16 minute read
Tissue expansion as an option for reconstruction of craniofacial defects and alopecia area: Report of two cases
SYLVIO LUIZ COSTA DE MORAES 1,2,3 | ALEXANDRE MAURITY DE PAULA AFONSO 1,3,4 | ROBERTO GOMES DOS SANTOS 1,3 | RICARDO PEREIRA MATTOS 1,3 | MARIANA BROZOSKI 1 | JONATHAN RIBEIRO 3,5 | BRUNO GOMES DUARTE 6 | BRUNO COSTA FERREIRA 1,4
Advertisement
ABSTRACT
The repair of defects by restoring the cranial vault in some cases is difficult because of the scalps inextensible tissue, which results in the unavoidable exposure of neighboring areas, or even the material used in the reconstruction, which represents a potential risk of infection and consequent surgical losses. The purpose of this article is to describe the technique of scalp expansion as an adjuvant step for the correction of cranial vault contour and the alopecia area, associated with trauma and as a sequela of previous surgical time. We used non-customized 480ml silicone expanders (SILIMED - Comércio de Produtos Médico-Hospitalares, LTDA - Rio de Janeiro - Brazil), with external valve, on the scalp to enable correction of cranial vault and alopecia area associated with craniofacial trauma sequelae. Expansion procedures, techniques and recommendations for insertion and removal of the expander are described. The previous tissue expansion of the scalp is a feature that allows adequate recoating of the craniofacial region to be reconstructed, avoiding exposure of the biomaterial and allowing the correction of alopecia area.
Keywords: Tissue expansion. Skull. Reconstruction.
1 Hospital São Francisco na Providência de Deus, Serviço de Cirurgia e Traumatologia Bucomaxilofacial, Crânio-Maxilo-Facial e Reparadora da Face (Rio de Janeiro/RJ, Brazil). 2 Universidade Federal Fluminense, Serviço de Emergência do Hospital Universitário Antônio
Pedro (Niterói/RJ, Brazil). 3 Centro Universitário São José (UNISJ, Rio de Janeiro/RJ, Brazil). 4 Hospital Federal de Bonsucesso, Serviço de Cirurgia e Traumatologia Bucomaxilofacial (Rio de Janeiro/RJ, Brazil). 5 Centro Universitário Serra dos Órgãos, Programa de Residência em Cirurgia e Traumatologia
Bucomaxilofacial (Teresópolis/RJ, Brazil). 6 Universidade de São Paulo, Faculdade de Odontologia de Bauru, Departamento de Cirurgia,
Estomatologia, Patologia e Radiologia (Bauru/SP, Brazil).
How to cite: Moraes SLC, Afonso AMP, Santos RG, Mattos RP, Brozoski M, Ribeiro J, Duarte BG, Ferreira BC. Tissue expansion as an option for reconstruction of craniofacial defects and alopecia area: Report of two cases. J Braz Coll Oral Maxillofac Surg. 2019 Sept-Dec;5(3):56-63. DOI: https://doi.org/10.14436/2358-2782.5.3.056-063.oar
Submitted: July 17, 2018 - Revised and accepted: August 15, 2018
» The authors report no commercial, proprietary or financial interest in the products or companies described in this article.
» Patients displayed in this article previously approved the use of their facial and intraoral photo graphs.
Contact address: Sylvio Luiz Costa de Moraes Rua: Conde de Bonfim, 211, sala 213, Tijuca – Rio de Janeiro/RJ CEP: 87.140-000 – E-mail: sdmoraes@yahoo.com.br
INTRODUCTION
Patients submitted to surgical procedures that result in loss of bone tissue evolve with retraction and/or atrophy of adjacent soft tissue. 1 Thus, it is necessary to recover the extent of soft tissue in the region, to allow adequate coverage of the area to be repaired, preventing complications as exposure of biomaterial, potential risk of infection and loss of the surgical goal. 2
However, the repair of soft tissue defects represents a significant challenge for repair surgery, 3 since the reconstruction of cranial contour, in some cases, is extremely difficult, due to the limited extensibility of the scalp, leading to the need of rotation flaps, which can result in cranial exposure of surrounding areas or even of the material used for contour reconstruction. 3
Techniques as local flaps, regional or distant, or free pedicles 3,4 are described, but do not solve the issue of limited expansibility of the scalp. 3,4
The concept of tissue expansion for reconstruction of defects in the maxillofacial region was first proposed by Neuman in 1957 5,6 and later developed by Manders et al. in 1984 Radovan in 1984 and also by Van Rappard et al. in 1988. 4
The scalp expansion technique is based on gradual tissue increase by a tissue expander located between the subgaleal plane and the pericranium. 7
The expander selection depends on the area to be reconstructed, the defect size, 3,5,7 the existing “hollow effect”, and also an occasional surrounding area of alopecia, 3,4 which can be repaired by advance of the hairy area of expanded tissue, thus covering the defect after resection of the glabrous skin area (Fig. 1A, 1B, 1C).
