INTRODUCTION
The face has its great importance in giving the
person his self-identity, beauty and individual
characteristics. However, being an exposed and
easily susceptible to trauma and wounds, it is the
part which faces a great risk of injuries and as a
result it resembles a common site of scars [1,2].
303
The patients suffering from scars are looking
forward to restoring the pre-injury look and becoming
again without scar which is almost impossible.
So, if scar revision procedure were expected
as a scar elimination one, the surgery may be
considered disappointing. So, detailed consultation
for those patients is the precious experience even
from the basic plastic surgery training time. Also,
both the surgeon and the patient must agree preoperatively
that the goal of surgery is to improve
not eliminate the scar to be satisfying management
[3].
The cheek is relatively broad facial aesthetic
unit which surrounds the central facial structures
i.e. the nose and lips and fuses with forehead,
eyelids, neck and ear with different reconstructive
considerations. The cheek differs from men to
women in unique characters which are of great
aesthetic and reconstructive values. Homogeneous
women cheeks are different from those covered
with thicker hairbearing skin in men. The borders
of the cheek subunit are composed of the nasofacial
junction and nasolabial fold medially, the infraorbital
rim superiorly, the temporal hairline and
preauricular crease laterally, and the lower of the
mandible inferiorly [4].
The facial skin exerts a sort of intrinsic tension
which occurs in invisible lines named the relaxed
skin tension lines (RSTL s) along which the incisions
tend to heal in least tension and spreading
with better aesthetic results. These lines occur in
the face nearly paralel to rhytids lined. The cheek
subunit borders and RSTLs provide the basis for
proper scar positioning and orientation to maximize
eventual scar camouflage [5]. Tissue expansion is
an ideal strategy that generates a new skin with
the same color, nature and characters of the surrounding
healthy skin [6].
The motive of this study was that the results
of some cheek scars revisions may appear to be
disappointing owing to their sites or direction even
with much efforts. By using tissue expanders, the
scars repositioning and reorientation in relation to
the cheek unit borders and RSTLs may provide
the basis of superior results in scar revision and
management.
So, we aim to demonstrate the effect of cheek
skin expansion by tissue expanders on repositioning
and reorientation of the cheek scar to maximize
the scar aesthetic outcome.
PATIENTS AND METHODS
This prospective study was conducted on 13
patients with obvious linear (8 cases) or irregular
(5 cases) cheek scars who were willing to move
these scars to less conspicuous sites. In fact, the
closest expandable skin to the scar area in one side
is considered as the donor tissue. The scars included
in the study must be in the cheek unit in a place
permitting the insertion of a rectangular expander
under the nearby haelthy skin. This potential donor
skin must have the enough size and expandability
to replace the required area in repositioning the
scar. All patients included in the study have been
undergone all the stages of the reconstruction from
May 2013 to May 2017 with 6 months follow-up
period at least in the unit of plastic and reconstructive
surgery, Zagazig university hospitals. Adequate
patients' consultation and written informed consents
from all included patients were fullfiled.
We have designed a computerized custom-made
chart (Fig. 1) including facial photographs of our
patients to simulate face with the scar and tissue
expander insertion site in a flat two-dimensional
setting. We provisionally simulate the face pre,
during and post expansion. For accurate analysis
and planning, we have assigned the coordinates of
three points in each scar (two ends and one midpoint).
Based on a previous study [7], rectangular tissue
expanders are believed to have more expandability
compared to crescent and round ones. Therefore,
we used rectangular tissue expanders in all cases
with (40 to 200ml.) capacity. They were selected
suitable to be inserted under the donor tissue and
generate the proposed expansion.
At the day of expander insertion, preoperative
marking of the original incision site, anatomical
sites of vital structures and proposed subcutaneous
pocket was done according to the previously
planned chart paper.
Operative technique:
All surgeries were performed under general
anesthesia. By scrub betadine the face was prepared
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followed by injection of adrenaline solution (from
1/100000 to 1/200000) in both the incision site
and the pocket area. Limited skin incision (3-6cm)
is done at the edge of the scar nearby the pocket
side and the subcutaneous pocket using fine skin
hooks is done 10-20% larger than the tissue expander.
