PEDIATRIC/CRANIOFACIAL

External Port Tissue Expansion in the

Pediatric Population: Confirming Its
Safety and Efficacy
Beina Azadgoli, M.S.
Artur Fahradyan, M.D.
Erik M. Wolfswinkel, M.D.
Michaela Tsuha, B.S.
William Magee III, M.D.,
D.D.S.
Jeffrey A. Hammoudeh,
M.D., D.D.S.
Mark M. Urata, M.D.,
D.D.S.
Lori K. Howell, M.D.
Los Angeles, Calif.
Background: External filling ports in tissue expander–based reconstruction
have the advantages of being associated with less pain and emotional distress.
However, among practicing surgeons using tissue expansion, a theoretical
concern remains regarding higher risk of infection. The authors’ goal was
to evaluate external port safety in the pediatric population by looking at the
complications and overall success rate of reconstruction.
Methods: A retrospective review of all patients undergoing tissue expansion
using external ports at Children’s Hospital Los Angeles between January of
2008 and June of 2016 was conducted. Patient demographic and perioperative
data were collected and analyzed.
Results: Two hundred forty-one expanders were placed in 100 pediatric pa-
tients, resulting in 123 procedures for congenital and acquired conditions,
with an average age at the time of surgery of 7.1 years (range, 1 month to
19.9 years) and average follow-up length of 2.5 years (range, 2.8 months to
8.8 years). The overall complication rate was 29.9 percent, and the infection
rate was 17 percent. The majority of these cases were treated conservatively
without additional need for surgery. Of 123 cases, 25 required premature ex-
pander removal because of complications. Despite early intervention, 21 of
these cases underwent successful completion of their reconstruction according
to the preoperative plan, resulting in an overall 96.7 percent success rate of
tissue expander reconstruction.
Conclusions: In children, who are often less tolerant of the pain and distress
associated with internal port expansion, the authors encourage the use of
external ports. This study found a high success rate in terms of successful
reconstruction, with the majority of complications being treated conservative-
ly. (Plast. Reconstr. Surg. 141: 883e, 2018.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

S
ince the introduction of tissue expansion
by Neumann in 1957, it has become a well-
established and widely used technique for
soft-tissue reconstruction in the field of plastic sur-
gery.1 The use of tissue expanders is particularly
popular in the pediatric patient population for
the management of a large variety of congenital
and acquired lesions throughout the body, includ-
ing congenital nevi, alopecia, and burn scars.2
A variety of port placements have been used to
fill tissue expanders. Keskin et al. first published
the use of external filling ports in 1987.3 Since
that time, it has become the mainstay of recon-
struction in many institutions. Despite the obvious
advantages of external filling ports (including less
Disclosure: The authors have no financial interest
to declare in relation to the content of this article.

From the Division of Plastic and Reconstructive Surgery,

Keck School of Medicine, University of Southern California;
and the Division of Plastic and Maxillofacial Surgery, Chil-
dren’s Hospital Los Angeles.
Received for publication July 13, 2017; accepted December
19, 2017.
Copyright © 2018 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000004372
By reading this article, you are entitled to
claim one (1) hour of Category 2 Patient Safety
Credit.  ASPS members can claim this credit
by logging in to PlasticSurgery.org Dashboard,
clicking “Submit CME,” and completing the
form.