The purpose of this paper is to describe the scalp expansion technique as a method of cranial vault contour correction and alopecia area associated with trauma, and/or as a sequel of previous surgical procedure.
A
B
C
Figure 1: A) Soft tissue retraction in the frontal region, resulting from craniofacial trauma that led to frontal bone loss. Tissue expander positioned in the occipital region to allow previous advance of scalp hair to reposition the hairline area. B) Area corresponding to the scalp loss. C) Reconstruction of the frontal region contour with biomaterial and anatomical repositioning of the hairline area, according to the characteristics of the patient’s face. D) Photograph 18 months postoperatively.
CASE REPORT Procedure for tissue expansion
The expanders used by the authors were made of silicone with 480ml volumetric capacity, reference 830-480-3 (SILIMED - Comércio de Produtos Médico-Hospitalares, LTDA - Rio de Janeiro - Brazil), stock type, which may have semi-implanted (external) or implanted valves. The authors preferred to use the external valve for ease of handling.
To use the expander, two operative times are necessary: » The first operative time aims at expander placement. Therefore, it is a unique, essential procedure. » The second operative time intends to remove the expander and also to perform cranioplasty and reconstruction of the hairy area. Therefore, it is an associated procedure.
Expander insertion technique
The initial incisions for expander placement must be performed adjacent to the area to be reconstructed, considering the flap planning to be used later.
Under general anesthesia and orotracheal intubation, two incisions are performed with conventional scalpel blade 23 (Feather Safety Razor CO., Ltd. 3-70, Ohyodo Minami 3-chome, Kita-KU, Osaka, 531-0075 – Japan). The first and second incisions should have extension corresponding to the expander width plus 1.0 cm on each side and are parallel. These parallel incisions must be distant from each other, considering the greater defect distance plus 2.0 cm in each end, 1 i.e. the distance between incisions is equal to the long axis of the defect plus four centimeters (defect in centimeters + four centimeters) (Fig 2A, 2B, 2C and 2D). If one of the incisions should be performed in the area near the hair implantation line, it should start at least 2.0 cm from the hair implantation line to prevent any noticeable and thus unesthetic scar.
The authors recommend that the expander should not be directly positioned over the resulting defect of a prior craniotomy, since the progressive expansion may cause brain compression. The expander should be placed in a remote area at least 5.0 cm lateral to the defect (Fig 3).
Between the parallel incisions previously made, detachment of the avascular region localized between the subgaleal plan and pericranium should be performed, allowing tissue dissection with lower compression without exceeding the incision limits, forming a “rectangular niche”, a “tunnel” for expander placement, as shown in Figures 2C and 2D.
Before placing the expander and accommodating it in the created niche, two maneuvers should be performed: » First: making an “underwater inflation test” using a bowl with 0.9% saline covering the expander and then inflating it with air injected from a 60ml syringe, thus determining possible defects (perforations), followed by expander deflation using the same syringe. » Second: transfixation of incisions with nylon suture 3-0 (Black Nylon Monofilament – Ethicon – Johnson & Johnson do Brazil Ind. e Com. de Prod. para a Saúde, Ltda) without completing the knot, leaving them not stressed. The sutures should be sufficiently long to allow the introduction and accommodation of expander in the created niche.
After this step, the sutures must be tied, properly occluding the incisions.
The outer valve should exit through a small incision, by “counter opening”, lateral to the expander placement region.
Then, initial injection of 5% of the total volumetric capacity 8 of the expander is made to avoid “dead spaces” and excessive compression of the suture region. 9
The authors recommend starting the expansion from the tenth day postoperatively to allow proper tissue healing, free from the action of tensile forces in the incision areas.
Due to the limited extensibility of the scalp, it is recommended to inject 5% of the total volumetric capacity of the expander daily, allowing slow and gradual tissue expansion.
The number of injections depends on the volume deemed necessary for adequate coverage of the biomaterial for contour reconstruction and/or alopecia area to be corrected.
Between fifteen and twenty days of injections are usually required to obtain the desired expansion. The initial expansion should be considered in the total count of days.
Using the external valve expander, the expansion will not depend on patient hospitalization. The expansion may be performed by the patient, relative or other health professional as instructed.
