The impact of national health insurance on the cost of auricular reconstruction with skin expansion for microtia in China: A single-center retrospective study based on 1290 surgeries.

BACKGROUND: Congenital microtia presents challenges that encompass physical disabilities and psychosocial distress. It is reported that people with low income have a higher possibility of giving birth to babies with congenital malformations. At the end of June 2023, auricular reconstruction was partially incorporated into national health insurance in our hospital. METHODS: Briefly, 1290 surgeries, including stage-I and stage-II auricular reconstruction with tissue expansion were performed in 2023, involving 779 patients. Patient data, including age, sex, length of stay, residence, and costs, were retrieved from the electronic medical record system. The final cost before and after health insurance coverage, as well as the medical insurance reimbursement ratio in each province and municipality were statistically analyzed. RESULTS: Following insurance coverage, a significant increase in the number of surgeries was observed (514 [39.84%] vs. 776 [60.16%], χ2 = 45.99, p = 0.000), with notable reductions in out-of-pocket costs for unilateral and bilateral stage-I and -II auricular reconstructions ($3915.01 vs. $6645.28, p < 0.05; $11546.80 vs. $5198.08, p < 0.05). Disparities in reimbursement rates across regions were evident, but showed no correlation to the local GDP per capita. There was a positive correlation between the length of stay and inpatient cost. Patient's age was not related to the inpatient cost, but to the length of stay. CONCLUSION: The health insurance coverage for microtia treatment significantly alleviated financial burdens on the patients' family and increased the number of auricular reconstruction surgeries. These findings underscore the critical role of insurance coverage in enhancing healthcare accessibility and affordability for patients with congenital microtia.

Utility and Cost Effectiveness of Routine, Histologic Evaluation of the Mastectomy Scar in Two-Stage, Implant-Based Reconstruction during Expander-to-Implant Exchange.

BACKGROUND: Routine histologic analysis of the mastectomy scar is well studied in the delayed breast construction population; no data regarding its utility in the immediate, staged reconstruction cohort have been published. METHODS: A retrospective review of all of the senior author's (C.D.C.) patients who underwent immediate, staged reconstruction was performed. The mastectomy scar was analyzed routinely at the time of expander-to-implant exchange. Six hundred forty-seven breasts were identified. The mastectomy scar, time between expander and permanent implant, average patient age, and mastectomy indication were calculated. A cost analysis was completed. RESULTS: All scar pathologic results were negative for in-scar recurrence. The majority, 353 breasts, underwent mastectomy for carcinoma, 94 for germline mutations, 15 for high-risk lesions, six for high family risk, and 179 for contralateral symmetry/risk reduction. The average age at mastectomy/expander placement was 47.7 ± 10.3 years, and the average time between expander placement and implant exchange was 254 ± 152 days. The total histologic charge per breast was $602. CONCLUSIONS: A clinically silent in-scar recurrence is, at most, a rare occurrence. Routine histologic analysis of the mastectomy scar can be safely avoided in the immediate, staged reconstruction cohort. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Primary Closure of Wide Fasciotomy and Surgical Wounds Using Rubber Band-Assisted External Tissue Expansion: A Simple, Safe, and Cost-effective Technique.

BACKGROUND: Although decompressive fasciotomy is a limb-saving procedure in the setting of acute compartment syndrome, it leaves a large wound defect with tissue edema and skin retraction that can preclude primary closure. Numerous techniques have been described to address the challenge of closing fasciotomy wounds. This study reports our experience with fasciotomy closure using rubber bands (RBs) for external tissue expansion. METHODS: Patients were informed about RB closure and split-thickness skin graft options. Only patients who opted for RB closure and had wounds that could not be approximated using the pinch test underwent the procedure. Starting from the apex and progressively advancing, the RBs were applied to the skin edges at 3 to 4 mm intervals using staples. The RBs were advanced by twisting back-and-forth to create a criss-cross pattern. One week after application, fasciotomy wounds were closed primarily or underwent further RB application, based on clinical assessment of adequacy of skin advancement, compartment tension, and perfusion. Review of a prospectively maintained database was performed, including demographics, comorbidities, etiology, wound and operative details, hospital stay, and complications. RESULTS: Seventeen consecutive patients with 25 wounds (22 fasciotomy and 3 other surgical wounds) were treated using the RB technique. Average wound length and width measured 15.7 cm (range, 5-32 cm) and 5.2 cm (range, 1-12 cm), respectively. Locations of wounds included forearm (n = 12, 48.0%), leg (n = 7, 28.0%), hand (n = 4, 16.0%), elbow (n = 1, 4.0%), and hip (n = 1, 4.0%). Eighteen of 25 wounds (72.0%) were closed primarily after 1 RB application. Additional RB application was required for 5 wounds to achieve primary closure. Between stages, patients were discharged home if they did not have other conditions requiring in-hospital stay. No complications were observed, and no revision surgeries were required. Patient satisfaction was 100%, and all indicated that they would choose the RB technique over skin grafting. CONCLUSIONS: The modified RB technique is a simple, safe, and cost-effective alternative for treating fasciotomy and other surgical defects resulting in high patient satisfaction and good cosmetic outcome, without the need for split-thickness skin graft or flap coverage.