www.PRSJournal.com 883e
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

pain and emotional distress for the patient), theo-
retical concern remains with regard to a higher
infection risk through the external port tunnel.
The results of the literature contradict the pre-
sumed increased infection rate, with relatively
equivalent infection rates compared to internal
port expansion. The infection rates range from 5
to 6.5 percent with the use of internal and subcu-
taneous remote ports versus 6 to 8.8 percent with
the use of external ports.3–12
Few of these studies have focused on these
complications in the pediatric patients.7,8 Our
goal was to evaluate external port tissue expan-
sion safety by looking at their complications and
overall success rate of reconstruction in the pedi-
atric population.
PATIENTS AND METHODS
An institutional review board–approved ret-
rospective review of all patients who underwent
tissue expansion with external ports at Children’s
Hospital Los Angeles from January of 2008 to
June of 2016 was conducted (Fig. 1). Informa-
tion regarding patient age and sex; indication for
expansion; location of the lesion; and the number
of expanders used, their size, anatomical location,
shape, and length of time in place was collected.
All patients are treated routinely with peri-
operative antibiotics and generally continue with
antibiotics for 3 days postoperatively. Incisions
for expander placement are carefully planned
with consideration of the final flap design. The
subcutaneous pocket size is determined based on
Fig. 1. Tissue expanders with external filling ports placed in a
4-year-old patient with congenital melanocytic nevus.
884e
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2018
the expander size, allowing 1 to 2 cm of extra
space so that the tissue expander lies comfort-
ably without being folded. A small separate inci-
sion is made to exit the expander tubing, which
is secured to the patient’s body so that the port
does not constantly move at the entry site. Drains
are not routinely used. The patients or caregivers
are instructed to wash the port exit site with soap
and water and cover with clean gauze. Expansion
is usually started within 1 to 2 weeks of placement
when the incisions are healed. It is usually started
aggressively from 5 cc up to 40 cc daily, depend-
ing on the expander size and location, then later
slowed as the tension on the skin increases. Daily
fill volume is adjusted to achieve final desired
volume within 8 to 12 weeks. Occasionally, if the
patient does not tolerate daily expansion because
of pain and discomfort, it can be done every
other day. The patients/caregivers are instructed
to immediately discontinue expansion and call
the providers in case of signs and symptoms of
infection or expander exposure. Regular daily
activities are usually not restricted, but patients
are instructed to avoid physical activities that
may increase the risk of falling on expanders and
rupturing them.
Complications were divided into major, inter-
mediate, and minor categories. Major complica-
tions were defined as those that required surgical
intervention, intermediate complications were
those requiring hospitalization but no surgi-
cal intervention, and minor complications were
those that required neither. Infections were deter-
mined clinically, and all presumed infections were
treated with either oral or parenteral antibiotics.
Reconstruction failures were defined as cases that
were unable to be completed according to the
preoperative plan because of premature removal
of the expander.
Each expander was treated as an indepen-
dent observation in the statistical analysis, as with
­Friedman et al., except to determine the asso-
ciation between infection rates and number of
expanders or surgical indication for which results
were determined per individual case.9 To study
the relationship between complication rate and
patient age, patients were categorized into the
following age groups: 0 to 1, 1 to 5, 5 to 10, and
10 years or older. Results were analyzed by means
of chi-square using SPSS 15.0 (SPSS, Inc., Chi-
cago, Ill.). Multiple regression analysis was also
performed to estimate the effect on the infection
rate of patient age and race, indication for tissue
expansion, multiple expansion procedures, and
number and location of expanders placed.
 Volume 141, Number 6 • External Tissue Expansion Ports

