Local Flaps in Facial Reconstruction

646
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 24-6  ■  Galeal relaxing incisions allow greater stretching of scalp tissue. Incisions are made cautiously to avoid major vessels.
A, Artist’s depiction. B, Intraoperative view.
Galea
Subcutaneous
tissue
Galea
Periosteum
A
B

24  RECONSTRUCTION OF THE SCALP
647
provide temporary immediate coverage of a scalp defect
while the patient is being prepared for a more definitive
repair with an expanded local flap or microsurgical free
flap. Skin grafts may be useful in assisting with the closure
of secondary defects, which are frequently located in a
less visible area of the scalp, such as the occiput. A skin
graft may be indicated when patients have a high risk of
local recurrence after removal of a scalp malignant neo­
plasm. In such instances, repair with a scalp flap is per­
formed at some time in the future after the major risk of
recurrence has passed. In most cases, the subsequent
removal of the skin graft is accomplished by serial exci­
sions or a single excision followed by a scalp flap with or
without prior tissue expansion. Ideally, skin grafts should
be placed over viable pericranium, muscle, or fascia.
When a sizable area of exposed bone without periosteum
is present, an adjacent pericranial, temporoparietal fascial,
or muscle flap can be used to cover the exposed bone and
serve as a vascularized recipient site for the skin graft.
FIGURE 24-7  ■  Repair of large scalp and forehead defect with
split-thickness skin graft. Note crusting and ulceration in supe­
rior aspect of graft.
FIGURE 24-8  ■  A, A 3.5 × 5-cm defect of anterior scalp. B, Wound closed primarily by bilateral wide undermining of scalp in subgaleal
plane. Standing cutaneous deformity of forehead resulting from wound closure left undisturbed. C, Postoperative result at 3 months.
No revision surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
C
Some skin grafts may even survive over denuded cranium,
although certainly this is considerably less reliable and
more prone to subsequent traumatic ulceration even
when the graft is successful. As with secondary intention
healing, there may be some benefit to removing the outer
cranial table to allow contact of the skin graft with the
diploic space and its vasculature or to allow the wound
to granulate before the graft is placed. The best locations
for use of a skin graft to repair defects of the scalp are on
the vertex in a balding patient and on the forehead. Use
of skin grafts should be limited in patients who require
postoperative radiation therapy because of the propensity
of the graft to break down during or after radiation
treatments.
LOCAL FLAPS
Scalp flaps can be designed as advancement, pivotal, or
interpolated.9 Unlike in other regions of the face, there
are no relaxed skin tension lines in the scalp. Thus, inci­
sions can be positioned to maximize vascular supply and
tissue recruitment. The principal anatomic landmark that
the surgeon should be cognizant of during flap design is
the anterior hairline. All incisions in the scalp should be
made parallel to the direction of hair growth to minimize
hair follicle injury. Electrocautery should be used judi­
ciously for the same reason.
Advancement flaps have limited usefulness for recon­
struction of the scalp because of the inelasticity of scalp
tissue. Primary closure of a linear wound is in essence
two large opposing advancement flaps. Primary wound
closure can typically be used to repair small (3 cm or less)
scalp defects (Fig. 24-8). The most useful flap employed
for the repair of the majority of scalp defects is a rotation
flap15-18 (Figs. 24-9 and 24-10). The curvilinear incision
necessary to create a rotation flap is well suited to the
spherical shape of the cranium. Even relatively small
defects require a rather long flap incision. Rotation scalp
flaps are designed four to six times as long as the defect
is wide. The incision is beveled to parallel the direction
of growth of the hair follicles to minimize alopecia along
the incision. For defects located in the anterior scalp, the

648
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 24-9  ■  Length of border of rotation flap is four to six times width of defect. Wide undermining of scalp is required. A, Large
defect of parietal scalp after excision of basal cell carcinoma. B, Drawing depicting rotation flap designed for repair. C, Single rota­
tion flap designed for repair of defect. D, Postoperative result.
A
B
C
D

24  RECONSTRUCTION OF THE SCALP
649
A
B
C
D
E
F
FIGURE 24-10  ■  Border of flaps should be at least four to six times width of defects. Back cuts reduce wound closure tension but
narrow base. Secondary defect can be covered by skin graft or may heal by secondary intention.
Continued

650
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
Split-thickness
skin graft
G
H
I
J
K
FIGURE 24-10, cont’d

24  RECONSTRUCTION OF THE SCALP
651
near the base. This is often in a more inconspicuous site
than the primary defect and can heal by secondary inten­
tion (see Fig. 24-10) or be covered with a skin graft if
closure by advancement of adjacent tissue is not possible.
If the skin graft cannot be adequately covered with hair
styling, it may be removed at a later date after the flap
has healed and the scalp has relaxed to its natural state
through the process of tissue creep. If the defect is near
or involves the anterior hairline, the rotation flap should
be designed so that the hairline is restored as naturally as
possible (see Fig. 24-11). It is also helpful to bevel the
flap edges bordering the hairline, preserving the underly­
ing follicles. This facilitates the growth of hair through
the incision line in a trichophytic fashion that assists with
camouflaging the scar line.
Frequently, it may be beneficial to employ multiple
rotation flaps simultaneously (Fig. 24-12). This has the
advantage of distributing wound closure tension over a
larger area of the scalp. It also enables the recruitment of
scalp for repair of the wound from multiple donor areas
(Fig. 24-13). This in turn allows the use of smaller flaps
that do not span a large expanse of convex bone, which
has the effect of increasing wound closure tension. The
use of multiple flaps also allows the recruitment of tissue
from areas of the scalp with more tissue elasticity, such as
scalp covering the occiput and the temporalis muscle. The
primary disadvantage of using multiple rotation scalp
flaps to repair a defect is the greater number of incisions
required, each with the potential for development of alo­
pecia. Multiple rotation flaps are especially well suited for
repair of scalp defects of the vertex (Fig. 24-14). For cen­
trally located scalp defects, two rotation flaps may be
designed to pivot from either opposite directions or the
same direction (Fig. 24-15). Three rotation flaps may be
used concurrently to repair central defects of the anterior
or posterior scalp. All three flaps are designed to pivot in
incision is designed to follow the hairline whenever pos­
sible (Fig. 24-11). Keeping with the concept of recon­
structing different aesthetic regions of the face with
independent flaps, defects that involve the forehead and
hair-bearing scalp should be repaired with separate flaps.
One flap is used to reconstruct the scalp component of
the defect, and a separate flap is used to repair the fore­
head component of the defect. This approach will place
the borders of the flaps along the aesthetic boundary of
the anterior hairline to maximize scar camouflage. Scalp
flaps should be elevated in the subgaleal plane in most
cases, and the surrounding scalp must be widely under­
mined in the same tissue plane to distribute wound
closure tension over a wide area. As the flap is pivoted
into the defect, tension develops from the tip of the flap
to its base over the convex cranium. On occasion, a
“relaxing” incision or back cut extending from the base
of the flap may be helpful to reduce the tension (see Fig.
24-10). A back cut has the effect of reducing the width
of the pedicle of the flap. Thus, care should be taken so
that the back cut does not compromise the flap’s vascular­
ity. The surgeon should resist the temptation to excise
standing cutaneous deformities that develop with flap
movement because doing so has the same effect as a back
cut in reducing the width of the base of the flap. Even
large standing cutaneous deformities will diminish sig­
nificantly over time. If necessary, the deformity can be
excised at a later date without jeopardizing the vascularity
of the flap. Transfer of the flap is typically best accom­
plished by first pivoting the flap into the defect and sutur­
ing the leading border of the flap in place. The curvilinear
border of the flap is sutured next, using the principle of
halves to distribute the inequity of the lengths of the
border of the flap and the peripheral border of the wound.
Depending on the size of the flap and the degree of pivot­
ing, a secondary defect of considerable size may develop
FIGURE 24-11  ■  A, Defect in left hair-bearing temple. Bilateral rotation flaps designed for repair. B, Wound repaired. Incisions designed
as trichophytic to allow hair growth through incision scar. C, Postoperative result with well-concealed scar.
A
B
C

652
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 24-12  ■  Two rotation flaps used for O-Z wound repair. A, Defect of scalp vertex. Broken lines represent two opposing rotation
scalp flaps, each pivoting in counterclockwise direction. B, Postoperative result.
A
B
FIGURE 24-13  ■  Multiple rotation flaps for repair of defect of scalp vertex in hair-bearing area. A, A 6-cm scalp defect. Rotation flaps
designed for O to Z wound repair. B, Postoperative result.
A
B

24  RECONSTRUCTION OF THE SCALP
653
FIGURE 24-14  ■  A, Melanoma of posterior parietal scalp marked by circle. Two rotation flaps pivoting in clockwise direction designed
for O to Z wound repair. B, C, Melanoma excised and flaps incised, undermined, and pivoted toward defect. D, Wound repaired.
E, Postoperative result at 3 months. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
E

654
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
(Fig. 24-17). More recent reports have shown that these
flaps are useful for reconstruction of scalp defects up to
9 × 12 cm.20 The three-flap technique described by Orti­
cochea may be particularly useful in patients who cannot
tolerate a prolonged anesthesia required for repair with
a microsurgical flap or who desire optimal aesthetic
reconstruction with hair-bearing flaps and are unwilling
to undergo prolonged tissue expansion of the scalp. The
the same direction as in a pinwheel (Fig. 24-16). Whether
one or more rotation flaps are used, undermining of the
scalp must be extensive, typically extending from ear to
ear and from forehead to occiput.
Large defects of the scalp can also be repaired with
multiple transposition flaps that essentially involve the
entire scalp. First described by Orticochea in 1967,19
these flaps have proved useful in selected patients
FIGURE 24-15  ■  A, Large full-thickness defect including periosteum of anterior scalp. Two rotation flaps designed for repair. Anterior
flap designed to recruit forehead skin. B, Postoperative result.
A
B
FIGURE 24-16  ■  Three-flap “pinwheel” technique. Three separate rotation flaps, equally positioned around defect, raised and pivoted
in same direction. Wound closure is analogous to closing camera lens aperture.

24  RECONSTRUCTION OF THE SCALP
655
FIGURE 24-17  ■  Three-flap technique of Orticochea for repair of
large forehead defect.
A
C
B
D
E
G
H
F
technique of Orticochea can be combined with simulta­
neous cranial vault reconstruction; however, microsurgi­
cal tissue transfer has become so reliable and versatile
that many would consider a microsurgical flap to be a
better option when significant bone reconstruction is
required.21 If multiple scalp flaps are being considered for
repair of a defect after an oncologic resection, the surgeon
should be confident that the surgical margins are free of
persistent tumor because recurrent disease beneath the
flaps may be difficult to detect.
The three-flap technique of Orticochea mandates that
the entire scalp be undermined in the course of dissection
and transfer of the flaps (Fig. 24-18). Multiple transposi­
tion flaps are particularly useful for reconstruction of
defects that involve the anterior scalp and hairline. The
technique typically involves the creation of three or four
flaps, but a two-flap technique may occasionally be
employed22 (Fig. 24-19). An advantage of transposition
flaps as described is that they allow the transfer of hair-
bearing scalp to more visible areas in the anterior and
temporal regions; the posterior donor sites can be covered
with a skin graft. Less visible areas of the posterior scalp
that are devoid of hair after flap transfer can sometimes be
corrected by hair transplantation. Prolonged controlled
tissue expansion can be combined with transposition flaps
to facilitate the repair of large scalp defects.23
Scalp advancement flaps play a limited role in scalp
reconstruction principally because the inelastic nature of
the scalp limits their usefulness. Advancement flaps can
be useful for repair of small (3 cm or less) defects located
in the lateral scalp. Because the scalp is loose in this area
relative to the more central scalp, advancement flaps can
be stretched sufficiently to repair defects (Fig. 24-20).
This is especially true if two advancement flaps are com­
bined to reconstruct the defect. Advancement of scalp
tissue to repair a relatively linear defect (Fig. 24-21) is
also required whenever a scalp wound is closed primarily.
Galeal relaxing incisions are used if necessary to achieve
wound closure. All wound closing tension should be born
by the galeal sutures to minimize trauma to the hair
follicles.
REGIONAL FLAPS
On occasion, regional pedicled musculocutaneous flaps
or muscle flaps may be necessary for reconstruction of
extensive scalp defects. These flaps are largely confined
to the repair of defects of the inferior occipital or tem­
poral regions of the scalp because of the limited reach of
their vascular pedicles. Several authors have reported
success with trapezius and latissimus dorsi musculocuta­
neous flaps for reconstruction of large defects in these
areas.24-26 Regional flaps do not provide hair-bearing
tissues and they have significant donor site morbidity.
TEMPOROPARIETAL FASCIA FLAP
The temporoparietal fascia flap or fasciocutaneous flap
is useful for reconstruction of selected scalp and facial
Text continued on p. 660

