The Role of Tissue Expansion Before Baclofen Pump Insertion in the Pediatric Population.

BACKGROUND: Tissue expansion is a well-established technique for soft tissue reconstruction in the pediatric population. We present a case series of this technique to create a safe pocket for baclofen pump insertion to minimize risk of complications including pump migration, extrusion, wound dehiscence and infection. METHODS: A case series of 3 pediatric patients undergoing tissue expansion prior to baclofen pump insertion at a single center in Melbourne. The expansion procedure was performed by senior surgeon N Low in all cases, and patients followed up 6 months after expander-pump exchange. The study was conducted over a 4-year period 2019 to 2023. RESULTS: We suffered 2 minor complications with the tissue expansion process including cellulitis and pump deflation. Neither complication precluded further tissue expansion nor led to premature removal of the expander. All patients proceeded to safely complete expander-pump exchange. One patient suffered a small (6 mL) abdominal seroma associated with pump insertion, which required no intervention. All patients have had a successful outcome 6 months after pump insertion. CONCLUSIONS: We describe a reliable and reproducible approach in creating a safe abdominal wall pocket to better accommodate baclofen pump insertion. Our series has overcome the imbalance between device size and abdominal wall pocket, now offering an alternative approach to achieve the safe delivery of intrathecal baclofen in the pediatric population.

Safety Profile Comparison of 2 Smooth Tissue Expander Types: Artoura and CPX4.

INTRODUCTION: With the recent transition to smooth tissue expanders (TEs), functional differences between TE subtypes have not been fully elucidated. This study evaluated the differences in TE characteristics and complications between 2 commonly used Mentor smooth TE models, Artoura and CPX4. METHODS: A retrospective review of patients who received either smooth Mentor Artoura or CPX4 TE from 2012 to 2022 was conducted. Demographic data, perioperative information, pain scores, TE variables, cancer characteristics, and complications were collected. A multivariate analysis was used to evaluate the relationship between TE subtype and complications while controlling for demographic, TE characteristics, radiation, and chemotherapy exposure. RESULTS: During the study period, 62 smooth Artoura TEs and 79 smooth CPX4 TEs were used. Patients who received CPX4 smooth implants tended to be older (51.09 vs 46.18 years old, P = 0.02) and have a higher body mass index (28.66 vs 23.50 kg/m 2 , P < 0.001). There were no differences among patient comorbidities. CPX4 required on average a greater total fill volume (422.23 vs 348.07 mL, P = 0.01) and had a greater drain duration (16.91 vs 14.33 days, P = 0.05). There were no differences in TE plane placement between Artoura and CPX4. Additionally, there were no differences in complication rates, including infection, hematomas, seromas, wound breakdown, TE replacement, and capsular contracture. When controlling for body mass index, diabetes, TE plane placement, acellular dermal matrix use, radiation exposure, and chemotherapy, there was no association between TE subtype and any individual complication. DISCUSSION: Differences in total fill volume and drain duration were significantly different between Mentor Artoura and CPX4 implants, which may influence TE subtype selection. However, Artoura and CPX4 have excellent and equivalent safety profiles with similar complication rates, even when controlling for demographic and TE characteristics.

Multivariate Analysis of Risk Factors for Complications in Pediatric Tissue Expansion.

BACKGROUND: Tissue expanders represent one of the main surgical options for skin reconstruction in cases of tumors, traumalike burn injury, scar contracture, and alopecia. However, the tissue expander device is also associated with complications such as infection and extrusion. The aim of this study was to analyze risk factors for major complications of use of tissue expanders in pediatric patients using multivariate analysis. METHODS: A retrospective, single-center observational study was performed over 10 years in pediatric patients who were treated with tissue expanders for tumors, nevus, scars, burn reconstruction, and alopecia from April 2012 to March 2022. The primary outcome was overall complications per operation and expander, including infection and extrusion. Ten predictor variables were included as risk factors based on previous studies and as new factors considered important from clinical experience. Univariate and multivariate logistic regression analyses were performed to identify risk factors for major complications such as expander infection or extrusion. RESULTS: The study included 44 patients who underwent 92 operations using 238 tissue expanders. The overall complication rate per expander was 14.3%. Univariate logistic regression analysis identified associations of younger age, number of expanders used per operation, history of infection, and tissue expander locations with a higher complication rate. In multivariate logistic regression analysis, younger age (odds ratio, 1.14; P = 0.043) was associated with a high likelihood of expander complications. CONCLUSIONS: Younger age is an independent risk factor for tissue expander complications in pediatric patients. This factor should be considered in preoperative planning and discussions with the patient's family.

