Tissue Expanders in the Lower Face and Anterior Neck in Pediatric Burn Patients

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Abstract
Radovan's 1982 landmark work on the clinical use of tissue expanders was felt to be a panacea for multiple reconstructive problems.1 We have used and probably overused tissue expanders for reconstruction of many complicated pediatric facial burn problems. This has enlightened us to some of the limitations of their use, and we have, therefore, reassessed our indications for their use. From 1984 through 1990, 52 tissue expanders were used in 37 pediatric patients for face and anterior neck burn scar resurfacing. This experience, combined with the unique problems encountered with face and neck tissue expansion, provided the groundwork for operative guidelines. The long-term effects of gravity, growth, and scarring on facial features adjacent to expanded skin led to the following principles. (1) Caution should be used in advancing expanded neck skin beyond the border of the mandible. The risk of scar widening or possible lip or eyelid ectropion needs to be considered when planning these flaps. Extreme overexpansion is necessary to advance unburned neck flaps over the mandibular border to avoid these problems. (2) After advancement or rotational flaps neck flaps to the face, vertically directed suture lines in the neck may need redirection to prevent linear contracture. This correction may be performed during the primary operation or during revisions. (3) Expanded cheek or neck skin should preferably replace burned areas, but at the same time, not violate unburned facial aesthetic units. (4) To counteract the affects of gravity, expanded cheek skin in conjunction with expanded neck skin, if unburned, may be the best choice for face or mandibular border scar replacement. Caudal advancement poses less risk of lid or lip ectropion than cephalad advancement. (5) Staged serial excision, full thickness sheet grafts, local interdigitating flaps, regional rotation, or advancement of large neck flaps or even free flaps may be more efficacious with less stages and morbidity than the use of tissue expanders. (6) Flap advancement or rotation is always performed with the head extended or turned away. This position places the flap under the least amount of tension and decreases the incidence of ectropion of the lip and mouth and scar widening. Even a modest improvement of facial burn scarring makes a tremendous psychological difference to children who are forming their body images. Careful patient selection for the appropriate surgical procedure and proper surgical planning with attention to these guidelines can lead to significant improvement in their appearances.

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