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We retrospectively reviewed 105 consecutive children in whom 191 tissue expanders were placed by the Plastic Surgical Service at The Children's Hospital from 1987 to 1995. The age range was 1 month to 28 years. The series included 68 females and 37 males. The indications for tissue expansion were congenital pigmented nevus (N = 55), craniofacial anomaly (N = 13), aplasia cutis congenita (N = 7), meningomyelocele (N = 7), posttumor resection (N = 5), unstable scar (N = 4), burn scar (N = 3), and miscellaneous disorders. The expanders were located in the scalp (N = 59), cervicofacial area (N = 23), back (N = 18), chest (N = 6), and extremities (N = 6). A single expander was used in 47 patients and the mean number of expanders per patient was 1.8. All patients were given preoperative intravenous antibiotics. There were 25 complications in 20 patients (19%), which comprised 13% of all expanders. The most common complications were infection (6%, N = 11), deflation (3%, N = 6), and exposure (2%, N = 5). These complication rates were not related to either the gender, site of implantation, number of expanders, use of closed suction drains, or the indication for expansion. The complications were related to age, being higher in children (age 1-12 years) compared with infants and adolescents. Tissue expanders can be successfully used in children to construct and reconstruct a variety of cutaneous defects, but there is an irreducible minimum for the three major complications.

Soft-tissue reconstruction of the foot and ankle has long presented challenging problems for the plastic surgeon. Limitations of available local tissue, the need for specialized tissue, and donor site morbidity restrict the options available to the reconstructive surgeon. In an effort to solve these difficult problems, we have begun to use musculofascial flaps based on the branches of the dorsalis pedis artery. We present our early experience of 5 patients treated with an extensor digitorum brevis muscle flap with fascial extensions often containing the contents of the first web space. Our patients ranged from 6 to 60 years in age and included 4 males and 1 female. The etiologies of the wounds were secondary to trauma (N = 2), complications of surgery for rheumatoid arthritis (N = 2), and were secondary to a defect following resection of an arteriovenous malformation (N = 1). The flaps had antegrade blood flow in 3 patients and reverse flow in 2 patients. The flaps were covered with a split-thickness skin graft and the donor site was closed primarily. The donor sites healed without the need for further surgery. One patient required additional procedures. This flap proved to be both versatile and effective for closure of difficult wounds of the foot and ankle.

The present study describes the techniques available for single-stage sarcoma resection, soft-tissue reconstruction, and radiotherapy for limb preservation in patients who are unable to undergo primary wound closure after a complete soft-tissue resection of their primary sarcoma. From 1989 to 1994, 19 patients (age range, 18-79 years; mean, 51.2 years) underwent radical resection of extremity sarcomas followed by immediate reconstruction. Seven patients had tumors in the upper extremity and 12 patients had tumors in the lower extremity. There were 13 primary tumors and 6 recurrent tumors. Fifteen patients (79%) received radiation therapy, 7 patients by external beam and 8 patients by brachytherapy. Reconstruction included 16 regional flaps in 13 patients and 7 free tissue transfers in 6 patients. Commonly used flaps included the rectus abdominis (N = 5), the latissimus dorsi (N = 4), the anterolateral thigh (N = 4), the reverse-flow radial forearm (N = 2), and the gastrocnemius (N = 2) flaps. Complications included wound breakdown (N = 2), partial skin graft failure (N = 1), hematoma requiring operative evacuation (N = 1), and partial flap necrosis (N = 1). There were no operative mortalities. Eight patients underwent wide local excision, flap closure, and brachytherapy. Mean length of hospital stay for this group was 12.3 days compared with 13.8 days for the remaining 11 patients. There was one complication (13%) in this group and four complications in the remaining patients (4 of 11; 36%). Our study confirms the utility of soft-tissue reconstruction to permit wide local excision with clear margins as well as the delivery of postoperative radiotherapy. It demonstrates the ability of pedicled flaps and free tissue transfers to remain viable and provide sufficient wound coverage in the setting of early postoperative brachytherapy. In addition, this series illustrates the efficacy of a team approach and one-stage therapy for extremity soft-tissue sarcomas that includes excision, reconstruction, and early postoperative brachytherapy in a single hospitalization.

A simple and inexpensive method for closure of large wounds is presented. A rib approximator and two spinal needles, which are readily available in most operating rooms, have been utilized to close large cutaneous wounds of the chest and thigh after flap harvest.