Lower Extremity Pediatric Tissue Expansion: A Single Surgeon's 16-Year Experience.

BACKGROUND: Tissue expansion is a well-established approach to soft tissue reconstruction in the pediatric population for lower extremity pathologies. Unfortunately, complication rates range from 19% to 40% in literature, including infection and implant extrusion, leading to delays in reconstruction. These challenges have prompted investigation toward categorizing risk factors for lower extremity tissue expander placement. METHODS: A retrospective study of pediatric patients who underwent lower extremity tissue expander placement by the senior author (R.J.R.) was performed over a 16-year period. Patient charts were reviewed to categorize baseline and operative characteristics. Primary outcome variables were surgical-site infection, expander extrusion, and expander deflation. Univariate and multivariate logistic regressions were performed ( α < 0.05). RESULTS: There were 59 tissue expanders in our cohort. The overall complication rate was 27.1% with a 77.2% successful reconstruction rate. Greater number of expanders placed during 1 operation is associated with 2.5 increased odds of having any complication and is associated with 0.4 decreased odds of having a successful reconstruction. Incisions made in scar tissue for expander placement appear to be associated with a greater than 7 times increased odds of readmission. CONCLUSIONS: Reconstruction of soft tissue pathologies using lower extremity tissue expanders in the pediatric population is an effective yet challenging technique. This study identified that the number of expanders inserted during 1 operation, incisions made over scar tissue, and expanders placed in the anterior thigh were correlated with having a negative impact on reconstructive outcomes. Extra care should be taken with patients who require multiple expanders during 1 operation and with choosing the location and incision of expander placement.

Immediate Prepectoral Tissue Expander Breast Reconstruction Without Acellular Dermal Matrix Is Equally Safe Following Skin-Sparing and Nipple-Sparing Mastectomy.

BACKGROUND: Prepectoral breast reconstruction has become increasingly popular over the last decade. There is a paucity of data surrounding the impact of mastectomy type on clinical outcomes when comparing prepectoral immediate breast reconstruction without acellular dermal matrix (ADM) using tissue expansion. The purpose of this study was to compare 90-day reconstructive surgical outcomes in immediate prepectoral tissue expander reconstruction between patients with nipple-sparing mastectomy (NSM) and skin-sparing mastectomy (SSM). METHODS: A retrospective review of patient records was carried out on all patients undergoing NSM or SSM with immediate prepectoral tissue expander reconstruction without ADM, in a single institution, from June 2020 to December 2021. All complications were recorded, categorized, and statistically analyzed for significance. RESULTS: Seventy-nine patients (97 breasts) were studied. The mean age was 51 years old (range, 31-77). Twenty-two patients suffered complications recorded in 22 breasts (22.7%). There was no statistically significant difference in the total complications between the NSM (25.7%) and SSM (21.0%) groups or in the incidence of all major and minor complications. CONCLUSIONS: Breast reconstruction using tissue expanders without ADM has similar reconstructive outcomes in both NSM and SSM. There were no significant differences in complication rates between either groups. Breast reconstruction without ADM can confer institutional cost savings without compromising safety.

Complications Following Tissue Expander-Based Reconstruction in Pediatric Burn Injuries: A Retrospective Analysis.

