PEDIATRIC/CRANIOFACIAL

Salvaging the Unavoidable: A Review of

Complications in Pediatric Tissue Expansion
Arun K. Gosain, M.D.
Background: Tissue expansion, while a mainstay of reconstruction for pe-
Sergey Y. Turin, M.D.
diatric cutaneous lesions, has significant complication rates. The authors
Harvey Chim, M.D.
review the complications in a single-surgeon series of tissue expansion to
John A. LoGiudice, M.D. identify risk factors for complications and guide subsequent therapy so
Chicago, Ill.; Gainesville, Fla.; and that reconstructive goals in patients can be met irrespective of intervening
Milwaukee, Wis. complications.
Methods: A retrospective chart review was conducted of all pediatric patients
cpt who underwent tissue expansion performed by the senior author (A.K.G.) over
a 12-year period. In total, 282 expanders were placed in 94 patients.
Results: A total of 65 complications occurred in 39 of 94 patients (41.5 per-
cent), involving 65 of the 282 expanders (23.0 percent) placed. Major compli-
cations that required expander removal included exposure (n = 11), rupture
(n = 15), and migration (n = 11). The most frequent minor complications,
which did not require immediate expander removal, included migration
(n = 13) and port malfunction (n = 9). The majority of expanders were placed
in the scalp (n = 114), followed by the torso (n = 100), face and neck (n = 52),
and the extremities (n = 16). Serial expansion beyond the second round re-
sulted in a marked increase in complications. Despite complications, tissue
expansion in the majority of patients could be salvaged, and a satisfactory
outcome was achieved.
Conclusions: Families must be made aware that approximately one-third of
patients may have a complication requiring additional surgery or modifica-
tion of the initial reconstructive plan. However, these complications need not
preclude attainment of reconstructive goals.  (Plast. Reconstr. Surg. 142: 759,
2018.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

T
issue expansion is a powerful technique that
allows reconstruction of defects with tissue of
similar tone, color, and texture, and results
in minimal donor-site morbidity.1,2 Although it was
initially described as a modality for ear reconstruc-
tion in the pediatric population, tissue expansion
has evolved toward a wide variety of applications,
allowing achievement of aesthetic and functional
endpoints that were not previously obtainable
with other methods of reconstruction.3 Current
indications for the use of tissue expansion include
treatment of burn scars, giant congenital nevi,
From the Division of Plastic and Reconstructive Surgery,
Lurie Children’s Hospital of Chicago, Northwestern Fein-
berg School of Medicine; the Division of Plastic and Recon-
structive Surgery, University of Florida; and the Department
of Plastic Surgery, Medical College of Wisconsin.
Received for publication September 24, 2017; accepted
March 1, 2018.
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000004650
aplasia cutis congenita, microtia, meningomyelo-
cele, hemangioma, midfacial cleft, Romberg dis-
ease, Poland syndrome, scrotal reconstruction,
and vaginal agenesis, among others.4–8
Soft-tissue expansion may be used to increase
the surface area of full-thickness skin grafts, local
and regional flaps, or free flaps before transfer. Evi-
dence has shown that expanded tissue has similar
durability and contracture compared to nonex-
panded tissue when harvested for a full-thickness
skin graft or flap.9 Expansion should ideally be
started early (before school age) to avoid peer pres-
sure that may develop later in childhood because
of the changes in the patient’s appearance with
expander filling. Scalp expansion should be delayed
until at least 9 months of age to minimize molding
of the pliable cranium by the tissue expander.
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

