c l i n i c a l f o l i o s : n a r r a t i v e





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Scalp Reconstruction with Tissue Expansion: 1

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An 8-year-old child presented to clinic accompanied by his mother for evaluation of a scalp injury that occurred 2 years ago. The child was bitten by a dog and underwent split-thickness skin grafting on his scalp for an area of approximately 10 x 16 cm. The area of the scalp that had been grafted healed completely but the patient was left with a large defect. At this point, the family was requesting additional scalp reconstruction.      

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Scalp Reconstruction with Tissue Expansion: 2

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Tissue expansion was discussed with the family as a means of stretching the hair-bearing tissue for future reapproximation. A staged approach was discussed in which tissue expanders would be inserted into the scalp and allowed to stretch the skin. After sufficient expansion has been achieved, the expanders would be removed and the skin reapproximated. This technique is repeated until the scalp can be completely reconstructed. 

Tissue expansion is a method that gradually expands an area of skin in preparation for its use to correct a defect. This technique can be useful in areas such as the scalp where specialized hair-bearing areas are needed for reconstruction. Capitalizing on the good vascular supply and elasticity of undamaged tissue, the skin is allowed to stretch over time. The expanded skin will match the damaged tissue making this a good correction strategy.    

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Scalp Reconstruction with Tissue Expansion: 3

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Schematic representation of neurogenic inflammation and the different signaling substances involved in this process. CGRP, calcitonin gene-related peptide; EGF, epithelial growth factor; H, histamine; NGF, nerve growth factor; SP, substance P; TGF[beta]1, transforming growth factor [beta]1; VEGF, vascular endothelial growth factor. 

Tissue expanders utilize the skinís viscoelastic properties, specifically mechanical creep, to aid in correction of a defect. By applying static stretch force, the skin is stressed in a continuous fashion. This force elicits a response that triggers a signaling cascade mediated by pro-inflammatory and soluble growth factors that results in cellular proliferation and vascular remodeling. The activation of skin mechanoreceptors and the signaling cascade that follows has been recognized as neurogenic inflammation.

During this process, VEGF, EGF, TGF[beta]1, and NGF become significantly elevated suggesting induction of angiogenesis, epithelialization, and collagen production. Because skin adapts to the stress induced by mechanical  stretch, gradual volume expansion is necessary to ensure that the tissue expanders prompt a continuous growth response.  

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This page was last modified on 6/22/2016.