It should be created below the donor area
superficially to superficial musculaponeuotic system
(SMAS). The use of sharp scissors with careful
dissection and being under direct vision are the
keystones for the technical safety. SMAS layer
acts as a barrier to the plane containing facial nerve
with its branches, parotid duct and other facial
vital structures. Using bipolar diathermy, fine
hemostasis was secured and the pocket area was
washed with normal saline and antibiotic solution
(160mg gentamicin and 500ml normal saline).
After the expander was examined for safety and
leakage, it was inserted in the pocket. During the
insertion procedure, knuckling and bending of the
prosthesis were carefully avoided. Also, the injection
port was placed subcutaneously far from the
pocket and the tissue expander under the healthy
skin. It must be easily distinguishable and accessible
for the following injections with avoidance of
kinking and tension to insure successful expansion.
Also, intraoperative examination for port performance
should take place. Careful hemostasis was
secured and vacuum drains were not used in any
case but they were available to be placed in the
pocket site if necessary. Then, using vicryl sutures,
subcutaneous and deep dermal layers were closed.
Subcuticular prolyne suture were taken afterwards
to close the skin. Normal saline, 10% to 20%
percent of the of the tissue expander volume, was
injected as required. This induce an average pocket
wall intrinsic compression with not much tension
to the repaired wound. After the surgery, with the
use of sterile gauze the wounds were dressed.
According to the wound state, two to three weeks
postoperatively, the expander inflation began and
continued at 5-7 days intervals. The wound must
be free of any sign of infection, inflammation or
discontinuation to start the expander inflation.
It has been continued on average 2 to 3 months
long according to the needs and the site of the
surface area to reconstruct. We relayed on blanching
of the skin and the patient discomfort to determine
the safe filling endpoint indicator. To measure the
tissue expansion, we were subtracting the width
of the expander base from the width of the expanded
skin on the expander. The expander inflation must
be at least 10-20% more than the proposed size of
the area planned to be excised to compensate the
elastic recoil of the facial skin. Afterwards, we
Egypt, J. Plast. Reconstr. Surg., July 2018 305
removed the expander in the second stage surgery.
At this stage we excised the original scar and the
planned nearby healthy skin to modify the wound
place or direction. According to the availability,
the expanded skin was used to shift the scar to
more favorable site i.e. borders of the face, borders
of the cheek subunit, to be reoriented in relaxed
skin tension lines (RSTLs) or outside the malar
region or in the hair bearing area. The incision site
was repaired in two layers. (Fig. 2).
Fig. (1): Pre operative custom-made planning chart.
Fig. (2): Operative technique.
First Stage: (A): Marking. (B): Dissection. (C): Incrtion.
Second Stage: (D): Expansion. (E): Excision. (F): Closure.
All the patients were analyzed and compared
in terms of demographic variables, such as age
and gender, etiology of scar, shape and the dimensions
of the scar, the mean final volume of the
prosthesis, the mean time interval between the two
procedures.
Complications were assessed as major complications
(infection, leakage, exposure, wound dehiscence,
extrusion, and tissue necrosis) and minor
complications (hematoma, seroma).
Regarding technical success, if no complications
occurred, it was considered a ''straight forward'
expansion. Completion of expansion after treatment
of complications was termed ''salvage'' while if
the expansion had to be abandoned it was considered
''failure''.
For interpretation of the quantitative variables,
age, filling volume, time of treatment. Standard
deviation, mean, minimum, and maximum values
were used.
For interpretation of the qualitative variables,
three plastic surgeons not included in the study
have aesthetically evaluated the scar pre-expansion
and post-expansion to determine the aesthetic
outcome i.e. complete repositioning the scar outside
the cheek unit (optimal), scar reorientation typically
in RSTLs or repositioning the scar outside the
malar region (suboptimal), incomplete scar resection
(partial) and the expansion was terminated
without any scar resection (failed). Also, they
evaluated homogeneity between the generated and
the surrounding skin, facial symmetry with normal
performance of the tissue and patient satisfaction
at least 6 months after the reconstruction surgery
and absolute frequency and relative frequency were
used. The analyses were performed using the SPSS
statistical software for windows (version 17.0 SPSS
Inc., Chicago, IL, USA).
RESULTS
A total of 13 expanders were placed in 13
patients with cheek scars between May 2013 and
December 2014. This series comprised 4 females
and 9 males with a mean age 19.25±9.2 years
(range: 11- 31). Skin expansion was performed for
patients of linear scars due to sharp injuries (7
males and one female) and irregular scars due to
burns with boiling water (2 males and 3 females).