www.PRSJournal.com 759
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 Plastic and Reconstructive Surgery • September 2018
Despite the increasing use of tissue expansion
in a variety of clinical applications, complications
are common, with rates as high as 40 percent in
children and infants quoted in earlier reports.4
However, these reports did not deter the accep-
tance of tissue expansion as a major reconstruc-
tive modality. In our experience, we have found
that although complications are inherent in the
process of tissue expansion, they do not preclude
meeting the goals of reconstruction. We pres-
ent the 12-year experience of the senior author
(A.K.G.) in the use of tissue expansion in the
pediatric population. We describe the major and
minor complications encountered, and iden-
tify risk factors and make recommendations on
means of avoiding complications. We also pro-
pose treatment and salvage strategies in the event
that complications should arise in the process of
tissue expansion.
PATIENTS AND METHODS
Institutional review board approval was
obtained to conduct a retrospective chart review
of the senior author’s (A.K.G.) patients over a
12-year period. All patients who underwent tis-
sue expansion performed by the author during
the study period were included in the analysis. All
patients were operated on and followed at a single
institution. Patient charts were reviewed to deter-
mine patient age at the time of initial expander
placement, diagnosis, number of expanders
placed, expander location, expander type, capac-
ity of the expander, and volume instilled relative
to capacity. Indications for expansion included
giant congenital nevi (most common present-
ing complaint in this series), burn reconstruc-
tion, hemangioma, cutis aplasia, keloids, dog bite
injuries, Pfeiffer syndrome, nevus sebaceous, and
bladder exstrophy. Complications encountered in
the process of tissue expansion were categorized
as major or minor. Major complications were
defined as loss of expander before completion of
the reconstruction caused by expander rupture
or exposure. Minor complications were defined
as those in which the expander was not explanted
and the reconstructive goals were achieved. The
results were analyzed using binomial and multi-
factorial logistic regressions in IBM SPSS (IBM
Corp., Armonk, N.Y.).
Expanders were placed under general anes-
thesia, with perioperative antibiotic admin-
istration to cover skin flora. Both rigid and
flexible-backed expanders were placed. Seamless
(flexible-backed) expanders were placed under
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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
flaps located over bony prominences such as the
calvaria or rib cage. Rigid expanders were placed
in areas where control of expansion vector was
more difficult, such as the abdominal wall. Inte-
grated internal ports were used in a limited fash-
ion in this series. Double-stage expanders (i.e.,
expanders in which the base unit expands first
and then the upper unit expands) were used ear-
lier in the series, but placement ceased when an
inordinate number of exposures and infections
resulted.
The considerations used in flap design
included, among other factors, the region of the
body expanded, the likelihood of serial expan-
sion, and the stage of the reconstruction. Inci-
sions were placed radially (perpendicular) relative
to the direction of expansion. If an incision was
placed near the potential defect, the pocket was
dissected as far from the lesion as possible. The
expander pocket was dissected wider than the
base of the expander in a blunt fashion to pre-
serve the longitudinal blood supply. In antici-
pation of contraction following expansion, the
expander was planned to create a flap 30 to 50
percent longer than necessary when maximally
filled. Rather than choosing an expander size
arbitrarily, we chose the expander with the largest
surface area possible to expand the tissue avail-
able for transposition.
The expander was placed on top of the deep
fascia unless underlying muscle was integrated
into the flap. Scalp expanders were placed in a
subgaleal pocket. Because of the propensity for
complications in the lower extremities previously
described in the literature,10,11 few expanders
were placed inferior to the buttocks. Back-cuts
were used in a very limited number of patients in
the lower extremities. The expanded flaps were
secured in a layered fashion with interrupted 3-0
Monocryl (Ethicon, Inc., Somerville, N.J.) sutures
in the deep fascia and interrupted 4-0 or 5-0 nylon
skin sutures. No drains were placed.
If expander placement was performed for
reconstruction of a giant congenital nevus, the
incision was placed least 2 cm inside the nevus
border to remain remote from the expander. The
incisions were made parallel to the edge of the
nevus for better access to dissect the expander
pocket and to avoid tension. The length of the
incision was made shorter than the length of
the expander to leave undissected tissues that
would prevent subsequent transposition of the
expander. The authors feel that it is more difficult
to control the expander pocket and subsequent
expander transposition if the incision is placed
 Volume 142, Number 3 • Pediatric Tissue Expansion Complications