A
B
C
D
Figure 2: A) Yellow dotted line = expander width; black lines = first and second incisions, parallel to each other and 1cm longer than the expander width. B) Red dotted line = defect long axis plus 2cm on each side; black lines = first and second incisions. C) Frontal view of surgical access for expander placement. External valve observed by counter opening. D) Posterior view of surgical access for expander placement. External valve observed by counter opening. E) 24-month postoperative image.
Conversely, the internal valve expander requires strict routine antisepsis, as well as knowledge of anatomical reference, important for proper transcutaneous insertion of the syringe needle in the valve region, which may require hospitalization for patients who live in remote areas, or daily outpatient visit to perform the injection for expansion.
Expander removal technique
In the second operative time, the access is usually performed through the scar from the neurosurgical procedure performed during the initial care immediately after trauma.
The access allows expander extraction, thereby providing a scalp extension that enables wound closure without stress (Fig. 4).
Due to adherence of the pericranium to the dura mater, the authors do not recommend detachment of these structures, to prevent meningeal lesions.
Completion of reconstruction
The cranial vault contour is then reconstructed, using the biomaterial fixed by titanium microplates and microscrews and repair of possible alopecia regions.
The internal suture the scalp is performed with Vicryl 2-0 (Polyglactin 910 Suture - Ethicon - Johnson & Johnson do Brasil Ind. e Com. de Prod. para a Saúde, Ltda), and skin suture with metal sutures - staplers SW 35 (VICARE SKIN Stapler - Victor Medical Instruments CO. Ltd. Changzhou - China. Ref PDSS35G).
The use of vacuum drain with “counter opening” output with previously passed and fixed suture, and siphoning, avoids the formation of bloody collections and will be removed when the collection in 24 hours is smaller than 30 ml, which usually occurs on the second day postoperatively. At the time of drain removal, the knot is completed in the suture left in the small access to the externalization of the drain.
Expander
Cranial defect
Figure 3: Red dotted line = 5cm distance between the cranial defect and the expander; black lines = first and second incisions.
A
B
Figure 4: A) Access for expander removal and reconstruction of temporoparietal region contour. B) Detail of removed expander.
RESULTS
The cases presented in this paper involve two male patients (Fig. 1 and 2), aged 28 and 26 years, respectively.
The etiological factors were car accident (double crash) and motorcycle accident, respectively. The first patient (Fig 1) reported that he was using the safety belt at the time of the accident. The second patient (Fig 2) reported that he was not using a helmet at the time of the accident. Both patients had multiple trauma (presenting systemic trauma, such as traumatic brain injury [TBI], chest injuries, abdominal and orthopedic trauma), and required long hospital stay to recover and, after emergency care, they underwent neurosurgical procedures that resulted in craniotomy, with loss of cranial bone segment. The reason for the loss of the cranial segment is unknown.
The first patient (Fig 1) had associated facial fractures and the second patient (Fig 2) had no facial fractures yet presented a Superior Orbital Fissure Syndrome (SOFS) as a sequel of cranioencephalic trauma.
Concerning the present injuries, the first patient (Fig. 1) had frontal bone loss and extensive alopecia area, resulting from surgery that followed the initial care. The second patient (Fig 2) showed bone loss at the temporoparietal region and small area of alopecia, also due to the initial neurosurgical procedure.
Both patients underwent scalp expansion. In the first patient (Fig 1) an expander with total capacity of 500 ml was used, to which 480 ml were injected. In the second patient (Fig 2) an expander with total capacity of 480 ml was used, to which 360 ml were injected.
Concerning reconstruction, both had the bone loss areas reconstructed with custom biomaterials. In the first patient (Fig 1) an HTR®-PMI prosthesis was used (Hard Tissue Replacement Patient-matched Implant - BIOMET MICROFIXATION, 1520 Tradeport Drive Jacksonville, FL 32218 - USA), and the second patient (Fig. 2) received a castor oil polymer prosthesis (Poliquil Polímeros Químicos, Rua Pedro José Laroca, 150 / B - 5° Distrito Industrial - 14808- 300 - Araraquara - São Paulo - Brazil). The prostheses were fixed with titanium miniplates and miniscrews. In the same surgery, the expanded areas, besides fully covering the prostheses, were used to correct the alopecia areas.
DISCUSSION
Tissue expanders revolutionized reconstructive surgery, allowing correction of scars 7 and defects by flaps of the same color and texture 5,6 with better functional and esthetic results. One of the advantages of the use of expanders is the adequate defect coverage with minimal morbidity to the donor area, besides good vascularization of the flap skin.
The Cranial, Oral and Maxillofacial Surgery and Traumatology and Face Repair Service of Hospital São Francisco (HSF, Rio de Janeiro) uses tissue expansion for such cases since 2003, with encouraging results.
