Reconstruction of difficult wounds with tissue-expanded free flaps.

Tissue expansion of free flaps before transfer have been used to increase the size of the transferred tissue and to allow primary closure of the donor site. This is especially important in burns when there is a lack of healthy tissue, and in children when there is a relative lack of tissue. In this study the authors present their 17-year experience with tissue-expanded free flaps. Between 1985 and 2002, 14 cases of tissue expansion of free flaps before transfer were performed at the authors' institution. The indications for vascularized tissue were 9 facial defects (8 severe burns and 1 neurofibromatosis), 3 large lumbosacral ulcers resulting from spina bifida, 1 large vulvoperineal defect resulting from resection for Chron disease, and 1 large circumferential tissue defect at the lower extremity resulting from tumor extirpation. The flaps were 6 radial forearm, 4 parascapular, and 4 lateral arm free flaps. Tissue expanders were placed under the subcutaneous plane between the deep fascia and the muscle layer, preserving the pedicle architecture and integrity. The size of the tissue expander ranged from 250 to 700 mL and expansions were done either weekly or biweekly for a 10- to 20-week period. The patients were followed for 1 to 17 years. The outcome of the study was based on donor and recipient site morbidity, rate of complications, patient satisfaction, and long-term outcome of the donor and recipient sites. There was no failure in any of the transferred tissue at the recipient site and no tissue loss. Three patients had transient congestion of the free flaps, which resolved without any intervention. In all patients the donor area was closed primarily. One black patient had hypertrophic scar formation at the radial forearm donor site requiring reexpansion and primary closure. In other patients the scar was acceptable. One patient had an infection at the tissue expander site that was treated with removal of the implant and transfer of the free flap to the recipient defect the following day. In 4 patients with facial burns, posttransfer tissue expansion of the free flap at the recipient site was performed for minor revisions at later dates. All patients had good outcomes and were satisfied with the procedure. Preexpansion of free flaps is an effective but underused method. It is safe in terms of complications, results in a better appearing donor site scar, and allows transfer of larger amounts of tissue in patients with tissue deficiency.