656
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 24-18  ■  Three-flap technique of Orticochea for repair of large posterior scalp defect.
A
B
C
D
E
F
G
H

24  RECONSTRUCTION OF THE SCALP
657
FIGURE 24-19  ■  Two-flap Orticochea technique for traumatic anterior scalp defects. A, Traumatic anterior scalp defect. B, Drawing
depicting design of two transposition flaps. C, Flaps raised and surrounding scalp widely undermined. D, Flaps transposed, restoring
anterior hairline. (Courtesy of John Frodel, MD.)
A
A
B
B
C
D

658
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 24-20  ■  A-D, Bilateral or unilateral advancement scalp flaps can be effective in repair of small (less than 3 cm) defects in
lateral areas of scalp.
A
B
C
D

24  RECONSTRUCTION OF THE SCALP
659
FIGURE 24-21  ■  Longitudinal defects of scalp may be repaired with large, bilateral advancement flaps. Wide undermining is required,
and galeal relaxing incisions made parallel to long axis of defect will help reduce wound closure tension. A, A 10-cm-long cerebri­
form nevus of scalp. B, Drawing depicting primary wound repair with galeotomies (broken lines) to assist in wound closure.
C, Nevus excised and wound repaired with bilateral advancement flaps.
A
B
C

660
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
defects.2,5,27, 28 This flap is supplied by branches of the
superficial temporal artery and vein and can be raised as
a pedicled flap measuring as large as 14 × 17 cm. The
temporoparietal fascia flap can be designed in many dif­
ferent forms: local pedicled flap, microsurgical flap, or
composite flap containing underlying bone or overlying
hair-bearing scalp. The course of the temporal artery that
supplies the flap is variable and tortuous. Because the
vessel must be included in the pedicle of the flap, it
should be carefully mapped with a Doppler probe before
the flap is designed or a local anesthetic is injected. Flaps
can be based on either the anterior or posterior branches
of the temporal artery. Most often, a flap that includes
the hair-bearing scalp will be based on the posterior
branches of the temporal artery so that the donor site is
hidden posteriorly and less likely to distort the anterior
hairline. Hair-bearing flaps may require controlled tissue
expansion of the adjacent scalp to allow closure of the
secondary defect created by the flap.27 A temporoparietal
fascia flap may also be used as a pure fascial flap that can
provide coverage of exposed bone with well-vascularized
tissue to support a skin graft.
MICROSURGICAL TISSUE TRANSFER
In recent years, free tissue transfer has become a reliable
technique for the repair of large head and neck defects.
Microsurgical flaps are now considered by many to be the
best option for reconstruction of extensive scalp defects,
especially those that require cranial vault reconstruc­
tion.21,29-33 Microsurgical techniques enable the transfer
of large flaps of soft tissue and skin to the scalp with a
high degree of success. Such flaps are resilient during
postoperative radiation therapy. The most commonly
employed microsurgical flaps for scalp reconstruction are
the latissimus dorsi (Figs. 24-22 and 24-23), scapula,
rectus abdominis, radial forearm (Fig. 24-24), and antero­
lateral thigh flaps.34-38 The latissimus flap has enjoyed the
most widespread use because of its flexibility, long and
large-caliber vascular pedicle, large surface area, and
relatively minor donor site morbidity. The anterolateral
thigh flap shares similar advantages with the latissimus
flap and is gaining use in repair of extensive scalp
defects.36,38 Although muscle flaps tend to be bulky ini­
tially, the muscle component of the flap atrophies over
time, ultimately providing a natural contour and thick­
ness comparable to normal scalp. The greatest disadvan­
tage of microsurgical flaps used for scalp reconstruction
is the lack of hair replacement. However, this aesthetic
concern is typically secondary in patients with extensive
and critical scalp and cranial bone defects. The reliability,
flexibility, and durability of microsurgical flaps make
them invaluable for repair of extensive scalp wounds.
ADJUVANT TECHNIQUES
Controlled Tissue Expansion
Although the subject of tissue expansion is covered in
detail in Chapter 25, the specific application of tissue
expansion for scalp reconstruction is important to discuss
as part of this chapter. Prolonged controlled tissue expan­
sion has played an important role in the management of
large scalp defects for decades.23,39-44 Tissue expansion
enables the creation of large, well-vascularized hair-
bearing scalp flaps.45,46 Although microsurgical tissue
transfer can provide large robust flaps, these flaps are less
desirable than scalp flaps because they do not possess
hair-bearing tissue. Prolonged tissue expansion induces
profound metabolic and physical changes in the expanded
scalp. Tissue expansion is a process that takes weeks or
months to complete, and considerable mechanical stress
in the form of tension is placed on wound margins and
tissues surrounding the defect. Therefore, tissue expan­
sion is applicable only to stable, healed wounds or as a
preliminary stage before the resection of a scalp lesion.
This greatly limits the applications in acute traumatic
wounds or in many oncologic cases, in which a long delay
before resection is inadvisable.
In many ways, the scalp is the ideal tissue to use expan­
sion. The cranium provides a smooth and firm base on
which the expander can rest. The scalp is thick and
vascular and hence is resistant to excessive thinning
and tissue breakdown, which could expose the expander
or allow it to extrude in later stages of expansion. The
advantages of tissue expansion are many: the surface area
of a flap can be greatly increased, the vascularity of the
flap is enhanced, and the thinning of the tissue in the later
stages of expansion makes the flaps more malleable and
elastic. Hair follicles are somewhat vulnerable to the
physical and metabolic stresses of expansion. However,
most alopecia resulting from prolonged tissue expansion
is temporary. Hair density does decline during expansion
because the number of hair follicles remains the same as
the scalp surface area increases. The capsule that forms
around the expander contains large numbers of myofi­
broblasts that may lead to some contraction of the flap
after expanders have been removed and flaps transferred.
Therefore, conservative resection of the capsule may be
advisable when the expander is removed as long as the
vascularity of the flap is not compromised.
The most significant disadvantages of prolonged con­
trolled tissue expansion of the scalp are the time required
for expansion, the discomfort, the temporary deformity
of the scalp, and the need for multiple surgeries and
frequent office visits. Careful preoperative planning is
essential. As multiple scalp flaps are often beneficial in
reconstruction of the scalp, multiple expanders are fre­
quently employed.23 An expander is commonly placed on
each side of the head so that large bilateral advancement
flaps can be created. Expanders should be selected that
have a shape similar to the intended flap design. Because
the majority of scalp flaps are designed as rotation flaps,
a crescent-shaped or oval expander is frequently the most
appropriate configuration. An expander with an easily
palpable remote injection port is used. The injection port
is placed where it is readily palpable through the thick
scalp and in a location that will be the most comfortable
for the patient. When planning the placement of a tissue
expander, the surgeon should keep in mind where flap
incisions will be located and use a portion of the planned
border of the flap as the access incision for placement of

24  RECONSTRUCTION OF THE SCALP
661
FIGURE 24-22  ■  Microsurgical flap reconstruction. A, Full-thickness defect of parietal and occipital scalp with exposed bone flap.
B, Reconstruction with latissimus dorsi microsurgical muscle flap covered with split-thickness skin graft. C, Postoperative result at
9 months. (Courtesy of Neal Futran, MD, DDS.)
A
B
C

662
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 24-23  ■  Microsurgical flap reconstruction of anterior scalp defect. A, Defect with exposed cranial bone. Initial attempts at
stimulating granulation tissue in anticipation of using skin graft for repair were unsuccessful. B, Postoperative result at 6 months
after repair with latissimus dorsi muscle microsurgical flap and split-thickness skin graft. Note thinness of flap from denervated
muscle.
A
B
FIGURE 24-24  ■  Radial forearm microsurgical flap repair after resection of radiation necrosis and osteomyelitis of posterior skull.
A, Defect with exposed necrotic outer table bone. B, Radial forearm microsurgical flap in place.
A
B

24  RECONSTRUCTION OF THE SCALP
663
expanded during the course of approximately 2 months.
Once the expansion was complete, the expanders were
removed, the scar tissue was excised, and hair-bearing
advancement flaps were developed and used to close the
defect.
Intraoperative Tissue Expansion
Intraoperative tissue expansion is a process in which scalp
tissue is sequentially and rapidly stretched in one setting
for a period of a few minutes immediately before a flap
is raised and transferred. Three cycles of expander infla­
tion lasting 3 minutes each are typically employed with a
the expander. The expander is most commonly placed
under the galea and on top of the periosteum. Two weeks
after insertion of the expander, inflation is commenced.
Progressive inflation is performed once or twice a week
until sufficient tissue expansion has been achieved. At
that point, the expander is removed and flaps are created
and transferred. In this manner, large scalp defects can
be repaired with hair-bearing flaps with a high degree of
success. An example of this surgical approach is shown in
Figure 24-25. A large anterior traumatic scalp wound was
initially managed with a pericranial flap and secondary
intention healing. After the wound had healed, two
expanders were placed on either side of the defect and
FIGURE 24-25  ■  Large anterior traumatic scalp wound. Wound was initially managed with pericranial flap and secondary intention
healing. After healing, tissue expanders were placed on either side of defect and expanded for 2 months. Subsequently, expanders
were removed, scar tissue was excised, and hair-bearing advancement flaps were developed and used to close the defect. A, Trau­
matic defect with exposed bone. B, Tissue expanders in place at conclusion of expansion process. Expander locations marked by
X’s. C, Postoperative result at 3 months after reconstruction with expanded scalp advancement flaps.
A
X
B
X
C

664
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
this technique offers any advantage over well-designed
and widely undermined flaps remains uncertain.
Continuous External Tissue Expansion and
Wound Closure
A recent innovation in complex wound closure is the
introduction of an external wound closure device.12,50
Skin anchors are applied to the perimeter of the wound,
and the device is attached to the anchors with heavy
nylon threaded radially around the wound (Fig. 24-27).
rest period between inflations. The expander is inflated
until tissue blanching is observed. In contrast to pro­
longed controlled tissue expansion, intraoperative rapid
expansion causes mechanical changes in the tissue rather
than metabolic and physiologic changes. Many have
argued that this merely represents a way of facilitating
undermining of tissues,47,48 whereas others have champi­
oned its use.7,49 Intraoperative tissue expansion can be
employed with fresh scalp defects because it does not
place the same requirements on the tissues that pro­
longed controlled expansion does (Fig. 24-26). Whether
FIGURE 24-26  ■  Intraoperative tissue expansion. A, Defect of parietal scalp. B, Intraoperative tissue expansion with large Foley catheter
placed under designed flap. C, Wound closed with expanded flap. D, Postoperative result.
A
B
C
D

