Fine-needle aspiration for periprosthetic fluid removal after implantation of a remote internal-port tissue expander

Xifeng Lin ,Shuchen Gu ,Yshn Go ,Hinn Zhu ,Bin Gu ,Feng Xie ,Qingfeng Li,To Zn,Hizhou Li,*

a Department of Plastic and Prosthetic Surgery,Hainan Western Central Hospital,Danzhou Medical Association of Shanghai Ninth People’s Hospital Group,Danzhou 571700,Hainan,China

b Department of Plastic and Reconstructive Surgery,Shanghai Ninth People’s Hospital,Shanghai Jiao Tong University School of Medicine,Shanghai 200011,China

Keywords:Tissue expansion Prosthesis Fine-needle aspiration Fluid removal Seroma

ABSTRACT Background: Use of internal filling ports in tissue expander-based reconstructions are advantageous because of easier self-care,lower infection rates,and fewer instances of capsule formation.The appearance of periprosthetic fluid accumulation after internal-port tissue expander implantation is a common complication that warrants treatment.In this study,we introduced a noninvasive method using fine-needle aspiration(FNA)to remove fluids accumulated after implantation of a remote internal-port tissue expander.Methods:In this study,245 patients who underwent implantation of remote internal-port tissue expanders in our hospital from July 1,2012,to July 1,2019,were included and divided into two groups.In the control group,patients underwent tissue expander implantation before July 1,2016,and large quantities of fluids were removed with surgical aspiration procedures in most cases.In the FNA group,the patients underwent implantation after July 1,2016,and large quantities of fluids were removed first with the FNA procedure.Patients’ demographic data,indications for FNA application,and related complications were collected and analyzed.Results: Overall,395 expanders were placed in 245 patients.Postoperative management was similar in both groups.Fluids were managed with 23 expanders in the control group and with 31 expanders in the FNA group.There was no difference in the fluid aspiration rate between the two groups.The surgical aspiration rate was 11.1%(23/208)in the control group.The success rate of FNA was 90.3%(28/31).In the FNA group,the surgical aspiration rate was 1.6% (3/187),which was significantly lower than that in the control group.There were no significant differences in complications between the two groups.Conclusion:FNA can be used for periprosthetic fluid removal after the implantation of a remote internal-port tissue expander in most cases.This method is more convenient and safer than surgical aspiration for the postoperative management of internal-port tissue expander implantation.

1.Introduction

Tissue expansion was initiated in the 1950s1when an inflatable rubber balloon was placed subcutaneously to expand the temporal skin during ear reconstruction.Tissue expansion is a commonly used technique in reconstructive surgery.The entire treatment requires the implantation of an expander;after weeks or months of inflation,the expander is removed,and the expanded extra tissue is used for flap transfer or long-term breast prosthesis implantation.For better functional and esthetic outcomes,this procedure can more or less replace skin grafts in the treatment of extensive post-burn scars and benign tumors,such as congenital giant pigmented nevi.

A remote-port tissue expander includes a silicone bag (which is inflated with saline),an injection port through which the saline is infused,and a silicone tube,which connects the silicone bag and the injection port.The injection port can be placed externally or implanted subcutaneously near the silicone bag.

Ease in self-care,low infection rate in the long term,and low risk of capsule formation render internal-port tissue expansion preferable for long-term tissue expansion,which can last for several months or even years in some extreme cases.However,the major drawback of internalport tissue expansion is that surgeons must pay more attention to early postoperative care.Since blood or exudate does not naturally run out from the silicone tube through the external port tunnel,the rates of hematoma or seroma are relatively high with internal-port tissue expansion and may lead to prolonged surgical drainage time and an increased risk of infection.2,3

In this study,we introduced a noninvasive method to remove fluids with fine-needle aspiration (FNA) after the implantation of an internalport tissue expander.The aspiration-related data before and after the wide application of FNA were summarized to evaluate the effectiveness and safety of this method.

2.Patients and methods

2.1.Patient data

In this study,245 patients who underwent implantation of remote internal-port tissue expanders at the Shanghai Ninth People’s Hospital from July 1,2012,to July 1,2019,were enrolled.All implantations were performed by the senior authors (Li QF,Gu B,Zan T,and Xie F).Data regarding patients’age and sex,indications for tissue expansion,and size and anatomical location of placement of the expanders were collected.