BACKGROUND: Tissue expansion has been widely used to reconstruct soft tissue defects following burn injuries in pediatric patients, allowing for satisfactory cosmetic and functional outcomes. Factors impacting the success of tissue expander (TE)-based reconstruction in these patients are poorly understood. Herein, we aim to determine the risk factors for postoperative complications following TE-based reconstruction in pediatric burn patients. METHODS: A retrospective review of pediatric patients who underwent TE placement for burn reconstruction from 2006 to 2019 was performed. Primary outcomes were major complications (TE explantation, extrusion, replacement, flap necrosis, unplanned reoperation, readmission) and wound complications (surgical site infection and wound dehiscence). Descriptive statistics were calculated. The association between primary outcomes, patient demographics, burn characteristics, and TE characteristics was assessed using the chi-squared, Fisher's exact, and Mann-Whitney U tests. RESULTS: Of 28 patients included in the study, the median [interquartile range (IQR)] age was 6.5 (3.3-11.8) years, with a follow-up of 12 (7-32) months. The majority were males [n = 20 (71%)], Black patients [n = 11 (39%)], and experienced burns due to flames [n = 78 (29%)]. Eleven (39%) patients experienced major complications, most commonly TE premature explantation [n = 6 (21%)]. Patients who experienced major complications, compared to those who did not, had a significantly greater median (IQR) % total body surface area (TBSA) [38 (27-52), 10 (5-19), P = 0.002] and number of TEs inserted [2 (2-3), 1 (1-2), P = 0.01]. Ten (36%) patients experienced wound complications, most commonly surgical site infection following TE placement [n = 6 (21%)]. Patients who experienced wound complications, compared to those who did not, had a significantly greater median (IQR) %TBSA [35 (18-45), 19 (13-24), P = 0.02]. CONCLUSION: Pediatric burn injuries involving greater than 30% TBSA and necessitating an increasing number of TEs were associated with worse postoperative complications following TE-based reconstruction.

One-Stage Deep Inferior Epigastric Perforator Flap Salvage of Infected Tissue Expanders.

BACKGROUND: Tissue expander-based breast reconstruction is associated with high rates of infectious complications, often leading to tissue expander explants and delays in receipt of definitive breast reconstruction and adjuvant therapy. In this study, we describe a single-stage technique where deep inferior epigastric artery perforator (DIEP) flaps are used to salvage actively infected tissue expanders among patients originally planning for free flap reconstruction. METHODS: In this technique, patients with tissue expander infections without systemic illness are maintained on oral antibiotics until the day of their DIEP flap surgery, at which time tissue expander explant is performed in conjunction with aggressive attempt at total capsulectomy and immediate DIEP flap reconstruction. Patients are maintained on 1-2 weeks of oral antibiotics tailored to culture data. Patients undergoing this immediate salvage protocol were retrospectively reviewed, and complications and length of stay were assessed. RESULTS: In a retrospective series, a total of six consecutive patients with culture-proven tissue expander infections underwent tissue expander removal and DIEP flap reconstruction in a single stage and were maintained on 7-14 days of oral antibiotics postoperatively. Within this cohort, no surgical site infections, microvascular complications, partial flap losses, reoperations, or returns to the operating room were noted within a 90-day period. CONCLUSIONS: Among a select cohort of patients, actively infected tissue expanders may be salvaged with free flap breast reconstruction in a single surgery with a low incidence of postoperative complications. Prospective studies are needed to evaluate the influence of this treatment strategy on costs, number of surgeries, and dissatisfaction after staged breast reconstruction complicated by tissue expander infections.

Reconstructed Mid-Face Lifting After Tissue Expansion by Suspending the Expander Capsule.

BACKGROUND: An obvious saggy tendency was observed in the expanded flaps from mid-facial reconstruction and resulted in an unsatisfactory postoperative cosmetic outcome. At the time of this writing, the authors introduced a novel technique of mid-face lifting to correct the phenomenon by suspending the expander capsule. METHODS: From September 2018 to August 2023, 11 patients who had undergone our mid-face lifting technique were enrolled in our study. The expanded flap was divided into 2 layers during the surgical procedure. The upper layer, which consists of the skin and the subcutaneous layer, was lifted, and the lower layer, consisting of the expander capsule and SMAS system, was left at the base. Then a capsular flap was lifted from the base and folded upward to lift the reconstructed mid-face. The capsular flap was fixed in the temporal or mastoid region when the saggy tendency was corrected, and the mid-facial contour became symmetric. Finally, the upper layer was trimmed and fixed at the base. Facial movements were restricted after the surgery. RESULTS: The saggy tendency of all the expanded flaps was corrected, and the mid-facial symmetry was rebuilt immediately after the surgery. The effect were long-lasting at 3 months to 2 years of follow-ups. No serious postoperative complications occurred. The patients or their legal guardians were satisfied with the esthetic improvement. CONCLUSION: Reconstructed mid-face lifting with capsular flap was an effective and reliable way to correct the saggy tendency of a mid-facial expanded flap and rebuilt the mid-facial symmetry.

