Swgery(1991), 44,4143 0 1991 The Trustees of British Association of Plastic Surgeons
BrititishJournalofPlmtic
_ _I
Pain and forehead expansion R. P. Cole, D. T. Gault, B. J. Mayou and P. K. B. Davis Department ofPlastic Surgery, St Thomas’ Hospital, London SUMMARY. Tissue expansion of the forehead by intermittent holus injection in three patients was noted to be extremely painful. This stimulated a prospective study in four patients whose discomfort was found to be related to a sharp rise in brtraluminal pressure after bolus inflation. Tolerable infusion volumes were small (mean 6.25 cc) and associated with high pain scores (mean 7/10). Adequate expansion was protracted (mean 4% days) and was limited by pain. To eliminate the sharp rises in pressure associated with expansion by bolus b+ztion, a syringe pump was used in two further inpatients. Adequate expansion was both quicker (mean 8.5 days) and less painful (mean pain score 2.61 10).
Tissue expansion of the forehead is a useful technique for reconstruction of forehead defects and to facilitate direct closure of the donor site when forehead flaps are used for nasal reconstruction. Complications of tissue expansion include implant exposure, infection, skin necrosis and spontaneous deflation (Antonyshyn et al., 1988). Although rarely reported, some patients complain of severe pain, particularly during expansion of the forehead, distal extremities and dorsal trunk (Manders et al., 1984; Antonyshyn et al., 1988). This study was prompted by three patients who complained of such severe pain during forehead expansion that they wished they had never had the procedure.
intraluminal pressure and pain scores were measured at each attendance. Initial intraluminal pressure was measured using a pressure gauge connected via salinefilled tubing and a 3-way tap to the inflation apparatus. Pressure measurements were recorded after every 2 cc infused. Expansion ceased when the patients felt discomfort and the final intraluminal pressure was then recorded. Patients were asked to grade the
Patients and measurements
Three patients, aged 53, 60 and 71 years with basal cell carcinomas, all complained bitterly about the discomfort they experienced when their forehead expanders were inflated. In four subsequent cases in which forehead expansion was used, the filling volumes, intraluminal pressures and pain scores were recorded during each inflation session. In two further cases an attempt was then made to reduce the discomfort of forehead expansion by slowly inflating the expanders using a continuous infusion. The technique of continuous expansion using an external pump via an external valve has been previously described (Sharpe and Burd, 1989). Figure 1 shows an 8-year-old boy undergoing forehead expansion using a portable syringe driver. The details of these nine patients who underwent insertion of subfrontalis forehead tissue expanders are summarised in Table 1. Patients having their expanders inflated by bolus injections attended as outpatients twice weekly. In four of these cases (patients 4-7) the volume injected,
Fig. 1 Figure l-Case
41
8 undergoing
expansion
with syringe pump.
British Journal of Plastic Surgery
42 Table
1
Summary of patient details
Age (years)
Patient
Expander (cc)
Diagnosis
Time of expansion (days)
Total volume infused (cc)
Method of infusion
1
53
BCC nose
50
21
40
Bolus
2
60
BCC forehead
250
28
200
Bolus
3
71
BCC nose
100
14
80
Bolus
4
81
KC
100
56
104
Bolus
5
75
BCC forehead
50
49
89
Bolus
6
65
BCC nose
50
49
83
Bolus
7
71
BCC nose
100
28
78
Bolus
8
8
Naevus forehead
100
4
97
Continuous infusion
9
80
BCC nose
100
13
152
Continuous infusion
nose
severity of the discomfort on a linear analogue scale (Revill et al., 1976) with a line marked from 0 to 10 at 1 cm intervals. A pain score of zero represented no pain and a score of 10 represented the worst pain imaginable. The two patients having their expanders inflated using the syringe pump were admitted as inpatients. The syringe driver was connected to the tissue expander port using a 23G butterfly needle. The intraluminal pressures and pain scores were measured every 12 hours using the techniques described above. A record was kept of analgesia requirements in both groups.