2.2.Implantation of tissue expanders

All patients were treated routinely with antibiotics perioperatively and 48 h postoperatively.The subcutaneous pockets were dissected with electrocautery under direct vision,and bleeding was carefully sealed with bipolar electrocoagulation.Exceptionally,the pockets in the scalp were bluntly dissected with minimal incisions.All filling ports were placed 3-5 cm away from the subcutaneous pockets to prevent accidental damage to the expander during inflation.Drainage tubes were used routinely.The surgical area was dressed,with gentle pressure,for 48 h,and the drainage tubes were removed 48-72 h postoperatively.

2.3.Fluid aspiration

Expansion and removal of the stitches was usually performed 7-14 days after the operation.Before inflation with saline,the feeling of fluid consistency on palpation of the subcutaneous pocket was used as an indicator for further removal of fluids.

Two methods were used to aspirate the fluid.The surgical aspiration procedure removed the fluids with 1.5-mm blunt-head liposuction needles,under local anesthesia,through the previous surgical incision made for implantation.FNA(Figs.1 and 2)was used to remove the fluids with needles,while obviating the need for surgical procedures;25-G scalp needles and 20-mL syringes were used for both saline inflation and fluid aspiration.First,the needle was inserted perpendicularly through the skin at the center of the injection port,just up to the metal sheet of the port.Thereafter,the expander was inflated with saline to approximately 40%-60%of its volume to fill the entire subcutaneous pocket.A portion of the fluid disseminated in the space around the injection port.Next,the needle was pulled a few millimeters out with the application of negative pressure generated by the syringe.Therefore,the fluid was aspirated once the needle reached the space of fluid accumulation.Gentle pressure was applied on the surface of the expanded skin to accelerate the aspiration.In the case of a large amount of fluid,the expander was not sufficiently inflated for the first time and needed to be inflated again after the fluid was aspirated.

2.4.Group division

Fig.1.Illustration of FNA.Before inflation with saline,the fluctuating feeling from the subcutaneous pocket indicated the need for further fluid removal.Without inflation,most of the fluid was contained in the periprosthetic space(up).The periprosthetic space was filled after the expander was inflated with saline by up to approximately 40%-60% of the expander volume.A portion of the fluid also disseminated to the space around the injection port(middle).The needle was pulled a few millimeters out with the application of negative pressure,and the fluid was aspirated from the periportal space (down).

Fig.2.A fine needle (a) was used to aspirate the fluid from the surrounding space of the remote port;a second needle (b) was used for additional saline infusion into the expander.

The FNA method has been widely used since July 2016.To study the improvement in the postoperative management of expander implantation with the FNA procedure,we divided the patients into two groups:control and FNA.In the control group,the patients underwent implantation of tissue expanders before July 1,2016,and large quantities of fluids were removed with surgical aspiration procedures in most of the cases.In the FNA group,the patients underwent implantation after July 1,2016,and large quantities of fluids were removed first with the FNA procedure.If the FNA failed,surgical aspiration with a 1.5-mm liposuction needle was performed as previously described.

Several factors might influence the rate of fluid formation,including the duration of drainage,different standards of drain removal,and different standards of postoperative observation and care.We reviewed the day of drain removal,drainage in the last 24 h before drain removal,and postoperative hospital days.The comparison of these data was used to evaluate the differences in postoperative management between the two groups.The results were analyzed using at-test with SPSS 15.0(SPSS,Inc.,Chicago,IL,USA).

Complications included hematoma and active bleeding that required emergent surgery,severe infection that required surgical debridement and lavage,minor infections that were cured with intravenous antibiotics,leakage of the expander that required surgical replacement,port displacement leading to failure of inflation,and incision dehiscence that required surgical debridement and resuturing.Complications that occurred within 1 month after implantation were considered to be related to aspiration procedures in both the groups.Each expander was treated as an independent observation,except for the analysis of length of hospital stay.The results were analyzed using the chi-square test.

3.Results

Fig.3.Data collection.

Fifty-one of the 446 cases of expanders were excluded because of missing data.A total of 395 expanders were placed in 245 patients(Fig.3).The control group(Table 1)had 68 female and 56 male patients,and the average age at the time of surgery was 22.7 years (range,4-63 years).The FNA group had 66 female and 55 male patients,and the average age at the time of surgery was 14.2 years (range,3-52 years).The patients in the FNA group were significantly younger than those in the control group (P＜0.01).The indications for tissue expansion were burns (101,control group;87,FNA group),congenital nevi (12 control group;22,FNA group),trauma (two,control group;eight,FNA group),vascular anomalies (eight,control group;four,FNA group),and hemifacial atrophy(one patient,control group)(Fig.4).

