Review Article Creative Commons, CC-BY

Therapeutic Strategies for Early Recurrent Exposure in the Treatment of Giant Scalp Masses with Scalp Expanders: Systematic Review and Case Report/h1>

• Yihan Zhang MD, Yixing Kang MD, Zhuolin Liu MD, Luotai Chen MD, Tingyin Lin MD et al

*Corresponding author: Yongyan Cui, MD, Xiangwen Xu, MD, Department of Plastic and Reconstructive Surgery, Peking university Shenzhen hospital, 1120 Lianghua Road, Shenzhen, Guangdong, 518036, P.R. China.

Received:April 10, 2025; Published:April 14, 2025

DOI: 10.34297/AJBSR.2022.26.003470

Abstract

Background: The cosmetic treatment of large scalp masses is usually performed with a tissue dilator two-stage surgery. Dilator exposure is the most common complication during dilation, with repeated exposure being the biggest challenge.
Methods: The literature on exposure management of expander under different conditions was systematically reviewed. Screening consists of searching for keywords (exposure, squeeze, management, skin extension, skin extension, and complications) in a format suitable for PubMed, Medline, and Embase database syntax. The risk of bias in included studies was assessed using the Joanna Briggs Institute (JBI) Critical Assessment Checklist.
Results: Eleven studies were included, with a total of 29 extender exposed patients. Seven exposures from four studies reported a success rate of 85.7% (6/7) of removing the expander at late exposure and performing a second stage of surgery. Twenty-one exposures from seven studies reported an early sustained expansion success rate of 81.0% (17/21). Four studies reported five failures, but only two of them analyzed the factors that led to the failure.
Conclusion: This paper initially conducts a systematic review of the existing literature, examining the management strategies for dilator exposure at both early and late. Subsequently, the article presents a case report, where the patient experienced early repeated exposure of the expander and refused its removal. In this condition, a detailed treatment plan was formulated, which included ultra-rapid dilation without suturing, combined with antibiotic therapy, and rapid tissue reconstruction with the aid of flap rearrangement.

Keywords:Tissue Expansion Devices, Scalp Expander, Expander Exposure, Nevus, Systemic Review, Case Report

Introduction

A two-stage procedure involving the use of tissue dilators is often used to treat large lumps for cosmetic purposes [1, 2], especially those located in the scalp area. During the first stage of the procedure, a tissue dilator is inserted under the aponeurotic cap to prevent harmful loss of scalp vascularization [3] and pressure on the hair follicles [4]. The presence of distinct anatomical features in the scalp, such as a hard skull, lack of elasticity in scalp tissue, and considerable tension at the wound edge caused by the aponeurotic flap, may lead to an increased likelihood of exposure of the dilator after surgery [5, 6]. When the tissue dilator is exposed, removing the dilator immediately or continuing the dilation and then performing a second stage surgery are two common strategies. While earlier studies have documented the management of extender exposure in a variety of situations, there is still a lack of research that specifically addresses detailed aspects of this management.

This paper systematically reviewed the literature on the treatment of expander rupture at different stages. At the same time, we also presented a case report involving repeated exposure to a dilator during treatment of a large scalp sebaceous nevus. In addition, through the exposure management of the expander in this case, a thorough plan of repeated exposure of the expander is proposed.

Methods

This study was conducted using the 2020 Preferred Reporting Project Statement for Systematic Review and Meta-Analysis (PRISMA).

Acceptance Standard

A comprehensive systematic review of the published literature describing extended exposure management was conducted under the preferred reporting item of the guidelines for systematic reviews and meta-analyses. Those that did not discuss skin dilators, where the management plan was unclear, non-English studies, conference abstracts, review articles, letters and reviews were excluded.

Medical Literature Search

The Medline and Embase databases were searched from their creation until June 6, 2024. Filtering consists of searching for the following keywords in a format that fits the syntax of each database: exposure, squeeze, management, skin extender, skin extender, and complications. For example, PubMed’s search strategy is “scalp and (dilation or dilation) and complications and (management or repair or salvage).” After deleting duplicate references, the remaining 215 references were screened according to title and abstract, of which 147 were excluded. We obtained the full text of 68 articles, and 11 studies were selected for inclusion in this review based on the application of inclusion and exclusion criteria. Includes articles detailing the risk management of expansion machines.

Study Selection and Data Collection

The authors initially screened the full text of these studies by title/abstract respectively. The data included in the study were extracted into Microsoft Excel sheets. Information on eligible studies, including the first author’s name, year of publication, study background, patient demographics, cause of exposure, complications, treatment, and end results, was extracted and cross-checked by the two authors. Differences between authors are resolved by a third author.

