Tissue Expansion 101
Mim, Sara, Dr. Bauer and Susan.
By , Staff Writer, Nevus Outreach
If you check in to the Nevus Outreach support group now and then, you may have come across director Mark Beckwith commenting that Bruce Bauer, MD, FACS, FAAP, is “the undisputed world expert for removing large congenital melanocytic nevi (CMN) using tissue expanders.” Bauer heads Pediatric Plastic Surgery at NorthShore University Health System, in Chicago, Ill.
While more than a dozen other plastic surgeons offer this same procedure, Chicago is clearly the hub of nevus removal in the United States. Bauer — along with his trusted nurses Mim Tournell and Susan Hoadley, and assistant Chrissy — may be caring for 30 or more children at any one time.
Bauer has been developing these skills for decades. He graduated from Northwestern University Feinberg School of Medicine in 1979, as one of the first graduating residents to specialize exclusively in pediatric plastic surgery. He performed his first tissue expansion surgery in the early 1980s.
“I have placed more than 3,000 tissue expanders since then — at least two-thirds for nevus patients,” he says.
While removing a nevus is a personal decision and may not be the right for every family affected by CMN, it is an option that some families choose. For those families, tissue expansion allows a good way around the poor results of procedures such as grafting, dermabrasion, and chemical peels that are used in other parts of the world. “Tissue expansion is a powerful tool in plastic surgery.”
Consultation and preoperative planning
Because CMN is such a rare condition, Bauer’s patients are not clustered in and around Chicago, but are likely to come from afar. For this reason, he and his team depend heavily on the Internet for everything from the initial consultation to the vigilant monitoring of their patients’ progress, once they go home.
Initial consultations, for example, typically start online. Bauer has a set of what he calls his Tissue Expander Bites, which are short PowerPoint presentations with many dozens of photos that he sends to parents.
One set covers the basics of tissue expansion. Another set covers cases similar to the prospective patient, demonstrating what the expanders look like and how the reconstruction is planned, along with before and after photos of children who have had this surgery.
“At this stage, there is virtually no nevus pattern that I have not seen and do not at least have some examples of,” he says.
After parents have a chance to review the presentations, he often chats with them one-on-one by phone or Skype, if they wish, to answer any final questions. If he is traveling in close proximity to potential patients, he may meet with families closer to their homes, if that is of help. He may not meet with many of these patients and their parents until the day or two before surgery, unless the complexity of the reconstruction is such that a face-to-face meeting is necessary well before the surgery date.
While each case is unique and no single technique will work in all cases, Bauer finds that there are remarkably repeatable patterns of nevus involvement among children. Because of that repetition, comes the ability to work out standardized treatment plans for removing nevi in each body region.
That said, some nevi are more complex and require more complex planning. It is here, even before surgery, that his skill, confidence, and years of experience begin to pay huge dividends.
“We can put tissue expanders almost anywhere, given the opportunity. It may not be every problem that I can explain our approach immediately, though. Sometimes I say, I think this is what we may do, but I’m going to take pictures and I’ll get back in touch with you.”
One key question Bauer needs to answer is where is the supply of blood coming from? “All over the body there are territories with different blood supplies. Any particular area of skin, where you are going to raise a flap of tissue, has to be oriented a particular way to have a blood supply and there are all kinds of ways of doing that. With some reconstructions, you can get so distant from where the main blood supply is coming in that you start running into issues. That area may take more time to heal. But that’s all part of understanding what flaps do — and understanding what you can do and cannot do.”
Other considerations include color match, skin texture, contour of the recipient site, and hair direction for scalp expansion to maximize the aesthetics and functional outcome of surgery.
“Parents want someone to take charge and say, ‘This is our plan. This is how we should approach this,’” Bauer says. “Most of the time we can do that.”
Preoperative training for families
Once surgery has been scheduled and first timers arrive, Mim and/or Susan will do a thorough preoperative training for families. Boys and girls are included in these teaching sessions from the time they are babies. These sessions cover everything from expander management to saline (salt-water) injections, providing detailed instructions that families take home.
Each round of expanders involves two distinct surgical procedures. Temporary tissue expanders are first placed in an initial surgery. Then, gradually, over the next 11 or 12 weeks, they are filled with a salt-water solution to stretch existing cells and encourage the growth of new cells. The patient then returns to have the nevus removed. The new flap of skin made possible from the earlier procedure provides a similar thickness and quality skin, and subcutaneous fat layer with a rich blood supply for rapid healing, where the nevus was removed.
The actual surgery and recovery
According to Bauer, tissue expansion can be used safely in almost all body regions starting at six months of age. Tissue is more flexible at this early age, too, and it heals quickly, as well.
The risk of problems during surgery is extremely slim with pediatric anesthesiologists well versed in the needs of this surgery. While some procedures are long, the children wake quickly, comfortably, and may leave the hospital the same day as surgery.
