CE: D.C.; SCS-17-048; Total nos of Pages: 4;
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ORIGINAL ARTICLE
Repair of Craniomaxillofacial Traumatic Soft Tissue Defects With Tissue Expansion in the Early Stage Yan Han, MD, PhD, Jianhui Zhao, MD, PhD, Ran Tao, MD, PhD, Lingli Guo, MD, PhD, Hongyan Yang, MD, PhD, Wei Zeng, MD, PhD, Baoqiang Song, MD, PhD,y and Wensen Xia, MD, PhDy Background: Craniomaxillofacial traumatic soft tissue defects severely affect the function and appearance of the patients. The traditional skin grafting or free flap transplantation can only close the defects in the early stage of operation but cannot ensure similar color, texture, and relative aesthetic contour. In the present study, the authors have explored a novel strategy to repair craniomaxillofacial traumatic soft tissue defects by tissue expansion in the early stage and have obtained satisfactory results. Methods: Eighteen patients suffering large craniomaxillofacial traumatic soft tissue defects were treated by thorough debridement leaving the wounds unclosed or simply closed with thin splitthickness scalp grafts, adjacent expander implantation in the first stage, and expanded flap transposition in the second stage. Results: There were 11 male patients and 7 female patients ranging in age from 3.5 to 40 years (mean, 19.4 12.2 years), with average 15 months follow-up (range, 3–67 months). The average expansion time was 74.3 days (range, 53–96 days). The 18 patients with a total of 22 expanders were treated with satisfactory results. All the flaps survived and the skin color, texture, and contour well matched those of the peripheral tissue. Only 1 complication of infection happened in the 18 cases (5.56%) and the 22 expanders (4.55%), which was similar to the rate reported in the literature. No other complications related to the expanders occurred. Conclusion: Debridement and tissue expansion in the early stage has been proved to be a more effective strategy to repair craniomaxillofacial traumatic soft tissue defects. This strategy can not only achieve satisfactory color, unbulky and well-matched texture similar to normal, but also avoid unnecessary donor site injuries. Key Words: Craniomaxillofacial traumatic soft tissue defects, early repair, expanded flap transfer, tissue expansion (J Craniofac Surg 2017;00: 00–00)
T
rauma is one of the most common injuries, and face is an exposed aesthetic organ which is susceptible to injuries. From 2006 to 2011 in China, the annual recorded injury cases increased From the Department of Plastic and Reconstructive Surgery, Chinese PLA General Hospital, Beijing; and yDepartment of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China. Received December 25, 2016. Accepted for publication March 24, 2017. Address correspondence and reprint requests to Yan Han, MD, PhD, Department of Plastic and Reconstructive Surgery, Chinese PLA General Hospital (No. 301 Hospital of PLA), 28# Fuxing Road, Haidian District, Beijing 100853, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2017 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000003852
The Journal of Craniofacial Surgery
from 340,000 to 630,000, the majority being male (65%) and over 80% aged 15 to 64 years, and falls (32%), road traffic injuries (23%), and blunt injuries (19%) were the most common causes.1 Craniomaxillofacial traumatic soft tissue defects due to various causes have been challenging the plastic surgeons. Skin grafts, local flaps, adjacent flaps, and free flaps are routinely applied to repair and reconstruct craniomaxillofacial soft tissue defects caused by trauma in the early stage according to the area and severity.2 Face is one of the most important aesthetic units, which is the central point of the physical features of the human being.3 Traditional treatment of craniomaxillofacial traumatic soft tissue defects is wound debridement and closure with every kind of tissue transplantation in the early stage.4 When the tissue defects are too large to close directly or to be closed with local flaps and adjacent flaps, only free flap transplantation could close the defects in the early stage. Of course, skin grafting could close the defects if there were superficial defects of the skin tissue.5 Once in the early stage the treatment is not optimized, the therapeutic outcome would be unsatisfactory, and the subsequent repair would also be also difficult. Eventually, the formerly transplanted tissue would also be sacrificed unfortunately, which would increase the unnecessary damages to both the donor and the recipient sites. We once adopted the right scapular free flap transplantation to treat a 10-year-old boy with a 12 cm 9 cm craniomaxillofacial traumatic soft tissue defect caused by a car accident in the left frontal part, the left temporal region, and the left upper half side of the face. The flap survived well and the defect was closed in the early stage. However, about 1 year later, the boy came to us asking for help because the color of the flap did not match that of the surrounding facial skin as a result of pigmentation. The patient and his parents were not satisfied with chromatic aberration and appealed for the replacement of the pigmented flap. We tried to implant 2 expanders (one in the frontal part, the other in the occiput region) in the first stage and replaced the partial transplanted flap with expanded surrounding tissue in the second stage. In the third stage, 1 expander was implanted in the left side of the face and the remnant part was resected later. After the 4 operations, the transplanted free scapular flap was fully replaced by expanded local flaps. The linear scar and the color of the expanded local flaps were accepted by the patient and his family. Besides, we also treated another similar case with unsatisfied skin color and texture by means of previous free flap resection. These 2 cases draw us to reflect on our therapeutic strategies. In the repair of craniomaxillofacial traumatic soft tissue defects, immediate free flap transplantation covering the wound after debridement failed to satisfy the patients’ appearance requirement. We tried to explore whether it was feasible to debride the wound thoroughly, leave it open, and implant expanders in it in the first stage and then to close it with expanded local flaps in the second stage. There are a lot of reports in which the expanded skin flaps were transposed for the reconstruction of craniomaxillofacial traumatic soft tissue defects in the later period.6– 8 However, few reports have