Biased Risk Assessment

The potential risk of bias in this study was assessed by the Joanna Briggs Institute (JBI) Case Series Critical Assessment Tool. The validity and reliability of the condition assessment, continuous recruitment of participants, reporting of patient demographics and clinical data, clinical management, and follow-up are sources of bias in the assessment of this checklist.

Results

Search Procedure

The filtering process is shown in Figure 1. Ten case serials and one case report published between 1987 and 2017 were included.

Figure 1:

Research Characteristics

Table1 summarizes data including authors, number of patients reported, causes of exposure, complications, corresponding management, and outcomes. And depending on the time of exposure during dilation, cases were classified as either “early” (stage 2 surgery with insufficient skin dilation) or “late” (Stage 2 surgery with sufficient skin dilation). A total of 29 patients in 11 studies experienced dilator exposure (Table 1). Be included. Seven exposures from four studies reported a success rate of 85.7% (6/7) when the expander was removed at a later stage and a second stage surgery was performed. Twenty-one exposure cases from seven studies reported early sustained expansion, with a success rate of 81.0% (17/21). Of the included studies, four reported five failures, but only two of them analyzed factors that contributed to the failure, including early exposure to self-aerating osmotic dilators and lack of systemic antibiotics.

Table 1:Summary of characteristics of included studies.

Risk of Bias in Research

Figure 2 is a summary of the risk of bias assessment based on the key assessment tools of the JBI case series. Details are set out in Supplement 1. According to our assessment, the most common sources of possible bias in the included studies were continuous and complete participant inclusion and statistical analyses, which were not reported in an explicit form to make conclusive judgments. Inappropriate demographic reporting is also another source of bias in these studies.

Figure 2:

Case Report

A 49-year-old woman was admitted on June 2, 2023, complaining of progressive enlargement of the occipital tubercles over 40 years. Nodules were found at birth, up to about 10×5cm, accompanied by progressive pruritus and occasional secretions, which had a certain impact on sleep. On June 5, 2023, a 400 cm3 rectangular tissue dilator was implanted. Start dilating gradually 1 week after surgery with 10-20mL saline twice a week. Over a period of 1.5 months, the dilator expanded by a total of 150mL, and the patient complained of extreme discomfort during the expansion. A week later, the patient returned to the hospital reporting a 2cm crack at the incision site (the left edge of the dilator) and yellow transparent exudate. The skin covering the expander redness and temperature rise. Since then, she has suffered from 3 times of expander exposure (Table 2).

Table 2:Strategies and corresponding outcome of the expander exposure in case report.

After the 3rd exposure of expander, since the patient was adamant about keeping the dilator, we decided to go for ultra-rapid dilation without closing the wound (Figure 2A to 2C). Here is the volume of saline injected into the expander: 120mL in the first week, 50mL in the second week, and 35 mL in the third week, for a total exposed area of 21.2cm2. Fewer complaints of pain are heard from patients due to the de-tensioning effect caused by the wound opening. Over the course of 17 days, 205mL of normal saline was injected into the expander. Given that a quarter of the dilator is exposed to the outside of the wound, continuing the injection will reduce skin expansion and may make the infection worse. Therefore, dilation surgery is suspended and the patient is prepared for surgical intervention.

When the patient returned to the clinic on September 8, 2023, there was a laceration of approximately 3.5×6cm between the dilator and the mass, as shown in Figure 2D. The folds of the expander protruded from the wound, and a yellow, cloudy liquid flowed out at the same time. The temperature near the edge of the wound increases slightly, with a reddish tinge. After a thorough evaluation of the enlarged skin, we decided to perform reconstructive surgery with Z-plasty (Figures 2E and 2F). After surgery, acupuncture was used to relieve congestion at the edges of the flap (Figure 2G). The patient returned to the clinic one month and six months after the operation without any complications (Figures 2H and 2I).

Discussion

Causes of exposure include scalp expansion, inadequate skin closure, incorrect placement of dilators, pre-irradiated areas, simultaneous insertion of more tissue dilators, use of two-stage dilators, refusal to use dilators, and sharp folds of dilators [7-11]. In this case, scalp expansion and sharpening of the dilated pleats may be the cause of exposure. As shown in Figure 2, with the help of high tension and these folds, the expander can be pushed out from the incision site, which is similar to Vergnes ‘s findings [12]. As Onishi has found, repeated failures of wound closure are inevitable despite debridement and antibiotic treatment [13]. This can be explained by the fact that after the first exposure, the synergistic effect of infection at the wound edge and further expansion may lead to repeated failure of wound healing.

