Pediatric Tissue Expansion: Predictors of Premature Expander Removal in a Single Surgeon’s Experience with 472 Expanders

Abstract

Background: Tissue expansion is used for soft-tissue reconstruction in pediatric patients. The expansion process can be complicated by infection and extrusion, leading to premature expander removal. The aim of this study was to identify risk factors associated with premature expander removal caused by infection or extrusion in pediatric patients. Methods: A retrospective study of pediatric patients who underwent tissue expansion performed by the senior author (R.J.R.) over a 12-year period was performed. Predictor variables included age, sex, race, indication, anatomical location, number of expanders, serial expansion, and expander size. Bivariate and multivariate analyses were performed to identify risk factors for premature expander removal. Results: A total of 139 patients with 472 expanders were included in this study. Complications occurred with 78 expanders (16.5 percent). Premature expander removal caused by infection or exposure occurred with 51 expanders (10.8 percent). In terms of location, the highest rates of premature removal occurred in the lower extremity (20.0 percent) and scalp (16.3 percent). Multivariate analysis identified younger age (0 to 6 years compared with 13 to 17 years; OR, 3.98; 95 percent CI, 1.13 to 14.08; p = 0.03), greater number of expanders (OR, 1.45; 95 percent CI, 1.03 to 2.03; p = 0.03), and lower extremity location (OR, 4.27; 95 percent CI, 1.45 to 12.53; p = 0.008) were associated with an increased odds of premature expander removal. Conclusions: Expander removal occurred in approximately 10 percent of tissue expanders. Odds of premature removal is increased with younger age, greater number of expanders, and lower extremity location. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Pediatric Tissue Expansion: Analysis of the National Surgical Quality Improvement Program–Pediatric

“…Multiple expander placement is commonly reported ranging from 2 to 6 expanders, with Wang and colleagues reporting an average of 1.7 ± 0.6 expanders placed per operation. 8,14 Seventynine patients had multiple TE placed in our cohort accounting for 19.7%, but remarkably, only 14.3% of those with complications had multiple TE. Studies have reported differing conclusions on the safety profile of multiple expansions.…”

“…5,6,[12][13][14] The overall complication rate of 5.7% reported in the NSQIP-P was much lower than rates between 12% and 40% described in smaller single-site retrospective reviews. 14,15 As with other studies using NSQIP-P, complications are typically recorded by staff who are not surgeons based on keywords and codes from the electronic medical record. This can lead to underreporting or inaccurate reporting of complication rates.…”

“…Although antibiotics are typically given to treat minor infections, instances with a lack of resolution after initial treatment, extrusion through the skin, and signs of systemic infections including fever, leukocytosis, and hemodynamic instability may necessitate additional operations to remove the expanders 8,14. In their analysis of risk factors for expander removal, Wang et al14 reported infections as the primary cause of removal operations, occurring in 10.8% of expanders placed at their institution. Fortunately, a consensus supports that those infections during TE generally do not preclude the satisfactory achievement of treatment goals 7,8,14…”

Results of Split Thickness Skin Grafts after Scalp Rotation Flap Surgeries: A Cross-Sectional Study

“…Wang et al (2019) reported a complication rate of 16.5% in scalp reconstruction with the staged tissue expansion method. (15) Tissue growth can impose pressure on the underlying dura/brain in the event of pre-existing cranial anomalies. (16,17) In the context of cranioplasty reconstruction, free tissue transfer is typically recognized as the optimal approach to restoration for large-scale scalp covering.…”

Pediatric Fronto-Orbital Skull Reconstruction

“…Tissue expanders may be undesirable for some patients as they have an associated 16.5% complication rate and can elicit significant discomfort for the patient. 42 When an underlying vascular bed is unavailable, local pedicled flaps or free tissue transfer is needed (►Fig. 8).…”