Maximising the use of tissue expanded flaps Donald A Hudson  British Journal of Plastic Surgery  Volume 56, Issue 8, Pages 784-790 (December 2003) DOI: 10.1016/S0007-1226(03)00379-5

Fig. 1 Preop view. Six-year-old girl with anterior scalp burn alopecia. The patchy alopecia anterior to the tissue expander was discarded. A 400 ml rectangular tissue expander had been inserted and inflated to 800 ml. (A) Bird's eye view. Two triangles of adjacent local tissue were identified (marked with white arrows) on the left side, and one on the right side of the defect as ‘potential’ sources of adjacent tissue to be advanced into the defects created by backcutting the tissue expanded flap. (B) Left lateral view. Lateral view showing two triangles of adjacent local tissue which will be advanced into the backcuts which were used to allow the tissue expanded flap to flatten and advance. British Journal of Plastic Surgery 2003 56, 784-790DOI: (10.1016/S0007-1226(03)00379-5)

Diagram 1 Rectangular (three-dimensional) box. The thickened black line diagrammatically indicates the site of the initial incision at the base of the box (flap) (i.e. along lines A to X to Y to B). If this is performed on a cardboard box it would remain a three-dimensional structure. It is only when the side walls of the box are cut and flipped outwards that the front wall can move forward and flattening can occur. British Journal of Plastic Surgery 2003 56, 784-790DOI: (10.1016/S0007-1226(03)00379-5)

Fig. 2 Intraop view: patient 1. Three backcuts were made on the flap—two on the left and one on the right (these are shown as white, off/spickled white and black arrows). Three triangles of adjacent local tissue had been identified (again marked with arrows of complimentary colours to those on the flap) which would be advanced into these backcuts. The flap after backcuts now forms a two-dimensional (flat) ‘sheet’. The defect covered measured 14cm×12 cm. British Journal of Plastic Surgery 2003 56, 784-790DOI: (10.1016/S0007-1226(03)00379-5)

Diagram 2 For the box to flatten, the two side walls of the box need to be flipped/rotated outward. This is achieved by making two cuts per side up the whole length of each side wall. In the clinical situation this represents a backcut. British Journal of Plastic Surgery 2003 56, 784-790DOI: (10.1016/S0007-1226(03)00379-5)

Diagram 3 Shows the box starting to flatten, as the two side walls flip outwards (a1 and x1, and b2 and y2) and the anterior wall (x2 and y1) advances forward. British Journal of Plastic Surgery 2003 56, 784-790DOI: (10.1016/S0007-1226(03)00379-5)

Diagram 4 Rectangular box which has been converted into a two-dimensional flat structure. When completely flat, the box has the configuration of an aeroplane. The areas where triangles of local tissue are required can be seen (four black arrows). In the clinical situation a2 to b1 represents the pedicle of the expanded flap. British Journal of Plastic Surgery 2003 56, 784-790DOI: (10.1016/S0007-1226(03)00379-5)

Fig. 3 Patient 1 postop at 2 weeks. Postop result at 2 weeks with staples still in situ to show the backcuts on the tissue expanded flap and triangles of local tissue to be advanced. (A) Left lateral view. The two triangles of local tissue, which was advanced into the triangular defects created by backcutting, the flap (which permitted the tissue expanded flap to advance and flatten) is shown by white arrows. (B) Right lateral view. Only one backcut was used on this side of the tissue expanded flap (Fig. 2) and only one triangle of local tissue was needed to be advanced into this backcut (shown by white arrow). (C) Bird's eye view again highlighting the two triangles of local tissue needed to fill the two backcuts on the tissue expanded flap. British Journal of Plastic Surgery 2003 56, 784-790DOI: (10.1016/S0007-1226(03)00379-5)

Fig. 4 Preop right-sided view: patient 2. 12-year old boy with burn alopecia. Again the patchy alopecia anterior to the tissue expander was discarded. A 160 ml rectangular expander was inflated to 450 ml. A triangle of adjacent local tissue has been identified (white arrow). British Journal of Plastic Surgery 2003 56, 784-790DOI: (10.1016/S0007-1226(03)00379-5)

Fig. 5 Intraop view: patient 2. (A) Bird's eye view. In this patient, two backcuts were used on the right side and one was performed on the left side. The one backcut on the flap is marked by a white arrow and the triangle of local tissue which will be advanced into this backcut (see also (B)) is also marked with a white arrow. The five black arrows indicate radial ‘scoring’ at the periphery of the flap. Note flap after scoring and backcuts forms a flat sheet which measured 14cm×8 cm. (B) Lateral view. Lateral view showing triangle of local tissue (white arrow and also dissecting scissors) which will be advanced into the backcut. See Fig. 6. British Journal of Plastic Surgery 2003 56, 784-790DOI: (10.1016/S0007-1226(03)00379-5)

Fig. 6 Patient 2, postop right-sided view. Result at 2 weeks with staples in situ to show flap backcut and triangle of local tissue advanced into the backcut. British Journal of Plastic Surgery 2003 56, 784-790DOI: (10.1016/S0007-1226(03)00379-5)

Fig. 7 Preop view: patient number 3. Posterior scalp burn alopecia. The two triangles of local tissue which will be advanced into the backcuts after the tissue expanded flap has been identified (white arrows). British Journal of Plastic Surgery 2003 56, 784-790DOI: (10.1016/S0007-1226(03)00379-5)

Fig. 8 Postop view, patient number 3. Postop result at 2 weeks with staples in situ. The sites of the backcuts on the flap as well as the triangles of local tissue advanced into the backcuts can be seen. British Journal of Plastic Surgery 2003 56, 784-790DOI: (10.1016/S0007-1226(03)00379-5)