The bolus inflation technique caused sharp rises in intraluminal pressure at each visit. A typical example is shown in Figure 2. These pressure peaks were avoided when the expander was filled using the syringe pump (Fig. 3). The mean time taken to achieve adequate expansion in the bolus group was 4% days compared with 8f days for the infusion patients (Table 3).
Results The mean pain score in the four patients undergoing boius inflation was 7110 and that in the two patients undergoing infusion inflation 2.6/10 (Table 2). The mean intraluminal pressure at the end of each injection for the bolus group was 153.7 mmHg and that in the patients undergoing infusion inflation 46.9 mmHg (Table 2). Table 2
m.m. Hp. 100
Summary of results
VOLUMEco.
Patient
Method of infusion
Mean pain score
4
Bolus
6.4
163.9
5
Bolus
6.7
212.4
6
Bolus
7.1
125.8
7
Bolus
7.8
112.7
8
Continuous
infusion
2.4
48.8
9
Continuous
infusion
2.9
45.0
Table 3
Pressure
Mean pressure CmmHgl
Fig. 2 FipreZ-Relationship between peak pressure andexpander for bolus inflation (case 5).
volume
PRESSURE M.M.Hg.
Mean measurements for cases 4-9
100
Method
Patients
Pain (lOi
Pressure (mm&l
Time taken (days)
Bolus inflation
4
7.0
154
45.5
Infusion inflation
2
2.6
47
8.5
/./q/“\
,._._.“\, .*_/
I
75
25 “O&
100
C.C.
Fig. 3 Figure SRelationship pump infusion inflation
between pressure (case 8).
and expander
volume for
43
Pain and Forehead Expansion
Discussion Pain has previously been noted to be a problem in expansion of the forehead and of the extremities (Manders er al., 1984). In one case intractable pain during forehead expansion warranted removal of the expander (Antonyshyn et al., 1988). Pain was found to be the rate-limiting factor for bolus expansion in this study. One patient who had initially tolerated a bolus injection found that the pain became intolerable one hour after leaving the clinic. It has been suggested that an interval of a few weeks between implant insertion and initiation of expansion permits capsule formation. Extra pressure may be required to expand such a capsule and might cause additional discomfort (Fenton, 1988). However, in the present series expansion was started within 2 weeks of implant insertion. Moreover, a delay of 3 to 4 weeks between implant insertion and inflation was not found to be associated with pain in Adamson’s series (Adamson, 1988) and it is unlikely that capsule formation contributes significantly to the discomfort experienced. It is unclear why forehead expansion should be more painful than expansion at other sites. A patient who underwent intermittent bolus inflation of an expander placed deep to occipitalis, in the same anatomical plane as the forehead expanders, tolerated greater volume increments (mean 36 cc) with similar intraluminal pressures (mean 133 mmHg) but had much lower pain scores (mean l/10). Pressure on the supraorbital nerve as it passes through the ciliary notch is a well-known means of inflicting pain sufficient to rouse patients with a reduced level of consciousness. It is possible that inflation of forehead expanders stretches these nerves which are vulnerable as they turn sharply round a bony prominence, making expansion at this site particularly uncomfortable. It has been proposed that temporary over-expansion (to the point where dermal blood flow is abolished) followed by removal of enough fluid for circulation to re-establish itself allows accelerated tissue expansion (PietilP ef al., 1988). In this series, however, pain rather than skin blood flow limited the volume that could be injected at each visit.
A comparison of Figures 2 and 3 shows that lower expander pressures occurred using the infusion technique. A pain score greater than 5/ 10 occurred only on one occasion during infusion at a rate of 2 ml/hour. This peak pain level was rapidly controlled and the expansion continued uneventfully. Forehead expansion by intermittent bolus injection can be extremely painful. The use of an infusion pump enables expansion to be achieved more rapidly with lower intraluminal pressures and less pain.