Volume 00, Number 00, Month 2017
1
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: D.C.; SCS-17-048; Total nos of Pages: 4;
SCS-17-048
2
None None None None Infection None None None None None None None None None None 61 63 85 75 80 78 89 79 67 59 53 67 70 72 69
None None None 96 83 91 3.5 3 ¼ 10.5 3.9 3.2 ¼ 12.48 8.6 4.4 ¼ 37.84
3.1 3 ¼ 9.3 4.9 3.8 ¼ 18.62 4.7 3.5 ¼ 16.45 4.1 3.6 ¼ 14.76 3.3 3.0 ¼ 9.9 6.2 4.5 ¼ 27.9 4.9 4 ¼ 19.6 5 4.4 ¼ 22 5.7 4.5 ¼ 25.65 2.6 2.6 ¼ 6.76 2.5 2 ¼ 5 4.0 3.7 ¼ 14.8 3.7 3.6 ¼ 13.32 5.3 3.4 ¼ 18.02 5.7 4.3 ¼ 24.51
4.3 3.4 ¼ 14.62 4.2 3.6 ¼ 15.12 10 5 ¼ 50
3.5 3.5 ¼ 12.25 5.3 4.1 ¼ 21.73 5.7 4.3 ¼ 24.51 4.4 3.9 ¼ 17.16 3.6 3.2 ¼ 11.52 7.3 5.1 ¼ 37.23 5.4 4.3 ¼ 23.22 5.3 4.6 ¼ 24.38 6.1 4.8 ¼ 29.28 2.9 2.8 ¼ 8.12 2.6 2.1 ¼ 5.46 4.3 3.9 ¼ 16.77 3.9 3.8 ¼ 14.82 5.7 3.7 ¼ 21.09 6.2 4.7 ¼ 29.14 Car accident Car accident Car accident Car accident Knife cuts Burns Burn trauma Car accident Burn trauma Construction trauma Sulfuric acid burn Glass trauma Car accident Car accident Motorcycle accident Female Male Female Female Male Male Male Female Male Male Female Male Male Male Male 35 24 40 16 20 36 8 10 11 29 24 39 14 11 19
Female Female Male
Car accident Car accident Car accident
Left side of the forehead Left frontoparietal Right frontoparietal and the temporal region Right side of the forehead Right side of the forehead Left frontoparietal Left side of the forehead Right side of the forehead Left side of the temporal region Right side of the forehead Right side of the forehead Left side of the face Right side of the forehead Right zygomaticofacil-region Right side of the forehead Left side of the forehead Right side of the forehead Right side of the forehead
Final Defect Area (cm2) Initial Defect Area (cm2)
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Assessment on whether the expanded skin tissue could cover the wound was performed clinically. When the skin tissue was expanded appropriately, the flap incision and transfer methods were
3.5 4 6
The Second-Stage Operation
1 2 3
This was wound debridement and expander implantation. After general anesthesia, the face was disinfected and washed by hydrogen peroxide, iodophor, and normal saline repeatedly at least for 3 times. Necrotic tissue was excised and skin edge was trimmed with scissors. After thorough respective debridements, the defects were carefully assessed. If there was only bone exposure, the open wound was covered with iodophor gauze without any other excess management. However, if there was soft tissue defect with blood circulation, the thin split-thickness scalp graft was applied to temporarily cover the defect. In the head, the expanders were implanted under the galea aponeurotica and on the surface of periosteum. In the frontal part, the expander was implanted under the frontalis muscle. In the facio-buccal part, the expander was implanted under the subcutaneous tissue and on the surface of superficial muscular aponeurotic system. The implantation site should be at least 2 cm to the wound edge and the incision should not affect the blood circulation of expanded flaps in the second-stage operation. The incisions were sutured, and closed suction drains were remained in place until the draining volume was less than 5 mL per day for 2 consecutive days. All the expander ports were placed internally. In the operation, the expander was injected with moderately sterile normal saline. About 7 days after the operation, the stitches were taken out and then approximately 5 mL of normal saline was injected into the expander 2 or 3 times per week. In the expanding period, the wound was put aside and the dressing was changed 2 or 3 times per week.
Defect Location
The First-Stage Operation
Defect Etiology
Generally, the patients needed 2 operations: wound debridement and expander implantation; expander removal and expanded local flap transfer. Below are the detailed descriptions of the operation procedures.
Sex
Operative Techniques
Age (Y)
A retrospective study of 18 patients suffering from craniomaxillofacial traumatic soft tissue defects treated by the 2-stage surgery (the first stage: debridement and expander implantation; the second stage: wound closure with expanded local flap transfer) was conducted from 2005 to 2016. There were 11 male patients and 7 female patients, ranging in age from 3.5 to 40 years old (mean, 19.4 12.2 years). The average expansion time was 74.3 days (range, 53–96 days) and the average time of follow-up was 15 months (range, 3–67 months). All the wounds resulted from different injuries. Of the 18 patients, 14 were treated with unilateral flaps, and the remaining 4 were each implanted with 2 expanders and treated with bilateral flaps. The largest area of the initial craniomaxillofacial soft tissue defect was 10 cm 5 cm, and the smallest was 2.6 cm 2.1 cm (Table 1). There were 7 cases with skull exposure in these defects but without fracture.