24  RECONSTRUCTION OF THE SCALP
665
The nylon thread is then tightened; continuous tension
on the wound perimeter facilitates gradual wound closure.
The device is designed to apply sufficient tension to allow
mechanical tissue creep without causing wound necro­
sis.50 The wound closure process typically takes 1 to 2
weeks (Fig. 24-28). Although it is likely that most of the
FIGURE 24-27  ■  External wound closure with intermediate tissue
expansion device. (Courtesy of Wound Care Technologies, Inc.)
FIGURE 24-28  ■  Wound closure with external tissue expander and wound closure device. A, A 5.0 × 9.5-cm scalp wound after excision
of cutaneous malignant neoplasm. B, Application of wound closure device with partial closure. C, Wound closure at conclusion of
expansion and removal of device. D, Final result. (Courtesy of Ashley O’Reilly, MD.)
A
B
C
D
benefit obtained with this device is mechanical in nature,
the time involved in wound closure, specifically 1 to 2
weeks, may allow some physiologic response as well. Any
physiologic response that may occur certainly is not to
the extent observed with prolonged tissue expansion.
These devices may offer some advantages in the closure
of defects deemed too large for traditional advancement
flaps, although more clinical experience is required.
Hair Transplants
Widely accepted in the management of baldness, hair
transplants can also be a valuable adjunct in scalp recon­
struction.51,52 Successful hair transplantation requires a
vascular recipient site, and as such, hair transplants should
rarely be used acutely in the management of a scalp
defect. Rather, they are planned as a secondary proce­
dure. Wounds that have healed by secondary intention
rarely contain hair. However, these wounds will support
hair transplants once they are healed and the resulting
scar has matured (Fig. 24-29). Similarly, areas of alopecia
resulting from incisional scars or from excessive wound
closure tension can be managed secondarily with hair
transplantation by minigrafts or micrografts. Typical of
hair replacement surgery, multiple stages of grafting are
required, with each stage separated by several months of

666
SECTION II  RECONSTRUCTION OF FACIAL STRUCTURES
FIGURE 24-29  ■  Traumatic scalp wound initially allowed to heal by secondary intention. After healing, three hair grafting procedures
separated by intervals of 3 months were performed in scar area. A, Scar after secondary intention healing. B, Hair grafts. C, Nine
months after final hair grafting procedure.
A
B
C
healing. With patience, even large areas of alopecia can
be restored to an acceptable hair density.
SUMMARY
Defects of the scalp are inherently difficult to repair
because of the inelastic nature of the scalp, the convexity
of the cranium, and the limited availability of hair-bearing
tissues. Small and moderately sized defects are most
commonly repaired with either single or multiple rota­
tion flaps. Large, full-thickness defects are often best
managed with microsurgical tissue transfer. Prolonged
tissue expansion is a valuable adjunct to scalp reconstruc­
tion when the repair can be anticipated or delayed, and
newer external wound closure devices hold promise.
With careful planning and execution, even large and
complex defects can be managed successfully.
REFERENCES
1. Jurkiewicz MJ. Scalp reconstruction with multiple flaps. In: Brent
B, editor. The artistry of reconstructive surgery. St. Louis: CV
Mosby; 1987.
2. Bekara F, Yachouch J, Ziade M, et al. Reconstruction of anterior
scalp defect with V-Y advancement flap pedicled on the temporal
fascia superficialis. J Craniofac Surg 2012;23:1434.
3. Higgins KM, Ashford B, Erovic BM, et al. Temporoparietal fascia
free flap for pharyngeal coverage after salvage total laryngectomy.
Laryngoscope 2012;122:523.
4. Duvdevani S, Magnitz R, Siegert R. Sulcus construction in microtia
repair: a retrospective comparison of different techniques. Arch
Facial Plast Surg 2012;22:1.
5. Jacquet Y, Higgins KM, Enepekides DJ. The temporoparietal
fascia flap: a versatile tool in head and neck reconstruction. Curr
Opin Otolaryngol Head Neck Surg 2011;19:235.
6. Becker GD, Adams LA, Levin BC. Secondary intention healing of
exposed scalp and forehead bone after Mohs surgery. Otolaryngol
Head Neck Surg 1999;121:751.
7. Mandy SH. Intraoperative expander-assisted scalp reduction.
J Dermatol Surg Oncol 1993;19:1110.
8. Ling EH, Wang TD. Local flaps in forehead and temporal recon­
struction. Facial Plast Surg Clin North Am 1996;4:469.
9. Marathe US, Sniezek JC. Use of vacuum-assisted closure device in
enhancing closure of a massive skull defect. Laryngoscope 2004;
114:961.
10. Chaouat M, Lalanne B, Levan P, Mimoun M. Skin expansion and
external extension techniques in the treatment of a traumatic scalp
defect. Scand J Plast Reconstr Surg Hand Surg 2002;36:50.
11. Cox AJ, Wang TD, Cook TA. Closure of a scalp defect. Arch Facial
Plast Surg 1999;1:212.
12. O’Reilly AG, Schmitt WR, Roenigk RK, et al. Closure of scalp and
forehead defects using external tissue expander. Arch Facial Plast
Surg 2012;14:419.
13. Newman MI, Hanasono MM, Disa JJ, et al. Scalp reconstruction:
a 15 year experience. Ann Plast Surg 2004;52:501.
14. Seline PC, Siegle RJ. Scalp reconstruction. Dermatol Clin 2005;
23:13.
15. Hoffmann JF. Management of scalp defects. Otolaryngol Clin
North Am 2001;34:571.
16. Lesavoy MA, Dubrow TJ, Schwartz RJ, et al. Management of large
scalp defects with local pedicle flaps. Plast Reconstr Surg 1993;
91:783.
17. Ahuja RB. Geometric consideration in the design of rotational flaps
in the scalp and forehead region. Plast Reconstr Surg 1988;81:900.
18. Terkonda RP, Sykes JM. Concepts in scalp and forehead recon­
struction. Otolaryngol Clin North Am 1997;30:519.
19. Orticochea M. Four flap scalp reconstruction technique. Br J Plast
Surg 1967;20:159.
20. Orticochea M. Three flap scalp reconstruction technique. Br J Plast
Surg 1971;24:184.
21. Beasley NJ, Gilbert RW, Gullane PJ, et al. Scalp and forehead
reconstruction using free revascularized tissue transfer. Arch Facial
Plast Surg 2004;6:16.
22. Frodel JL, Ahlstrom K. Reconstruction of complex scalp defects.
Arch Facial Plast Surg 2004;6:54.

24  RECONSTRUCTION OF THE SCALP
667
23. Bauer BS, Margulis A. The expanded transposition flap: shifting
paradigms based on experience from two decades of pediatric tissue
expansion. Plast Reconstr Surg 2004;114:98.
24. Lynch JR, Hansen JE, Chaffoo R, Seyfer AE. The lower trapezius
musculocutaneous flap revisited: versatile coverage for complicated
wounds to the posterior cervical and occipital regions based on the
deep branch of the transverse cervical artery. Plast Reconstr Surg
2002;109:444.
25. Tanaka Y, Miki K, Tajima S, et al. Reconstruction of an extensive
scalp defect using the split latissimus dorsi flap in combination
with the serratus anterior musculo-osseous flap. Br J Plast Surg
1998;51:250.
26. Har-El G, Bhaya M, Sundaram K. Latissimus dorsi myocutaneous
flap for secondary head and neck reconstruction. Am J Otolaryngol
1999;20:287.
27. Kim JC, Hadlock T, Varvares MA, Cheney ML. Hair-bearing
temporoparietal fascial flap reconstruction of upper lip and scalp
defects. Arch Facial Plast Surg 2001;3:170.
28. Tellioglu AT, Tekdemir I, Erdemli EA, et al. Temporoparietal
fascia: an anatomic and histological reinvestigation with new poten­
tial clinical applications. Plast Reconstr Surg 2000;105:40.
29. Lipa JE, Butler CE. Enhancing the outcome of free latissimus dorsi
muscle flap reconstruction of scalp defects. Head Neck 2004;26:46.
30. Wax MK, Burkey BB, Bascom D, Rosenthal EL. The role of free
tissue transfer in the reconstruction of massive neglected skin
cancers of the head and neck. Arch Facial Plast Surg 2003;5:479.
31. Hussussian CJ, Reece GP. Microsurgical scalp reconstruction in the
patient with cancer. Plast Reconstr Surg 2002;109:1828.
32. Anderson PJ, Ragbir M, Berry RB, McLean NR. Reconstruction
of the scalp and cranium using multiple free-tissue transfers follow­
ing recurrent basal cell carcinoma. J Reconstr Microsurg 2000;16:89.
33. Lutz BS, Wei FC, Chen HC, et al. Reconstruction of scalp defects
with free flaps in 30 cases. Br J Plast Surg 1998;51:186.
34. O’Connell DA, Teng MS, Mendez E, Futran ND. Microvascular
free tissue transfer in the reconstruction of scalp and lateral tem­
poral bone defects. J Craniofacial Surg 2011;22:801.
35. Park CW, Miles BA. The expanding role of the anterolateral thigh
free flap in head and neck reconstruction. Curr Opin Otolaryngol
Head Neck Surg 2011;19:263.
36. Kwee MM, Rozen WM, Ting JW, et al. Total scalp reconstruction
with bilateral anterolateral thigh flaps. Microsurgery 2012;32:393.
37. Sweeny L, Eby B, Magnuson JS, et al. Reconstruction of
scalp defects with the radial forearm free flap. Head Neck Oncol
2012;4:21.
38. Park JH, Min KH, Eun SC, et al. Scalp free flap reconstruction
using anterolateral thigh flap pedicle for interposition artery and
vein grafts. Arch Plast Surg 2012;39:55.
39. Gurlek A, Alaybeyoglu N, Demir CY, et al. Aesthetic reconstruc­
tion of large scalp defects by sequential tissue expansion without
interval. Aesthetic Plast Surg 2004;28:245.
40. Bilkay U, Kerem H, Ozek C, et al. Alopecia treatment with scalp
expansion: some fine points and a simple modification to improve
the results. J Craniofac Surg 2004;15:758.
41. Hudson DA, Lazarus D, Silfen R. The use of serial tissue expansion
in pediatric plastic surgery. Ann Plast Surg 2000;45:589.
42. Chun JT, Rohrich RJ. Versatility of tissue expansion in head and
neck burn reconstruction. Ann Plast Surg 1998;41:11.
43. Konior RJ, Kridel RWH. Tissue expansion in scalp surgery. Facial
Plast Surg Clin North Am 1994;2:203.
44. Baker SR, Swanson NA. Clinical applications of tissue expansion
in head and neck surgery. Laryngoscope 1990;10:313.
45. Kasper EM, Ridgway EB, Rabie A, et al. Staged soft tissue expan­
sion before delayed allograft cranioplasty: a technical report.
Neurosurgery 2012;71:15.
46. Maillet-DeClerck M, Calibre C, Herbaux B, Duquennoy-Martinoy
V. Long-term results in scalp tissue expansion in children. Eur J
Pediatr Surg 2012;22:269.
47. Shapiro AL, Hochman M, Thomas JR, Branham G. Effects of
intraoperative tissue expansion and skin flaps on wound closure
tension. Arch Otolaryngol Head Neck Surg 1996;122:1107.
48. Siegert R, Weerda H, Hoffman S, et al. Clinical and experimental
evaluation of intermittent intraoperative tissue expansion. Plast
Reconstr Surg 1993;92:248.
49. Sasaki GH. Tissue expanders and general guidelines for tissue
expansion technique. In: Sasaki GH, editor. Tissue expansion in
reconstructive and aesthetic surgery. St. Louis: Mosby; 1998.
50. Santiago GF, Bograd B, Basile PL, et al. Soft tissue injury manage­
ment with a continuous external tissue expander. Ann Plast Surg
2012;69:418.
51. Barrera A. The use of micrografts and minigrafts in the aesthetic
reconstruction of the face and scalp. Plast Reconstr Surg 2003;
112:883.
52. Limmer BL, Buchwach KA. Hair transplantation using follicular
unit micrografting. Facial Plast Surg Clin North Am 1999;7:523.