Trends in Physician Payments for Breast Reconstruction.

BACKGROUND: Prosthetic breast reconstruction rates have risen in the United States, whereas autologous techniques have stagnated. Meanwhile, single-institution data demonstrate that physician payments for prosthetic reconstruction are rising, while payments for autologous techniques are unchanged. This study aims to assess payment trends and variation for tissue expander and free flap breast reconstruction. METHODS: The Blue Health Intelligence database was queried from 2009 to 2013, identifying women with claims for breast reconstruction. Trends in the incidence of surgery and physician reimbursement were characterized by method and year using regression models. RESULTS: There were 21,259 episodes of breast reconstruction, with a significant rise in tissue expander cases (incidence rate ratio, 1.09; p < 0.001) and an unchanged incidence of free flap cases (incidence rate ratio, 1.02; p = 0.222). Bilateral tissue expander cases reimbursed 1.32 times more than unilateral tissue expanders, whereas bilateral free flaps reimbursed 1.61 times more than unilateral variants. The total growth in adjusted tissue expander mean payments was 6.5 percent (from $2232 to $2378) compared with -1.8 percent (from $3858 to $3788) for free flaps. Linear modeling showed significant increases for tissue expander reimbursements only. Surgeon payments varied more for free flaps (the 25th to 75th percentile interquartile range was $2243 for free flaps versus $987 for tissue expanders). CONCLUSIONS: The incidence of tissue expander cases and reimbursements rose over a period where the incidence of free flap cases and reimbursements plateaued. Reasons for stagnation in free flaps are unclear; however, the opportunity cost of performing this procedure may incentivize the alternative technique. Greater payment variation in autologous reconstruction suggests the opportunity for negotiation with payers.

The Economics of Prepectoral Breast Reconstruction.

The world of breast reconstruction over the last several years has seen a dramatic shift in focus to discussion and the application of placing tissue expanders and implants back into the prepectoral space. Although this technique failed during the early advent of breast reconstruction, newer technologies such as advances in fat grafting, improved acellular dermal matrices, better methods of assessing breast flap viability, and enhanced implants appear to have set the stage for the resurgence and positive early results seen with this technique. The main benefits of a switch to prepectoral breast reconstruction clinically appears to be less associated pain, lower incidence of animation deformities, and its associated symptoms as well as presumably better aesthetics. Early data suggest that the results are extremely promising and early adopters have attempted to define the ideal patients for prepectoral breast reconstruction. As with any new operative procedure, an assessment of finances and costs are crucial to its successful implementation. Although current data are minimal, this article attempts to build the fundamentals of an economic model that exhibits and displays potential savings through the use of prepectoral breast reconstruction.

Cost analysis of postmastectomy reconstruction: A comparison of two staged implant reconstruction using tissue expander and acellular dermal matrix with abdominal-based perforator free flaps.

BACKGROUND AND OBJECTIVES: Two staged tissue expander-implant with acellular dermal matrix (TE/I + ADM) and deep inferior epigastric perforator (DIEP) flap are the most common implant and autologous methods of reconstruction in the U.S. Implant-based techniques are disproportionally more popular, partially due to its presumed cost effectiveness. We performed a comprehensive cost analysis to compare TE/I + ADM and DIEP flap. METHODS: A comparative cost analysis of TE/I + ADM and DIEP flap was performed. Medicare reimbursement costs for each procedure and their associated complications were calculated. Pooled probabilities of complications including cellulitis, seroma, skin necrosis, implant removal, flap loss, partial flap loss, and fat necrosis, were calculated using published studies from 2010 to 2016. RESULTS: Average actual cost for successful TE/I + ADM and DIEP flap were $13 304.55 and $10 237.13, respectively. Incorporating pooled complication data from published literature resulted in an increase in cost to $13 963.46 for TE/I + ADM and $12 624.29 for DIEP flap. The expected costs for successful TE/I + ADM and DIEP flap were $9700.35 and $8644.23, which are lower than the actual costs. CONCLUSIONS: DIEP flap breast reconstruction incurs lower costs compared to TE/I + ADM. These costs are lower at baseline and when additional costs from pooled complications are incorporated.