TABLE 1. Characteristics of Patients With Craniomaxillofacial Traumatic Soft Tissue Defects Repaired by Debridement and Tissue Expansion in the Early Stage
Patients
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No
METHODS
Expander Shape—Volume
Expansion Duration (d)
been found in tissue expansion to repair craniomaxillofacial traumatic soft tissue defects in the early stage. In this study, we are to introduce a series of craniomaxillofacial traumatic soft tissue defects repaired satisfactorily with debridement and tissue expansion in the early stage.
Oval, 80 mL Oval, 100 mL; oval, 100 mL Kidney shaped, 100 mL; Kidney shaped, 100 mL Oval, 80 mL Oval, 100 mL Oval, 80 mL; oval, 80 mL Oval, 100 mL Oval, 100 mL Oval, 100 mL; oval, 100 mL Oval, 100 mL Oval, 100 mL Oval, 100 mL; oval, 100 mL Oval, 100 mL Oval, 80 mL Oval, 100 mL Oval, 80 mL Oval, 80 mL Oval, 100 mL
Complications
The Journal of Craniofacial Surgery
Han et al
#
2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: D.C.; SCS-17-048; Total nos of Pages: 4;
SCS-17-048
The Journal of Craniofacial Surgery
Volume 00, Number 00, Month 2017
designed before the operation. After general or local anesthesia, the patients were disinfected and draped. Following the designed incision, the open defect was debrided or the thin split-thickness scalp graft was resected and the expander was removed. For the bone exposure, the superficial external table of calvaria of exposed bone should be abraded by osteotome because of dry necrosis. The flap was transferred or advanced to close the wound using interrupted absorbable suture in the subcutaneous tissue. It was unnecessary for the majority of the patients to receive a third surgery if the flap was not fat or clumsy. However, if the expanded flap was not enough to cover the defect in one time, another expansion was needed. After the stitches were removed, silicone gel, pressure therapy, and sequential laser resurfacing of scar would be suggested to minimize the scar formation.
RESULTS The 18 patients were treated with satisfactory results. All the local flaps survived and without distal disturbance of blood circulation or necrosis. The skin color, texture, and contour of the flaps matched well with the facial peripheral tissue. There was only slight scar formation on the wound edges. No complications occurred except that 1 patient suffered expander infection, which was controlled by antibiotics, and the expander was then removed.
Patient 1 A three and a half years old girl, presented herself with a 3.5 cm 3 cm craniomaxillofacial soft tissue defect in the left side of the forehead and frontal bone exposure due to car accident (Fig. 1A and B). An 80 mL oval expander was implanted into her right side of the forehead (Fig. 1C). About 3 months after the implantation, the expanded frontal flap was transferred to cover the defect (Fig. 1D–F). There was almost no color and contour deformity in the head and the hairline was reconstructed (Fig. 1G and H).
Patient 2 A 4-year-old girl presented herself with a 4.2 cm 3.6 cm craniomaxillofacial soft tissue defect in the left frontoparietal due to a car accident (Fig. 2A). A 100 mL kidney-shaped expander was implanted in her right forehead and another 100 mL kidneyshaped expander in the parietal region (Fig. 2B). Eighty-three days after the implantation, the flap was transferred to repair the defect
FIGURE 1. (A) Left frontoparietal soft tissue defect and skull exposure after debridement. (B) Open wound with bone exposure covered with iodophor gauze. (C) Immediate postoperative view of expander implantation. (D) Postoperative third month view after defect debridement and adjacent tissue expansion (80 mL expander up to about 100 mL). (E, F) One week view of expanded flap transfer (frontal view and left half side-view). (G, H) One year view of expanded tissue repair (frontal view and left half side-view).
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2017 Mutaz B. Habal, MD
Tissue Expansion in Traumatic Defect Repair
FIGURE 2. (A) Preoperative left frontoparietal soft tissue defect and skull exposure. (B) Three months view after defect debridement and adjacent tissue expansion. (C) Instant postoperative view after expanded flap transfer.
(Fig. 2C). The patient’s family was satisfied with the color and texture.
Patient 3 A 36-year-old man presented himself with a 7.3 cm 5.1 cm craniomaxillofacial soft tissue defect, left eye necrosis, upper and lower eyelid defects with a little bone exposure in the left temporal region due to burns. In early stage, a 100 mL oval expander was implanted in his forehead and another 100 mL oval expander in the left buccal region (Fig. 3A). The soft tissue defect in the temporal region was covered with thin split-thickness skin grafting. About 3 months later, the flap was transferred to repair the temporal region and eyelid defects (Fig. 3B). The patient was satisfied with the color and texture after 6 months (Fig. 3C).
DISCUSSION Face is an important aesthetic complex, and craniomaxillofacial soft tissue defects caused by many kinds of traumas are hard to aesthetic and function repair.9,10 Debridement and wound closure with skin grafts or various skin flaps is the principle of trauma treatment in the early stage. However, the color and texture of the craniomaxillofacial region is different from those of other skin. In addition, scalp defects are repaired best by adjacent scalp with hair follicles. So craniomaxillofacial skin defects should be repaired with skin or flaps of similar texture. Tissue expansion has been extremely useful to restore the contour and function along with good esthetics that were otherwise unobtainable.11 The concept of skin and soft tissue expansion has been conceived first by Neumann CG in subtotal reconstruction of the ear since the 1950s. In 1976, Radovan12,13 designed and used controlled expander in various body sites and for different indications such as scars, open wounds, and contractures. The biological effects of expansion included movement of the adjacent skin, increased mitotic activity and cell proliferation, and promoted
FIGURE 3. (A) Preoperative left temporal region soft tissue defect and bone exposure. (B) Three months view after defect debridement, thin split-thickness skin grafting, and adjacent tissue expansion. (C) Six months view after expanded flap transfer.