RESULTS Table 1.  Patient Demographics

A total of 241 expanders were placed in 100 Characteristics Value (%)
patients, with 17 patients requiring staged expan-
Total no. of patients 100
sions because of very large lesions, resulting in Sex
a total of 123 procedures. The average age of  Male 45 (45)
our patients at the time of surgery was 7.1 years  Female 55 (55)
Patient race
(range, 1 month to 19.9 years), with an average  Hispanic 74 (74)
follow-up length of 2.5 years (range, 2.8 months  Caucasian 11 (11)
to 8.8 years). Of note, there were only two patients  Asian 7 (7)
 African American 1 (1)
older than 18 years. There were 45 (45 percent)  Other 7 (7)
male patients and 55 (55 percent) female patients Lesion locations per patient
included in the study. The races of the patients  Head/neck 76 (76)
 Trunk 14 (14)
were as follows: Hispanic, 74 (74 percent); Cau-  Lower extremity 5 (5)
casian, 11 (11 percent); Asian, seven (7 percent);  Upper extremity 3 (3)
African American, one (1 percent); and other,  Trunk plus upper extremity 1 (1)
 Trunk plus upper plus lower extremity 1 (1)
seven (7 percent) (Table 1). Indications per patient
The indications for tissue expansion were  Congenital nevus 37 (37)
congenital nevus in 37 patients (37 percent),  Scar (other than burn) 16 (16)
 Microtia 15 (15)
scar other than burn in 16 patients (16 percent),  Burn 11 (11)
microtia in 15 patients (15 percent), burns in 11  Alopecia 9 (9)
patients (11 percent), alopecia in nine patients  Vascular anomaly 4 (4)
 Omphalocele 2 (2)
(9 percent), vascular anomaly in four patients  Conjoined twins 2 (2)
(4 percent), soft-tissue loss secondary to previous  Ectropion 1 (1)
surgery in three patients (3 percent), omphalo-  Soft-tissue loss secondary to surgery 3 (3)
Age at expander placement
cele in two patients (2 percent), conjoined twins  Average ± SD 7.1 ± 4.87 yr
in two patients (2 percent), and ectropion in  Range 1 mo–19.9 yr
one patient (1 percent). The average number of Follow-up length (from date of expander
expander placement operations per patient was placement)
 Average ± SD 2.5 ± 1.8 yr
1.23 ± 0.548 (range, 1 to 3). The average number  Range 2.8 mo–8.8 yr
of expanders per case was 1.96 ± 1.13 (range, 1 No. of expansions per patient
to 6) (Table 1). Per case, 55 patients (44.7 per-  Average ± SD 1.23 ± 0.548
 Range 1–3
cent) received one expander, 37 (30.1 percent) No. of expanders per case
received two, 17 (13.8 percent) received three, 10  Average ± SD 1.96 ± 1.13
(8.1 percent) received four, three (2.4 percent)  Range 1–6
Expansion frequency per case
received five, and one (0.8 percent) received six  Daily 73 (59.3)
(Table 2).  3–5×/wk 7 (5.7)
Of our 241 expanders, 151 (62.7 percent)  1–2×/wk 18 (14.6)
 Once/1–2 wk 5 (4.1)
were placed in the head and neck, 62 (25.7 per-  Not started 3 (2.4)
cent) were placed in the trunk, 21 (8.7 percent)  Not specified 17 (13.8)
were placed in the lower extremity, and seven Time of expansion per case (days)
 Average ± SD 74.3 ± 44.1
(2.9 percent) were placed in the upper extrem-  Range 0.0–282.0
ity (Table 3). The average expander volume was No. of clinic visits per case
259.5 cc (range, 25 to 1600 cc).  Average ± SD 5.9 ± 3.5
 Range 1.0–21.0
The following tissue expander shapes were
used: rectangular, 157 (65.15 percent); crescent,
32 (13.3 percent); curvilinear, 29 (12.0 percent); (13.8 percent). In three patients (2.4 percent),
round, one (0.4 percent); and unspecified, 22 expansion was never started in any of the placed
(9.13 percent) (Fig. 2). expanders because of early infection. As such,
Of our 123 cases, 73 (59.3 percent) were these were counted as failures. In another three
expanded daily, seven (5.7 percent) were patients, expansion was never started in one
expanded three to five times per week, 18 (14.6 expander (of four, two, and two, respectively)
percent) were expanded one to two times per because of early infection, but this did not inter-
week, and five (4.1 percent) were expanded once fere with the overall surgical plan. The average
every 1 to 2 weeks. This information was not time of expansion was 74.3 ± 44.1 days (range,
available in the notes for the remaining 17 cases 0.0 to 282.0 days), and the average number of

885e
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • June 2018

Table 2.  Number of Expanders per Case and Anatomical Location of Lesion*
Total (%) Head/Neck Trunk Upper Extremity Lower Extremity
No. of cases 123 87 27 3 6
No. of expanders placed per case
 1 55 (44.7) 49 6
 2 37 (30.1) 23 11 1 2
 3 17 (13.8) 9 4 2 2
 4 10 (8.1) 6 2 2
 5 3 (2.4) 3
 6 1 (0.8) 1
*Some patients with large lesions had expanders placed in multiple anatomical locations.

