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Tissue Expansion FAQs

Different sizes of tissue expanders.

Q: What is Tissue Expansion?
A: Tissue Expansion is a technique used to grow extra skin and soft tissue. It involves placing a deflated balloon (called a tissue expander) under normal skin next to the nevus or defect. Over 6-12 weeks, saline is injected into a small disk, called a port, which connects to the tissue expander under the skin. As the expander fills with fluid it gets bigger and bigger. The skin over it stretches and grows. This “expands” the skin. When enough skin has been made, the expander is removed and the extra skin is used to fill in the area that needs to be reconstructed.

A child with two expanders, one in the occipital scalp and one in the forehead.

Q: How is the Expander placed under the skin?
A: This is a surgical procedure.  Patients are asleep with general anesthesia. An incision is made through the skin and a section of skin and soft tissue is separated from the underlying tissues to make a pocket. In this pocket, the tissue expander is placed and then the skin is sewn back together. The tissue expander has a disk, called a port, which is connected to it by a tube. This is also placed under the skin, some distance away from the expander at a site that is easy to feel and access for injections. The port is where the saline will be injected in order to fill the balloon.

Q: Who needs tissue Expansion?
A: We use tissue expansion to reconstruct areas of skin we plan to remove. This may be a large birth mark, skin tumor or scar defect. Any lesion or defect involving skin that needs to be removed and we anticipate the amount of skin left over will not be enough to close the wound will be a candidate for tissue expansion

Q: How does it work?
A: Saline is injected into the port every week. As the expander grows, so does the skin and the soft tissue overlying the expander. A benefit of tissue expansion is that it creates skin that matches in color, texture, contour and hair to the area that needs reconstruction. Often times this has a better aesthetic outcome than a skin graft. The expanded skin also grows normally with a child.

Q: How many rounds of expansion will I need?
A: Every case is different. Sometimes a patient will need multiple expanders at one time and others may need one expander multiple times. It will depend on the lesion that needs to be removed and a little bit on how well each expansion goes. Each sequence of expander placement, expansion and surgery to reconstruct the defect with the expanded skin constitutes a “round of expansion”.

An area of expander exposure on and expanded shoulder flap.

Q: What are the possible complications?
A: 

  • Pain: After each surgery your child will experience normal surgical pain that can be easily controlled with Tylenol or Advil and occasionally something stronger. This only lasts for a few days and then they will be back to their normal, playful selves. The expansion process should not hurt. We will provide you with an anesthetic cream to place on the skin over the port before each injection. This will numb the skin so he or she will not feel the pain of the needle.
     
  • Infection: Expander infection is rare. We give oral antibiotics after the surgery for one week. If your child experiences a fever when he or she has an expander, we will also recommend antibiotics. If the skin over the expander gets red, sometimes this is just the normal blood vessel changes that go along with expanders. However, if the skin looks red and your child is sick in other ways, we have them take antibiotics as well. Rarely, an expander becomes infected and we are unable to treat it with oral antibiotics and we may need to give intravenous antibiotics in the hospital. Even in these cases we rarely need to remove the expander early. 
     
  • Exposure: there are times the skin over the expander becomes thin and the expander pushes through the skin. This is uncommon, but more frequent in patients who have had multiple rounds of expansion. When it happens we have treatment methods that will help to control the size of the exposure and may even prevent it. Usually we are still able to use the expanded skin in reconstruction. Very rarely, the open area becomes so big that the expander could fall out, this is called Extrusion.  It does not cause pain, although it can be alarming. If this happens, we wait for the skin to heal and plan to place another expander at a later date.

While none of these complications are anticipated, our team is very adept at managing them. We are happy to answer any and all questions. Even in cases where we have complications it is extremely rare that we are unable to complete our treatment plan, even if additional surgery is needed.

Will there be scars?
A: Finally, a word about scars; no surgery can be performed without scars. Our goal is to create scars that avoid tethering of the skin and restriction in movement. We aim to hide scars in areas of shadow or natural skin folds so they are less noticeable.  In almost every case, tissue expansion allows us to make better scars and have more options in their placement than if we used other techniques. For the best scar outcome we recommend scar massage. This can be started 3 weeks after surgery. Massage is done by applying firm, circular pressure along the entire scar line for 30 minutes a day broken up into shorter intervals. This should be done in increments of no less than 3 times, 10 minutes a day. There are many scar creams and gels on the market. While none are bad, none have been proven to work any better than over the counter moisturizers. We recommend Aquaphor. 

A butterfly needle is placed into the port, which is under the skin. Saline is injected through this into the expander.

The same child as pictured left after expander reconstruction and removal of her giant nevus as a pre-teen.

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