671
C H A P T E R 2 5 
CONTROLLED TISSUE EXPANSION IN
FACIAL RECONSTRUCTION
Randal W. Swenson
INTRODUCTION
During the past three decades, many reconstructive sur­
gical procedures have been developed or improved, pro­
viding a functional and an aesthetic benefit. Among these,
tissue expansion offers a unique potential to preserve
both form and function. One of the major benefits of
tissue expansion for correction of cutaneous defects is the
ability to use tissue optimally matched in color, texture,
thickness, and hair-bearing qualities. It may also obviate
the need for multiple flaps or grafts and avoids creation
of a second defect at a distant area to correct the primary
deformity. Expansion of tissue is a dynamic process pro­
ducing a dividend of tissue available for flap transfer. A
basic understanding of the physiologic changes that occur
with skin expansion and the techniques of expansion is
imperative for any surgeon performing reconstructive
procedures of the head and neck. Other than rapid intra­
operative tissue expansion, the term tissue expansion is
used in this chapter to refer to the prolonged expansion
of skin during an interval of days to weeks.
HISTORY
Tissue expansion can be a natural physiologic process
encountered in normal life, pregnancy and obesity being
the most obvious examples. This process has been used
for centuries in certain cultures to modify facial features
as illustrated on the pages of National Geographic maga­
zine. Modern use of tissue expansion was first introduced
in the early 1900s. A technique was described that used
progressively larger objects to expand tissue with multi­
ple operations required.1 Because of the number of pro­
cedures required and the high morbidity, the procedure
was abandoned. The practical application of tissue expan­
sion was not possible until the introduction of plastic
materials later in the century. In 1957, Neumann pub­
lished “The Expansion of an Area of Skin by Progressive
Distension of a Subcutaneous Balloon.” This article
described the use of a latex balloon to expand the skin for
reconstruction of an ear.2 He placed the balloon above
the ear in a subcutaneous tissue pocket and brought a
polyethylene tube out through an independent skin inci­
sion. He gradually injected air into the implant through
a stopcock. His procedure was a success, but the potential
impact of his work was not recognized at the time. No
other work was performed on tissue expansion for almost
20 years.
In the early 1970s, Radovan and Austed independently
began studying the use of tissue expansion to repair soft
tissue defects. Radovan’s early expanders consisted of a
balloon and two separate tubing systems for injection and
removal of saline. The entire system was placed under
the skin.3 His first experiments were performed in 1976
and were met with skepticism when his results were pre­
sented to the medical community later that year. This was
most likely because of his unscientific methodology. He
was not discouraged by the skepticism and continued his
clinical trials. The results of Radovan’s experiments met
wider acceptance 3 years later accompanied by Austed’s
work using an osmotically driven, self-inflating expander.4
Austed, unaware of Neumann’s and Radovan’s work, first
suggested the idea of implanting a device beneath the
skin to induce tissue expansion in 1975. His work estab­
lished the basis for understanding of the tissue response
to expansion. His early laboratory experience and histo­
logic studies confirmed that tissue expansion is safe and
effective.5
PHYSICAL PROPERTIES AND
MORPHOLOGIC CHANGES
It is important for surgeons performing tissue expansion
to understand the physiologic and morphologic changes
associated with the process. This knowledge will help the
surgeon understand the potential benefits, limitations,
and complications of this procedure. When the technique
of tissue expansion was first introduced, the unanswered
question was whether skin is stretched or new skin is
created. If skin is simply stretched, a permanent gain in
terms of surface area would not occur. Gibson6 studied
the properties of skin and described its inherent extensi­
bility. He noted that skin could stretch beyond its inher­
ent extensibility and called this mechanical creep. The
beneficial effects of mechanical creep are attributed to
displacement of interstitial fluids and mucopolysaccha­
ride ground substance, parallel alignment of randomly
oriented collagen fibers, and migration of tissue into the
field by the stretching force.
He referred to biologic creep as the gradual stretching
of skin overlying a slowly expanding subcutaneous

672
SECTION III  ADJUNCTIVE SURGERY
FIGURE 25-1  ■  A, Biopsy specimen of nonexpanded skin. B, Biopsy specimen of expanded skin in same area. Note that thickness of
epidermis is maintained.
A
B
structure. This is not simple stretching because the skin
is affected by metabolic activity, including the creation of
epithelium, blood vessels, nerves, lymphatics, collagen,
and elastin fibers. All of this occurs during sustained
prolonged expansion of the skin.
The first experimental studies of skin expansion were
performed by Austed et al5 and Pasyk et al7 using guinea
pigs. They used self-inflating expanders, causing gradual
uninterrupted expansion. Unlike humans, guinea pigs
have loose skin, allowing it to move freely over the muscle
beneath and to be picked up in large folds. These quali­
ties make the guinea pig model less than ideal for under­
standing the effects of expansion on human skin. However,
even with these limitations, their studies provided valu­
able information about tissue expansion. Because pig skin
lacks a well-developed panniculus carnosus and has elastic
tissue comparable with that of humans, it has been used
in place of guinea pig skin for subsequent laboratory
studies of skin expansion.
Epidermis
The epidermis is composed of stratified squamous epi­
thelium of the keratinized type. The epidermis shows no
thinning during or after expansion. In fact, most studies
have noted an increase in thickness during skin expan­
sion. The active basal layer of the epidermis increases in
density and thickness. The basal layer normally composes
10% of the thickness of the epidermis but during expan­
sion increases to 40%. van Rappard et al8 described the
histologic changes found in expanded pig skin. They
observed that during skin expansion, epidermal thickness
increases; however, there is no histologic change in the
layers of the epidermis. Other studies have also demon­
strated that epidermal thickness increases or remains
unchanged during expansion in spite of an obvious
increase in surface area (Fig. 25-1). These findings would
indicate that the epidermis is not merely being stretched.
Using tritiated thymidine labeling, Austed et al9 demon­
strated an increase in the cellular mitotic rate in the
stratum basale of expanded skin and showed a net gain in
donor tissue. van Rappard et al10 confirmed these find­
ings in the pig model. They demonstrated that the
number of epidermal cells for a given surface area
remained the same in expanded and nonexpanded skin.
Initial stretching of the epidermis from inflation of
an expander increases the intercellular spaces, which in
turn probably signals the cells to increase mitotic activity

25  CONTROLLED TISSUE EXPANSION IN FACIAL RECONSTRUCTION
673
FIGURE 25-2  ■  A, Biopsy specimen of nonexpanded skin. Note presence of numerous fat cells. B, Biopsy specimen of expanded skin
in same area. Note absence of fat cells.
A
B
and restore the epidermis to a normal cellular density
and thickness. The increase in mitotic activity caused
by tissue expansion eventually returns to normal but
remains active for as long as 2 months after expansion is
discontinued.
Dermis
The dermis, which is a sheet of connective tissue underly­
ing and supporting the epidermis, is composed of the
papillary layer and the reticular layer. The papillary layer
contains finer collagen fibers than the reticular layer and
contains numerous elastic fibers. The reticular layer is
composed of dense, irregular collagen fibers. The reticu­
lar layer is responsible for the lines of tension. The dermis
does not tolerate expansion as well as the epidermis.
During tissue expansion, a rapid decrease in dermal
thickness is observed and averages 20%.11 Total restora­
tion of dermal thickness after skin expansion has not been
demonstrated. The amount of thinning depends on the
rate of expansion. Greater thinning is noted with more
rapid expansion. The expanded dermis contains large
bundles of collagen fibers and active fibroblasts. An
increase in collagen synthesis occurs in the dermis during
tissue expansion.5 Normal collagen fibers contain bundles
cross-linked at angles of 70°. With expansion, these
angles gradually decrease until the collagen bundles are
almost parallel to the skin surface. This effect is noted
for 6 months after cessation of the expansion process.8
Melanin production increases during skin expansion and
can cause a temporary hyperpigmentation of the skin.
This disappears, in most cases, within a few months.
Olenius et al12 described an increase in the amount of
melanin pigment granules in the basal layers of expanded
human skin.
Subcutaneous Tissue
The subcutaneous tissue is composed of fat, loose con­
nective tissue, collagen, arteries, veins, nerves, lymphat­
ics, hair follicles, and sebaceous glands. The thickness of
the subcutaneous layer is diminished as much as 50%
during prolonged expansion. However, Pasyk et al11
noted the return to greater than normal thickness of the
subcutaneous tissue within 2 years after removal of
expanders in a series of three patients. During skin expan­
sion, there is a marked decrease in the number of fat cells
within the subcutaneous tissue, and those that remain
have less lipid content (Fig. 25-2).11 There is also an
increase in the interlobular spaces and an increase in the

674
SECTION III  ADJUNCTIVE SURGERY
clinical reports of nerve deficits attributed to tissue
expansion. The potential benefit of nerve expansion for
nerve grafting or transposition is promising. Elongation
of peripheral nerves by use of an expander has been suc­
cessful. Manders et al18 described their experience with
expansion of peripheral nerves and made some important
observations. They monitored the intraluminal pressure
of expanders while measuring nerve response to expan­
sion with electroneuromyography. They observed no
neurologic changes in response to expansion if the intra­
luminal pressure of expanders remained below 40 mm
Hg. If higher pressures were used, reduction in axon
potential was immediately noted. They recommend
monitoring of intraluminal pressure of all expanders used
in patients undergoing expansion of peripheral nerves.
Capsule
A dense fibrous capsule develops around tissue expanders
(Fig. 25-4). The capsule is composed of elongated fibro­
blasts that are active in collagen production.5 Granulation
tissue consisting of macrophages, fibroblasts, and lym­
phocytes is first observed, followed by development of a
double-layered capsule within 7 days after an expander is
implanted. The inner layer consists of macrophages and
the outer layer eventually becomes rich in collagen fibers.
collagen content within these spaces. A varying amount
of fat necrosis is also noted. The more rapid the skin
expansion, the greater is the fat necrosis. Restoration of
normal-appearing fat cells after skin expansion is not
observed for as long as 12 months after expansion.8
Hair follicle morphology remains the same during and
after skin expansion. The follicles become separated
during expansion, but the number of follicles remains
unchanged. However, hair shock is common and is mani­
fested by conversion of follicles to their telogen phase,
which results in temporary alopecia. These phenomena
may take several months to recover. Sebaceous glands in
the subcutaneous tissue show little if any change in
response to expansion. However, expansion can cause
blockage of some of the glandular ducts.
Skeletal Muscle
Skeletal muscle is sensitive to tissue expansion. Ultra­
structural changes of expanded muscle occur. An increase
in the number and size of mitochondria, number of vesi­
cles, and amount of sarcoplasm is observed. The number
of muscle cells remains unchanged, but significant thin­
ning of muscle occurs during tissue expansion.8 The stri­
ated pattern of muscle cells decreases, and some cells may
become necrotic. Hyalinization of muscle cells is also
observed and may be followed by calcification in some
cases. The significance of these changes is not fully under­
stood, but expansion may lead to a decrease in muscle
function and strength in the region of tissue expansion.
Sasaki13 has reported visible muscle atrophy and weakness
after tissue expansion, but permanent sequelae are rare.
Blood Vessels
Blood vessels undergo some of the most important
changes during tissue expansion. Tissue expansion stimu­
lates the proliferation of blood vessels, creating highly
vascular tissue (Fig. 25-3). Distention of capillaries is first
noted during tissue expansion, followed by an increase in
the number of venules and arterioles within a few days.
Barium angiography demonstrates a dense vascular
pattern in expanded tissue.14 Stark et al15 demonstrated a
rapid elongation of arteries and veins with no loss of
vessel wall diameter or intimal integrity. They also found
no difference in tolerance to tissue expansion between
arteries and veins. Studies of flap survival, which is depen­
dent on skin vascularity, reveal that flaps raised from
expanded tissue have survival rates comparable to those
of delayed flaps. Cherry et al14 demonstrated that flaps
raised from expanded tissue have a 117% increase in
survival length compared with random pattern flaps
raised in nonexpanded skin. Other authors have described
similar findings.16,17 In essence, expanded skin has char­
acteristics similar to delayed flaps. These studies indicate
that tissue expansion enhances the vascularity of skin and
improves flap survival.
Nerves
Nerve tissue appears to tolerate expansion well without
demyelination or necrosis of nerve tissue. There are no
FIGURE 25-3  ■  Expanded skin demonstrating vascular proliferation.