Table 1.  Types of Major and Minor Complications
Encountered
No. of Expanders
Type of Complication Complication (%)
Major (necessitating expander removal)
 Exposure
 Rupture
 Infection
Minor (did not require expander
removal)
 Migration
 Port malfunction or access difficulty
 Skin compromise without expander
exposure
 Wound dehiscence or separation
 Facial nerve palsy
*Three required surgery to replace a port.
radially within the nevus. The expander pocket
was dissected beneath normal skin, extending to,
but not beyond, the junction of normal skin and
nevus except in the situation of serial expansion
for giant congenital nevus.
In the case of serial expansion, placement
of subsequent expanders occurred 3 months
after flap advancement. Earlier in the series, we
did attempt immediate expander re-placement
after flap advancement, but we found that the
expander pocket could not be reliably controlled
in this situation and had a high risk of implant
migration. Tissue expansion commenced 3 to 4
weeks after expander placement, with expanders
filled up to two times the recommended capacity.
Because many patients resided far away from the
hospital, expansion was performed routinely by a
patient’s family member, primary care physician,
or a physician extender after adequate education,
Suffering with regular review by the senior author. The t test
was used for all statistical analyses.
37 (13.1)
11
15 RESULTS
11 The retrospective chart review showed that 94
28 (9.9) pediatric patients underwent expansion with a total
13 of 282 expanders placed during the 12-year study
11* period. The mean age of patients at the time of
2 initial expander placement was 39 months (range,
1 7 to 163 months). A total of 65 complications were
1 encountered, of which 37 were major and 28 were
minor. Major complications were defined as those
requiring expander removal, such as infection,
rupture, and exposure. Minor complications were
defined as those that did not necessitate expander
removal, but did delay or affect the course of the
reconstruction in some way. The complication rate
per patient was 41.5 percent (39 complications
per 94 patients), which was higher than the 23.0
percent complication rate per expander (65 com-
plications per 282 expanders), because of many
patients undergoing serial expansion.
The types of complications encountered are
listed in Table 1. Rupture was most commonly
encountered in the scalp, accounting for nine of 20
complications (45 percent) in this region. Other
complication data are shown by anatomical site
of expansion in Table 2 and by expander fill and
chronicity in Table 3. According to our protocol,

Table 2.  Complication Rate by Site of Expansion

No. of No. of Expanders No. of Major No. of Minor
Expanders Placed Suffering Complication (%) Complications Complications
Anatomical site 282 65 37 28
Scalp 114 20 (17.5) 14 6
Torso 100 30 (30.0) 15 15
Face and neck 52 12 (23.1) 6 6
Extremities 16 3 (18.8) 2 1

Table 3.  Expander Complication Rates by Fill and Chronicity

No. of Expanders No. of Expanders
Placed Suffering Complication (%)
Expander fill
 Underfilled (<90% of recommended volume) 56 34 (60.7)
 Filled to goal (90–110% of recommended volume) 41 4 (9.8)
 Overfilled (>110% of recommended volume) 185 27 (14.6)
Type of expansion
 Primary expansion 195 37 (19.0)
 Serial expansion 87 28 (32.2)
Serial expansion stages
 Immediate subsequent placement 51 17 (33.3)
 Delayed subsequent placement 36 11 (30.6)

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 Plastic and Reconstructive Surgery • September 2018