Smooth surface rectangular expanders with a remote
valve were used in the cheek aesthetic unit.
These were classified according to the place of
expander insertion (location of the majority of
306 Vol. 42, No. 2 / Using Facial Tissue Expanders in Repositioning of Linear
expander base surface area) into suborbital (3
cases), buccal (3 cases) and preauricular subunits
(7 cases).
Rectangular expanders were used in the subcutaneous
plane in all cases through an incision that
was included in the scar to be removed. The volume
of expanders used ranged between 40ml and 200ml
(mean: 162ml), while the fully expanded volumes
ranged between 80 and 270ml (mean: 178ml).
Time of treatment (time from expander placement
to expander removal at the time of reconstruction
ranged between 9 and 13 weeks with a mean of
10.2 weeks.
In 10 out of 13 cases (77%) tissue expansion
were achieved without complications. At the same
time, one minor complication has occurred in one
patient i.e. hematoma (resolved within one month)
was termed “salvage”. Major complications have
occurred in 2 cases i.e. expanders were exposed.
Since, in one case of these patients, this occurred
during the final stages of expansion not affecting
the outcome and termed “salvage”. Only in one
case, implant was withdrawn two weeks after
insertion in the early period and it was termed
“failure”.
Case 1:
A 27 years old man presented with an aesthetically
unpleasant scar interrupting the middle cheek
aesthetic unit. It was because of sharp injury 3
years ago in a criminal accident (knife mark).
Although the scar was not so wide, he was anxiously
willing to move the scar more peripherally
as he failed to find a job many times. In the first
session, 150cc (rectangular) subcutaneous tissue
expander was inserted in middle cheek regions.
Expansion was continued for 10 weeks. The expanded
flap allowed excision of the scar and the
nearby skin shifting the scar 4cm lateral, placing
it more peripherally in the cheek within anterior
hair line of the chin and outside malar region. (Fig.
3).
Case 2:
A 19 years old girl sustained a severe burn
resulted in unpleasant scar in the lower lateral
cheek region. She requested revision of her cheek
scar. In first reconstruction session, 150cc (rectangular)
tissue expander implant was inserted. Expansion
was continued for 9 weeks. The saline
volume instilled was 250cc. In the second session,
the expanded flap allowed excision of the 3cm
width of the cheek skin and reconstruction of the
burnt area. (Fig. 4).
Egypt, J. Plast. Reconstr. Surg., July 2018 307
Table (1): Results of using facial tissue expander in repositioning and resection in 13 cheek scar patients.
Case
number Gender
M
M
M
M
M
M
F
M
M
F
F
M
F
1
2
3
4
5
6
7
8
9
10
11
12
13
Injury
Cut wound
Cut wound
Cut wound
Cut wound
Cut wound
Cut wound
Cut wound
Cut wound
Burn
Burn
Burn
Burn
Burn
Scar
Shape
Linear
Linear
Linear
Linear
Linear
Linear
Linear
Linear
Irregular
Irregular
Irregular
Irregular
Irregular
12W
10W
11W
12W
2W
10W
12W
12W
12W
9W
12W
9W
13W
Treatment
time
150
230
80cc
20cc
220cc
150cc
180cc
190cc
270cc
170cc
140cc
160cc
Final
expansion
volume
_
_
Hematoma
(salvage)
_
_
_
_
_
_
_
_
_
Minor
Age Complications
16Y
22Y
18Y
!9Y
23Y
27Y
17Y
31Y
27Y
19Y
27Y
29Y
26Y
Expander
100cc
(rectangular)
150cc
(rectangular)
40cc
(rectangular)
200cc
(rectangular)
100cc
(rectangular)
150cc
(rectangular)
100cc
(rectangular)
150cc
(rectangular)
200cc
(rectangular)
250cc
(rectangular)
100cc
(rectangular)
100cc
(rectangular)
100cc
(rectangular)
Major
Complications
_
_
_
_
Expander
exposure
(withdrawn)
_
_
_
_
_
_
Expander
exposure
(salvage)
_
Homogeneity
+
+
+
+
_
+
+
+
+
+
_
+
Facial
symmetry
+
+
_
+
+
+
+
+
+
+
_
+
Patient
satisfaction
+
+
_
+
_
+
+
+
+
+
+
_
+
Repositioning &
esection
Suboptimal
Optimal
Suboptimal
Optimal
Failure
Suboptimal
Op timal
Optimal
Suboptimal
Optimal
Suboptimal
Partial
Suboptimal
DISCUSSION
Scar revision procedure(s) usually focuses on
providing the scar the least conspicuous shape with
satisfying long-term results. This may be still
considered a challenge. Different options of facial
scar revision have been routinely used to improve
the unsightly scar to more ideal one. These techniques
include excisional techniques i.e. simple
fusiform excision with or without wound irregularization,
serial excision and shave. Also, adjunctive
techniques have been used like dermabrasion,
laser resurfacing and intralesional steroid injection.