25  CONTROLLED TISSUE EXPANSION IN FACIAL RECONSTRUCTION
675
inflation. The necessary multiple percutaneous injections
may also traumatize the expanding skin, leading to a
greater risk of complications.
A directional expander has been developed for breast
reconstruction. Becker20 developed a permanent expander
prosthesis for the same purpose. Manders and Friedman21
introduced a differential expander for the treatment of
male pattern baldness. Despite many manufacturers’
modifications, the high technical standards for the devices
have persisted. Their durability has been thoroughly
tested, and their safety is well established.
Hallock22,23 was the first to study durability of expand­
ers in a scientific way. He demonstrated in vitro that
expanders can be overinflated at least 15 times the amount
recommended by the manufacturer before rupture
occurs. From in vivo studies, he concluded that expanders
in the body could be safely overinflated to at least twice
the amount recommended by the manufacturer without
risk of rupture. However, the greater the pressure within
the expander, the greater is the risk for leakage from the
injection port. Nordstrom found that the average pres­
sure necessary for leakage of the injection port is 32 mm
Hg. This may explain reports of volume loss of saline
injected into some expanders. To avoid such leakage, it is
recommended to use the largest expander that can
Histologic remnants of the capsule can be found up to 1
year after removal of an expander, but grossly the capsule
disappears within a few weeks after removal of an
expander. The contribution the capsule makes to the
blood supply of expanded skin is not fully understood,
but in flaps in which capsulectomies have been per­
formed, there appears to be no difference in flap survival
compared with those with intact capsules.19 Myofibro­
blasts are also present in the capsule, and some believe
that leaving the capsule intact may add to stretchback.
The significance and function of the myofibroblasts are
not fully understood.
Summary
The changes that are noted with prolonged skin expan­
sion demonstrate that the skin is not just an elastic mem­
brane but has a dynamic ability to respond to physical
stimuli, resulting in an increase in tissue. Expanded skin
is optimally matched in characteristics to the surrounding
skin. Although the epidermis demonstrates the ability to
generate more tissue in response to expansion, the other
layers of the skin are simply stretched and do not form
new tissue during the expansion process. The formation
of a capsule around an expander aids in strengthening and
thickening of the tissue during the early phase of tissue
expansion. After removal of an expander, tissue is restored
to a natural state and clinically returns to normal thick­
ness and appearance.
TISSUE EXPANSION DEVICES
Because nearly every part of the body has been consid­
ered for tissue expansion, a wide variety of expander
styles, sizes, and shapes have been introduced (Fig. 25-5).
Custom-made expanders can also be used for irregular
defects or unusual areas. The standard Radovan expander
is composed of a Silastic reservoir, a self-sealing injection
port, and connecting tubing. This design remains the
most commonly used system. Expanders with self-
contained injection ports are useful in some situations,
but the injection port may be more difficult to identify,
leading to a greater risk of damage to the expander during
FIGURE 25-4  ■  Example of capsule that forms around tissue
expanders.
FIGURE 25-5  ■  Expanders are available in many sizes and shapes.

676
SECTION III  ADJUNCTIVE SURGERY
site and orientation of the implanted expander cannot
be overemphasized. Preferably, the access incision for
implanting the expander is in an area adjacent to the area
to be reconstructed. For small areas of planned resection
and for scars, the expander can be placed directly beneath
or adjacent to the same area. Inappropriate incisions may
limit the options for reconstruction after skin expansion.
The incision for insertion of the expander is made with
careful consideration of the anticipated flap design and
with respect for preservation of the vascularity and motor
and sensory nerve innervation of the area. Access inci­
sions are usually made at the junction of normal tissue
with the tissue to be replaced. However, incisions should
not be placed in areas of reduced vascularity, such as in
healed skin grafts or burn scars, because there is a high
risk of dehiscence of the incision during expansion.
In developing the subcutaneous tissue recipient pocket
for placement of an expander, it is important not to com­
promise the overlying tissue, which may lead to an
increase in risk of tissue breakdown and extrusion of the
expander. In the face and neck, the implant is placed
beneath the subcutaneous tissue layer of the skin on
muscle or bone. It may also be placed deep to the platys­
mal muscle when the skin is thin or when more bulk is
required for the purpose of reconstruction. For scalp
expansion, the expander is placed in a subgaleal pocket,
leaving the pericranium intact.
It is important to create a sufficiently large subcutane­
ous tissue pocket to accommodate the implant without
causing folds in the expander. The ridges made by folds
may compromise the overlying tissue by creating focal
points of increased pressure, leading to implant extrusion
(Fig. 25-6). If these folds are noticed during inflation, it
is recommended to gently manipulate them to dissipate
the folds. If the area for expansion cannot accommodate
the ideal-sized expander, a smaller expander can be used
and overinflated to compensate for the smaller size.
The injection port of the tissue expander is placed
through the same incision used for insertion of the
expander. A separate subcutaneous tissue pocket several
centimeters removed from the pocket created for the
expander is developed to accommodate the port. Place­
ment should be sufficiently removed from the expander
so that the port can be easily palpated and accessible for
saline injections. Placement must be such that inflation
of the expander will not result in the expander’s covering
the port, preventing further injections. The port should
be placed in an area where the overlying tissue has suf­
ficient thickness to avoid breakdown from repeated injec­
tions. The postauricular skin area over the mastoid should
be avoided. The skin in this area is thin, and there is a
high incidence of tissue breakdown and extrusion when
the port is placed beneath this skin (Fig. 25-7).
The access incision for implanting a tissue expander is
closed in layers with a strong permanent suture for the
deep wound closure. This assists with counteracting
wound closure tension on the incision line during tissue
expansion. After closure of the incision, the expander may
be injected with saline to obliterate the remaining dead
space in the subcutaneous pocket. The volume injected
should not create tension on the suture line. To allow
sufficient healing, inflation of the expander is commenced
reasonably be inserted beneath the planned expansion
area.
EXPANDER SELECTION
Skin of the head and neck is unique because of its variety
of texture, color, and hair-bearing characteristics. This
presents a challenge when replacement of large areas of
skin is necessary. Because the skin of the head and neck
is always visible to the observer, optimal aesthetic recon­
struction of a cutaneous defect is important. Tissue
expansion can increase the availability of local matching
tissue for reconstruction rather than relying on distant
flaps and grafts that may be aesthetically incompatible.
When the shape of an expander is selected, the area
to be reconstructed should be considered. For breast
reconstruction, a round, pear-shaped, or directional
expander is most helpful. For covering a large defect on
the head or neck area, a rectangular expander is pre­
ferred. A crescent-shaped expander has been advocated
for reconstruction of round defects. van Rappard et al24
compared the three most commonly used expander
shapes (i.e., rectangular, round, and crescent) for their
effectiveness. By mathematic calculations, rectangular
expanders provided the most effective gain of surface area
in expanded skin. In clinical situations, the gain in surface
area compared with the area of the expander base is 38%
for rectangular expanders, 32% for crescent-shaped
expanders, and 25% for round expanders.24 Compared
with conventionally shaped expanders, Brobmann and
Huber25 found that less expansion is required to gain suf­
ficient skin for repair when custom-made expanders are
used for reconstruction of irregularly shaped defects.
In determining the appropriate size of an expander,
Radovan26 initially suggested that the expander base be
the same size as the defect to be reconstructed. It was
thought that the surface area of expanded skin would be
twice the area of the base of the expander used. However,
with clinical experience, van Rappard demonstrated that
only a fraction of the expected surface area is actually
gained.24 Gibney27 recommended that the expander base
be 2.3 to 3 times the surface area of the defect to be
closed. This ratio of base size to expected increase in skin
surface area is the generally accepted guideline and has
been supported by van Rappard et al.24
In addition to the size of an expander, there are other
factors that influence the amount of skin gained from
expansion. These factors, described by Gibson6 and Sugi­
hara et al,28 include the amount of undermining per­
formed and the inherent extensibility of the skin. The
response of skin to expansion differs according to the area
of the body expanded and between individuals.
TECHNIQUE
Tissue expanders can often be implanted with local
anesthesia consisting of 1% lidocaine with epinephrine
(1 : 100,000 epinephrine concentration). For larger
expanders, general anesthesia is occasionally required.
The importance of preoperative planning of the incision

25  CONTROLLED TISSUE EXPANSION IN FACIAL RECONSTRUCTION
677
area of the head or neck. When this is the case, a signifi­
cant amount of flap length may be lost when the skin is
advanced because of the convexity. Sufficient skin must
be created to raise a flap that will close both the donor
site and the defect. It is wise to continue skin expansion
to a point at which more skin is available than is neces­
sary. This is especially true for scalp expansion. The
width of the anticipated area to be reconstructed is mea­
sured and skin expansion is continued until the length of
the planned skin flap is three times this measurement.
Expanded skin is measured from the base of the expander
across the dome to the opposite side of the base in the
direction of the linear axis (length) of the planned
advancement flap.
The second surgical stage is performed when suffi­
cient additional skin has been created. Expanded skin
appears to act like a delayed flap, so use of epinephrine
should be avoided in removing expanders and proceeding
with reconstruction. This recommendation is based on
studies by Reinisch and Myers,29 who studied the effect
of epinephrine on delayed and nondelayed random
pattern flaps. The authors found that when 1 : 200,000
concentration of epinephrine was used in dissecting a
flap, the surviving length of nondelayed flaps was
2 weeks after implantation. Injections of isotonic saline
are performed every 1 to 7 days, depending on the volume
injected and the response of the tissue. Too rapid inflation
may thin the tissue and potentially compromise the final
reconstruction.8 Because the goal of expansion is to create
additional skin, sufficient time is required for proper
tissue response.
In a sterile manner, a 23-gauge or smaller needle is
used to inject saline through the injection port. The
larger the needle, the greater is the risk for leakage. Injec­
tion of saline is usually continued until the skin overlying
the expander feels tense or the patient complains of dis­
comfort. If blanching is noted and it does not resolve
after a few minutes, it is recommended that a few milli­
liters of saline be removed until blanching disappears.
Skin perfusion over the expander may be tested by finger
pressure to check capillary refill. Relaxation of the skin
over a recently inflated expander usually begins within 24
hours of injection. Periodic inflation of the expander is
continued until sufficient skin is generated to allow
reconstruction. This generally takes 6 to 12 weeks once
the expansion process is started.
When large defects are reconstructed with the aid of
tissue expansion, it is usually required to advance
expanded skin in the form of a flap over a convex surface
FIGURE 25-6  ■  Exposure of tissue expander resulting from fold
in expander, causing internal pressure point.
FIGURE 25-7  ■  Exposure of injection port placed under postau­
ricular skin.

678
SECTION III  ADJUNCTIVE SURGERY
deflated expanders can be replaced in their subcutaneous
pockets, the flaps advanced beyond the expanders as
much as possible, and the appropriate amount of tissue
removed at the recipient site. Inflation of the expanders
is commenced after a few weeks of healing. Expansion
progresses until sufficient skin is available for coverage of
the remaining area to be removed at the recipient site.
SCALP EXPANSION
The scalp is unique because of its density and the pres­
ence of hair. Defects of the scalp secondary to burns,
those due to avulsion-type injuries (Fig. 25-8), and those
unaffected, whereas that of delayed flaps was significantly
reduced.
The expander is inflated with saline immediately
before removal because it aids in undermining of the
tissue in the process of developing a skin flap. Capsuloto­
mies and sometimes capsulectomies are necessary to
increase the mobility of the flap. It is still uncertain how
much the capsule contributes to the vascularity of the
flap, so limited resection of the capsule is recommended
to avoid vascular impairment. It is important to ensure
that sufficient expanded skin is available to resurface the
anticipated defect. This is confirmed by advancing the
expanded skin into position before removal of any tissue
at the recipient site. In the event of insufficient skin, the
A
B
C
D
FIGURE 25-8  ■  A, Complete avul­
sion of scalp and forehead skin.
B, Avulsed scalp was replaced
as full-thickness graft over peri­
cranium after removal of hair,
galea, and subcutaneous fat.
C, D, Entire scalp graft dies,
leaving eschar. Eschar débrided
anteriorly.