Sizeable Facial and Cervical Defect Repair using a Medial Arm Flap Combined With the Tissue Expansion Technique: Clinical Applications and Fifteen-year Follow-up.

BACKGROUND: The aim of this study was to present the 15-year clinical results using a preexpanded pedicle medial arm flap for repairing massive facial and cervical defects. METHODS: The process of our method is divided into 3 stages. In the first stage, the rectangle-shaped tissue expander was implanted subcutaneously in the medial arm region and serially inflated for ~3 months. In the second stage, the distal portion of the flap was to cover the defects, the proximal portion was overlapped with the residual lesion flap. The pedicle was divided 3 weeks later, and the extra tissue was reinserted back to the donor site. RESULTS: A total of 27 patients were retained. All donor sites were closed directly. Maximum and minimum sizes of preexpanded cervical flaps were 2015 cm2 to 5.54 cm2. In 2 cases, partial necrosis occurred at the distal end of the flap, while the remaining flap survived completely. The median duration of follow-up was 7.5 years. During follow-up, 24 patients (88.9%) had satisfactory outcomes and 3 patients (11.1%) had partially satisfactory results. CONCLUSION: Using expanded pedicle medial arm flap for face or neck defects' reconstruction showed that it was safe and effective, and had satisfying results in the long-term follow-up. The flap based on the proximal pedicle has a more reliable blood supply.

Resurfacing of Sleeve-Like Circumferential Giant Congenital Melanocytic Nevi on the Upper Extremity With Pre-Expanded Pedicled Flap.

As the relative shortage of healthy tissue obviates the option of local soft tissue coverage, reconstruction of circumferential giant congenital melanocytic nevi (GCMN) on the upper extremity remains particularly challenging. Here the authors report a 3-stage procedure involving pre-expanded pedicled flap from the torso for the reconstruction of upper extremity after circumferential GCMN excision in pediatric patients. The giant nevus was completely removed and the size of the excised nevus was 31 × 14.5 cm. The donor site was primarily closed. No major complication was encountered. Reconstruction with expanded pedicled flap achieved satisfactory results, both functionally and cosmetically.

Scalp Closure in Midline Cutis Aplasia-An Absolute Indication for Preoperative Imaging.

The ideal evaluation and treatment of aplasia cutis congenita remains disputed. We present a case of midline scalp cutis aplasia that healed by secondary intention, leaving an area of residual alopecia. There were no clinical indicators of an underlying calvarial defect. Tissue expansion of the scalp was done in preparation for scalp closure. However, on the removal of the expanders and scalp advancement, an unrecognized midline calvarial defect in which a scar tract of herniated dura was found. This resulted in a dural tear, repaired with minimal hemorrhage. However, manipulation of the sagittal sinus resulted in a right subdural hemorrhage followed by cerebral ischemia and a stroke. On the basis of this clinical scenario, we recommend that all cases of midline scalp cutis aplasia undergo preoperative imaging with thin slices of the calvaria before performing scalp advancement-even if the only clinical indication for surgery is scalp alopecia without a palpable skull defect.

The Dynamic Changes in Skin Thickness of Forehead during Tissue Expansion.

In addition to providing extra flap size, the tissue expansion process also brings changes in flap thickness. This study aims to identify the changes in the forehead flap thickness during the tissue expansion period. Patients undergoing forehead expander embedment from September 2021 to September 2022 were included. The thickness of the forehead skin and subcutaneous tissue were measured with ultrasound before and 1, 2, 3, and 4 months after expansion. Twelve patients were included. The average expansion period was 4.6 months, and the mean expansion volume was 657.1 mL. The thickness of skin and subcutaneous tissue in the central forehead changed from 1.09 ± 0.06 to 0.63 ± 0.05 mm and from 2.53 ± 0.25 to 0.71 ± 0.09 mm, respectively. In the left frontotemporal region, skin and subcutaneous tissue thickness changed from 1.03 ± 0.05 to 0.52 ± 0.05 mm and 2.02 ± 0.21 to 0.62 ± 0.08 mm. On the right side, skin and subcutaneous tissue thickness changed from 1.01 ± 0.05 to 0.50 ± 0.04 mm and 2.06 ± 0.21 to 0.50 ± 0.05 mm. This study measured the dynamic changes in the thickness of the forehead flap during expansion. The thickness of the forehead flap decreased the fastest in the first 2 months of expansion, and the changes in skin and subcutaneous thickness slowed down in the third and fourth months and tended to a minimum value. Additionally, the thickness of subcutaneous tissue decreased greater in magnitude than the dermal tissue.