A comparison of patient-centered economic and clinical outcomes of post-mastectomy breast reconstruction between obese and non-obese patients.

BACKGROUND: The objectives of this study were to compare, by patient obesity status, the contemporary utilization patterns of different reconstruction surgery types, understand postoperative complication profiles in the community setting, and analyze the financial impact on health care payers and patients. METHODS: Using data from the MarketScan Health Risk Assessment Database and Commercial Claims and Encounters Database, we identified breast cancer patients who received breast reconstruction surgery following mastectomy between 2009 and 2012. The Cochran-Armitage test was used to evaluate the utilization pattern of breast reconstruction surgery. Multivariable logistic regressions were used to estimate the association between obesity status and infectious, wound, and perfusion complications within one year of surgery. A generalized linear model was used to compare total, complication-related, and out-of-pocket costs. RESULTS: The rate of TE/implant-based reconstruction increased significantly for non-obese patients but not for obese patients during the years analyzed, whereas autologous reconstruction decreased for both patient groups. Obesity was associated with higher odds of infectious, wound, and perfusion complications after TE/implant-based reconstruction, and higher odds of perfusion complications after autologous reconstruction. The adjusted total healthcare costs and out-of-pocket costs were similar for obese and non-obese patients for either type of breast reconstruction surgery. CONCLUSIONS: A greater likelihood of one-year complications arose from TE/implant-based vs autologous reconstruction surgery in obese patients. Given that out-of-pocket costs were independent of the type of reconstruction, greater emphasis should be placed on conveying the surgery-related complications to obese patients to aid in patient-based decision making with their plastic surgeons and oncologists.

Swiveling a Single Expanded Forehead Flap: A Novel Effective Economical Approach to Total Bilateral Upper and Lower Eyelid Reconstruction.

In our novel approach, a single expanded forehead flap was used to reconstruct bilateral upper and lower eyelids in orbital trauma. A 40-year-old man sustained blast injury resulting in bilateral orbital exenteration and need for bilateral socket and eyelid reconstruction. The sockets were each resurfaced with a temporalis flap. A subgaleal forehead tissue expander was expanded during several weeks until enough tissue was obtained. The single expanded forehead flap was swiveled in stages to reconstruct both upper and lower eyelids beginning with the left eye then the right. With this method, the authors recreated the bilateral upper and lower eyelids with a single pedicled flap and ensured secure retention of prostheses to give an acceptable appearance. The novel approach of swiveling a single expanded pedicled forehead flap to reconstruct bilateral upper and lower eyelids is easy and effective providing adequate like for like autologous tissue, and economical requiring only 1 donor site.

A Longitudinal Assessment of Outcomes and Healthcare Resource Utilization After Immediate Breast Reconstruction-Comparing Implant- and Autologous-based Breast Reconstruction.

OBJECTIVES: Immediate breast reconstruction (IBR) after mastectomy for cancer has increased in recent years, yet long-term, modality-specific comparative data are lacking. We performed this study to compare short- and long-term outcomes after expander, autologous (AT), and direct-to-implant (DI) breast reconstruction. METHODS: Using four state-level inpatient and ambulatory surgery databases, we conducted a retrospective cohort study of adult women who underwent mastectomy with immediate breast reconstruction from 2008 to 2009. Our primary outcomes were complications within 90 days of surgery, rate of secondary breast surgery within 3 years, and cumulative healthcare charges. RESULTS: The final cohort included 15,154 women who underwent mastectomy with tissue expander (TE: 70.5%), autologous (AT: 18.1%), or direct to implant (DI: 11.3%) reconstruction. Ninety-day complications were lowest after expander and highest after AT breast reconstruction (TE = 6.5% [reference] vs AT = 13.1% [2.09, 1.82-2.41] vs DI = 6.6% [1.03, 0.84-1.27], P < 0.001). However, adjusted rates of secondary breast procedures were most frequent after expander (2021/1000 discharges) and least frequent after AT (949.0/1000 discharges) reconstruction (P < 0.001). Specifically, unplanned revisions were highest among the tissue expander cohort (TE = 59.2% vs AT = 34.4% vs DI = 45.9%, P < 0.001). The cumulative, adjusted healthcare charges for secondary breast procedures differed slightly across groups (TE = $63,806 vs AT = $66,882 vs DI = $64,145, P < 0.001). CONCLUSIONS: Complications and secondary breast procedures, including unplanned revisions, after breast reconstruction are common and vary by reconstructive modality. The frequency of these secondary procedures adds substantial healthcare charges to the care of the breast reconstruction patient.