References Adamaon, J. E. (1988). Nasal reconstruction with the expanded forehead flap. Plastic ana’ Reconstructive Surgery, 81, 12. Antonyshyn, O., Gruss, J. S., Mackkmon, S. E. and Zuker, R. (1988). Complications of soft tissue expansion. British Journal of Plastic Surgery, 41,239. Fenton, 0. (1988). Discussion of “Complications of soft tissue expansion”. British Journal of Plastic Surgery, 41,249. Mariders., E. K.,Schenden,M. J.,Furrey, J. A., Hetzler,P. T., Davis, T. S. and Graham, W. P. (1984). Soft-tissue expansion: concepts and complications. Plastic and Reconstructive Surgery, 74,493. Pied& J. P., Nordstriim, R. E. A., Virkknnen, P. J., Voutilalneo, P. E. J. and Riotala, A. E. (1988). Accelerated tissue expansion with the “overfilling” technique. Plastic and Reconstructiue Surgery, 81,204. ReviIl, S. I., Rohll, J. O., Rosen, M. and Hngg, M. I. J. (1976). The reliability of a linear analogue for evaluating pain. Anaesthesia,31,1191. Sharpe, D. T. and Burd, R. M. (1989). Tissue expansion in perspective. Annals of the Royal College of Surgeons of England, 71,175.
The Authors R. P. Cole, FRCS, Registrar in Plastic Surgery, Odstock Hospital, Salisbury, Wilts SP2 8BJ; formerly SHO in Plastic Surgery, St Thomas’ Hospital, London. D. T. Gault, FRCS, Senior Registrar in Plastic Surgery, St Thomas’ Hospital. B. J. Mayou, FRCS, Consultant Plastic Surgeon, St Thomas’ Hospital. P. K. B. Davis, MS, FRCS, Consultant Plastic Surgeon, St Thomas’ Hospital. Requests for reprints to Mr Cole at Salisbury. Paper received 6 February 1990. Accepted 26 June 1990 after revision.
BrititishJournalofPlmtic
_ _I
Pain and forehead expansion R. P. Cole, D. T. Gault, B. J. Mayou and P. K. B. Davis Department ofPlastic Surgery, St Thomas’ Hospital, London SUMMARY. Tissue expansion of the forehead by intermittent holus injection in three patients was noted to be extremely painful. This stimulated a prospective study in four patients whose discomfort was found to be related to a sharp rise in brtraluminal pressure after bolus inflation. Tolerable infusion volumes were small (mean 6.25 cc) and associated with high pain scores (mean 7/10). Adequate expansion was protracted (mean 4% days) and was limited by pain. To eliminate the sharp rises in pressure associated with expansion by bolus b+ztion, a syringe pump was used in two further inpatients. Adequate expansion was both quicker (mean 8.5 days) and less painful (mean pain score 2.61 10).
Tissue expansion of the forehead is a useful technique for reconstruction of forehead defects and to facilitate direct closure of the donor site when forehead flaps are used for nasal reconstruction. Complications of tissue expansion include implant exposure, infection, skin necrosis and spontaneous deflation (Antonyshyn et al., 1988). Although rarely reported, some patients complain of severe pain, particularly during expansion of the forehead, distal extremities and dorsal trunk (Manders et al., 1984; Antonyshyn et al., 1988). This study was prompted by three patients who complained of such severe pain during forehead expansion that they wished they had never had the procedure.