3
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: D.C.; SCS-17-048; Total nos of Pages: 4;
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Han et al
The Journal of Craniofacial Surgery
angiogenesis.14,15 Skin and soft tissue expansion technique is one of the most pivotal innovations of plastic surgery in addition to microsurgery and craniomaxillofacial surgery. Local flaps are preferred in face by plastic surgeons because of their similar color and texture that are similar to the normal. In our study, the trauma wound was first debrided traditionally, and left unclosed, and the dressing was changed routinely. In the second stage, after adequate expansion, the flaps were transferred to close the defects flatly. For some scalp defects, adjacent expanded scalp transposition, which can provide hair follicles, is better than free skin grafting. Another advantage of the adjacent expanded scalp transposition is that it will not induce any new distal injuries of healthy donor sites. At last, after long-term wound dressing change, the wound is narrowed down gradually which is easier to close in the second stage. Besides thorough systemic examination, the indications suitable for this method include all craniomaxillofacial traumatic soft tissue defects without other life-threatening comorbidities. The contraindication for this method is any local wound infections before debridement. Formerly, soft tissue expansion was often used in the second-stage wound repair after wound closure. It was rarely applied in the first stage for fear of possible infections. Only 1 complication of expander infection happened in the 18 cases (5.56%) with 22 expanders (4.55%), which was similar to the rate reported in the literature (4.58%).16 If there was expander infection, taking out the expander and systemic antibiotics had been proved to be an effective strategy.17 After the slow and graduate expansion, there were no other complications such as expander extrusion or necrosis of the transferred flap occurred in this study. Although the results are satisfactory, there are also some common shortcomings for tissue expansion. First, there are risks of long treating period, expander-related complications (such as hematoma, leakage, infection, and skin dehiscence), and transferred flap distal poor circulation may happen in all tissue expansion.18 Second, there are increasing risks of infection when the traumatic defects are left open. Third, the clinical work load of dress changing and nursing is increased. Taking into consideration the advantages and disadvantages above, we think it worthwhile to choose the novel strategy and take above risks for a better look. Strict choices in indications and careful treatments have proved the effectiveness and feasibility of repairing craniomaxillofacial traumatic soft tissue defects with debridement and tissue expansion in the first stage. We would like to share our experiences and provide some tips for this strategy: in the debridement, the wound can be covered by suturing with the iodophor gauze in order to avoid infection, which makes the wound sterile relatively. The location of the implantation should be far away from the wound so as not to affect the expanded flap transfer in the second stage. To prevent the expander exposure in the wound edge, the incision should be 3 to 5 cm long and kept a distance about 2 cm to the wound edge. The craniomaxillofacial traumatic soft tissue defects with blood circulation should be covered with thin split-thickness scalp grafts, but the wound with bone exposure should not be covered. In the second operation, the scar and grafted split-thickness skin should be dissected. Before the expanded flap transfer, the superficial external table of calvaria of exposed bone should be abraded by an osteotome.
4
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CONCLUSION In summary, tissue expansion is an efficient and valuable technique for the reconstruction of large craniomaxillofacial soft tissue defects resulting from traumas. The novel strategy involves thorough debridement leaving the wound unclosed and adjacent expander implantation in the early stage and expanded flap transposition in the second stage, which can not only achieve satisfactory color, unbulky and well-matched texture similar to the normal, but also can avoid unnecessary donor site injuries. Besides, it also shortens the overall therapeutic time, decreases the number of operations, and reduces the expense. However, the infection risk should be evaluated reasonably according to the wound conditions so as to reduce it to the minimum.