The cost effectiveness of acellular dermal matrix in expander-implant immediate breast reconstruction.

BACKGROUND: Expander-implant breast reconstruction is often supplemented with acellular dermal matrix (ADM). The use of acellular dermal matrix has allowed for faster, less painful expansions and improved aesthetics, but with increased cost. Our goal was to provide the first cost utility analysis of using acellular dermal matrix in two-stage, expander-implant immediate breast reconstruction following mastectomy. METHODS: A comprehensive literature review was conducted to identify complication rates for two-stage, expander-implant immediate breast reconstruction with and without acellular dermal matrix. The probabilities of the most common complications were combined with Medicare Current Procedural Terminology reimbursement codes and expert utility estimates to fit into a decision model. The decision model evaluated the cost effectiveness of acellular dermal matrix relative to reconstructions without it. Retail costs for ADM were derived from the LifeCell 2012 company catalogue for Alloderm. RESULTS: The overall complication rates were 30% and 34.5% with and without ADM. The decision model revealed a baseline cost increase of $361.96 when acellular dermal matrix is used. The increase in Quality-Adjusted Life Years (QALYs) is 1.37 in the population with acellular dermal matrix. This yields a cost effective incremental cost-utility ratio (ICUR) of $264.20/QALY. Univariate sensitivity analysis confirmed that using acellular dermal matrix is cost effective even when using retail costs for unilateral and bilateral reconstructions. CONCLUSIONS: Our study shows that, despite an increased cost, acellular dermal matrix is a cost effective technology for patients undergoing two-stage, expander-implant immediate breast reconstruction due to its increased utility in successful procedures.

Cost and outcome analysis of breast reconstruction paradigm shift.

Increased bilateral mastectomy for breast cancer treatment has generated an increased demand for bilateral breast reconstruction. This study examines changing patterns of reconstruction over the last decade to accommodate increased case volume and decreased morbidity associated with reconstruction. A single institution series of 3171 consecutive breast reconstruction cases of more than 10 years was divided into 2 periods, that is, 1999 to 2004 and 2005 to 2010. Bilateral breast reconstruction case volume increased 260% from 1999 to 2004 (n = 237) to 2005 to 2010 (n = 634). Mean patient age at diagnosis decreased by 7 years (P < 0.001). In 2005 to 2010, autologous reconstruction decreased from 60% to 26%, implant-based reconstruction increased from 40% to 74%. There was a noted increase in single-stage implant reconstruction and selective application of perforator flaps for bilateral autologous reconstruction (P < 0.001). Two-staged tissue expander reconstruction accounted for the greatest share of total cost (45%) in the later period. A younger patient demographic and increased case volume were accommodated through increased single-staged and prosthesis-based procedures.

Dermal autografts as a substitute for acellular dermal matrices (ADM) in tissue expander breast reconstruction: a prospective comparative study.

The use of acellular dermal matrix (ADM) in tissue expander breast reconstruction has several advantages but increased complications have been reported. Dermal autografts may offer a safer and more cost-effective alternative. The purpose of this prospective study was to compare the outcomes of tissue expander breast reconstruction using dermal autografts with ADM-assisted reconstruction. Patients undergoing tissue expander breast reconstruction with either ADM or dermal autografts were enrolled. Autografts were harvested from the lower abdomen. At each follow-up visit, patients were surveyed on a seven-point scale for scar and overall satisfaction. Biopsies taken at the time of device exchange were evaluated histologically with CD34 staining to assess tissue integration and vessel ingrowth. Expansion parameters, complications, procedural costs, and operative times were compared. Forty-eight patients were enrolled (76 breasts). Twenty-seven patients received ADM, and twenty-one patients received dermal autograft. Wound healing complications were significantly higher in the ADM group (14.8% versus 4.8%, p-value = 0.03), as were major complications (18.5% versus 0%, p-value < 0.01). Histologic vessel counts in the autograft group averaged 21 vessels/mm(2), compared to 7 vessels/mm(2) in the ADM group (p-value < 0.01). There was no difference between the two groups in scar satisfaction or overall satisfaction. Patients receiving dermal autograft had a lower incidence of major complications and delayed wound healing than patients who received ADM. Despite harvest time, the overall cost of the ADM-assisted expander placement was higher. Dermal autograft-assisted breast reconstruction offers many of the benefits of ADM, but with a lower cost and improved safety profile.