Referring to the previous article, the treatment of exposure can be divided into two types (Table 1). If the dilator exposure occurs at an advanced stage and it is considered that there is sufficient skin for reconstruction or that it can be obtained using an auxiliary flap, the dilator can be removed and then a second stage of surgery can be performed [8,11,12,14,15]. If exposure occurs early, resulting in insufficient reconstructed skin, the implementation of extended repair becomes more complicated. In the case of infection-induced exposure, the dilator must be removed promptly, along with pocket irrigation using an antibacterial solution. After reinserting the dilator, care should be taken to close the wound without straining it. After debridement, systemic antibiotic therapy is also required under the guidance of pathogen examination and drug sensitivity test [13]. When exposure is not caused by infection, debridement of the wound is recommended without replacing the dilator [16- 20]. In addition, reducing the volume of tissue dilators and suturing with minimal tension have been shown to be effective in preventing wound rupture [17]. Unlike exposure due to infection, systemic antibiotic use is limited to cases where there is clinical or laboratory evidence of infection [18,19]. In both conditions, dilation can begin after the lesion has healed. Another notable advantage of an extender is that multiple extenders are plugged in and the exposed extender cannot be retained after evaluation. In this case, the expander can be removed by overexpansion of the remaining expander [21,22].

While many studies have reported various rescue options, most lack detail. In this case, we provide an exhaustive plan to repeatedly expose the expander. First, we used an approach similar to the one described earlier. Studies have shown up to three exposures in the same location. As soon as the first dilator exposure was detected, we performed dilator drainage and debridement, followed by sutures and intravenous sequential oral antibiotics. After the wound heals, dilation surgery is performed.

Unfortunately, recurrent cracking occurs at the insertion site during dilation. Since the patient showed no signs of serious infection at the time of treatment, and strongly rejected dilation replacement due to financial and time constraints, we optimized the rescue plan from the following aspects while continuing the dilation [1]. (1) The schedule of saline injection after exposure: Compared to a traditional injection schedule, we give relatively large amounts of saline solution in a short period of time to achieve the required volume (ultra-rapid expansion). Although it may aggravate the tearing of the incision, this can reduce the risk of infection from prolonged exposure. (2) Evaluation of skin dilation: In the previous study, there is a formula describing the relationship between the injection solution and the expanded skin: at this time, when 150mL of solution was injected, the area of the expanded skin should be 38.2cm2 [2,23]. In the absence of exposure, when the volume of the solution in the expander reaches 205mL, the area of the expansion skin should be 60.82cm2. But in this case, a quarter of the expander is exposed, that is, the area of the expansion skin should be 45.62cm2. Since the sebaceous nevus is about 50cm2 in size, the enlarged skin area is almost sufficient for reconstruction. As expected, after the dilator was removed, the actual measured area of expanded skin during reconstruction surgery was 47.5cm2, which was very close to 45.62 cm2. The successful results of this case show that, in the case of preventing infection, even if the expansion caused by wound tearing is slightly reduced, sustained expansion under exposure can reach the target volume with the help of wound edge structures. (3) Flap design: When faced with a large defect caused by a wound, direct suturing can cause excessive tension, which can lead to necrosis of the skin edges, resulting in skin loss after expansion [3]. Therefore, aileron flaps is a widely used technique in the field of tissue expansion and reconstruction [8,24]. In this particular case, a Z-shaped flap was used. On the one hand, the amount of stretched skin required to effectively close the defect is less compared to the rotary flap technique. On the other hand, it has the potential to significantly reduce regional tensions, thereby reducing recurrent problems and the opening of wounds [25]. Without the need to remove the dilator after repeated exposure, this protocol provides another option to achieve the desired results through ultra-fast dilation techniques and flap rearrangement.

Conclusion

This paper initially conducts a systematic review of the existing literature, examining the management strategies for dilator exposure at various stages-both early and late. Subsequently, the article presents a case report involving the treatment of a large scalp mass with a scalp expander, where the patient experienced early repeated exposure of the dilator and refused its removal. In response to this situation, we formulated a detailed treatment plan, which included ultra-rapid dilation without suturing, combined with antibiotic therapy, and rapid tissue reconstruction with the aid of flap rearrangement.

Acknowledgements

This study was supported by Shenzhen Key Medical Discipline Construction Fund (SZXK026).

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