reported [18] many of
these disadvantages, could be circumvented by the
use of AISE instead.
The available expanders are designed for single
use and then must be discarded; so they are relatively
expensive prosthesis. In the other hand,
Foley catheters are disposable and inexpensive.
Also, they are of immediate use with the advantages
of absence of the complications of the prolonged
implant use [21,22,23] or capsule formation being
a completely intraoperative procedure [12].
Several authors had described the AISE technique
by using Foley catheters in managing palatal
defects ,after resection of alopecia or basal cell
carcinoma or nevi masses in lid, temple or extremities
[12,15,16]. In this study, we also used Foley
catheter in handling facial disfigurement, it was
readily accessible, suitable, and practical device
for intraoperative tissue expansion.
We agree with these notes with using Foley
catheters and reported also less bleeding during
some dissection procedures, less endangering the
anatomical facial structures when done in the
superficial subcutaneous plane and relatively rapid
rising technical curve.
As regard mechanism of action, when applying
chronic tissue expansion, the mechanism of tissue
widening includes mitotic cellular changes, thinning
of the dermis with a fibrosis around the expander
capsule [10]. On the other hand, since Sasaki's
initial report, the fundamentals of AISE are still
underestimated, Hochman et al., claimed that the
effect of minimizing wound closure tension by
AISE was primarily owing to the undermining by
implant and not the real tissue expansion itself
[13].
Raposio and Bertozzi [14] had proved statistically
significant biomechanical improvements by
examining the ex-vivo biomechanical properties
of acutely expanded skin flaps in fourteen fresh
male cadavers.
They stated that as the cutaneous tissues possess
both viscous and elastic properties, under low
stress, it behaves like an elastic material, it demonstrates
reversible immediate strain. However,
under higher stress, it behaves like a viscous material,
resulting in an increase in the skin length
as a consequence of collagen fibers straightening
and interstitial fluid displacement resulting in
irreversible expansion; by a phenomenon called
mechanical creep and stress relaxation [14].
Auletta et al., [15] reported 16-36% tissue gain
by intra-operative tissue expansion, beyond what
was achieved by undermining alone in patients
operated post Moh’s surgery in the forehead, temple
and scalp areas, he was able to close a 5cm diameter
facial skin defect. Others such as Baker and Swanson,
and Johnson et al., achieved superior results
and reported up to 31% tissue add with Intraoperative
immediate tissue expansion [16,19,20].
Regarding this work, AISE showed success to
gain up to 3cm length skin or 7cm total surface
area with each expansion site by dissection, expansion,
or both with means of 14.2%, 16.5% and
30.7% of the involved basic relaxing skin surface
area respectively. although Foley catheter is available
but the use of it is still considered by us as an
immature instrumentation and in need for more
modification to a specialized expander designed
for intraoperative immediate tissue expansion with
thick walled pressure bearing balloon, without tip
and probe supported as we hope to share in it later
on to overcome these technical difficulties.
Repeated inflation cycles in our experience
showed more expandability than the first cycle, in
agree with Johnson et al., [19], perhaps reorientation
of fiber direction of the skin layers or fiber fatigue
may be possibly the causes for further evaluation.
Also, this technique has shown another advantage
by authors of providing less bleeding and
easier dissection [19]. We agree with that concept,
however early in the study, two expansion sites
showed blood collection and discovered just postoperatively.
Later we have considered that hemostasis
should be carefully checked with superadded
moderate compressive dressing for the first 24
hours postoperatively, especially if the drain is not
preferred.
Conclusion: In selected cases, acute intraoperative
sustained expansion can be a reliable reconstructive
tool to facial disfigurements, generates
a good matched skin in single procedure and more
aesthetically reliable if associated with fat grafting
injected in multiple subcutaneous planes in the
same setting in cases with contour defects.