Cost-effectiveness of a topically applied pre-operative tissue expansion device for radial forearm free flaps: a cohort study.

OBJECTIVES: The objective of this study is to test the hypothesis that using a non-invasive and inexpensive pre-operative tissue expansion device (DynaClose) for radial forearm free-flap donor sites will result in a significant reduction in the cost of both in-hospital and out-of-hospital wound care compared with that of unexpanded radial forearm free-flap donor sites. DESIGN: A cohort study consisting of patients previously randomised in a randomised controlled trial. An intention to treat design was utilised. SETTING: A large tertiary care centre in eastern Ontario, Canada. PATIENTS: Thirty-four patients presenting to Otolaryngology Head and Neck clinic were enroled. Of these patients, 29 were previously enroled in a randomised controlled trial, while an additional five patients were enroled and randomised for the purpose of this study. INTERVENTIONS: Patients were randomised to either the treatment (pre-operative tissue expansion, DynaClose Expansion System) or control group. MAIN OUTCOME MEASURES: Wound care costs (in US dollars) were calculated for all patients for both in-hospital care and for patients requiring home care. Non-parametric data analysis was utilised for statistical assessment. RESULTS: There was a 93% reduction in the use of split-thickness skin grafts in the treatment group. There was a significant reduction in total wound care cost for patients in the treatment group versus the control group (P < 0.0001). Patients in the treatment group required a mean (SD) total of $36.00 (23.50) per patient, while the control group required $277.00 (325.00) of wound care. After excluding the cost of home care, the treatment group continued to have a significant reduction in total and in-hospital wound care costs compared with the control group (P < 0.001). CONCLUSIONS: Using a simple, inexpensive and non-invasive method of pre-operative tissue expansion results in a significant reduction in the costs of wound care for both in-hospital and out-of-hospital treatment. The DynaClose dynamic skin expansion system results in a cost-effective method to reduce the need of a split-thickness skin graft for coverage of a radial forearm free-flap donor site.

Medium-term cost analysis of breast reconstructions in a single Dutch centre: a comparison of implants, implants preceded by tissue expansion, LD transpositions and DIEP flaps.

BACKGROUND: Free flap breast reconstruction (BR) is generally believed to be more expensive than implant BR, but costs were previously shown to level out over time due to complications and re-operations. The aim of this study was to assess the economic implications of four BR techniques: silicone prosthesis (SP), implant preceded by tissue expansion (TE/SP), latissimus dorsi transposition with or without implant (LD ± SP) and deep inferior epigastric perforator (DIEP) flap. METHODS: A prospective historic cohort study was performed to evaluate intramural medical costs in 427 patients, who had undergone BR between 2002 and 2009. Short- and medium-term complications were incorporated. In addition, 58 patients, who had recently undergone BR, participated in a questionnaire study to prospectively evaluate extramural medical and non-medical costs. Estimates of mean short- and medium-term costs are presented per patient. RESULTS: Intramural medical costs for BR and short-term complications for unilateral DIEP flaps (€ 12,848) and TE/SP reconstructions (€ 12,400) were significantly higher than those for LD ± SP reconstructions (€ 5804), which, in turn, were more expensive than SP reconstructions (€ 4731). In bilateral cases, costs of TE/SP (€ 12,723) and LD ± SP (€ 10,760) reconstructions were comparable, while DIEP flaps (€ 15,747) were significantly more expensive and SP reconstructions were significantly cheaper (€ 6784). Overall, the medium-term costs for complications and additional operations were not significantly different (€ 3017-€ 4503). Extramural medical costs and non-medical costs were approximately € 9300 per stage, regardless of technique. CONCLUSIONS: Differences in short-term costs between techniques did not level out during follow-up and SP reconstructions remained least expensive. Single-stage SP reconstructions, however, are not suitable for all patients due to high complication rates. Definite implant placement is therefore increasingly preceded by tissue expansion at more comparable costs to autologous BR. Incorporation of non-medical costs into the cost analysis would render two-stage procedures more costly than autologous BR. To achieve the optimal result, careful patient selection is critical. Only in select cases where two options are equally applicable, cost comparison becomes a valid argument for treatment selection.