Table 1 Clinical data.

The average volume of the tissue expander was 180.1 mL (range,30-600 mL)in the control group and 204.7 mL(range,30-1200 mL)in the FNA group.There were no significant differences between the two groups.The location of implantation varied from the scalp to the extremities.More than half of the expanders were implanted in the head and neck in both the groups(Fig.5).

The difference in postoperative management between the two groups was evaluated(Fig.6).The average drain duration was 3.63±1.37 days in the control group and 3.47±1.44 days in the FNA group.The average drainage volume of the last 24 h in the control group(12.1 ± 7.62 mL)was slightly but significantly higher(P＜0.05)than that in the FNA group(10.45 ± 5.82 mL).The length of postoperative hospital stay days was 6.62 ± 2.74 days in the control group and 6.9 ± 2.69 days in the FNA group.There was no significant difference in drainage duration or postoperative hospital stay between the two groups.

Fluids were managed with 23 expanders in the control group and 31 expanders in the FNA group (Figs.3 and 7).There was no difference in the fluid aspiration rate between the two groups.The control group was treated with surgical aspiration for 21 expanders and with FNA for two expanders.To reduce grouping bias,the two FNA-treated expanders were also regarded as surgical aspirations for the comparison of surgical aspiration rates between the two groups.The surgical aspiration rate was 11.1% (23/208) in the control group.In the FNA group,fluids were successfully treated with FNA in 28 patients.FNA failed to remove a large amount of hematoma from two expanders in the scalp and was alleviated with surgical aspiration.In one case,fluids were directly treated with surgical aspiration and were also regarded as failed FNA.The success rate of FNA was 90.3%(28/31).In the FNA group,the surgical aspiration rate was 1.6%(3/187),which was significantly lower than that in the control group.

Complications at 1 month were related to aspiration (Table 2).Hematoma and active bleeding occurred in seven expanders in the control group and five expanders in the FNA group.In these cases,fluids were noticed and aspirated for two and three expanders of the control and FNA groups,respectively.Severe infection occurred in six expanders in the control group and five expanders in the FNA group.Surgical debridement and antibiotics were used for treatment.Nevertheless,two expanders were removed unwillingly in each group.Minor infection occurred in 17 expanders in the control group and nine expanders in the FNA group.Only one minor infection was related to surgical aspiration in the control group.Leakage of the expander occurred in one expander of the control group because of accidental injury to the expander during implantation.Overturn or displacement of the port leading to inflation failure occurred in two expanders in the control group and one expander in the FNA group.Two expanders from the control group and one expander from the FNA group were removed for severe infection-caused dehiscence and exposure of the expanders.One case of dehiscence occurred after surgical aspiration and was treated with a changed dressing.There were no significant differences in the complications between the two groups.

Table 2 Complications 1 month after expander implantation.

Fig.5.Locations of implanted expanders.

Fig.6.Postoperative data of the control and FNA groups.

Case report

A 26-year-old man suffered a flame burn injury to the face and neck.The shortage of the integument distorted the lower face,which caused chilectropion of the lower lip.The patient was unable to extend his head.A 150-mL rectangular tissue expander was implanted.Approximately 20 mL exudate was removed with FNA,and the tissue expanders were successfully inflated with 387 mL of saline.A 15 cm×12 cm free internal mammary artery perforator flap was harvested and revascularized to the left facial vessels to resurface the right chin and neck.After the operation,restoration of the cervicomandibular angle,correction of the chilectropion,and normal neck and mouth movements were noted at the 2-year follow-up(Fig.8).

4.Discussion

Fig.7.Locations of fluid aspirations.

Fig.8.A 26-year-old man suffered a flame burn injury of the face and neck.The patient could hardly extend his head (left).After the operation,restoration of the cervicomandibular angle,correction of the chilectropion,and normal neck and mouth movement were noted at the 2-year follow-up (right).