25  CONTROLLED TISSUE EXPANSION IN FACIAL RECONSTRUCTION
679
E
F
G
H
E, F, Supraclavicular fossa and groin skin expanded to provide source for harvesting of full-thickness skin graft
used to cover cranium. G, H, Intraoperative view immediately after covering of cranium with full-thickness skin graft.
FIGURE 25-8, cont’d  ■
resulting from cancer or tumor removal have often been
difficult to correct. The scalp is well suited for expansion
because of its vascularity and thickness. The abundant
vascularity of the scalp allows expedient healing and a low
rate of complications from expansion. Large defects of
the scalp have traditionally been reconstructed with skin
grafts or flaps with little or no hair-bearing skin. Although
this provides coverage of the area, it results in an unac­
ceptable aesthetic appearance (Fig. 25-9). Tissue expan­
sion has enabled the correction of such defects with
hair-bearing skin and has revolutionized scalp recon­
struction, offering results that were previously impossible
to achieve (Figs. 25-10 and 25-11). Defects or deformities
of up to half of the surface area of the scalp can be recon­
structed with expansion of the remaining scalp. Serial
expansion is sometimes necessary. In such instances, the
expander is immediately replaced in a subgaleal pocket
and the expansion process continued after an appropriate
time for the wounds resulting from the most recent pro­
cedure to heal.
Incisions for implantation of scalp expanders are best
placed at the margin of the area planned for resection so
that the incision eventually is at the advancing edge of an
expanded scalp flap. The incision can also be placed
within the area to be resected if the tissue is healthy.
When possible, a radial incision is made at right angles
to the long axis of the expander pocket to prevent tension
on the incision line during expansion. The recipient site
for the expander should be created at an adequate dis­
tance from the access incision to prevent tension on the
suture line and possible tissue breakdown. The expander
is best placed deep to the galea and superficial to the
pericranium. This is a relatively avascular plane that dis­
sects easily during creation of a pocket. This level of
dissection prevents traumatizing of the overlying tissue
and preserves its vascularity.
Kabaker et al30 described the use of expanders for the
treatment of male pattern baldness. They described a
technique for implanting expanders and design of
expanded flaps that created a double Y-shaped wound
closure (Fig. 25-12). This procedure can offer dramatic
results (Figs. 25-13 and 25-14). Other authors have also
described their successful results with this technique, but
proper patient selection is imperative.31 A minimum of 6
Continued

680
SECTION III  ADJUNCTIVE SURGERY
I
J
K
L
I, J, Healed skin graft provided stable covering over cranium to enable patient to wear wig. K, L, Patient fitted
with wig. (Courtesy of Shan R. Baker, MD.)
FIGURE 25-8, cont’d  ■

25  CONTROLLED TISSUE EXPANSION IN FACIAL RECONSTRUCTION
681
deformity in the underlying soft tissue and bone because
of pressure from the expander and the effect of the
capsule. Resorption of bone with thinning of the outer
layer of the calvarium is sometimes observed, creating a
depression after removal of an expander. This deformity
resolves with time (Fig. 25-15).
Figure 25-16 shows a patient who was reconstructed
with use of tissue expansion in multiple surgical stages
for excision of a skin graft on the lateral forehead, temple,
and superior cheek. The skin graft was deforming and
had a poor color match with adjacent facial skin. The
patient was also troubled with breakdown of the graft,
resulting in recurrent ulcerations and poor tissue healing.
Initially, two 250-mL rectangular expanders were
implanted, one beneath the skin of the forehead and one
beneath the parietal scalp. During the expansion process,
the expander under the scalp became exposed because of
a fold in the expander (see Fig. 25-6). Because of this, the
scalp expander was removed prematurely, but sufficient
scalp expansion had been achieved to enable the anterior
advancement of the parietal scalp to restore a normal-
appearing temporal hairline. The forehead expander was
weeks to 2 months of scalp expansion is required before
the transfer of expanded advancement flaps. The patient
must understand the interval required for use of this
method and the physical appearance during the expan­
sion process.
FOREHEAD EXPANSION
The expander is placed in the subfascial plane, deep to
the frontalis muscle and superficial to the periosteum of
the frontal bone, when the skin of the forehead is
expanded. The anatomic location of the temporal branch
of the facial nerve is considered in planning the incisions
for placement of the expander and the design of the sub­
sequent flap used for reconstruction.
Forehead skin can tolerate expansion well because of
its thickness and vascularity. However, expansion of the
forehead usually produces more pain than expansion of
other areas of the head and neck. This limits the rate at
which expansion can be performed. Expansion of the
forehead and scalp often creates a depression or “bathtub”
FIGURE 25-9  ■  A, Scalp scarring resulting from burn. Multiple surgeries had previously been attempted to remove burn scar. Area
was scarred tightly to skull with no mobility of tissue. B, A 250-mL rectangular expander used to create additional hair-bearing scalp.
Patient was able to work full-time during expansion because expander was camouflaged by hairstyle. C, Six months after removal
of expander, resection of scar and advancement of expanded scalp to close defect.
A
B
C
FIGURE 25-10  ■  A, Giant pigmented hairy scalp nevus in a 17-month-old child. B, Two 250-mL rectangular tissue expanders used to
expand contralateral scalp in anticipation of excision of nevus. C, Nevus completely excised. Resulting defect repaired with expanded
scalp advancement flaps. (Courtesy of Shan R. Baker, MD.)
A
B
C

682
SECTION III  ADJUNCTIVE SURGERY
FIGURE 25-11  ■  A, B, Giant pigmented hairy scalp nevus in a 20-month-old child. C, Contralateral scalp expanded with 250-mL rect­
angular tissue expander. D, Two weeks after complete excision of nevus and repair with expanded scalp advancement flap. (Courtesy
of Shan R. Baker, MD.)
A
B
C
D

25  CONTROLLED TISSUE EXPANSION IN FACIAL RECONSTRUCTION
683
FIGURE 25-12  ■  A, Expanders implanted beneath hair-bearing parietal scalp to treat male pattern baldness. Access incisions are at
border of balding areas. B, Injection ports are positioned in accessible areas. C, After scalp expansion, expanders removed and flaps
undermined. D, Bald scalp removed and expanded advancement flaps used to close wound.
A
C
B
D

684
SECTION III  ADJUNCTIVE SURGERY
FIGURE 25-13  ■  A, Preoperative photograph of patient with baldness of crown. B, One year after excision of bald scalp and repair
with expanded advancement scalp flap created with 1000-mL horseshoe-shaped tissue expander.
A
B
FIGURE 25-14  ■  A, Male pattern central baldness. Peripheral hair-bearing scalp expanded with bilateral 250-mL rectangular tissue
expanders. B, Expanders removed and large central area of baldness excised. C, Resulting defect repaired with bilateral expanded
scalp advancement flaps. D, E, Preoperative and postoperative views. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
E

25  CONTROLLED TISSUE EXPANSION IN FACIAL RECONSTRUCTION
685
A
B
FIGURE 25-15  ■  A, Immediately after removal of tissue expander demonstrating “bathtub” deformity. B, Same patient 4 months later
showing complete resolution of deformity.
left in place and expansion continued to complete the
expansion process. A total of 300 mL of saline was
injected into the expander. The expander was then
removed and an advancement flap was created and used
to cover the left side of the forehead after removal of the
skin graft.
The forehead and scalp expanders were effective in
providing sufficient skin to enable the removal of the skin
graft covering the left side of the forehead and to restore
a normal temporal hairline. The patient still had a skin
graft covering the zygomatic area. A third tissue expander
was placed beneath cheek skin to create an expanded
cheek advancement flap. The cheek flap was used to
resurface the zygomatic area, enabling the complete
resection of the skin graft covering the area. A similar
case is shown in Figure 25-17, in which a large skin graft
was excised from the temple aided by expanded forehead
and scalp flaps.
FACE AND NECK EXPANSION
Expanders can be used to expand skin of the face, neck,
and chest.32 The expander is generally placed in a more
superficial tissue plane in the face and neck than it is in
the scalp and forehead. Because many of the deformities
to be corrected are large scars from burns and other
trauma, dissection can be difficult when expanders are
implanted and advancement flaps are created from the
expanded skin. In the region of the cheek, extreme care
is required to avoid damage to the facial nerve during
dissection. The expander may be placed directly over the
vicinity of the facial nerve and expansion performed
without nerve impairment. When possible, incisions are
placed in natural creases to allow the best long-term
aesthetic results. When the skin of the cheek or neck is
expanded, a periauricular facelift-type incision is often
used for implanting the expander (Fig. 25-18).
Because the expander is placed more superficially in
the face and the neck compared with the forehead and
because the skin is thinner in these areas, the expanded
skin may become very thin during the process (Fig.
25-19). The more rapid the expansion, the thinner the
skin becomes and the greater the risk of tissue break­
down. The expander may be placed deep to the platysmal
muscle in the neck. The author has not encountered
problems when placing tissue expanders over vital struc­
tures such as the carotid artery, trachea, or larynx, but the

C
D
E
FIGURE 25-16  ■  A, B, Skin graft covering temple, anterior parietal scalp, and lateral cheek. C, Expanded forehead skin. D, After tissue
expansion, expanded forehead skin used to cover defect created by partial resection of skin graft. E, Expansion provided sufficient
skin to cover temple.
A
B

25  CONTROLLED TISSUE EXPANSION IN FACIAL RECONSTRUCTION
687
F
G
H
F, Tissue expander beneath lateral cheek skin. G, Six days after removal of skin graft from cheek and recon­
struction with expanded cheek advancement flap. H, Postoperative result at 6 months.
FIGURE 25-16, cont’d  ■

688
SECTION III  ADJUNCTIVE SURGERY
FIGURE 25-17  ■  A, B, Unsightly split-thickness skin graft and large area of radiation alopecia. C, D, In anticipation of excision of skin
graft and area of alopecia, forehead skin and posterior scalp on ipsilateral side of skin graft expanded with 250-mL rectangular tissue
expanders. E, Postoperative result after complete excision of skin graft and area of alopecia. Resulting defect repaired with expanded
forehead skin and scalp advancement flaps. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
E

25  CONTROLLED TISSUE EXPANSION IN FACIAL RECONSTRUCTION
689
the neck through postauricular incisions. The expanders
were placed superficial to the platysmal muscle, and
expansion was continued for 2 months. Each expander
was inflated to a total volume of 300 mL of saline. Once
expansion was completed, the expanders were removed,
advancement flaps were developed, and the deformity
was reconstructed with the expanded tissue. At the time
of repair, a small expander was inserted in a soft tissue
pocket in the area of the missing section of the mandible.
The expander served as a “spacer” preserving a cavity for
subsequent placement of a bone graft. The expander also
served as a stimulus to create additional soft tissue as a
vascularized recipient site for the bone graft. Two previ­
ous bone grafts had failed because of poor vascularity and
lack of sufficient soft tissue coverage of the grafts.
In anticipation of using an iliac crest bone graft
for mandible reconstruction, titanium implants were
placed into the crest concurrently with implantation of
the last tissue expander. The implants became integrated
with the iliac crest bone. The implants served to anchor
a permanent denture after reconstruction. The implants
were transferred with the bone graft to the anterior
mandible.
The expander in the area of the chin was left in place
for 8 weeks, serially inflating it to a volume of 30 mL of
saline. After completion of expansion, the expander was
removed and an iliac crest bone graft placed in the pocket
created by the expander. The expanded soft tissue in the
area of the chin and lower lip provided a thick capsule to
protect the bone graft from exposure. To ensure survival
of the bone graft, the patient was also treated with several
sessions of hyperbaric oxygen. He did well and experi­
enced no problems with infection or tissue breakdown.
Permanent dental implants were eventually inserted, and
the patient was able to eat foods of all types. He continues
to do well 16 years after reconstruction.
The patient shown in Figure 25-22 was a 12-year-old
girl with a giant pigmented hairy nevus covering the left
side of her face. She was referred to the author after
having laser treatment, dermabrasion, and electrolysis. It
was elected to use tissue expansion before attempting
surgical excision. A 500-mL crescent-shaped expander
FIGURE 25-18  ■  Preoperative planning of incision location is
important to avoid compromising subsequent design of
expanded flap. Facelift-type incision is useful for implanting
expanders beneath cheek and upper neck skin.
FIGURE 25-19  ■  Significant thinning of expanded skin from too
rapid expansion.
FIGURE 25-20  ■  Expanders beneath neck skin in preparation for
reconstruction of mandible, lower lip, and chin.
surgeon is still obligated to observe patients closely
for possible signs and symptoms of complications
(Fig. 25-20).
Tissue expansion has been used to reconstruct trau­
matic defects of the mandible.33 Successful bone grafting
of the mandible has been used in conjunction with
expanded neck flaps and expanded oral mucosa to provide
an improvement in the form and function of the recon­
structed mandible . The patient in Figure 25-21 sustained
a gunshot wound to the face, resulting in the loss of the
anterior mandible and overlying soft tissue in addition to
a portion of the tongue, maxilla, and nose. Before the
author’s care of this patient, he had multiple reconstruc­
tive procedures including skin grafts, myocutaneous
flaps, and bone grafts, many of which failed because of
poor vascularity of the traumatized tissue. Tissue expan­
sion of the neck skin was recommended for the purpose
of replacing the traumatized tissue and to add additional
skin and soft tissue to the area of the chin. Two 250-mL
rectangular expanders were implanted on either side of

690
SECTION III  ADJUNCTIVE SURGERY
A
B
C
FIGURE 25-21  ■  A, B, Patient with healed gunshot wound of mandible, lower lip, and chin. Several reconstructive procedures previ­
ously performed. Functional and aesthetic deformity persisted. C, External biphasic apparatus used for two years because of lack
of anterior mandibular bone replacement.