Closing fasciotomy wounds using plastic bands: an alternative simple and cheap method.

Fasciotomy incisions are essential to relieve pressure on the neurovascular structures in the limbs. However, closing such wounds often becomes a challenge to the surgeon. The aim of this study is to describe a simple and cheap method of closing these wounds. Plastic bands were used to gradually close fasciotomy wounds in five patients. All fasciotomy wounds in the five patients closed successfully within 4-12 days. Only two patients developed minimal complications in the form of minor wound infection and a hypertrophic scar. We conclude that the plastic band method used here is cheaper and simpler in comparison to similar techniques using the same device.

[Use of iterative expansion in the early surgical treatment of complex nevi of the head in children]. / Utilisation des expansions itératives dans le traitement chirurgical précoce des naevus complexes céphaliques de l'enfant.

Extensive of congenital pigmented nevi to the face in an infant is an indication for early exeresis to prevent the risk of degeneration. Search for the best esthetic result has led many authors to healthy skin to a maximum, often relying on tissue expansion. The aim of this study was to present the combination of two expansion techniques, prosthetic expansion and differed natural expansion. Five infants with congenital pigmentary nevi extending to more than 50% of a facial anatomic unit were treated. Total treatment was achieved in all patients with three or four procedures. By combining different expansion techniques early treatment can be proposed with good esthetic results and moderate cost.

Various methods of breast reconstruction after mastectomy: an economic comparison.

This study is an economic comparison of various methods of breast reconstruction after mastectomy. The hospital bills of 287 patients undergoing breast reconstruction at three institutions from June of 1988 to March of 1991 were analyzed. The procedures examined included mastectomy, implant and tissue-expander reconstruction, and TRAM and latissimus pedicle flaps, as well as free TRAM and free gluteal flaps. These procedures were subdivided into those which were performed at the time of mastectomy and those performed at a later admission. In addition, auxiliary procedures (i.e., revision, nipple reconstruction, tissue-expander exchange, and contralateral mastopexy/reduction) also were examined. Where appropriate, these procedures were subdivided into those performed under general or local anesthesia and by inpatient or outpatient status. Data from the three institutions were converted to N.Y.U. Medical Center costs for standardization. A table is presented that summarizes the costs of each individual procedure with all the pertinent variations. In addition, a unique and novel method of analyzing the data was developed. This paper describes a menu system whereby other data regarding morbidity, mortality, and revision rates may be superimposed. With this information, the final cost of reconstruction can be extrapolated and the various methods of reconstruction can be compared. This method can be applied to almost any complex series of multiple procedures. The most salient points elucidated by this study are as follows: The savings generated by performing immediate reconstruction varies between $5092 (p < 0.05) for free gluteal flaps and $10,616 (p < 0.05) for pedicled TRAM flaps.(ABSTRACT TRUNCATED AT 250 WORDS)

Skin expansion. Long term follow up of complications and costs of care.

To find out our rate of complications after tissue expansion, and the cost of treatment in terms of use of hospital resources and length of sick leave, we analysed our experience of 181 expansion treatments in 97 patients undertaken between 1986 and 1991. There were 60 women and 37 men, with a mean age of 22 (range 1-74). Twenty patients had more than one period of treatment (range 2-8). The most common conditions treated were naevi (n = 75); scars (trauma--n = 33, burns--n = 17, and operations--n = 16); and breasts that required reconstruction (n = 15). Of the 181 expansions there were 29 failures (16%), and 117 complete successes (64%); fifteen of the latter developed minor complications (8%), 35 were partly successful (20%). There were 77 complications in 71 treatments (38%), and 45 expanders (25%) had to be removed prematurely because of complications. The most common complications were skin penetration (n = 15), minor infection (n = 13), and breakdown of the surgical wound (n = 13). The median (range) inpatient hospital stay was 8 days (2-39); number of visits to the outpatient clinic for filling 7 days (0-20); and total treatment time/patient 82 (19-286). We conclude that skin expansion is a useful technique, but that there is room for improvement in reducing the rate of complications and the amount of time that patients spend being treated.