expander fill never exceeded twice the recom-
mended volume. As shown in Table 3, underfilled
expanders had the highest (60.7 percent) com-
plication rate. Contrary to intuition, overfilling of
expanders was instead associated with only a 14.6
percent complication rate, not much higher than
the 9.8 percent rate encountered when expand-
ers were filled to the recommended volume. To
illustrate this, exposure occurred in eight of 56
underfilled expanders (14 percent) compared
to one of 185 overfilled expanders (0.5 percent).
We believe, however, that the higher complication
rate in underfilled expanders is not necessarily
inherent in the fill of the expander, but perhaps is
caused by the natural course of complications such
as infection, which declare themselves before the
surgeon has had the chance to fill the expander to
or beyond capacity.
Double-stage expanders were used early in the
series but were subsequently abandoned, as they
were associated with a higher complication rate
compared with single-stage expanders. Of six dou-
ble-stage units placed, four had either migrated
or become exposed. This complication rate of 67
percent was much higher than the 21 percent com-
plication rate for single-stage expanders (58 com-
plications in 276 single-stage expanders placed).
Patients underwent either primary (n = 195)
or serial (n = 87) tissue expansion. There was a sta-
tistically significant difference (p = 0.012) between
the complication rate encountered per expander
for primary (19.0 percent) and serial expansion
(32.2 percent). However, there was no statistically
significant difference (p = 0.178) between the
33.3 percent complication rate encountered with
immediate placement of expanders after advance-
ment of a prior expanded flap or the 30.6 percent
complication rate encountered when subsequent
expander placement was delayed until after the
flap had healed. The complication rates during
successive rounds of serial expansion are illus-
trated in Figure 1. Five of the 94 patients required
five or more rounds of expansion. Importantly,
there was a marked rise in the complication rate
after the second round of serial expansion, with
expanders placed in the sixth round or later suf-
fering a 100 percent complication rate. Based on
this experience, it is our recommendation that
serial expansion should be limited to four rounds
if possible, and should not proceed to or beyond
a sixth round of expansion.
Statistical analysis of the results using a bino-
mial regression showed a strong correlation
between the presence of any complication and the
expander location (p < 0.005) or the stage of serial
expansion (p < 0.005). Multivariate regression
analysis showed no statistical significance between
the type of complication and the expander loca-
tion (p = 0.410) or the stage of serial expansion
(p = 0.298).
Despite the complications encountered in
the process of tissue expansion, the vast majority
of patients went on to achieve their reconstruc-
tive goals. Figure 2 illustrates a patient undergo-
ing scalp expansion in preparation for excision of
a congenital nevus. Her course was complicated

Fig. 1. Complication rate by round of expansion in patients undergoing serial

expansion. Round 1 includes data from patients undergoing primary tissue
expansion. Round 7 includes data for any subsequent rounds.

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 Volume 142, Number 3 • Pediatric Tissue Expansion Complications

Fig. 2. A 3-year-old girl had undergone three rounds of serial expansion in the head and neck
for planned future excision of congenital nevi (above, left). She was an avid gymnast and devel-
oped a partial-thickness skin abrasion (below, left) while performing somersaults 5 months after
initiation of tissue expansion. She subsequently developed rupture at this site 1 month later,
and was operated on earlier than planned. Intraoperatively, the calvaria has an irregular con-
tour characteristic of expansion in the scalp (above, right). Because of a concern about future
adverse effects of expander durability, burr contouring was performed before flap advance-
ment. Nevertheless, a satisfactory cosmetic result was achieved (below, right), and the patient
met the reconstructive goals.

by expander rupture, but after removal of the
expander and flap advancement, the defect site
could be closed and the reconstruction was suc-
cessfully completed. Expander exchange with
subsequent resumption of tissue expansion can
be used to manage cases of expander folding,
as in Figure 3, which shows a 5-year-old boy who
underwent expander placement in the abdomen.
The expander had folded and created pressure
points in the skin and could no longer be inflated.
Exchange of the expander allowed continuation
of the expansion protocol and provided adequate
skin for both donor- and recipient-site closure in
one stage.
Where expander exchange is not possible,
the reconstructive goals may still be met using
tissue available to resurface critical areas of
the defect and harvesting additional tissue as
required. This principle is illustrated in Fig-
ures 4 and 5. Figure 4 illustrates a patient who
was undergoing an expanded full-thickness skin
graft from the abdomen to resurface the dor-
sum of the hand. Because of exposure of the
abdominal tissue expander, further expansion
was stopped and a full-thickness skin graft was
harvested from the expanded lower abdomi-
nal skin. An additional split-thickness skin graft
was sufficient to resurface the rest of the defect