Single versus Double Drainage for Immediate Two-Stage Implant-Based Breast Reconstruction: A Propensity Score-Matched Analysis.

BACKGROUND: Reports evaluating plastic surgeons' practices indicate there are conflicting trends regarding the use of one or two drains for implant-based breast reconstruction (IBBR). Our study aimed to perform a matched cohort analysis to examine the postoperative outcomes and complications of immediate IBBR with tissue expander (TE) using two drains versus a single drain. METHODS: A propensity score-matched analysis (nearest neighbor, 1:1 matching) of immediate reconstructions using two versus one drain was conducted. Female patients undergoing immediate two-stage IBBR with TEs between January 2011 and May 2021 were included. The covariables were as follows: BMI, mastectomy weight, lymph node surgery, TE surface, plane of reconstruction, use of acellular dermal matrix products, fluorescence imaging use, and intraoperative TE volume. RESULTS: After matching using propensity scores, 192 reconstructions were included in the final analysis: 96 in each group. The rate of 30-day complications and overall complications during the first phase of IBBR were comparable between groups. The time for drain removal, time to initiate and finalize expansions, and time for TE-to-implant exchange were comparable between groups. Diabetes (OR 3.74, p = 0.025) and an increased estimated blood loss (OR 1.004, p = 0.01) were the only independent predictors for seroma formation. CONCLUSION: In this matched cohort analysis evaluating the role of one versus two drains for two-stage IBBR, we found a comparable rate of complications and surgical outcomes between the two cohorts. Using two drains for immediate IBBR needs to be tailored depending on intraoperative findings. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Air Versus Saline in Tissue Expanders: A Systematic Review of the Literature.

BACKGROUND: There has been a greater focus in recent literature proposing air to be a superior medium to saline in tissue expanders. This study aims to review the literature and assess the quality of data on the efficacy and safety of air as an alternative medium to saline in tissue expanders, in the setting of postmastectomy two-stage reconstruction. METHODS: A systematic review regarding air inflation of tissue expanders was conducted using PubMed, Embase, Cochrane Library, and Web of Science. The methods followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Three reviewers separately performed data extraction and comprehensive synthesis. RESULTS: A total of 427 articles were identified in our search query, of which 11 met the inclusion criteria. Three pertained to inflation with room air, and eight pertained to inflation with CO2 using the AeroForm device. They were comparable to decreased overall complication rates in the room air/CO2 cohort compared to saline, although statistical significance was only observed in one of five two-arm studies. Investigating specific complications in the five two-arm studies, significantly lower rates of skin flap necrosis were only observed in two CO2-based studies. Studies rarely discussed other safety profile concerns, such as the impacts of air travel, radiation planning, and air extravasation beyond descriptions of select patients within the cohort. CONCLUSION: There is insufficient evidence to suggest improved outcomes with room air inflation of tissue expanders. Further work is needed to fully characterize the benefits and safety profiles of air insufflation before being adopted into clinical practice.

Direct-to-Implant vs Tissue Expander Placement in Immediate Breast Reconstruction: A Prospective Cohort Study.

BACKGROUND: Direct-to-implant (DTI) breast reconstruction after mastectomy has gained increasing popularity. While concerns over ischemic complications related to tension on the mastectomy flap persist, newer techniques and technologies have enhanced safety of this technique. OBJECTIVES: To compare clinical and patient-reported outcomes of DTI and 2-stage tissue expander (TE) reconstruction. METHODS: A prospective cohort design was utilized to compare the incidence of reconstructive failure among patients undergoing DTI and TE reconstruction by unadjusted bivariate and adjusted multivariable logistic regression analyses. Secondary clinical outcomes of interest included specific complications requiring intervention (infection, seroma, hematoma, mastectomy flap necrosis, incisional dehiscence, device exposure) and time to final drain removal. Patient-reported outcomes on BREAST-Q were also compared. RESULTS: A total of 134 patients (257 breasts) underwent DTI reconstruction and 222 patients (405 breasts) received TEs. DTI patients were significantly younger with lower BMIs; less diabetes, hypertension, and smoking; and smaller breast sizes; they also underwent more nipple-sparing mastectomies with prepectoral reconstructions. Rates of any complication (18% DTI vs 24% TE, P = .047), reconstructive failure (5.1% vs 12%, P = .004), and seroma (3.9% vs 11%, P < .001) were significantly lower in the DTI cohort on unadjusted analyses; however, there were no significant differences on adjusted regressions. Patient-reported satisfaction with breasts, psychosocial well-being, and sexual well-being were more substantively improved with DTI reconstruction. CONCLUSIONS: Prepectoral DTI reconstruction is a viable option for postmastectomy reconstruction in carefully selected patients, with no significant increase in reconstructive failure or other complications.

