Risk Assessment for Early Complications in Tissue Expansion Surgery: Insights from a 9-Year Retrospective Study
Tissue expansion is a pivotal reconstructive strategy in plastic surgery, offering the advantage of using local tissue with similar characteristics to the defect area. While it’s particularly effective for conditions like congenital melanocytic nevi, burn scars, and aplasia cutis congenita, the technique isn’t without risks. A new 9-year retrospective study from Hadassah-Hebrew University Medical Center explores the early complications associated with nonbreast tissue expansion and sheds light on the demographic, operative, and postoperative parameters that influence outcomes.
A Closer Look at the Study
This extensive study, spanning from 2009 to 2018, evaluated 308 nonbreast tissue expanders (TEs) inserted in both adult and pediatric patients. The Clavien-Dindo Classification of Surgical Complications was utilized—an important step toward standardizing how complications are categorized and interpreted in surgical literature.
The median age of patients was 7 years, indicating a pediatric-heavy cohort. Most procedures were performed to address congenital melanocytic nevi (72.1%), with the trunk and back being the most common regions of expansion (78.6%). The study excluded cases where TE models were non-standard or demographic/postoperative data were missing.
Key Findings
Early complications occurred in 28.6% of cases, though most were minor (20.5% were Clavien-Dindo Grade 1, requiring no more than basic symptomatic care). Only 6.8% of cases required surgical intervention, and a mere 1.3% needed pharmacologic treatment.
Multivariate Analysis Highlights:
- Autoimmune Disease or Malignancy History: Patients with such a history had significantly higher odds (OR 4.17) of developing complications.
- Drainage Size: Larger drainage sizes (JP10 vs JP7) were associated with increased complication risk.
- Surgeon Experience: Less experienced teams had a notably higher rate of complications.
- Re-expansion in Previously Expanded Areas: Associated with complications that required active intervention (CDC Grade 2+).
- Surgical Indication: Aplasia cutis congenita and burn scar reconstructions had higher surgical complication risks.
Pediatric vs. Adult Subgroup Analysis
Interestingly, the complication rate did not significantly differ between pediatric and adult patients. However, risk factors such as autoimmune history, drainage size, and surgeon experience were more impactful in pediatric cases. The adult subgroup showed no statistically significant risk factors, though this might reflect its smaller sample size or case complexity.
Surgical Protocol and Antibiotic Prophylaxis
A standardized approach was adopted for TE placement, using rectangular soft-bottom expanders. Drains were routinely inserted, and prophylactic antibiotics—mainly cephalosporins—were administered until drain removal. Expansion began 1–2 weeks postoperatively and continued weekly over 10–12 weeks.
Fan et al. previously reported that lack of antibiotics increased infection risks post-TE insertion. In contrast, this study found no statistically significant difference in complications across antibiotic regimens. This might be due to the universal prophylactic practice adopted.
Limitations and Strengths
Being retrospective, the study naturally faces limitations in predicting causality. Additionally, the smaller adult patient subgroup might mask relevant trends. Nonetheless, the use of a standardized complication classification and the broad timespan of data collection provide a robust basis for the study’s conclusions.
Conclusions and Clinical Implications
This study affirms that tissue expansion, while inherently risky, can be safely administered with a relatively low rate of major complications. Recognizing key risk factors—especially autoimmune status, re-expansion procedures, and surgeon experience—can empower plastic surgeons to tailor preoperative planning and postoperative care more effectively.
Furthermore, the adoption of the Clavien-Dindo Classification offers a model for future research to uniformly define and evaluate surgical complications, enabling clearer comparisons across studies.
🔑 Key Points Highlighted:
- Early complication rate post-TE insertion: 28.6%, with only 6.8% requiring surgery.
- Autoimmune history, larger drains, and inexperienced surgeons were top risk factors.
- Re-expansion and aplasia cutis congenita linked with higher surgical complication risks.
- Use of Clavien-Dindo Classification helps standardize complication reporting.
- No significant difference in complication rates between pediatric and adult patients.
📚 Reference
Davidov B, Hassidim A, Bendor S, et al. Risk Assessment for Early Complications in Nonbreast Tissue Expansion: 9-year Experience With 308 Tissue Expanders. Plast Reconstr Surg Glob Open. 2025;13:e6765. doi:10.1097/GOX.0000000000006765.
FAQS:
❓ 1. What are early warning signs of complications after tissue expander surgery in children?
Answer:
Early signs include unusual redness, swelling, warmth around the surgical site, persistent pain, fever, or fluid leakage. While mild discomfort is common, symptoms that worsen or do not improve after a few days may indicate an infection or complication. Always contact your surgeon if any of these signs appear during the expansion period.
❓ 2. Can autoimmune diseases increase risks during tissue expansion procedures?
Answer:
Yes, patients with autoimmune conditions or a history of malignancy face a higher risk of surgical complications during tissue expander procedures, including delayed wound healing and infections. Your surgeon will take extra precautions and may adjust the surgical plan or antibiotics accordingly to ensure safety.
❓ 3. How safe is tissue expander surgery for congenital melanocytic nevus in toddlers?
Answer:
Tissue expansion is a commonly used and generally safe reconstructive technique for large congenital melanocytic nevi in toddlers. The study showed low rates of severe complications. However, toddlers may have thinner skin and be more prone to trauma at the expander site, so close monitoring and careful handling are essential.
❓ 4. Do tissue expanders in the scalp or trunk area pose different risks for healing?
Answer:
Yes, tissue expanders placed in the extremities or scalp—especially for conditions like aplasia cutis congenita—can have slightly higher risks of surgical complications due to vascular fragility or limited tissue availability. Trunk and back expansions generally have fewer complications and are considered safer zones.
❓ 5. Is prior tissue expansion surgery a risk factor for new complications?
Answer:
Absolutely. Re-expansion in a previously operated area increases the likelihood of complications because scar tissue may reduce skin elasticity and affect blood flow. This is particularly true in repeated surgeries involving the same anatomical region.
❓ 6. What are the chances of needing a second surgery after tissue expander placement?
Answer:
Most patients undergoing tissue expander-based reconstruction require a second surgery to remove the expander and complete the reconstruction. In rare cases, early complications may necessitate additional surgeries to correct issues like infection or expander displacement.
❓ 7. Does surgeon experience matter in preventing tissue expander complications?
Answer:
Yes, surgeon experience significantly affects outcomes. The study found that less experienced surgical teams had higher complication rates. Always choose a plastic surgeon with specific expertise in tissue expander surgeries, especially for pediatric or complex cases.
❓ 8. How do plastic surgeons manage complications after tissue expansion?
Answer:
Most complications are managed conservatively—through wound care, antibiotics, and observation. Only a small percentage (about 6.8%) required surgical intervention. Surgeons follow Clavien-Dindo classification to grade and respond to complications appropriately.
❓ 9. What should I know about tissue expansion for aplasia cutis congenita?
Answer:
Tissue expansion for aplasia cutis congenita, especially on the scalp, carries a higher surgical risk due to fragile skin and underlying defects. However, with careful planning and experienced care, successful reconstruction can be achieved. Discuss all risks and benefits thoroughly with your surgeon.
❓ 10. Are tissue expanders safe for burn scar reconstruction in children?
Answer:
Yes, they are commonly used and effective for burn scar revision. However, the study found a slightly higher complication rate in burn scar cases due to altered anatomy and tougher surgical planes. Choosing an experienced pediatric reconstructive surgeon improves safety and outcomes.
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