Although all these options have provided a better
aesthetic outcome, many patients and doctors still
have a constant quest for seeking superior results.
The skin has a great potential to expand by the
effect of tension and so tissue expansion has been
commonly used to generate a healthy skin to resect
scars. The concept of reposition of an existing scar
to a favorable site has been usually attempted in
midface scar revision with undermining and excision
techniques. However, this may result in some
facial asymmetry and contour distortion.
308 Vol. 42, No. 2 / Using Facial Tissue Expanders in Repositioning of Linear
In the present study, 13 cheek scars (8 secondary
to cut wounds and 5 burn scars) were managed
using tissue expanders. Tissue expansion in this
study has been used to over expand the cheek skin
and repositioning of the scars. So, it was primarily
a repositioning plus excisional rather than a merely
excisional technique. As a result, this approach
was used in this literature to get rid of scars interrupting
cheek aesthetic unit of the face or perpendicular
to RSTL. Also, it avoided wound closure
under tension with potential scar widening. Scar
analysis in this literature has been achieved by
printing the face photo on a computerized custom
- made chart. This permitted better planning of the
expander insertion site, the expansion needs and
second stage design. Furthermore, it provided an
efficient and clear tool and explain to the patients
in more realistic consultation.
The mean age of the patients in our study was
19.25±9.2 (range: 11-31) years. The mean age of
the patients in the study by Motamed et al., was
25.5±8.3 years. In the present study, 9 patients
were males (69%) and 4 patients were females
Fig. (3 - Case 1): A 27 year old man presented with an aesthetically
unpleasant scar interrupting the middle cheek
aesthetic unit because of sharp injury 3 years ago in a
criminal accident (knife mark).
Pre-reposition Post-reposition
Fig. (4 - Case 2): A 19 year old girl sustained a severe burn
resulted in unpleasant scar in the lower lateral cheek
region. She requested reconstruction of her cheek.
Pre-revision Post-revision
Egypt, J. Plast. Reconstr. Surg., July 2018 309
(31%). The types of the scars were linear scars
(62%) and irregular scars (38%). The causes of
these cheek scars were due to sharp injuries in the
linear scars (7 males and one female) and boiling
water burns in the irregular scars (2 males and 3
females). The majority of cases in the studies by
Motamed et al., [13], Gao et al., [18] and Farahvash
et al., [19] were females (70.59%), 57.17% and
57% respectively. The high incidence of males in
the present study compared to those studies is the
higher inclusion of linear post sharp injuries scars
which is seven folds commoner in males than
females in our study. The cause of scar in the study
by Ashab et al., was fire burn (60.61%) followed
by boiling water burn (15.15%) in most of the
cases [15]. In the series of Motamed et al. the most
common cause was flame (47%) and boiling water
(26.5%) [13]. This also may explain the majority
of females' numbers than males in both of these
studies who might be more subjected to burns in
home accidents during food preparation with less
safety precautions.
In the current study, all patients were operated
using rectangular expanders. Rectangular expanders
were found by Fattah to generate more tissue gain
than of round or crescent expanders [7]. This has
been supported by Hudson [8] and Motamed [9]
with better flap design and coverage chances.
Facial tissue expansion procedures necessitate
a special surgical experience. Tissue expanders
insertion in head and neck have been usually used
in reconstruction of extensively damaged tissues
[9]. During searching literatures, managing the
linear or small scars in the cheek using tissue
expanders was found an uncommon practice. However,
these scars may be a challenge in terms of
leading a normal life, joining certain jobs or having
a social and psychological balance. Complete
elimination trials of these scars by local excisional
and adjunctive techniques may be disappointing
in some instances.