REFERENCES 1. Duan L, Deng X, Wang Y, et al. The National Injury Surveillance System in China: a six-year review. Injury 2015;46:572–579 2. Song B, Zhao J, Guo S, et al. Repair of facial scars by the free expanded deltopectoral flap. Plast Reconstr Surg 2013;131:200e–208e 3. Leon-Villapalos J, Jeschke MG, Herndon DN. Topical management of facial burns. Burns 2008;34:903–911 4. Harris L, Wilkes GH, Wolfaardt JF. Autogenous soft-tissue procedures and osseointegrated alloplastic reconstruction: their role in the treatment of complex craniofacial defects. Plast Reconstr Surg 1996;98:387–392 5. Zhao JH, Diao JS, Xia WS, et al. Clinical application of full-face, whole, full-thickness skin grafting: a case report. J Plast Reconstr Aesthet Surg 2012;65:1576–1579 6. Xianjie M, Zheng Y, Ai Y, et al. Repair of faciocervical scars by expanded deltopectoral flap. Ann Plast Surg 2008;61:56–60 7. Zhang L, Yang Q, Jiang H, et al. Reconstruction of complex facial defects using cervical expanded flap prefabricated by temporoparietal fascia flap. J Craniofac Surg 2015;26:e472–e475 8. John J, Edward J, George J. Tissue expanders in reconstruction of maxillofacial defects. J Maxillofac Oral Surg 2015;14(suppl 1):374–382 ¨ ksu¨z S, Alago¨z MS¸, U ¨ lku¨r E. Changing the donor site selection 9. O concept of facial skin expansion from pure healthy tissue to defect and healthy tissue combination. Aesthetic Plast Surg 2015;39:745–751 10. Mobley SR, Sjogren PP. Soft tissue trauma and scar revision. Facial Plast Surg Clin North Am 2014;22:639–651 11. Balaji SM. A single center experience of craniofacial tissue expansion and reconstruction. Ann Maxillofac Surg 2015;5:37–43 12. Radovan C. Breast reconstruction after mastectomy using the temporary expander. Plast Reconstr Surg 1982;69:195–208 13. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg 1984;74:482–492 14. Agrawal K, Agrawal S. Tissue regeneration during tissue expansion and choosing an expander. Indian J Plast Surg 2012;45:7–15 15. Wang X, Li C, Zheng Y, et al. Bone marrow mesenchymal stem cells increase skin regeneration efficiency in skin and soft tissue expansion. Expert Opin Biol Ther 2012;12:1129–1139 16. Huang X, Qu X, Li Q. Risk factors for complications of tissue expansion: a 20-year systematic review and meta-analysis. Plast Reconstr Surg 2011;128:787–797 17. Turko A, Fuzaylov G, Savchyn V, et al. Immediate and early tissue expander placement for acute closure of scalp wounds. Ann Plast Surg 2013;71:160–165 18. Wang J, Huang X, Liu K, et al. Complications in tissue expansion: an updated retrospective analysis of risk factors. Handchir Mikrochir Plast Chir 2014;46:74–79
#
2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
SCS-17-048
ORIGINAL ARTICLE
Repair of Craniomaxillofacial Traumatic Soft Tissue Defects With Tissue Expansion in the Early Stage Yan Han, MD, PhD, Jianhui Zhao, MD, PhD, Ran Tao, MD, PhD, Lingli Guo, MD, PhD, Hongyan Yang, MD, PhD, Wei Zeng, MD, PhD, Baoqiang Song, MD, PhD,y and Wensen Xia, MD, PhDy Background: Craniomaxillofacial traumatic soft tissue defects severely affect the function and appearance of the patients. The traditional skin grafting or free flap transplantation can only close the defects in the early stage of operation but cannot ensure similar color, texture, and relative aesthetic contour. In the present study, the authors have explored a novel strategy to repair craniomaxillofacial traumatic soft tissue defects by tissue expansion in the early stage and have obtained satisfactory results. Methods: Eighteen patients suffering large craniomaxillofacial traumatic soft tissue defects were treated by thorough debridement leaving the wounds unclosed or simply closed with thin splitthickness scalp grafts, adjacent expander implantation in the first stage, and expanded flap transposition in the second stage. Results: There were 11 male patients and 7 female patients ranging in age from 3.5 to 40 years (mean, 19.4 12.2 years), with average 15 months follow-up (range, 3–67 months). The average expansion time was 74.3 days (range, 53–96 days). The 18 patients with a total of 22 expanders were treated with satisfactory results. All the flaps survived and the skin color, texture, and contour well matched those of the peripheral tissue. Only 1 complication of infection happened in the 18 cases (5.56%) and the 22 expanders (4.55%), which was similar to the rate reported in the literature. No other complications related to the expanders occurred. Conclusion: Debridement and tissue expansion in the early stage has been proved to be a more effective strategy to repair craniomaxillofacial traumatic soft tissue defects. This strategy can not only achieve satisfactory color, unbulky and well-matched texture similar to normal, but also avoid unnecessary donor site injuries. Key Words: Craniomaxillofacial traumatic soft tissue defects, early repair, expanded flap transfer, tissue expansion (J Craniofac Surg 2017;00: 00–00)
T
rauma is one of the most common injuries, and face is an exposed aesthetic organ which is susceptible to injuries. From 2006 to 2011 in China, the annual recorded injury cases increased From the Department of Plastic and Reconstructive Surgery, Chinese PLA General Hospital, Beijing; and yDepartment of Plastic Surgery, Xijing Hospital, Fourth Military Medical University, Xi’an, China. Received December 25, 2016. Accepted for publication March 24, 2017. Address correspondence and reprint requests to Yan Han, MD, PhD, Department of Plastic and Reconstructive Surgery, Chinese PLA General Hospital (No. 301 Hospital of PLA), 28# Fuxing Road, Haidian District, Beijing 100853, China; E-mail: [email protected] The authors report no conflicts of interest. Copyright # 2017 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000003852
The Journal of Craniofacial Surgery