Table 3.  Anatomical Location of Expander Placement

Total Head/Neck (%) Trunk (%) Lower Extremity (%) Upper Extremity (%)
No. of expanders 241 151 (62.7) 62 (25.7) 21 (8.7) 7 (2.9)

three intermediate complications (1.2 percent),

all consisting of cellulitis requiring hospital admis-
sion for intravenous antibiotics. There were 41
minor complications (17.0 percent). The minor
complications included infection treated with out-
patient antibiotics alone, n = 31 (12.9 percent);
tissue necrosis, n = 5 (2.1 percent); ulcerations,
n = 2 (0.8 percent); hematomas, n = 2 (0.8 per-
cent); and dehiscence, n = 1 (0.4 percent). None
of these had any effect on the planned expansion
and surgical reconstruction (Table 4).
Infections were seen in 41 (17.0 percent)
of all placed expanders (241) in 34 cases as
described above. There was no statistically signifi-
cant difference in infection rates between ana-
tomical sites (p = 0.261, chi-square test) (Table 5),
indication for expansion (p = 0.324, chi-square
test) (Table 6), age (p = 0.290, chi-square test),
or infection rate and race (p = 0.836, chi-square
Fig. 2. Expander shape.
test). Infection rates were highest (57.1 percent)

Table 4.  Expander Complications

clinic visits per case was 5.9 ± 3.5 (range, 1.0 to
21.0) during expansion. For 15 of the 123 cases Characteristic No. (%)
(12.2 percent), expansions were performed solely Total no. of expanders 241
in the clinic and these were performed typically Total no. of expander complications 72 (29.9)
Major complications 28 (11.6)
one or two times per week.  Exposure 11 (4.6)
 Infection 7 (2.9)
Complications  Rupture 3 (1.2)
 Dehiscence 3 (1.2)
Twenty-eight expanders (11.6 percent) suf-  Retracted port 1 (0.4)
fered major complications resulting in surgical  Hematoma 1 (0.4)
treatment. These consisted of 11 exposures (4.6  Concern for flap compromise 2 (0.8)
Intermediate complications 3 (1.2)
percent), seven infections (2.9 percent), three  Cellulitis 3 (1.2)
expander ruptures (1.2 percent), three cases of Minor complications 41 (17.0)
wound dehiscence (1.2 percent), two cases of  Infection 31 (12.9)
 Tissue necrosis 5 (2.1)
concern for flap compromise (0.8 percent), one  Ulceration 2 (0.8)
retracted port (0.4 percent), and one hematoma  Hematoma 2 (0.8)
 Dehiscence 1 (0.4)
causing skin necrosis (0.4 percent). There were

886e
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 141, Number 6 • External Tissue Expansion Ports

Table 5.  Infection Rates by Anatomical Location of Expanders

Head/Neck (%) Trunk (%) Lower Extremity (%) Upper Extremity (%) p*
No. 151 62 21 7
No. infected (n = 41) 23 (15.2) 12 (19.4) 6 (28.6) 0 (0) 0.261
*χ2 test.

Table 6.  Infection Rates by Indication per Case infection rate (OR, 1.9; 95 percent CI, 1.14 to 3.2;
p = 0.013). The predicted probabilities of getting
No. of an infection were also estimated for each number
No. of Infected
Indication Cases Cases (%) p* of expanders, which were 10.6 percent for one
Congenital nevus 50 13 (26.0) 0.324 expander, 18.5 percent for two, 30.3 percent for
Burns 16 8 (50) three, 45.4 percent for four, 61.3 percent for five,
Soft-tissue loss 3 1 (33.3) and 75 percent for six (Fig. 4).
Vascular anomaly 4 1 (25.0)
Microtia 17 1 (5.9) Exposures were the most common reason for
Omphalocele 2 1 (50.0) major complications resulting in surgical treat-
Scar 18 6 (33.3) ment. Exposures were seen in 11 of 241 expand-
Alopecia 9 2 (22.2)
Ectropion 2 0 (0) ers (4.6 percent). They occurred in eight of 151
Conjoined twins 2 1 (50.0) expanders (5.3 percent) placed in the head/
Total 123 34 (27.6) neck, two of 62 (3.2 percent) placed in the trunk,
*χ2 test. zero of seven (0 percent) placed in the upper
extremity, and one of 21 (4.8 percent) placed in
in patients who received four to six expanders, the lower extremity, with no statistically significant
followed by 35.2 percent in those who received difference in exposure rate between anatomical
two to three and 12.7 percent in those who locations (p = 0.291, chi-square test). There was
received just one expander (p = 0.001, chi-square also no statistically significant association between
test) (Fig. 3). Multiple regression analysis to esti- exposure rate and indication (p = 0.719, chi-square
mate the effects of patient age and race, indica- test), number of expanders placed (p = 0.136, chi-
tion for tissue expansion, multiple expansion square test), and patient age (p = 0.839, chi-square
procedures, and number and location of expand- test) and race (p = 0.847, chi-square test).
ers placed demonstrated that the number of
expanders placed at the same time is the only Success
statistically significant variable that affects the Patients required premature expander
removal in 25 of 123 cases. However, 21 of them
were able to successfully complete their recon-
struction according to the preoperative plan,
and only four failed. Therefore, we had total of
119 of 123 cases that successfully completed the
expansion, resulting in a 96.7 percent success
rate. Three case failures were attributable to early
infection, and the fourth was the result of a hema-
toma that caused overlying skin necrosis.