In the present study, optimal and suboptimal
(beneficial) scar revisions were achieved in 84.6%
of cases. The concept of complete moving the scar
outside the cheek unit (optimal revision) has been
applicable to 5 in 13 patients (38.5%). However,
suboptimal revision has been applicable in the
form of scar reorientation typically in RSTLs
succeeded in 5 of 13 patients (38.5%) or repositioning
the scar outside the malar region in one
case (7.7%). Partial revision in the form of incomplete
scar resection occurred in 1 case (7.7%).
Only in one case (7.7%), the expansion was aborted
due to early wound dehiscence (failure). As regards
to repositioning or reorientation of the linear cheek
scars by tissue expansion, no literature was found
to use the concept before this study according to
my data. Based on the results achieved by burn
scars of the current study, four in five cases (80%)
were completely reconstructed and one case (20%)
were incompletely resected. This is similar to the
results found in the series of Fattah in 2014 [7],
80% of total patients suffering from head and neck
burn scars have been reconstructed completely.
Also, this is comparable to the results achieved by
Hudson [8]. It is higher than that achieved by
Bozkurt et al who had completely reconstructed
71.6% of their patients [11] but lower than the
results of the study of Saleh et al., [12] 87.5% 12
and Hafezi et al., [16] which were 90% of cases.
In the current study, the results were approximate
to the results found in previous studies [7,8,11,12,16]
in spite of relatively difficult expansion of the
cheek in our populations than the other areas of
the head and neck [7,10,12,16] and other body areas
[8,11]. Also, larger number of cases in future researches
should be considered.
Generally, the insertion of tissue expander
should be nearby the scar wherever the expansion
site i.e. face, neck, scalp or body to generate a
well-matched tissue with most similarity to the
skin color and nature [14]. Based on our study data,
tissue expanders were inserted in subcutaneous
plane just on the SMAS layer of the cheek in all
cases and the initial volume of the tissue expanders
was between 40 and 200ml. In different studies,
the neck was the most common site for expander
placement in cheek scar revision [13,15,7] with the
largest applicable initial volumes. The mean initial
volume by Yamin et al., was 321.55±182.52 [15].
In another study, the initial volume for reconstruction
of cervicofacial angle was selected between
250 and 500ml [13]. In our series, marked over
expansion was avoided above 20% more than
planned preoperatively otherwise excessive skin
may need excision with additional scar.
In the current study, two patients developed
complications of the prosthesis (15.4%), including,
minor expander exposure (7.7%) and one wound
dehiscence (7.7%). The patient who sustained of
minor exposure was managed by continuation of
expansion for 4 weeks to gain maximum possible
skin expansion. The other case of wound dehiscence
which was in the beginning of the expansion period
was managed by prosthesis removal, wound lavage
and immediate closure with antibiotic according
to culture and sensitivity test. Limited hematoma
was reported in one case (7.7%) which was resolve
within one month follow-up. This result was comparable
to the series of Yamin et al., who reported
complications of prosthesis in (13.89%) of his
population [15]. The prosthetic complications reported
by him were including prosthesis site infection
(2.78%), prosthesis exposure (5.56%), hematoma
(2.78%), leakage of the prosthesis (2.78%),
and necrosis of the injection port site (2.78%). In
the present study, the total complication rate (23%)
which was lower to that reported by Hafezi et al.,
(27%) [16] and Saleh et al., (34.75%) [12] however
comparable with that reported by Tavares et al.
(24%) [17] and Hudson (25%) [8].
Bozkurt et al., [11] reported in there study approximately
30% complication rate. In the present
study, the failure rate (interruption of expansion
process) was 7.7%. This is lower than that of
Hudson (20%) and Saleh (13.25%) but comparable
to that of Bozkurt et al., 10% [11] and that of Hafezi
et al., (6%). We think that careful planning, meticulous
dissection on subcutaneous plane above the
SMAS, hemostasis and closure of dermal layer are
the keystones of minimization the complication
and failure rates.
Conclusion:
Facial tissue expander usage in repositioning
and revision of linear and irregular cheek scar is
a reasonable approach in obtaining superior aesthetic
results.