from 340,000 to 630,000, the majority being male (65%) and over 80% aged 15 to 64 years, and falls (32%), road traffic injuries (23%), and blunt injuries (19%) were the most common causes.1 Craniomaxillofacial traumatic soft tissue defects due to various causes have been challenging the plastic surgeons. Skin grafts, local flaps, adjacent flaps, and free flaps are routinely applied to repair and reconstruct craniomaxillofacial soft tissue defects caused by trauma in the early stage according to the area and severity.2 Face is one of the most important aesthetic units, which is the central point of the physical features of the human being.3 Traditional treatment of craniomaxillofacial traumatic soft tissue defects is wound debridement and closure with every kind of tissue transplantation in the early stage.4 When the tissue defects are too large to close directly or to be closed with local flaps and adjacent flaps, only free flap transplantation could close the defects in the early stage. Of course, skin grafting could close the defects if there were superficial defects of the skin tissue.5 Once in the early stage the treatment is not optimized, the therapeutic outcome would be unsatisfactory, and the subsequent repair would also be also difficult. Eventually, the formerly transplanted tissue would also be sacrificed unfortunately, which would increase the unnecessary damages to both the donor and the recipient sites. We once adopted the right scapular free flap transplantation to treat a 10-year-old boy with a 12 cm 9 cm craniomaxillofacial traumatic soft tissue defect caused by a car accident in the left frontal part, the left temporal region, and the left upper half side of the face. The flap survived well and the defect was closed in the early stage. However, about 1 year later, the boy came to us asking for help because the color of the flap did not match that of the surrounding facial skin as a result of pigmentation. The patient and his parents were not satisfied with chromatic aberration and appealed for the replacement of the pigmented flap. We tried to implant 2 expanders (one in the frontal part, the other in the occiput region) in the first stage and replaced the partial transplanted flap with expanded surrounding tissue in the second stage. In the third stage, 1 expander was implanted in the left side of the face and the remnant part was resected later. After the 4 operations, the transplanted free scapular flap was fully replaced by expanded local flaps. The linear scar and the color of the expanded local flaps were accepted by the patient and his family. Besides, we also treated another similar case with unsatisfied skin color and texture by means of previous free flap resection. These 2 cases draw us to reflect on our therapeutic strategies. In the repair of craniomaxillofacial traumatic soft tissue defects, immediate free flap transplantation covering the wound after debridement failed to satisfy the patients’ appearance requirement. We tried to explore whether it was feasible to debride the wound thoroughly, leave it open, and implant expanders in it in the first stage and then to close it with expanded local flaps in the second stage. There are a lot of reports in which the expanded skin flaps were transposed for the reconstruction of craniomaxillofacial traumatic soft tissue defects in the later period.6– 8 However, few reports have
Volume 00, Number 00, Month 2017
1
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: D.C.; SCS-17-048; Total nos of Pages: 4;
SCS-17-048
2
None None None None Infection None None None None None None None None None None 61 63 85 75 80 78 89 79 67 59 53 67 70 72 69
None None None 96 83 91 3.5 3 ¼ 10.5 3.9 3.2 ¼ 12.48 8.6 4.4 ¼ 37.84
3.1 3 ¼ 9.3 4.9 3.8 ¼ 18.62 4.7 3.5 ¼ 16.45 4.1 3.6 ¼ 14.76 3.3 3.0 ¼ 9.9 6.2 4.5 ¼ 27.9 4.9 4 ¼ 19.6 5 4.4 ¼ 22 5.7 4.5 ¼ 25.65 2.6 2.6 ¼ 6.76 2.5 2 ¼ 5 4.0 3.7 ¼ 14.8 3.7 3.6 ¼ 13.32 5.3 3.4 ¼ 18.02 5.7 4.3 ¼ 24.51
4.3 3.4 ¼ 14.62 4.2 3.6 ¼ 15.12 10 5 ¼ 50
3.5 3.5 ¼ 12.25 5.3 4.1 ¼ 21.73 5.7 4.3 ¼ 24.51 4.4 3.9 ¼ 17.16 3.6 3.2 ¼ 11.52 7.3 5.1 ¼ 37.23 5.4 4.3 ¼ 23.22 5.3 4.6 ¼ 24.38 6.1 4.8 ¼ 29.28 2.9 2.8 ¼ 8.12 2.6 2.1 ¼ 5.46 4.3 3.9 ¼ 16.77 3.9 3.8 ¼ 14.82 5.7 3.7 ¼ 21.09 6.2 4.7 ¼ 29.14 Car accident Car accident Car accident Car accident Knife cuts Burns Burn trauma Car accident Burn trauma Construction trauma Sulfuric acid burn Glass trauma Car accident Car accident Motorcycle accident Female Male Female Female Male Male Male Female Male Male Female Male Male Male Male 35 24 40 16 20 36 8 10 11 29 24 39 14 11 19
Female Female Male
Car accident Car accident Car accident
Left side of the forehead Left frontoparietal Right frontoparietal and the temporal region Right side of the forehead Right side of the forehead Left frontoparietal Left side of the forehead Right side of the forehead Left side of the temporal region Right side of the forehead Right side of the forehead Left side of the face Right side of the forehead Right zygomaticofacil-region Right side of the forehead Left side of the forehead Right side of the forehead Right side of the forehead
Final Defect Area (cm2) Initial Defect Area (cm2)
4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
Assessment on whether the expanded skin tissue could cover the wound was performed clinically. When the skin tissue was expanded appropriately, the flap incision and transfer methods were
3.5 4 6
The Second-Stage Operation
1 2 3
This was wound debridement and expander implantation. After general anesthesia, the face was disinfected and washed by hydrogen peroxide, iodophor, and normal saline repeatedly at least for 3 times. Necrotic tissue was excised and skin edge was trimmed with scissors. After thorough respective debridements, the defects were carefully assessed. If there was only bone exposure, the open wound was covered with iodophor gauze without any other excess management. However, if there was soft tissue defect with blood circulation, the thin split-thickness scalp graft was applied to temporarily cover the defect. In the head, the expanders were implanted under the galea aponeurotica and on the surface of periosteum. In the frontal part, the expander was implanted under the frontalis muscle. In the facio-buccal part, the expander was implanted under the subcutaneous tissue and on the surface of superficial muscular aponeurotic system. The implantation site should be at least 2 cm to the wound edge and the incision should not affect the blood circulation of expanded flaps in the second-stage operation. The incisions were sutured, and closed suction drains were remained in place until the draining volume was less than 5 mL per day for 2 consecutive days. All the expander ports were placed internally. In the operation, the expander was injected with moderately sterile normal saline. About 7 days after the operation, the stitches were taken out and then approximately 5 mL of normal saline was injected into the expander 2 or 3 times per week. In the expanding period, the wound was put aside and the dressing was changed 2 or 3 times per week.