Bauer says that he inserts the expander on top of the fascia, in most locations. The fascia is a thin sheath of fibrous connective tissue that lies between the skin and the underlying muscles, nerves, and bones. In the scalp the expanders are placed in the loose layer between the scalp and the covering of the bone, which is called the periosteum. Finally, he does a regional long acting local anesthetic block with marcaine to the area.
“These nerve blocks last six to eight hours, so our kids wake up pain free. We have learned that when a child wakes up with little pain the whole recovery is more rapid.”
Ordinarily, Bauer prescribes Tylenol or Motrin for children less than one year of age, with the addition of Tylenol with codeine in older patients. Most youngsters do not require medication after the first week.
“Surgery is not very traumatic for the child,” Bauer says. “They actually tolerate it quite well. It’s much more traumatic for parents. Even after the preoperative teaching our staff does with the parents, many are often more comfortable if their child is observed for the first night following surgery. The vast majority of children — like 98 percent — leave by the next day. Parents who have been through past surgeries know the routines and most often go home the same day.”
Bauer gives kids antibiotics, when they get their expanders, and for about a week afterwards. He does not put them back on antibiotics unless they start to have symptoms of an infection. Problems occur occasionally, but he has rarely had to remove expanders, he says. He tracked 200 cases in a recent four-year period and had to remove an expander only three times — so that’s 1-1/2 percent of surgeries with serious complications.
“Looking at some so-called problems from the standpoint of time, I can see that, even with our most difficult complications, we have been able to complete our reconstructive plan, although on some occasions with an altered time frame. This is a particularly important perspective to discuss, as it is some of the interim ‘disasters’ that may circulate on the Internet. At least for our own patients, I have always built in a fall back position. Plus, we have many years of follow-up to show we can still complete our plan. Fortunately, some parents who have been through complications with their children are quick to volunteer their help for others who cannot imagine a rosy outcome while in the midst of dealing with a complication.”
Drains placed during surgery remain for about five to seven days. The first post-operative fill injection is done about eight to 10 days after surgery. Some families stay in town that length of time, while others elect to stay a couple of days, go home, then fly back for the first fill.
With few exceptions, once parents learn the drill, they feel very empowered and take care of everything for subsequent surgeries, Bauer says. They even take the drains out themselves, though he maintains close tabs.
Parents are taught to do the fills before they leave Chicago and they do these approximately every week. They first apply a topical anesthetic to numb the skin.
“We don’t stretch too much, because we don’t want to make the kids hurt. We just inject until it’s firm.”
Expander volumes vary according to the anatomic site, with expanders holding anywhere between about 2 ounces to 2 cups of saline for the head and neck area and between 12 ounces to a rather stunning quart of solution, when expanding on the trunk.
According to Bauer, the expander he uses is one he actually worked with a number of companies over the years to design. It is made of silicone (same as in breast implants) and is remarkably sturdy. These expanders are popular in the United States, but are not commonly used elsewhere, because only a few countries have contractual agreements in place that allow their use. Other expanders are available around the world, but access and cost has limited their use.
“By and large, kids can pretty much go about their normal activities within about three weeks, unless the expanders are on the lower leg and they can’t play soccer or something,” Bauer says. “Kids are doing things that would drive us crazy if we knew about it, but the expanders are made to hold up to practically anything.”
Twelve weeks is a long stretch though for parents and kids going through this procedure — especially for the first time. But they have lots of support.
“We spend lots of time developing parents’ trust,” Bauer says. “They know if there is a problem, they can call me anytime. They all have my cell number and email address.
“But there is nothing I am going to tell a parent that Mim and Sue are not going to say the exact same thing. Emails and digital images going back and forth allow us to follow patients at even a long distance. This provides families with a measure of comfort, too, knowing they are never far from advice and support.”
In addition to checking in with Bauer and his nurses in Chicago, parents often turn to one another. They connect regularly through the Nevus Outreach online support group and a nevus removal group on Facebook, where they get both emotional support, along with practical tips for this and that.
Moms have a repertoire of strategies in place for doing fills, for example. Suggestions include best positions, time of day, the use of DVDs for distracting the patient, and how long to leave the numbing agent on before proceeding with an injection. Popsicles are a favorite treat during a fill, moms find. And having a third person, like Grammy, around to read a book or otherwise entertain the patient is a good plan as well. One mom surprised readers when she said that she avoids any angst with her little girl by applying the numbing agent before putting her to bed for the night. She then does the fill once her child has fallen asleep. “It doesn’t always happen, but that is our ideal situation.”
Finally, with Chicago being the hub of nevus removal and Bauer performing most of these surgeries, nevus families are coming and going all the time. The repetitive nature of family trips to the windy city for various procedures often inspires a flutter of activity on online message boards.
“We’ll be heading in for my son’s surgery next week,” one mom posts. “Is anyone around?” Thus, spontaneous gatherings of Nevus Outreach families are ongoing before and after surgery, lending welcome social support and even a little bit of fun to an otherwise stressful experience.
Bruce Bauer, MD: www.plasticsurgery.northshore.org/our-team/bruce-bauer