Fig. 3. Infection rates by number of expanders per case.
DISCUSSION
Advantages of external filling ports are well-
defined. They include less dissection, no need for
adequate soft-tissue coverage of the port, rapid
expansion with more frequent filling, decreased
risk of rupture, minimal activity restrictions, early
detection of leaks, painless and simpler injections,
fewer office visits, and lower associated economic
burden.3,7,8 The ease and painless filling reduce
the overall stress of expansion significantly for
the patient.7 This is because of elimination of

887e
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

Fig. 4. Predicted probability of infection based on number of tissue expanders
placed.
repeated skin punctures and interval large-vol-
ume expansion causing skin ischemia and pain.
This is particularly important in children, who
can be uncooperative with internal ports second-
ary to pain and emotional distress.9 We hypoth-
esize that more frequent expansion at smaller
volumes may result in less tissue ischemia. In
addition, with more frequent and smaller inter-
val expansions, there is less tissue relaxation after
injection, theoretically leading to less dead space
that can often accumulate peri-implant seromas
and result in infection. These additional benefits
counter the assumed increased infection risk with
an external port.
Although several studies have been conducted
to determine complication rates associated with
tissue expansion, few of these have focused spe-
cifically on the use of external ports, and fewer
on external ports in the pediatric population.2–19
Between studies, variations in the definition of
complication and heterogeneity in the anatomi-
cal location and indication for expansion have led
to significant differences in reported rates. The
current study aimed to build on the works of pre-
vious authors by studying a large, solely pediatric
patient population, and including a broad range
of indications and detailed reports of all encoun-
tered complications to better understand their
safety.
Our overall complication rate was 29.9 per-
cent (11.6 percent major, 1.2 percent intermedi-
ate, and 17.0 percent minor), with a total infection
888e
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2018
rate of 17 percent (2.9 percent major, 1.2 percent
intermediate, and 12.9 percent minor). Although
not statistically significant, our highest infection
rates were seen in patients with burns (50 percent
of burn cases). This finding is in agreement with
previous studies that have reported higher com-
plication rates in burn patients ranging from 18
to 37 percent, which is attributable to the limited
vascularity and availability of local tissue in these
patients.5,7,12–15 Other indications in our study that
also had a 50 percent infection rate were omphalo-
cele and conjoined twins; however, the small num-
ber of patients with each of these diagnoses (n = 2
for both) is insufficient to draw conclusions. More-
over, in their study, Adler and colleagues reported
that a subset of their patients who were at higher
risk for infection were those with congenital nevi
who had very fine hairs on the nevus at the loca-
tion of incision, which could possibly get irritated
and result in cellulitis.10 This could be a possible
explanation for our 26 percent infection rate in
patients with congenital nevi. This suggests that
our complication rate with external ports is con-
gruent with infection rates with the use of internal
and subcutaneous remote ports based on surgical
indication.
Our results suggest that placing multiple
expanders contributes more to infection than
the fact that external ports are being used. Of 14
cases where four to six expanders were placed,
eight (57.1 percent) resulted in infection, com-
pared with 19 of our 54 cases (35.2 percent) that
 Volume 141, Number 6 • External Tissue Expansion Ports
received two to three expanders and seven of our
55 cases (12.7 percent) that received one expander
(p = 0.001, chi-square test). Although Jackson and
colleagues reported a 5.6 percent complication
rate using external ports in a general population,
all of their patients received a maximum of two
expanders.8 If a high number of tissue expand-
ers are going to be placed, patients and parents
should be aware of the higher likelihood of com-
plications. This association is intuitive, as each
additional expander requires separate incisions,
more tissue dissection, and potentially more stress
on adjacent skin as it is expanded in varying direc-
tions. Of note, the use of multiple expanders did