Post-mastectomy Breast Reconstruction With Gas vs Saline Tissue Expanders: Does the Fill Type Matter?

The most common reconstruction technique following mastectomy is a 2-stage technique that involves tissue expansion followed by definitive implant-based reconstruction (IBR). Tissue expanders (TEs) have classically used saline for initial fill; however, TEs with an initial gas fill (GTE)-including the CO2-based AeroForm (AirXpanders, San Francisco, CA) TE and TEs initially filled with atmospheric air-have been increasingly used in the past decade. We aimed to compare the outcomes in breast reconstruction for tissue expanders initially filled with saline vs gas. PubMed was queried for studies comparing gas- and saline-filled tissue expanders (STEs) used in IBR. A meta-analysis was performed on major postoperative outcomes and the required expansion and definitive reconstruction time. Eleven studies were selected and included in the analysis. No significant differences existed between tissue expansion with GTEs vs STEs for 11 of the 13 postoperative outcomes investigated. Out of the complications investigated, only the risk of infection/cellulitis/abscess formation was significantly lower in the GTE cohort (odds ratio 0.62; 95% CI, 0.47 to 0.82; P = .0009). The time to definitive reconstruction was also significantly lower in the GTE cohort (mean difference [MD], 45.85 days; 95% CI, -57.80 to -33.90; P < .00001). The total time to full expansion approached significance in the GTE cohort (MD, -20.33 days; 95% CI, -41.71 to 1.04; P = .06). A cost analysis considering TE cost and infection risk determined that GTE use saved a predicted $2055.34 in overall healthcare costs. Surgical outcomes for both fill types were predominantly similar; however, GTEs were associated with a significantly decreased risk of postoperative infection compared to saline-filled TEs. GTEs could also reduce healthcare expenditures and require less time until definitive reconstruction after placement.

Comparison of Different Acellular Dermal Matrix in Breast Reconstruction: A Skin-to-Skin Study.

BACKGROUND: Since the early 2000s, acellular dermal matrix has been a popular adjunct to prepectoral breast reconstruction to enhance outcomes. OBJECTIVES: The aim of this study was to investigate the differences in the postoperative course of 2 standard acellular dermal matrix products, AlloDerm SELECT Ready To Use and DermACELL. METHODS: A prospective, patient-blind study of patients undergoing bilateral nipple and/or skin-sparing mastectomies with either tissue expander or silicone implant insertion between 2019 and 2022 were selected for this study. The study design used patients as their own controls between 2 products randomly assigned to the left or right breast. Outcomes between the products included average time for drain removal, infection rate, seroma rate, and incorporation rates. RESULTS: The prospective clinical data of 55 patients (110 breasts) were recorded for 90 days. There were no significant differences between drain removal time, average drain output, or seroma aspiration amount. A higher percentage of seromas was recorded in the breasts with AlloDerm (30.91%) compared with breasts containing DermACELL (14.55%, P < .05), and a statistically significant difference between the incorporation rates of AlloDerm (93.4%) and DermACELL (99.8%, P < .05) was observed. CONCLUSIONS: Irrespective of patient demographic disparities, both products had a 94.55% success rate for reconstruction outcomes. AlloDerm was determined to have a higher incidence of seromas as a postoperative complication and a trend to lower incorporation.

Enhanced Recovery After Surgery (ERAS) With Exparel in Tissue Expander-based Breast Reconstruction Following Mastectomy.