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 Plastic and Reconstructive Surgery • September 2018

Fig. 3. A 5-year-old boy with giant congenital pigmented nevus of the forearm and hand had expander placement
in the lower abdomen for an expanded full-thickness skin graft to resurface the palm of the hand. The green out-
line delineates the original expander pocket (above, left). The expander folded onto itself, limiting inflation of the
expander and creating pressure points in the overlying skin (above, left and above, right). The expander was replaced
and the expansion protocol was successfully completed; the full-thickness skin graft was harvested to close the
donor site and resurface the palm of the hand in one stage (below, left and right).

involving the wrist and forearm. Figure 5 illus-
trates an alternative method of salvage following
expander exposure when the expander cannot
be exchanged. A 6-year-old girl who underwent
tissue expansion in the scalp to reconstruct the
hairline following severe burns to the face and
scalp is shown. Expansion was complicated by
expander exposure. The expander was removed,
and flap advancement and rearrangement were
used to compensate for the defect caused by
exposure of the expander, with a satisfactory cos-
metic result.
DISCUSSION
Our experience with tissue expansion in the
pediatric population compares favorably with
recent studies, which report complication rates
ranging from 13 to 30 percent, with complication
rates as high as 65 percent reported in the litera-
ture.4–6,11–14 This study presents one of the largest
series to date with regard to tissue expansion in
the pediatric population, and is unique in that
it reflects the experience of a single surgeon
(A.K.G.).
Overall complications by anatomical region
in our series appeared to be greatest in the torso,
followed by the head and neck. Minimal compli-
cations were encountered in the lower extremi-
ties, although this is also because placement was
avoided in the lower extremities unless absolutely
necessary. Our experience, supported by other
series in the literature, indicates that expansion
below the waist is exceedingly problematic in the
pediatric population.5,13 We also found that tis-
sue expansion of the scalp was consistently asso-
ciated with a high incidence of complications. It
is reasonable to hypothesize that expanders in
this location are prone to disruption because of
vulnerability during falls or other trauma, and
because of their location on the fixed calvarial
surface. The gross irregularities that are pres-
ent on the calvaria as a result of remodeling may
also impinge on the expander, resulting in an

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 Volume 142, Number 3 • Pediatric Tissue Expansion Complications

Fig. 4. A 1-year-old boy underwent serial expansion of the lower abdomen in preparation for har-
vest of a full-thickness skin graft to resurface a defect in the left dorsal forearm and hand following
excision of a congenital nevus. The expander migrated into the left groin 3 months after placement
(above, left). With the resultant redistribution of stress on the skin, the expander became exposed 3
weeks after expander migration (above, right). Expansion was stopped and the expanded full-thick-
ness skin graft was harvested. Although the full-thickness skin graft was adequate for resurfacing the
dorsal digits and webspaces, an additional split-thickness skin graft was required to resurface the
wrist and forearm. A satisfactory cosmetic result was achieved, as shown at 1-year follow-up (below).

Fig. 5. A 6-year-old girl with burns to the face and scalp underwent tissue expansion to facilitate reconstruction of the
hairline. The expander became exposed in the posterior scalp (left). The problem was addressed by expander removal, flap
advancement to reconstruct the hairline, and rearrangement of flap redundancy to compensate for the defect caused by
exposure of the expander (center). Postoperatively, the reconstructive goals are achieved, and the hairline is restored (right).