25  CONTROLLED TISSUE EXPANSION IN FACIAL RECONSTRUCTION
691
D
E
F
G
H
D, Two 250-mL expanders beneath neck skin implanted through postauricular incisions. E, Titanium implants
placed in iliac crest in preparation for bone grafting of anterior mandible. F, Iliac crest bone graft in place to restore anterior man­
dible. G, H, Four years after reconstruction. In addition to mandible reconstruction, scar revisions of nose, lip, and commissure
performed.
FIGURE 25-21, cont’d  ■

692
SECTION III  ADJUNCTIVE SURGERY
A
B
C
FIGURE 25-22  ■  A, Patient with giant pigmented hairy nevus of left side of face. B, Persistent pigment and scarring present after
treatment by laser, dermabrasion, and electrolysis. C, A 500-mL expander implanted through facelift-type incision. Injection port
placed externally. D, During a 10-week period, 750 mL of saline was used to inflate expander.
D

25  CONTROLLED TISSUE EXPANSION IN FACIAL RECONSTRUCTION
693
skin flap advanced into position to assess whether the
nevus could be completely removed. The expanded skin
was sufficient to enable the resection of the entire nevus
without excessive wound closure tension.
EXPANDERS FOR NASAL AND
EAR RECONSTRUCTION
Myocutaneous flaps remain the preferred method for
reconstruction of large deformities in which bulk and
coverage of an open wound are required. Such is the case
when nasal defects require a paramedian forehead flap.
Expanders can be used as an aid to nasal reconstruction
when forehead flaps are required.21 Forehead skin expan­
sion provides the advantage of increasing the availability
of skin and the ability to close the donor site without
wound closure tension.
Tissue expanders have also been used for ear recon­
struction.34 In fact, the first use of an expander was for
reconstruction of an auricle. The expander is usually
inserted beneath the postauricular skin. Skin is expanded
until there is sufficient tissue to cover a framework for
the ear.
EXTERNAL INJECTION PORT
Most surgeons have been hesitant to use external injec­
tion ports when expanding skin because of concerns of
infection. For years, arteriovenous shunts, indwelling
intravenous lines for nutrition or chemotherapy, fracture
stabilization pins, and dental implants have been success­
fully used without the devices becoming infected. There
are several advantages to use of an external injection port.
A subcutaneous pocket for the port is not required, and
this can reduce the complexity of the procedure and
lessens the risk of hematoma or tissue breakdown in the
area of the port. The port can also be easily replaced if
it leaks. One of the most important advantages, especially
for children, is that pain is avoided because there are no
percutaneous injections. It is also easy to train nonmedi­
cal personnel to perform injections through the port.
was inserted beneath the cheek skin through a facelift-
type incision. A crescent-shaped expander was selected
because it allowed maximum skin expansion across the
central portion of the expander and minimized expansion
at the ends of the expander. This reduced the size of
standing cutaneous deformities after advancement of
expanded skin. The crescent-shaped expander is most
useful for repair of round defects, and the pigmented
nevus was circular in configuration. The injection port
was placed externally behind the ear (Fig. 25-23). The
patient was frightened of needles and lived 2 hours in
traveling time from the office. To relieve the patient from
traveling such long distances for inflation of the expander,
her father was instructed in how to perform sterile injec­
tions of saline through the external port. The external
port provided an easy access for her father to inflate the
expander and avoided the need for percutaneous needle
injections. The patient tolerated tissue expansion well
and was checked periodically to ensure that infection had
not occurred.
The expansion process required a 10-week interval,
injecting a total volume of 750 mL of saline. When the
expanded skin measured four times the size of the antici­
pated defect, the expander was removed and an expanded
F
G
E
E, Expanded flap measured to ensure adequate coverage. F, Patient immediately after complete excision of
nevus and advancement of expanded flap. G, Postoperative result at 1 year.
FIGURE 25-22, cont’d  ■
FIGURE 25-23  ■  Injection port placed externally in child to avoid
percutaneous injections. Patient completed 10 weeks of expan­
sion without complications.

694
SECTION III  ADJUNCTIVE SURGERY
vascularized skin of the head and neck areas makes isch­
emia from intraoperative expansion a rare problem.
The histologic changes in the skin associated with
prolonged expansion leading to biologic creep (described
earlier in this chapter) are not observed with intraopera­
tive expansion. On histologic evaluation, there are no
significant changes in the epidermis, dermis, subcutane­
ous tissue, or muscle. The origin of additional skin gained
by intraoperative expansion is not known. Hayden37 sug­
gested that it is not a true gain. He suggested that the
gain is from a more efficient undermining of the skin
provided by expansion than is provided by simple subcu­
taneous dissection alone.
COMPLICATIONS
The rate of complications associated with tissue expan­
sion is high, but most are minor. Manders et al38 studied
the rate of complications in patients undergoing
tissue expansion to treat a wide variety of deformities.
They defined a major complication as one that required
specific treatment and altered the planned procedure. By
use of these criteria, 25% of patients suffered major
complications. Antonyshyn et al39 reported an overall
complication rate of 48%. However, sufficient tissue was
generated to complete the planned reconstruction in
70% of the patients.
Erosion of the overlying skin is the most common
complication associated with tissue expansion. This
usually occurs at the incision site used for insertion of the
expander but may occur in any area of the expanded skin.
An access incision that is radial in relation to the axis of
the anticipated defect reduces the risk of dehiscence.
Antibiotic coverage is advised with any exposure of an
implant. Exposure of an implant does not necessarily lead
to failure of the procedure because significant skin expan­
sion has usually occurred by the time this complication
develops. If the exposure is at the injection port, expan­
sion can usually proceed without interruption.
Rapid tissue breakdown usually occurs when exposure
of an expander occurs in the center of the area of expanded
skin. In such instances, the expander should be removed
and the surgeon should proceed with the planned recon­
struction. If necessary, re-expansion can be performed at
a later time once the skin has healed adequately. When
exposure at the incision site for insertion of the expander
occurs and expansion is not complete, the expander can
be partially deflated to reduce wound closure tension and
the dehiscent incision surgically closed. The deflated
expander is left in situ and re-expansion commenced once
the dehiscent site has healed.
Infection associated with tissue expanders is rare in the
head and neck area because of the abundant blood supply
of facial skin.38 Perioperative antibiotics are recom­
mended when an expander is implanted initially and at
the first sign of infection. If infection occurs during the
expansion process and is not quickly controlled, the
expander should be removed and the infection treated
before re-expansion of the skin is attempted.
Mechanical failure of the expander is rare and is usually
associated with physician error. The expander can be
The first reported series using external ports showed
no increased risk of infections.35 Subsequently, other
authors have reported infections, but the incidence
appears to be statistically the same for internal and exter­
nal ports. An external injection port should not be used
when the expander is replaced by prostheses such as
breast implants.
INTRAOPERATIVE SKIN EXPANSION
In 1987, Sasaki reported his experience with the use of
rapid intraoperative skin expansion.36 Expansion is per­
formed at the time of the surgery rather than leaving the
expander implanted for a prolonged time. Sasaki first
observed that with long-term expansion, intraoperative
expansion just before removal of the expander created an
additional 1 to 3 cm of available skin for construction of
a flap. He also observed that this rapid expansion pro­
duced no adverse effect on the chronically expanded flap.
These observations led to the use of rapid expansion for
immediate closure of smaller defects.
Intraoperative expansion has been used in all areas of
the body, and the amount of skin gained from these pro­
cedures varies. In 295 cases, Sasaki found that up to
2.5 cm of skin could be gained by intraoperative expan­
sion. The skin of the scalp, nasal tip, and back is thicker
and more resistant to immediate expansion than skin on
the face, neck, or extremities. Sasaki suggested that more
skin could be gained by using more than one expander
placed beneath the skin surrounding the defect.
The technique of intraoperative tissue expansion con­
sists of developing a subcutaneous pocket to accommo­
date the expander adjacent to the defect to be closed. The
expander is inserted, and a series of inflations are per­
formed. Repetitive inflation allows cyclic loading of the
tissue as described by Gibson.6 Gibson noted that when
tension is placed on skin, the initial stretch of skin is from
displacement of fluid and ground substance in the dermis.
The maximum amount of stretch obtained does not occur
on the first stress load but after serial repetitive expansions
of the tissue. After three or four load cyclings, microfrag­
mentation of elastin fibers occurs, and collagen fibers
realign in a more parallel orientation. The expander is
inflated for 2 to 3 minutes with sufficient saline to cause
tissue pallor and firmness. The expander is then deflated
for 2 to 3 minutes. With each subsequent cycle, more
saline can be injected and the measurement across the
dome of the expander increases. After completion of
intraoperative expansion, the expander is removed and
the skin is advanced for a trial closure. It is important to
observe bleeding from the edge of the expanded skin
before creating a flap and transferring it. This ensures that
tissue ischemia has not occurred from the expansion.
Laser Doppler flow studies of skin undergoing intra­
operative skin expansion reveal a rapid decrease in blood
flow during expansion. However, blood flow returns to
nearly normal levels within 1 minute after deflation of
the expander. Skin ischemia from expansion is observed
more often in the distal extremities and can be avoided
if the expanded flap is trimmed of skin until bleeding
is observed before the flap is transferred. The highly