BACKGROUND: Enhanced recovery after surgery (ERAS) pathways have been widely shown to yield positive outcomes, including in plastic surgery. Our group has previously validated ERAS in our deep inferior epigastric perforator flap breast reconstruction population. OBJECTIVES: We evaluated whether the ERAS protocol and addition of liposomal bupivacaine affected patient outcomes at the time of mastectomy and first-stage tissue expander reconstruction. METHODS: All patients treated between July 2021 and May 2022 were reviewed retrospectively. The ERAS protocol was implemented in December 2021. Two patient groups were compared: pre-ERAS and ERAS. The ERAS protocol included use of liposomal bupivacaine in the pectoralis nerve block 1/2 planes. Primary outcomes were observed with postoperative length of stay and hospital narcotic use. RESULTS: Eighty-one patients were analyzed in this cohort. The pre-ERAS group was composed of 41 patients, the ERAS group was composed of 83 patients. Postoperative length of stay was significantly reduced in the ERAS group (1.7 pre-ERAS vs 1.1 ERAS, P = .0004). When looking at morphine equivalents during the hospital stay, the degree of narcotics in the recovery room was relatively similar. Average PACU pain morphine equivalents were 6.1 pre-ERAS vs 7.1 ERAS (P = .406). However, total hospital morphine equivalents were significantly lower in the ERAS group (65.0 pre-ERAS vs 26.2 ERAS, P = <.001). CONCLUSIONS: The introduction of an enhanced recovery after surgery protocol with liposomal bupivacaine pectoralis 1/2 nerve blocks decreased postoperative opioid consumption and hospital length of stay in mastectomy patients undergoing tissue expander-based reconstruction.

Reconstruction of High-Tension Scalp Defects by the Twizzler Technique: A Retrospective Case Series.

BACKGROUND: Scalp wounds are difficult to close primarily because of the inelasticity of the galea, often requiring adjacent tissue transfer or grafting. It is still debated whether intraoperative tissue expansion can occur on the scalp. OBJECTIVE: We report our experience with the Twizzler technique, a form of intraoperative tissue expansion and load cycling, to achieve primary closure of high-tension scalp wounds. MATERIALS AND METHODS: In this case series, scalp defects repaired by the Twizzler were identified and those with minimum 3 month follow-up underwent assessment by physicians and patients. RESULTS: All 50 scalp defects that could not be otherwise closed primarily were repaired successfully with the Twizzler. The average defect width was 2.0 cm (range 0.9-3.9 cm), the average physician aesthetic rating was 3.71 on a 5-point scale (very good; n = 25), and most patients rated the scars as "near normal skin" on the Patient and Observer Scar Assessment Scale 3.0 ( n = 32). CONCLUSION: Based on the findings of this case series, the Twizzler can be used to repair small and medium high-tension scalp defects after Mohs micrographic surgery. Intraoperative tissue expansion and creep deformation on the scalp is limited, but seemingly possible.

Tumescent local anaesthesia for the surgical therapy of congenital nevi in the first year of life.

BACKGROUND: The indication for surgical treatment of congenital nevi must be made after individual consideration of the expected benefit and risk and requires careful information of the parents as well as interdisciplinary psychological support. In addition to suspected malignancy, a relevant indication is the risk of stigmatization depending on the size and localization of the nevus. Objective was to show which size reduction of the congenital nevus can be achieved by surgical therapy under tumescent local anaesthesia (TLA) in infancy and how often complications of anaesthesia or surgery occur. METHODS: All infants up to 12 months of age who underwent surgery for a congenital nevus under TLA at the University Dermatological Clinic Tuebingen between January 2015 and December 2021 were included; surgeries were performed using serial excisions (powerstretching technique), whereby the incisions were made inside the nevus and mobilization was strictly limited to the skin side without nevus. RESULTS: Overall, a cumulative total area of 38.65 cm2 could be removed on average within the first year of life (trunk: 67 cm2 , head: 21.2 cm2 , legs: 21.6 cm2 , arms: 13.2 cm2 ). A cumulative maximum area reduction of 406.9 cm2 could be achieved. We evaluated 363 surgical sites (123 children) on all body regions. The median age of the children at the first surgery was 3.5 months (0.46-10.7 months). Complications occurred in 2.3% (seven procedures). All these complications were reversible in the course of the operation and did not lead to a prolonged hospital stay. No anaesthesia-related complications occurred. CONCLUSION: We were able to show that a reduction of large areas of congenital nevi is possible in the first year of life with the combination of serial excisions using powerstretching technique, TLA, and intracutaneous butterfly sutures.