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American Association of Plastic Surgeons
17. Complications in Pediatric Tissue Expansion: A Twelve-Year Experience
John A. LoGiudice, MD, Lane Groutage, Arun K. Gosain.
Medical College of Wisconsin, Milwaukee, WI, USA.

Tissue expansion provides an unparalleled quality of reconstruction in the pediatric population, and is a mainstay of treatment. However, complication rates following tissue expansion in children remain significant. The present 12-year review of complications following pediatric tissue expansion by a single surgeon is performed to identify factors associated with both increased and decreased complication rates, and to guide subsequent therapy so that the reconstructive needs of the patient can be met irrespective of the potential for intervening complications.
A retrospective study of all pediatric patients who underwent tissue expansion by the senior author from July 1992 to July 2004 was performed. A total of 282 expanders in 94 patients were placed. Indications for expansion included giant congenital nevi, burns, and hemangiomas.
A total of 65 complications occurred in 34 of 94 (36%) patients, involving 62 of the 282 (22%) expanders placed. Major complications which required expander removal included exposure (n=9), rupture (n=16) and migration (n=7). Infection (n=8) prompted removal of 5 (63%) expanders. Port malfunction occurred in 9 expanders. Complications were analyzed by the following criteria: A) Expander location: Complications occurred in 20 of 113 (18%) expanders placed in the scalp, 21 of 100 (15%) in the torso, 9 of 52 (17%) on the face and neck, and 2 of 16 (13%) expanders placed in the extremities. Rupture was most likely in the scalp, accounting for 9 of the 20 (45%) complications in this region. B) Fill volume: Expanders were considered under-filled if maximum volume was less than 90% of recommended volume. Over-filled expanders were defined as greater than 110% of recommended volume. Expander capacity never exceeded twice the recommended volume. Expanders that were under-filled had a 46% (26 of 56 expanders) complication rate, excluding infection as a complication. Over-filled expanders had a complication rate of 10% (18 of 185 expanders). Exposure occurred in 8 of the 56 (14%) under-filled expanders compared to 1 of the 185 (0.5%) over-filled expanders. C) Re-expansion of the same site: Initial expansion of a virgin donor site involved a complication rate of 15% (30 of 198 expanders). Subsequent expansion in these areas resulted in a 30% (26 of 87) complication rate. D) Expander type: Two-stage expanders and magnetic internal ports were used early in the series and abandoned due to complication rates (migration and exposure) of up to 67%. Thereafter, one stage expanders with remote internal ports were used exclusively.
Tissue expansion is an essential component of reconstruction for large pediatric cutaneous lesions. However, families must be made aware that approximately 1/3 of patients will have a complication requiring additional surgery or modification of the initial surgical plan. Nevertheless, almost all patients in the present series met their initial reconstructive goals. Factors more likely to be associated with complications include expander placement in the scalp (rupture), re-expansion of the same donor site, and specific expander design. Complication rates were increased with two-stage expanders, magnetic internal ports, and rigid-backed expanders in the scalp. Overfilling expanders can be performed without increased rates of rupture or exposure as long as fill volume does not exceed twice recommended fill capacity. Better understanding of complications associated with pediatric tissue expansion and adequate preparation to solve them make it more likely that the patient will achieve the initial reconstructive goals.

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