25  CONTROLLED TISSUE EXPANSION IN FACIAL RECONSTRUCTION
695
accidentally punctured when the expander is inserted or
when sutures are placed during closure of the access inci­
sion. The most common problem is leakage of the tubing
attaching the expander to the injection port when the
tubing has been shortened with a connector to adjust
the length. It is important to tie a suture on both sides of
the connector used to shorten the tubing to ensure a tight
seal and to prevent leakage. Leakage does not always
necessitate removal or replacement of the expander.
Several surgeons have reported successful expansion
despite leakage from the expander.40
Postoperative bleeding may lead to hematoma or
seroma formation after expander implantation. Meticu­
lous hemostasis and immediate partial inflation of the
expander at the time of implantation assist with oblitera­
tion of dead space and provide internal compression.
This reduces bleeding in the subcutaneous pocket. If
hematomas do occur, careful serial aspirations may be
necessary.
Expanding irradiated, scarred, or acutely traumatized
skin may lead to failure. These skin conditions are
not absolute contraindications for tissue expansion but
may increase the risk of expander extrusion before ade­
quate skin gain has occurred to complete the planned
procedure. However, when it is used with caution, expan­
sion has been shown to be successful under these
conditions.41
The patient’s mental condition must be considered
before the use of tissue expansion is recommended.
Patient selection is important because of the change in
appearance and length of time required to complete the
expansion process. The surgeon should use this proce­
dure with caution in a psychologically unstable patient.
Even mentally stable patients may undergo psychological
stress leading to a wide range of reactions, making it dif­
ficult to complete the expansion process.42 All patients
must thoroughly understand the temporary deformity
that expansion will cause as well as the risks and compli­
cations of skin expansion.
SUMMARY
When Radovan first introduced the use of tissue expand­
ers in 1976, the concept was met with skepticism
because of the concern for infection and erosion of
expanded skin. Fortunately, there were several surgeons
who realized the tremendous potential of this proce­
dure. It was this potential that led investigators to study
the histologic and biologic response of skin to pro­
longed expansion. Tissue expansion has proved to be a
useful addition to the surgeon’s armamentarium of
reconstructive procedures. Despite the frequency of
complications, the benefits far outweigh the risks in
appropriate patients. Tissue expansion is the only recon­
structive procedure that currently offers the capability
of increasing the number of cutaneous cells available for
incorporation into a skin flap. Skin expansion should be
considered whenever other reconstructive surgical pro­
cedures will not provide an acceptable result and where
skin expansion is likely to ensure a far superior func­
tional or aesthetic result.
REFERENCES
1. Versaci AD, Balkovich ME. Tissue expansion. In: Habal M, editor.
Advances in plastic and reconstructive surgery. Chicago: Year Book
Medical Publishers; 1984.
2. Neumann CG. The expansion of an area of skin by progressive
distension of a subcutaneous balloon. Plast Reconstr Surg
1957;19:124.
3. Radovan C. Adjacent flap development using expandable Silastic
implants. Presented at the annual meeting of the American Society
of Plastic and Reconstructive Surgeons, Boston, September 1976.
4. Austed E. A self-inflating tissue expander. Presented at the annual
meeting of the American Society of Plastic and Reconstructive
Surgeons, Toronto, October 25, 1979.
5. Austed ED, Pasyk KA, McClatchey KD, et al. Histomorphologic
evaluation of guinea pig skin and soft tissue after controlled tissue
expansion. Plast Reconstr Surg 1982;70:704.
6. Gibson T. The physical properties of skin. In: Converse JM, editor.
Reconstructive plastic surgery, vol. 1. Philadelphia: WB Saunders;
1977.
7. Pasyk KA, Austed ED, McClatchey KD, et al. Electron micro­
scopic evaluation of guinea pig skin and soft tissues “expanded”
with a self-inflating silicone implant. Plast Reconstr Surg
1982;70:37.
8. van Rappard JHA, Grubben MJAL, Jerusalem C, et al. Histological
changes in expanded soft tissue. In: van Rappard JHA, editor.
Controlled tissue expansion of reconstructive surgery. Nijmegen,
Netherlands: SSN; 1988.
9. Austed ED, Thomas SB, Pasyk K. Tissue expansion: dividend or
loan? Plast Reconstr Surg 1986;78:63.
10. van Rappard JHA, Bauer FW, Grubben MJAL, et al. Epidermo­
poiesis in controlled tissue expansion. In: van Rappard JHA, editor.
Controlled tissue expansion in reconstructive surgery. Nijmegan,
Netherlands: SSN; 1988.
11. Pasyk KA, Argenta LC, Hassett C. Quantitative analysis of the
thickness of a silicone implant. Plast Reconstr Surg 1988;81:516.
12. Olenius M, Jerell G, Froslind B. Histomorphologic changes in
expanded human tissue. Presented at the Plastic Surgery Educa­
tional Foundation International Tissue Expansion Symposium, San
Francisco, October 1987.
13. Sasaki GH. Expansion of extremities. Presented at the Plastic
Surgery Educational Foundation International Tissue Expansion
Symposium, San Francisco, October 1987.
14. Cherry GW, Austed ED, Pasyk KA, et al. Increased survival and
vascularity of random pattern skin flaps elevated in controlled
expanded skin. Plast Reconstr Surg 1983;72:680.
15. Stark GB, Hong C, Futrell JW. Rapid elongation of arteries and
veins in rats with a tissue expander. Plast Reconstr Surg 1987;80:570.
16. Leighton WD, Russell RC, Marcus DE, et al. Experimental pre­
transfer expansion of free-flap donor sites. II. Physiology, histology
and clinical correlation. Plast Reconstr Surg 1988;82:76.
17. Saxby PJ. Survival of island flaps after tissue expansion: a pig model.
Plast Reconstr Surg 1988;81:30.
18. Manders EK, Saggers GC, Diaz-Alonso P, et al. Elongation of
peripheral nerve and viscera containing smooth muscle. Clin Plast
Surg 1987;14:551.
19. Morris SF, Pang CY, Mahoney J, et al. Effect of capsulectomy on
the hemodynamics and viability of random-pattern skin flaps raised
on expanded skin of the pig. Plast Reconstr Surg 1989;84:314.
20. Becker H. The permanent tissue expander. Clin Plast Surg
1987;14:519.
21. Manders EK, Friedman M. The treatment of male pattern baldness
utilizing a differential expander. Presented at the annual meeting
of the American Society of Aesthetic Plastic Surgery, Boston, 1985.
22. Hallock GG. Maximum overinflation of tissue expansion. Plast
Reconstr Surg 1987;80:567.
23. Hallock GG, Rice DO. Objective monitoring for safe tissue expan­
sion. Plast Reconstr Surg 1986;77:416.
24. van Rappard JHA, Sonneveld GJ, Borghouts JMHM. Geometric
planning and the shape of the expander. Facial Plast Surg
1988;5:287.
25. Brobmann GF, Huber J. Effects of different-shaped tissue expand­
ers on transluminal pressure, oxygen tension, histologic changes,
and skin expansion in pigs. Plast Reconstr Surg 1985;76:731.
26. Radovan C. Tissue expansion in soft tissue reconstruction. Plast
Reconstr Surg 1984;74:482.

696
SECTION III  ADJUNCTIVE SURGERY
27. Gibney J. Tissue expansion in reconstructive surgery. Presented at
the American Society of Plastic and Reconstructive Surgeons
annual scientific meeting, Las Vegas, October 1984.
28. Sugihara T, Ohura T, Kim C, et al. The extensibility in human skin.
Presented at the Plastic Surgery Educational Foundation Interna­
tional Tissue Expansion Symposium, San Francisco, 1987.
29. Reinisch J, Myers B. The effect of local anesthesia with epinephrine
on skin flap survival. Plast Reconstr Surg 1974;54:324.
30. Kabaker SS, Kridel RWH, Krugman ME, et al. Tissue expansion
in the treatment of alopecia. Arch Otyolaryngol 1986;112:720.
31. Anderson RD, Argenta LC. Tissue expansion for the treatment of
alopecia. In: Unger WP, editor. Hair transplantation. 2nd ed. New
York: Marcel Dekker; 1987.
32. Hayden RE. Expansion of a pectoralis myocutaneous flap. Pre­
sented at the annual meeting of the American Academy of Facial
Plastic and Reconstructive Surgery, San Antonio, Texas, 1986.
33. Swenson RW. Expansion assisted reconstruction of gunshot wounds
to the mandible. Presented at the annual meeting of the American
Academy of Facial Plastic and Reconstructive Surgery, San Antonio,
Texas, 1986.
34. Nordstrom REA, Salo HP, Rintala AE. Auricle reconstruction with
the help of tissue expansion. Facial Plast Surg 1988;5:338.
35. Jackson IT, Sharpe DT, Polley J, et al. Use of external reservoirs
in tissue expansion. Plast Reconstr Surg 1987;80:266.
36. Sasaki GH. Intraoperative sustained limited expansion (ISLE) as
an immediate reconstructive technique. Clin Plast Surg 1987;14:563.
37. Hayden RE. Intraoperative tissue expansion: fact or fiction? Pre­
sented at the annual meeting of the American Academy of Facial
Plastic and Reconstructive Surgery, New Orleans, September 1989.
38. Manders EK, Schenden MJ, Furrey JA, et al. Soft tissue expansion:
concepts and complications. Plast Reconstr Surg 1984;74:493.
39. Antonyshyn O, Gruss JS, Zuker R, et al. Tissue expansion in head
and neck reconstruction. Plast Reconstr Surg 1988;82:58.
40. Manders EK, Sasaki G, Austed E. Tissue expansion today. A sym­
posium sponsored by the Plastic Surgery Educational Foundation,
Hershey, Pa, September 1986.
41. Fritz M, Swenson RW. Tissue expanders for reconstruction within
irradiated head and neck tissues. In: Stucker FJ, editor. Plastic and
reconstructive surgery of the head and neck: proceedings of the
American Academy of Facial Plastic and Reconstructive Surgery
Fifth International Symposium. Toronto, 1991.
42. Goin M. Psychological aspects of tissue expansion. Presented at the
American Society of Plastic and Reconstructive Surgery Sympo­
sium, Pasadena, November 1984.

697
C H A P T E R 2 6 
COMPLICATIONS OF LOCAL FLAPS
Brian S. Jewett
INTRODUCTION
Complications associated with surgery are perhaps
nowhere more apparent and devastating than when they
occur on the face. Conley spoke of surgical complications
by saying, “These untoward events, unpredictable and
unwanted, lurk in all surgical arenas, in the biological
process and in the patient. They give credence to our
frailty, from which there is no escape.”1 It is essential that
all facial surgeons become familiar with the potential
complications associated with facial reconstructive
surgery. Furthermore, it is of utmost importance that
surgeons anticipate these undesirable events and take
proper measures to help prevent their occurrence.
Establishing a consistent perioperative routine is the
first step in preventing complications. Appropriate pre­
operative counseling of the patient will reduce the likeli­
hood of complications. Informed consent should include
an open discussion of potential problems that may occur.
Hand scrubbing, sterile surgical attire, and surgical site
preparation are important in reducing the likelihood of
infection.2-6 Immediate and regular postoperative evalu­
ations of the patient will facilitate early recognition and
treatment of complications. Some complications are
reversible, and expeditious treatment may prevent a
reversible complication from becoming an irreversible
one. This chapter discusses complications inherent to
surgery, those related to the medical conditions of
patients, and complications associated with surgical tech­
nique and local flap design.
COMPLICATIONS INHERENT TO SURGERY
Adherence to well-established surgical principles is essen­
tial for minimizing the incidence of complications in per­
forming facial reconstructive surgery. Conley writes that
“hemostasis should be absolute … all flaps should be
viable and tissue should not be closed with undue wound
closure tension. The type and size of the suture material
should be appropriate for the job it has to do. Compli­
ance with these fundamental principles establishes the
groundwork for healing … the incidence of complica­
tions will develop in direct proportion to the violation of
these principles.”1
Bleeding
The most common causes of bleeding from facial recon­
struction with local flaps are drug-associated coagulopa­
thy and inadequate hemostasis.7 Patients are questioned
preoperatively concerning use of all prescription and
over-the-counter medications that may contribute to
perioperative bleeding. All aspirin-containing products,
nonsteroidal anti-inflammatory medicines, vitamin E,
and most herbal remedies are discontinued 1 week or
more before surgery. The exception to this policy is
patients with cardiac stents. These patients continue to
take aspirin if it is prescribed by their cardiologist. Cold
and sinus medications are avoided because many contain
substances that may affect clotting or cause adverse ele­
vation in blood pressure. Discontinuation of any medi­
cations prescribed by a physician to reduce blood
clotting is coordinated with the patient’s primary physi­
cian or cardiovascular specialist. Bleeding may also be
associated with hypertensive events, hepatic or renal
failure, vomiting, straining, or alterations in the hema­
topoietic system.
Hemostasis is essential. Larger (1 mm) arterial vessels
are securely ligated when they are interrupted, and uni­
polar or bipolar electrocoagulation is used to control
bleeding from smaller vessels. The wound is rinsed with
sterile water, and gauze moistened with saline may be
used to gently dab the wound bed to facilitate visualiza­
tion of bleeding vessels. If bleeding persists despite
electrocoagulation, the patient is placed in reverse Tren­
delenburg position and cotton pledgets soaked in a local
anesthetic containing a vasoconstrictor are applied to the
bleeding area with light compression. Electrocautery is
then used, perhaps more successfully, once bleeding
vessels are more easily visualized. If bleeding continues
and is excessive, a coagulopathy should be suspected. In
these cases, the procedure is discontinued, a drain is
inserted into the wound, and a compression dressing is
applied to the area. In addition, before any future surgery,
a hematologist is consulted to evaluate the possibility of
a hematologic disorder.
Drains are rarely used with local cutaneous flaps, with
the exception of ear reconstruction. However, an appro­
priately sized drain is employed when a significant “dead
space” is present or drainage is expected that cannot be
controlled with a compression dressing. The author’s
preference is to use a compression dressing that conforms
to the anatomic contour of the surgical site to facilitate
adherence of the facial flap to the recipient site. This is
typically left in place for 24 to 48 hours. The dressing
consists of nonadherent gauze, cotton balls, and elastic
mesh tape. Patients are instructed to keep their head
elevated, especially at night, for the first 36 to 48 hours
after surgery, and antiemetics are prescribed to prevent
nausea and vomiting. Coughing and straining are to be
avoided whenever possible.