Tissue expansion, which we began in 1983, is incomparable for reconstruction of neighboring skin areas because normal skin color, texture, and usually sensation can be achieved. The prerequisite is neighboring normal skin.1–6 In removal of giant nevi, the goal is to reduce the risk of malignancy and achieve results enabling normal social activities. One goal in girls should be to preserve function (i.e., breastfeeding ability). Is it possible to preserve growth and breastfeeding after covering a not yet developed breast with an expanded flap?
A girl born with a giant nevus covering the front and right side of her thorax underwent reconstruction after dermabrasion and local excisions using tissue expansion in two major procedures starting at age 14 years (Fig. 1). She had serious diabetes. Her thorax, including the breasts, was covered with a huge expanded abdominal flap. The breasts just starting to develop were preserved carefully during excision of the deformed skin. Nipple-areolae were pulled through incisions in the expanded flap. Using tissue expansion, virtually all deformed skin could also be removed in the upper and lateral part of the thorax (Fig. 2). The breasts grew slowly under the expanded flap. At age 19 years, the girl thought her breasts were small and augmentation was performed (Fig. 3).
Reconstruction was good even though skin expanded in upper parts of the thorax was thinner than normal. Some pigmentation around the right shoulder was left. The breasts are scar free. Ten years later, during pregnancy, her breasts enlarged and the patient breastfed her first child in 2007 (Fig. 4) and her second in 2008.
If there is normal skin in at least two opposite directions around a defect, we have—using tissue expansion—a choice of where to place the final scar. One large expander is better than several small ones if on the same side of the defect, because this limits the scar to the front edge of the flap. In a girl, it would be optimal to place the scar below the breasts. The thinner skin in the upper part of the thorax is excluded to expand this and reach the submammary fold. The choice was a huge expanded abdominal flap covering breasts meeting the superior flap cranial to the breasts. We removed the breast skin envelope after glandular growth had started. Small glands were easier to protect than if no glands were palpable. Larger breasts would have been more difficult to reconstruct. Glandular enlargement occurred under the expanded flap. We did not enter the glandular space or disturb the nipple-ductal connections while making expander pockets or covering the glands with the huge flap. There were no major or minor complications. The reasons were the small incisions placed radially and away (2 to 3 cm) from both expander pockets and defect and the immediate (intraoperative) start of expansion.6 In conclusion, it was possible to breast-feed from glands covered at the beginning of growth by an expanded flap. Furthermore, for the first time, we have shown breast glandular growth under expanded flaps.
Jan B. Wieslander, M.D., Ph.D.
Department of Plastic Surgery, Universitetssykehuset Nord-Norge, Tromsö, Norway, Institute of Plastic Surgery, Malmoe, Sweden
The author has no financial interest to declare in relation to the content of this article.
1. Neumann CG. The expansion of an area of skin by progressive distension of a subcutaneous balloon: Use of the method for securing skin for subtotal reconstruction of the ear. Plast Reconstr Surg (1946) 1957;19:124–130.
2. Radovan C. Development of adjacent flaps using a temporary expander. Plast Surg Forum 1979;2:62.
3. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg. 1984;70:107.
4. Manders EK, Schenden MJ, Furrey JA, Hetzler PT, Davis TS, Graham WP III. Soft tissue expansion: Concepts and complications. Plast Reconstr Surg. 1984;74:493–507.
5. Bauer BS, Vicari FA. An approach to extension of congenital giant pigmented nevi in infancy and early childhood. Plast Reconstr Surg. 1988;82:1012–1021.
6. Wieslander JB. Tissue expansion in functional and aesthetic reconstruction of the trunk and extremities: Case report. Scand J Plast Reconstr Surg Hand Surg. 1991;25:285–289.
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