intraluminal pressure and pain scores were measured at each attendance. Initial intraluminal pressure was measured using a pressure gauge connected via salinefilled tubing and a 3-way tap to the inflation apparatus. Pressure measurements were recorded after every 2 cc infused. Expansion ceased when the patients felt discomfort and the final intraluminal pressure was then recorded. Patients were asked to grade the
Patients and measurements
Three patients, aged 53, 60 and 71 years with basal cell carcinomas, all complained bitterly about the discomfort they experienced when their forehead expanders were inflated. In four subsequent cases in which forehead expansion was used, the filling volumes, intraluminal pressures and pain scores were recorded during each inflation session. In two further cases an attempt was then made to reduce the discomfort of forehead expansion by slowly inflating the expanders using a continuous infusion. The technique of continuous expansion using an external pump via an external valve has been previously described (Sharpe and Burd, 1989). Figure 1 shows an 8-year-old boy undergoing forehead expansion using a portable syringe driver. The details of these nine patients who underwent insertion of subfrontalis forehead tissue expanders are summarised in Table 1. Patients having their expanders inflated by bolus injections attended as outpatients twice weekly. In four of these cases (patients 4-7) the volume injected,
Fig. 1 Figure l-Case
41
8 undergoing
expansion
with syringe pump.
British Journal of Plastic Surgery
42 Table
1
Summary of patient details
Age (years)
Patient
Expander (cc)
Diagnosis
Time of expansion (days)
Total volume infused (cc)
Method of infusion
1
53
BCC nose
50
21
40
Bolus
2
60
BCC forehead
250
28
200
Bolus
3
71
BCC nose
100
14
80
Bolus
4
81
KC
100
56
104
Bolus
5
75
BCC forehead
50
49
89
Bolus
6
65
BCC nose
50
49
83
Bolus
7
71
BCC nose
100
28
78
Bolus
8
8
Naevus forehead
100
4
97
Continuous infusion
9
80
BCC nose
100
13
152
Continuous infusion
nose
severity of the discomfort on a linear analogue scale (Revill et al., 1976) with a line marked from 0 to 10 at 1 cm intervals. A pain score of zero represented no pain and a score of 10 represented the worst pain imaginable. The two patients having their expanders inflated using the syringe pump were admitted as inpatients. The syringe driver was connected to the tissue expander port using a 23G butterfly needle. The intraluminal pressures and pain scores were measured every 12 hours using the techniques described above. A record was kept of analgesia requirements in both groups.
The bolus inflation technique caused sharp rises in intraluminal pressure at each visit. A typical example is shown in Figure 2. These pressure peaks were avoided when the expander was filled using the syringe pump (Fig. 3). The mean time taken to achieve adequate expansion in the bolus group was 4% days compared with 8f days for the infusion patients (Table 3).
Results The mean pain score in the four patients undergoing boius inflation was 7110 and that in the two patients undergoing infusion inflation 2.6/10 (Table 2). The mean intraluminal pressure at the end of each injection for the bolus group was 153.7 mmHg and that in the patients undergoing infusion inflation 46.9 mmHg (Table 2). Table 2
m.m. Hp. 100
Summary of results
VOLUMEco.
Patient
Method of infusion
Mean pain score
4
Bolus
6.4
163.9
5
Bolus
6.7
212.4
6
Bolus
7.1
125.8
7
Bolus
7.8
112.7
8
Continuous
infusion
2.4
48.8
9
Continuous
infusion
2.9
45.0
Table 3
Pressure
Mean pressure CmmHgl
Fig. 2 FipreZ-Relationship between peak pressure andexpander for bolus inflation (case 5).
volume
PRESSURE M.M.Hg.
Mean measurements for cases 4-9
100
Method
Patients
Pain (lOi
Pressure (mm&l
Time taken (days)
Bolus inflation
4
7.0
154
45.5
Infusion inflation
2
2.6
47
8.5
/./q/“\
,._._.“\, .*_/
I
75
25 “O&
100
C.C.