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 Plastic and Reconstructive Surgery • September 2018
additional stress and increasing the likelihood of
disruption and rupture.
The type of expander placed appears to influ-
ence the complication rate of the reconstruction.
Double-stage expanders were associated with a
significantly higher complication rate compared
with single-stage devices, with migration and
expander exposure being prevalent. One double-
stage expander “flipped” while being filled, such
that expansion had to be terminated. Placement
of double-stage expanders in the present series
was therefore limited based on the observed
complications with these expanders. Likewise,
expanders with incorporated ports were seldom
used because of excessive thinning of the flap
overlying the port site, particularly in areas when
the skin was tight, such as in the scalp. In addition,
there were concerns that expander puncture may
occur during port access, the risk of which would
be increased in an uncooperative child. Interest-
ingly, we found that overfilling an expander had
no adverse effects on reconstruction, and thus this
is an option for achieving sufficient tissue surface
area for reconstruction.
We found that serial expansion is associ-
ated with an increased risk of expander-related
complications. This is consistent with a previ-
ous study by Friedman et al.,11 who reported
that a history of two or more prior expansions
resulted in a major complication in 40 percent
of patients. Vergnes et al.15 reported a decreased
net gain of 50 percent for each new expansion
in preparation for excision of congenital nevi
in the trunk. In contrast, Hudson et al.16 advo-
cated the safety of serial tissue expansion, and
reported major complication rates of 20, 18,
and 0 percent for the second, third, and fourth
expansions, respectively; however, the limited
sample size of 11 expanders for the third expan-
sion and three expanders for the fourth expan-
sion indicates that one must be cautious in
drawing conclusions from these data. Our expe-
rience suggests that serial expansion should not
proceed beyond the third round of expansion
if possible, and should definitely not proceed
beyond the fifth round of expansion.
Based on our experience in this study and
from the published literature, we can make sev-
eral recommendations in an effort to develop
guidelines in salvage of complications, which
thus far appear to be unavoidable in the process
of tissue expansion. In the event of expander
exposure, a logical treatment plan would involve
removal of the expander and replacement if pos-
sible. Where expander exchange is not possible
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Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
because of skin loss, flaps can be designed and
advanced to distribute redundancy into the
region of exposure. Risk factors for exposure
include rigid backed expanders in the scalp, and
serial expansion. Thus, these should be avoided
where possible.
In the event of expander rupture, if the
expander has been filled to less than the recom-
mended fill volume, we have found that expander
exchange with immediate refill serves to achieve
the reconstructive goals. If the expander has been
filled to greater than the recommended fill vol-
ume, the expander should be removed and flaps
designed and advanced to compensate for loss
of skin and subcutaneous tissue. A risk factor for
rupture appears to be placement of expanders
in the scalp; in addition, some patients by nature
of their activities (e.g., sports, tumbling) have an
increased risk of expander damage. Thus, tissue
expansion should be used with caution in these
patients.
In the event of infection, the expander should
be removed with immediate advancement of
flaps so as not to lose gains made from expan-
sion to date. Where serial expansion is contem-
plated, this should be delayed until the infection
has completely resolved. We have found that risk
factors for infection include prior infection and
use of serial expansion. To minimize risk of infec-
tion with serial tissue expansion, aseptic tech-
nique and use of perioperative antibiotics are of
utmost importance. Although oral antibiosis may
be attempted if the surgeon feels that the infec-
tious process is a cellulitis and is confined to the
skin, we believe that any infectious process involv-
ing the expander per se should be treated aggres-
sively, as described above.
With expander migration, replacement of the
expander is indicated only if further expansion
would be ineffective. However, migration of the
expander may predispose to other complications
such as exposure, and therefore patients should
be followed more closely. In the torso, where
expander migration was more common, one
option is to place bolsters around the periphery
of the expander for 2 to 3 weeks to allow the cap-
sule to secure the expander location before initi-