not significantly affect successful completion of
reconstruction, as most complications were able
to be managed conservatively.
Little agreement in the literature exists
regarding the relationship between anatomical
location and infection rates. In a meta-analysis by
Huang et al., the lower limb was the site found
most likely to develop complications, followed by
the head and neck, though this included all types
of expanders and all patient populations.12 Fried-
man et al. and Gibstein et al. found no significant
relationship between anatomical site and infec-
tion rate in pediatric patients, which is in agree-
ment with our results, although these studies did
not include expanders with an external port.5,9
Using external ports in both pediatric and adult
patients, Jackson et al. concluded that expan-
sion of the lower extremity distal to the knee is
generally more hazardous.8 Although the largest
proportion (25.8 percent) of infected expand-
ers in our study were also found in the lower
extremity, it is important to note that no expand-
ers were placed below the knee in our patients.
Complication rates were also common (19.4
percent) in patients who had expanders placed
in the trunk, which was a site reported to have
the highest complication rates in a study by Elias
and colleagues.11 One possible explanation for
this is that the trunk is the anatomical location
in which multiple expanders are often placed.
Regardless of these disagreements, there is con-
sensus regarding the fact that infection gener-
ally does not preclude completion of the original
preoperative plan.11,16,17 This is congruent with
our results, given our overall success rate of 96.7
percent of completed expansions and reconstruc-
tions according to the preoperative plan.
It is particularly important to note that the
complication rates found in our study were compa-
rable to those of other studies on tissue expansion
in pediatric patients using an internal or remote
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
port, although a lower percentage of our compli-
cations with external ports required additional
surgical intervention. In their study using internal
and remote ports, Elias and colleagues reported
an overall complication rate of 28 percent, with 15
of 17 of these resulting in premature termination
or additional surgery.11 Yeşilada et al. reported a 24
percent complication rate, with five of six of those
being major.18 Given the similarities in complica-
tion rates between the different types of ports, the
use of external ports should be strongly considered
given their many advantages described previously,
including less pain and less emotional distress, par-
ticularly in the pediatric population.
Despite an overall successful surgical correction
in 96.7 percent of patients, complications with tis-
sue expanders are a real possibility. One of the most
critical steps is setting patient and parental expec-
tation about the likelihood of this outcome. Par-
ents should be counseled regarding the risks and
benefits of and alternatives to tissue expansion in
general, regardless of port type used. If the patient
and parent understand that most complications
can be managed conservatively with a small propor-
tion requiring additional intervention including
unplanned hospitalization and/or surgery, han-
dling a complication and parental acceptance of a
complication can be more easily accomplished.
Our study carries the innate disadvantages of
a retrospective review. Retrospective studies are
inherently limited in their ability to identify cause
and predict outcome. Although being one of the
largest studies in the literature, our study has no
comparison group and has a limited sample size,
which may not be able to capture the full spec-
trum of complications. However, even with these
limitations, this study emphasizes the ability of
successful reconstruction using external port tis-
sue expansion in the pediatric population.
CONCLUSIONS
Using an external port in the pediatric pop-
ulation has a high success rate of 96.7 percent
despite an overall complication rate of 29.9 per-
cent. Most complications are able to be managed
conservatively on an outpatient basis. Given the
many advantages of external ports, most impor-
tantly decreased pain and emotional distress, we
recommend the use of external filling ports in the
pediatric population. A secondary finding of this
study suggests that placing multiple expanders in
the same anatomical region increases the risk of
infection; therefore, it should be considered dur-
ing surgical planning.
889e