Defect Location
The First-Stage Operation
Defect Etiology
Generally, the patients needed 2 operations: wound debridement and expander implantation; expander removal and expanded local flap transfer. Below are the detailed descriptions of the operation procedures.
Sex
Operative Techniques
Age (Y)
A retrospective study of 18 patients suffering from craniomaxillofacial traumatic soft tissue defects treated by the 2-stage surgery (the first stage: debridement and expander implantation; the second stage: wound closure with expanded local flap transfer) was conducted from 2005 to 2016. There were 11 male patients and 7 female patients, ranging in age from 3.5 to 40 years old (mean, 19.4 12.2 years). The average expansion time was 74.3 days (range, 53–96 days) and the average time of follow-up was 15 months (range, 3–67 months). All the wounds resulted from different injuries. Of the 18 patients, 14 were treated with unilateral flaps, and the remaining 4 were each implanted with 2 expanders and treated with bilateral flaps. The largest area of the initial craniomaxillofacial soft tissue defect was 10 cm 5 cm, and the smallest was 2.6 cm 2.1 cm (Table 1). There were 7 cases with skull exposure in these defects but without fracture.
TABLE 1. Characteristics of Patients With Craniomaxillofacial Traumatic Soft Tissue Defects Repaired by Debridement and Tissue Expansion in the Early Stage
Patients
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No
METHODS
Expander Shape—Volume
Expansion Duration (d)
been found in tissue expansion to repair craniomaxillofacial traumatic soft tissue defects in the early stage. In this study, we are to introduce a series of craniomaxillofacial traumatic soft tissue defects repaired satisfactorily with debridement and tissue expansion in the early stage.
Oval, 80 mL Oval, 100 mL; oval, 100 mL Kidney shaped, 100 mL; Kidney shaped, 100 mL Oval, 80 mL Oval, 100 mL Oval, 80 mL; oval, 80 mL Oval, 100 mL Oval, 100 mL Oval, 100 mL; oval, 100 mL Oval, 100 mL Oval, 100 mL Oval, 100 mL; oval, 100 mL Oval, 100 mL Oval, 80 mL Oval, 100 mL Oval, 80 mL Oval, 80 mL Oval, 100 mL
Complications
The Journal of Craniofacial Surgery
Han et al
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2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: D.C.; SCS-17-048; Total nos of Pages: 4;
SCS-17-048
The Journal of Craniofacial Surgery
Volume 00, Number 00, Month 2017
designed before the operation. After general or local anesthesia, the patients were disinfected and draped. Following the designed incision, the open defect was debrided or the thin split-thickness scalp graft was resected and the expander was removed. For the bone exposure, the superficial external table of calvaria of exposed bone should be abraded by osteotome because of dry necrosis. The flap was transferred or advanced to close the wound using interrupted absorbable suture in the subcutaneous tissue. It was unnecessary for the majority of the patients to receive a third surgery if the flap was not fat or clumsy. However, if the expanded flap was not enough to cover the defect in one time, another expansion was needed. After the stitches were removed, silicone gel, pressure therapy, and sequential laser resurfacing of scar would be suggested to minimize the scar formation.
RESULTS The 18 patients were treated with satisfactory results. All the local flaps survived and without distal disturbance of blood circulation or necrosis. The skin color, texture, and contour of the flaps matched well with the facial peripheral tissue. There was only slight scar formation on the wound edges. No complications occurred except that 1 patient suffered expander infection, which was controlled by antibiotics, and the expander was then removed.
Patient 1 A three and a half years old girl, presented herself with a 3.5 cm 3 cm craniomaxillofacial soft tissue defect in the left side of the forehead and frontal bone exposure due to car accident (Fig. 1A and B). An 80 mL oval expander was implanted into her right side of the forehead (Fig. 1C). About 3 months after the implantation, the expanded frontal flap was transferred to cover the defect (Fig. 1D–F). There was almost no color and contour deformity in the head and the hairline was reconstructed (Fig. 1G and H).
Patient 2 A 4-year-old girl presented herself with a 4.2 cm 3.6 cm craniomaxillofacial soft tissue defect in the left frontoparietal due to a car accident (Fig. 2A). A 100 mL kidney-shaped expander was implanted in her right forehead and another 100 mL kidneyshaped expander in the parietal region (Fig. 2B). Eighty-three days after the implantation, the flap was transferred to repair the defect
FIGURE 1. (A) Left frontoparietal soft tissue defect and skull exposure after debridement. (B) Open wound with bone exposure covered with iodophor gauze. (C) Immediate postoperative view of expander implantation. (D) Postoperative third month view after defect debridement and adjacent tissue expansion (80 mL expander up to about 100 mL). (E, F) One week view of expanded flap transfer (frontal view and left half side-view). (G, H) One year view of expanded tissue repair (frontal view and left half side-view).
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2017 Mutaz B. Habal, MD
Tissue Expansion in Traumatic Defect Repair
FIGURE 2. (A) Preoperative left frontoparietal soft tissue defect and skull exposure. (B) Three months view after defect debridement and adjacent tissue expansion. (C) Instant postoperative view after expanded flap transfer.