Cherry et al. 10 demonstrated that advanced flaps of expanded tissue last 117% longer compared with random flaps advanced from unexpanded skin.
Authors as Dos Santos Rubio et al 11 reported expansion on the frontal region, positioning the expander over the defect region, yet using a custom polymethyl methacrylate prosthesis between the expander and the brain tissue to prevent undesirable compression. The authors believe that this procedure requires a larger initial approach, which can be avoided by placing the expander laterally to the bone defect, as described in other studies. 7,8
The selection of the expander is determined by the craniofacial contour defect size. 5
The outer valves are much easier to handle; however, attention should be given to positioning of the valve outlet, avoiding areas under pressure during sleep. Proper positioning of the expander in relation to the defect area is an important step in the reconstruction technique.
The transfixion of sutures prior to expander placement brings safety to avoid the risk of accidental punctures.
The slow and gradual expansion enables painless expansion without risk of tissue suffering for the patient.
As a method limitation, the authors highlight the possible lack of understanding by the patient about the sequence of maneuvers for daily expansion, which occurs in cases of patients who are discharged and kept in outpatient control. Therefore, patients and families should have access to daily demonstration of saline injection maneuvers for expansion. The authors recommend delivering written instructions in accessible language to the patient’s family. It is noteworthy that patients with difficulty in understanding, either by neurologic or cognitive reasons, are indicated to receive the internal valve expander and maintenance of hospitalization.
Combined treatment modalities are often necessary to obtain better results in various deformities, especially in craniofacial deformities. 4 Lesions in this location are a great challenge, since they involve multiple anatomical structures, and the use of expanders is presented as an effective option for reconstruction.
FINAL CONSIDERATIONS
Tissue expansion is indicated for the treatment of multiple disorders. It is a safe and effective treatment option in cases of reconstruction of the craniofacial region, presenting a unique potential to preserve both the shape and function, preventing further scarring and decreasing the morbidity related to the need for a donor area.
The previous tissue expansion of the scalp, in cases of secondary correction of cranial vault contour defects, is a safe treatment option, allowing proper coverage of the craniofacial region to be reconstructed, avoiding biomaterial exposure and correction of alopecia areas.
References:
1.
2.
3.
4.
5. Merlino G, Carlucci S. Role of systematic scalp expansion before cranioplasty in patients with craniectomy defects. J Craniomaxillofac Surg. 2015 Oct;43(8):1416-21. Matsuno A, Tanaka H, Iwamuro H, Takanashi S, Miyawaki S, Nakashima M, et al. Analyses of the factors influencing bone graft infection after delayed cranioplasty. Acta Neurochir (Wien). 2006 May;148(5):535- 40; discussion 540. Epub 2006 Feb 9. Handschel J, Schultz S, Depprich RA, Smeets R, Sproll C, Ommerborn MA, et al. Tissue expanders for soft tissue reconstruction in the head and neck area- -requirements and limitations. Clin Oral Investig. 2013 Mar;17(2):573-8. Carloni R, Hersant B, Bosc R, Le Guerinel C, Meningaud JP. Soft tissue expansion and cranioplasty: For which indications? J Craniomaxillofac Surg. 2015 Oct;43(8):1409-15. McCarn K, Hilger PA. 3D analysis of tissue expanders. Facial Plast Surg Clin North Am. 2011 Nov;19(4):759- 65, x. 6. Lasheen AE, Saad K, Raslan M. External tissue expansion in head and neck reconstruction. J Plast Reconstr
Aesthet Surg. 2009 Aug;62(8):e251-4. 7. Mobley SR, Sjogren PP. Soft tissue trauma and scar revision. Facial Plast Surg Clin North Am. 2014
Nov;22(4):639-51. 8. Moraes SLC, Afonso AMP, Santos RGD, Mattos RP,
Duarte EBG. Reconstruction of the Cranial Vault Contour Using Tissue Expander and Castor Oil Prosthesis. Craniomaxillofac Trauma Reconstr. 2017
Sept;10(3):216-24. 9. Swenson RW. Controle da expansão do tecido na reconstrução facial. In: Baker SR. Retalhos Locais em Reconstrução Facial. 2a ed. Rio de Janeiro: DiLivros; 2009. p. 671-93. 10. Cherry GW, Austad E, Pasyk K, McClatchey K,
Rohrich RJ. Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin. Plast Reconstr Surg. 1983 Nov;72(5):680-7. 11. Santos Rubio EJ, Bos EM, Dammers R, Koudstaal MJ,
Dumans AG. Two-Stage Cranioplasty: Tissue Expansion Directly over the Craniectomy Defect Prior to Cranioplasty. Craniomaxillofac Trauma Reconstr. 2016 Nov;9(4):355-60.