Artur Fahradyan, M.D.
Division of Plastic and Maxillofacial Surgery
Children’s Hospital Los Angeles
University of Southern California
4560 Sunset Boulevard, Suite 96
Los Angeles, Calif. 90027
afahradyan@chla.usc.edu
PATIENT CONSENT
Parents or guardians provided written informed
consent for use of the patient’s image.
REFERENCES
1. Neumann CG. The expansion of an area of skin by progres-
sive distention of a subcutaneous balloon; use of the method
for securing skin for subtotal reconstruction of the ear. Plast
Reconstr Surg (1946) 1957;19:124–130.
2. Bauer BS, Johnson PE, Lovato G. Applications of soft tissue
expansion in children. Pediatr Dermatol. 1986;3:281–290.
3. Keskin M, Kelly CP, Yavuzer R, Miyawaki T, Jackson IT. External
filling ports in tissue expansion: Confirming their safety and
convenience. Plast Reconstr Surg. 2006;117:1543–1551.
4. Wagh MS, Dixit V. Tissue expansion: Concepts, techniques
and unfavourable results. Indian J Plast Surg. 2013;46:333–348.
5. Gibstein LA, Abramson DL, Bartlett RA, Orgill DP, Upton J,
Mulliken JB. Tissue expansion in children: A retrospective
study of complications. Ann Plast Surg. 1997;38:358–364.
6. Meland NB, Smith AA, Johnson CH. Tissue expansion in the
upper extremities. Hand Clin. 1997;13:303–314.
7. Lozano S, Drucker M. Use of tissue expanders with external
ports. Ann Plast Surg. 2000;44:14–17.
8. Jackson IT, Sharpe DT, Polley J, Costanzo C, Rosenberg L.
Use of external reservoirs in tissue expansion. Plast Reconstr
Surg. 1987;80:266–273.
890e
Copyright © 2018 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Plastic and Reconstructive Surgery • June 2018
9. Friedman RM, Ingram AE Jr, Rohrich RJ, et al. Risk factors
for complications in pediatric tissue expansion. Plast Reconstr
Surg. 1996;98:1242–1246.
10. Adler N, Dorafshar AH, Bauer BS, Hoadley S, Tournell M.
Tissue expander infections in pediatric patients: Management
and outcomes. Plast Reconstr Surg. 2009;124:484–489.
11. Elias DL, Baird WL, Zubowicz VN. Applications and com-
plications of tissue expansion in pediatric patients. J Pediatr
Surg. 1991;26:15–21.
12. Huang X, Qu X, Li Q. Risk factors for complications of tis-
sue expansion: A 20-year systematic review and meta-analysis.
Plast Reconstr Surg. 2011;128:787–797.
13. De Agustin JC, Morris SF, Zuker RM. Tissue expansion
in pediatric burn reconstruction. J Burn Care Rehabil.
1993;14:43–50.
14. Pisarski GP, Mertens D, Warden GD, Neale HW. Tissue
expander complications in the pediatric burn patient. Plast
Reconstr Surg. 1998;102:1008–1012.
15. Neale HW, Kurtzman LC, Goh KB, Billmire DA, Yakuboff KP,
Warden G. Tissue expanders in the lower face and anterior
neck in pediatric burn patients: Limitations and pitfalls. Plast
Reconstr Surg. 1993;91:624–631.
16. Adler N, Elia J, Billig A, Margulis A. Complications of nonbreast
tissue expansion: 9 years experience with 44 adult patients and
119 pediatric patients. J Pediatr Surg. 2015;50:1513–1516.
17. Antonyshyn O, Gruss JS, Mackinnon SE, Zuker R.
Complications of soft tissue expansion. Br J Plast Surg.
1988;41:239–250.
18. Yeşilada AK, Akçal A, Dağdelen D, Sucu DÖ, Kılınç L,
Tatlıdede HS. The feasibility of tissue expansion in recon-
struction of congenital and acquired deformities of pediatric
patients. Int J Burns Trauma 2013;3:144–150.
19. McCullough MC, Roubard M, Wolfswinkel E, Fahradyan A,
Magee W. Ectropion in facial tissue expansion in the pedi-
atric population: Incidence, risk factors, and treatment
options. Ann Plast Surg. 2017;78:280–283.