(Fig. 2C). The patient’s family was satisfied with the color and texture.
Patient 3 A 36-year-old man presented himself with a 7.3 cm 5.1 cm craniomaxillofacial soft tissue defect, left eye necrosis, upper and lower eyelid defects with a little bone exposure in the left temporal region due to burns. In early stage, a 100 mL oval expander was implanted in his forehead and another 100 mL oval expander in the left buccal region (Fig. 3A). The soft tissue defect in the temporal region was covered with thin split-thickness skin grafting. About 3 months later, the flap was transferred to repair the temporal region and eyelid defects (Fig. 3B). The patient was satisfied with the color and texture after 6 months (Fig. 3C).
DISCUSSION Face is an important aesthetic complex, and craniomaxillofacial soft tissue defects caused by many kinds of traumas are hard to aesthetic and function repair.9,10 Debridement and wound closure with skin grafts or various skin flaps is the principle of trauma treatment in the early stage. However, the color and texture of the craniomaxillofacial region is different from those of other skin. In addition, scalp defects are repaired best by adjacent scalp with hair follicles. So craniomaxillofacial skin defects should be repaired with skin or flaps of similar texture. Tissue expansion has been extremely useful to restore the contour and function along with good esthetics that were otherwise unobtainable.11 The concept of skin and soft tissue expansion has been conceived first by Neumann CG in subtotal reconstruction of the ear since the 1950s. In 1976, Radovan12,13 designed and used controlled expander in various body sites and for different indications such as scars, open wounds, and contractures. The biological effects of expansion included movement of the adjacent skin, increased mitotic activity and cell proliferation, and promoted
FIGURE 3. (A) Preoperative left temporal region soft tissue defect and bone exposure. (B) Three months view after defect debridement, thin split-thickness skin grafting, and adjacent tissue expansion. (C) Six months view after expanded flap transfer.
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Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
CE: D.C.; SCS-17-048; Total nos of Pages: 4;
SCS-17-048
Han et al
The Journal of Craniofacial Surgery
angiogenesis.14,15 Skin and soft tissue expansion technique is one of the most pivotal innovations of plastic surgery in addition to microsurgery and craniomaxillofacial surgery. Local flaps are preferred in face by plastic surgeons because of their similar color and texture that are similar to the normal. In our study, the trauma wound was first debrided traditionally, and left unclosed, and the dressing was changed routinely. In the second stage, after adequate expansion, the flaps were transferred to close the defects flatly. For some scalp defects, adjacent expanded scalp transposition, which can provide hair follicles, is better than free skin grafting. Another advantage of the adjacent expanded scalp transposition is that it will not induce any new distal injuries of healthy donor sites. At last, after long-term wound dressing change, the wound is narrowed down gradually which is easier to close in the second stage. Besides thorough systemic examination, the indications suitable for this method include all craniomaxillofacial traumatic soft tissue defects without other life-threatening comorbidities. The contraindication for this method is any local wound infections before debridement. Formerly, soft tissue expansion was often used in the second-stage wound repair after wound closure. It was rarely applied in the first stage for fear of possible infections. Only 1 complication of expander infection happened in the 18 cases (5.56%) with 22 expanders (4.55%), which was similar to the rate reported in the literature (4.58%).16 If there was expander infection, taking out the expander and systemic antibiotics had been proved to be an effective strategy.17 After the slow and graduate expansion, there were no other complications such as expander extrusion or necrosis of the transferred flap occurred in this study. Although the results are satisfactory, there are also some common shortcomings for tissue expansion. First, there are risks of long treating period, expander-related complications (such as hematoma, leakage, infection, and skin dehiscence), and transferred flap distal poor circulation may happen in all tissue expansion.18 Second, there are increasing risks of infection when the traumatic defects are left open. Third, the clinical work load of dress changing and nursing is increased. Taking into consideration the advantages and disadvantages above, we think it worthwhile to choose the novel strategy and take above risks for a better look. Strict choices in indications and careful treatments have proved the effectiveness and feasibility of repairing craniomaxillofacial traumatic soft tissue defects with debridement and tissue expansion in the first stage. We would like to share our experiences and provide some tips for this strategy: in the debridement, the wound can be covered by suturing with the iodophor gauze in order to avoid infection, which makes the wound sterile relatively. The location of the implantation should be far away from the wound so as not to affect the expanded flap transfer in the second stage. To prevent the expander exposure in the wound edge, the incision should be 3 to 5 cm long and kept a distance about 2 cm to the wound edge. The craniomaxillofacial traumatic soft tissue defects with blood circulation should be covered with thin split-thickness scalp grafts, but the wound with bone exposure should not be covered. In the second operation, the scar and grafted split-thickness skin should be dissected. Before the expanded flap transfer, the superficial external table of calvaria of exposed bone should be abraded by an osteotome.
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CONCLUSION In summary, tissue expansion is an efficient and valuable technique for the reconstruction of large craniomaxillofacial soft tissue defects resulting from traumas. The novel strategy involves thorough debridement leaving the wound unclosed and adjacent expander implantation in the early stage and expanded flap transposition in the second stage, which can not only achieve satisfactory color, unbulky and well-matched texture similar to the normal, but also can avoid unnecessary donor site injuries. Besides, it also shortens the overall therapeutic time, decreases the number of operations, and reduces the expense. However, the infection risk should be evaluated reasonably according to the wound conditions so as to reduce it to the minimum.
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2017 Mutaz B. Habal, MD
Copyright © 2017 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