Fig. 3 Figure SRelationship pump infusion inflation
between pressure (case 8).
and expander
volume for
43
Pain and Forehead Expansion
Discussion Pain has previously been noted to be a problem in expansion of the forehead and of the extremities (Manders er al., 1984). In one case intractable pain during forehead expansion warranted removal of the expander (Antonyshyn et al., 1988). Pain was found to be the rate-limiting factor for bolus expansion in this study. One patient who had initially tolerated a bolus injection found that the pain became intolerable one hour after leaving the clinic. It has been suggested that an interval of a few weeks between implant insertion and initiation of expansion permits capsule formation. Extra pressure may be required to expand such a capsule and might cause additional discomfort (Fenton, 1988). However, in the present series expansion was started within 2 weeks of implant insertion. Moreover, a delay of 3 to 4 weeks between implant insertion and inflation was not found to be associated with pain in Adamson’s series (Adamson, 1988) and it is unlikely that capsule formation contributes significantly to the discomfort experienced. It is unclear why forehead expansion should be more painful than expansion at other sites. A patient who underwent intermittent bolus inflation of an expander placed deep to occipitalis, in the same anatomical plane as the forehead expanders, tolerated greater volume increments (mean 36 cc) with similar intraluminal pressures (mean 133 mmHg) but had much lower pain scores (mean l/10). Pressure on the supraorbital nerve as it passes through the ciliary notch is a well-known means of inflicting pain sufficient to rouse patients with a reduced level of consciousness. It is possible that inflation of forehead expanders stretches these nerves which are vulnerable as they turn sharply round a bony prominence, making expansion at this site particularly uncomfortable. It has been proposed that temporary over-expansion (to the point where dermal blood flow is abolished) followed by removal of enough fluid for circulation to re-establish itself allows accelerated tissue expansion (PietilP ef al., 1988). In this series, however, pain rather than skin blood flow limited the volume that could be injected at each visit.
A comparison of Figures 2 and 3 shows that lower expander pressures occurred using the infusion technique. A pain score greater than 5/ 10 occurred only on one occasion during infusion at a rate of 2 ml/hour. This peak pain level was rapidly controlled and the expansion continued uneventfully. Forehead expansion by intermittent bolus injection can be extremely painful. The use of an infusion pump enables expansion to be achieved more rapidly with lower intraluminal pressures and less pain.
References Adamaon, J. E. (1988). Nasal reconstruction with the expanded forehead flap. Plastic ana’ Reconstructive Surgery, 81, 12. Antonyshyn, O., Gruss, J. S., Mackkmon, S. E. and Zuker, R. (1988). Complications of soft tissue expansion. British Journal of Plastic Surgery, 41,239. Fenton, 0. (1988). Discussion of “Complications of soft tissue expansion”. British Journal of Plastic Surgery, 41,249. Mariders., E. K.,Schenden,M. J.,Furrey, J. A., Hetzler,P. T., Davis, T. S. and Graham, W. P. (1984). Soft-tissue expansion: concepts and complications. Plastic and Reconstructive Surgery, 74,493. Pied& J. P., Nordstriim, R. E. A., Virkknnen, P. J., Voutilalneo, P. E. J. and Riotala, A. E. (1988). Accelerated tissue expansion with the “overfilling” technique. Plastic and Reconstructiue Surgery, 81,204. ReviIl, S. I., Rohll, J. O., Rosen, M. and Hngg, M. I. J. (1976). The reliability of a linear analogue for evaluating pain. Anaesthesia,31,1191. Sharpe, D. T. and Burd, R. M. (1989). Tissue expansion in perspective. Annals of the Royal College of Surgeons of England, 71,175.
The Authors R. P. Cole, FRCS, Registrar in Plastic Surgery, Odstock Hospital, Salisbury, Wilts SP2 8BJ; formerly SHO in Plastic Surgery, St Thomas’ Hospital, London. D. T. Gault, FRCS, Senior Registrar in Plastic Surgery, St Thomas’ Hospital. B. J. Mayou, FRCS, Consultant Plastic Surgeon, St Thomas’ Hospital. P. K. B. Davis, MS, FRCS, Consultant Plastic Surgeon, St Thomas’ Hospital. Requests for reprints to Mr Cole at Salisbury. Paper received 6 February 1990. Accepted 26 June 1990 after revision.