ating expansion. Alternatively, expander inflation
can be delayed up to 3 months to allow the cap-
sule to mature. These techniques are particularly
useful in cases of serial expansion in the torso
where expanders are being placed in previously
expanded beds.
In the event of port malfunction, use of a
remote port precludes the need for expander
 Volume 142, Number 3 • Pediatric Tissue Expansion Complications
removal and requires only port exchange. This
may be encountered in situations where the
port can flip, becoming inaccessible. Moreover,
as mentioned above, a port access error is less
likely to damage the vulnerable expander when
a remote port is used. This is especially important
if non–plastic surgery–trained providers or family
members are administering the expansion fills at
home when the patient is away from the primary
surgeon’s practice. Therefore, we recommend the
use of expanders with remote ports for all pediat-
ric patients.
CONCLUSIONS
Tissue expansion in the pediatric population
is an effective reconstructive modality, despite
potential complications. Patients and, more
importantly, their families must be made aware
that up to one-third of patients will have a com-
plication necessitating additional surgery or
modification of the initial reconstructive plan.
Many families perform expansion at home, and
therefore they should be made familiar with com-
mon complications such as expander exposure,
rupture, and infection to eliminate delay in sub-
sequent treatment. Patients and families who are
cooperative and compliant are most likely to have
a better outcome, and anticipatory guidance, psy-
chological support, and education are thus vital
components of the treatment process. Although
the majority of reported complications of tissue
expansion serve to deter or delay the final recon-
struction, few complications prevent the achieve-
ment of reconstructive goals. Proper patient
selection, thorough preoperative planning,
meticulous technique, and the capacity to modify
the reconstructive plan for each patient based on
their clinical response and complications are all
critical factors for achieving an optimal outcome.
Arun K. Gosain, M.D.
Division of Pediatric Plastic and Reconstructive Surgery
Lurie Children’s Hospital of Chicago
225 East Chicago Avenue, Box 93
Chicago, Ill. 60611
arun.gosain@northwestern.edu
ACKNOWLEDGMENTS
The authors thank Timothy Santoro, M.D., for
assistance in reviewing charts of the study patients.
PATIENT CONSENT
Parents or guardians provided written consent for
the use of patients’ images.
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
CODING PERSPECTIVE
Coding perspective provided by Dr.
cpt Raymond Janevicius is intended to
provide coding guidance.
11960 Insertion of tissue expander(s) for
other than breast, including subse-
quent expansion
11971 Removal of tissue expander(s) with-
out insertion of prosthesis
• The insertion of a tissue expander is re-
ported with code 11960.
• Code 11960 is used for the placement of
tissue expanders in all non-breast anatom-
ic sites. The code does not distinguish be-
tween sizes of expanders.
• The use of the term “expander(s)” is
sometimes misinterpreted by payers to
include all expanders placed during one
operative session. If one pocket is created,
and more than one expander is placed in
that pocket, then code 11960 is reported
once. This is the intent of the use of the
plural term “expander(s).”
• If, however, more than one pocket is cre-
ated and separate expanders are placed in
each pocket, then code 11960 is used for
each expander placed, as creation of addi-
tional pockets requires additional surgical
work.
• If four scalp tissue expanders are placed
in four separate pockets, the procedures
are reported:
°  11960
°  11960-59
°  11960-59
°  11960-59
• All office visits for tissue expansion dur-
ing the 90-day global period are included
in code 11960. If tissue expansion is per-
formed beyond the 90-day global period,
appropriate office visit codes (9921X) are
reported.
• The removal of a tissue expander is re-
ported with code 11971.
• If the tissue expander is removed with-
in the 90-day global period of code
11960, then modifier 58 is appended:
11971-58.
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 Plastic and Reconstructive Surgery • September 2018
CODING PRINCIPLES:
Code 11960 includes:
•  Creation of one pocket for expander(s).
•  Insertion of expander(s) into one pocket.
•  Intraoperative tissue expansion.
•  Wound closure.
• Tissue expansions during the 90-day
­global period.
Code 11971 does not include:
•  Lesion excisions.
• Reconstructive procedures (e.g., flaps,
complex repairs).
Disclosure: Dr. Janevicius (janeviciusray@
comcast.net) is the President of JCC, a firm
specializing in coding consulting services for
surgeons, government agencies, attorneys,
and other entities.
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