DOI: 10.1097/01.PRS.0000138705.40727.BB
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PMID: 15468420
Issn Print: 0032-1052
Publication Date: 2004/09/15
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Excerpt
A 34-year-old man presented to our outpatient clinic with a left earlobe lump that had been slowly growing over the past 5 years. A swelling cyst measuring 2.5 cm in diameter occupied the confined earlobe space. It projected posteriorly in a subcutaneous plane while significantly expanding the substance of the lobule anteriorly (Fig. 1).
With the patient under regional block anesthesia, a sebaceous cyst was dissected and removed through a posterior vertical incision that was extended to form the posterior limb of a full-thickness wedge excision of the substance of the lobule, for a Guerrero-Santos–type earlobe reduction1 (Fig. 2). This was necessary to remove the excess, thinned out, expanded lobular skin and to restore the normal size and shape of the earlobe. The postoperative cosmetic appearance of the earlobe was satisfactory (Fig. 3). This long-standing, slow-growing cyst in the limited space of the earlobe acted as a pathological tissue expander that stretched the earlobe and caused its hypertrophy. After removal of the cyst, it was necessary to reduce the expanded earlobe tissue and restore the normal size and shape of the earlobe. The simplicity of this everyday practice case provoked a discussion about the definition and types of tissue expansion.
Tissue expansion, as defined in the literature, has always meant surgically induced tissue expansion and has been viewed as a judicious manipulation of normal physiological processes: a biological dividend2 or more simply a mechanical process that increases the surface area of the local tissue available for reconstructive procedures.3
The first clinical application of implant-induced tissue expansion was reported by Neumann in 1957.4 Radovan5,6 was the first surgeon to gain extensive clinical experience with tissue expansion. Since 1982, tissue expansion has added new dimensions and offered genuine solutions to difficult problems in reconstructive surgery.5–7
The introduction of surgically induced tissue expansion to the plastic surgery field and the massive effect it had on the way of thinking about and managing reconstructive problems were based on the simple observation that all living tissues respond in a dynamic fashion to the mechanical stresses placed upon them.8 With that essence and on closer observation of Mother Nature, tissue expansion can be classified into three types: physiological, pathological, and surgically induced.
Physiological tissue expansion is when tissues expand due to the normal physiological functions of the body. This type of expansion includes the growth of the “skin envelope” from fetal life through maturity, illustrating the ability of soft tissue to accommodate skeletal growth,8 as well as stretching of the uterine muscles and anterior abdominal wall muscles and skin to accommodate the growing fetus in pregnancy.
In pathological tissue expansion, the expansion occurs due to an abnormal condition or a disease. This category includes morbid obesity, which causes expansion and stretching of normal skin and tissues all over the body that become more evident with weight loss and redundancy of these tissues. Expansion of different tissues over tumor growths, more manifest in long-standing benign tumors, is another example of pathological expansion.
Surgically induced tissue expansion was introduced to the plastic surgery field by Neumann and Radovan. Different shapes and sizes of commercially available tissue expanders are used.
This simple observational classification of tissue expansion is a useful tool for communication among peers and for teaching plastic surgery to undergraduate and postgraduate students.