Several methods have been reported for fluid drainage around tissue expanders or breast prostheses.Puncture is particularly risky because of the danger of puncturing the expander.Garcia-Tutor first reported moving the seroma to the area in which the injection valve is found and puncturing it with a fine needle perpendicular to the surface.If the needle went deeper,it reached the valve with posterior metal reinforcement and prevented damage to the expander.4As the remote-port tissue expander is thinner and less palpable,the puncture directed to the surrounding space of the expander is riskier.We previously aspirated fluids with blunt-head liposuction needles,which also permitted the lavage of blood clots.Potential injury to permanent implants can also be minimized by relying on access with 14-G angiocatheters5or a blunt SeromaCath.6The SeromaCath uses electrical cautery to easily advance through the subcutaneous tissue,muscle,and thick capsules,with minimal risk of puncturing the implant,which is an insulator that does not conduct electricity.

In this study,we introduced a noninvasive method to remove fluids from the subcutaneous pocket of expanders.This method improved the convenience and safety of the postoperative management of internal-port expander implantation.Aspiration was mostly performed when patients visited the clinic for stitch removal.The feeling of fluctuation in the subcutaneous pocket indicated a need for aspiration,and ultrasound might be more accurate in determining the fluid volume.Aspiration of the fluids was achieved with 25-G scalp needles,the same needles used for saline inflation.The puncture point was right in the middle of the internal port,and saline was injected at the same point.Therefore,the entire process was relatively safe.We reviewed 28 cases of FNA procedures,and no expander leakage related to aspiration occurred.

A major drawback of FNA is that the aspiration needle is too thin to remove large or unliquefied hematomas.In two cases,we attempted to remove the fluids with FNA but failed.Thick fluids and undissolved blood clots were found during subsequent surgical lavage and aspiration.Both aspiration failures occurred because of scalp expansion.There were two reasons:first,blunt dissection in the scalp caused increased and continuous exudation;second,the poor blood supply to the periosteum surface is not conducive to hematoma liquefaction.In our experience,a small quantity of hematoma can be dissolved in 7-14 days and aspirated with a fine needle.Liquefaction is faster in some locations with better blood supply,such as the face.

Although there are many problems with tissue expansion therapy,such as more procedures,longer periods of treatment,and more complications,tissue expansion enables surgeons to recover extensive defects with plentiful matched skin and to reduce donor-site morbidities.It has become an irreplaceable method for treating post-burn face and neck disfigurement,7breast reconstruction,8and giant congenital melanocytic nevi.9

The two different ways of placing inflation ports have their own advantages and disadvantages.Postoperative care is simpler for the external port,and surgeons have fewer concerns about postoperative hematoma or seroma,which can run out through the external port tunnel.Drains are not routinely used.10Inflation is simple and less painful.The major disadvantage is the higher infection rate.Because part of the expander is exposed,it is very important to prevent pathogens from passing through the tunnel,which mainly relies on the patients’ own daily care.Our previous meta-analysis11concluded that external ports are strongly associated with a high infection rate.For internal ports,the inflation process is more demanding and highly recommended for clinics,but home care is much simpler.The infection rate is significantly lower in internal ports than in external ports.In certain cases,the inflation period was prolonged to several months,even 2 years,to overexpand the prosthesis to meet the desired reconstructive requirements.Internal ports are preferred in cases of tissue overexpansion.12,13The major disadvantage of the internal port is the postoperative care required for expander implantation.The drain must be in place for several days.Debridement is needed in some patients with large hematomas to avoid secondary infections.One advantage of an external port is that leakage of the port can be sealed with a clip to the tunnel,and replacement of the expander is not necessary.In similar cases,patients with internal-port expansion had to undergo surgical procedures to replace their expanders.

The major limitation of this study was the retrospective design.The data for several years were grouped by the artificial setting of a time point.Therefore,grouping bias was unavoidable.To reduce the bias,we regarded fluids aspirated with FNA as surgical aspiration in the control group,and we regarded a direct surgical aspiration case as an FNA failure case.We also presumed that the fluids in the pocket might be different at the time of aspiration because of the drainage time or standards used to remove the drain.However,there were no significant differences in drain duration or postoperative hospital stay between the two groups.The average drainage volume in the last 24 h in the control group was slightly but significantly higher than that in the FNA group.Another limitation of this study was that the indication might be different for different individuals and is essentially based on the experience of each surgeon.In addition,this study included the experience of only a few surgeons at a single institution,which may limit the generalizability of these results.Other expander types,such as self-filling expanders or carbon dioxidefilled expanders,were not studied.

5.Conclusion

FNA offers a convenient,safe option for the postoperative management of internal-port tissue expander implantation.

Ethics declarations

Ethics approval and consent to participate

Ethical approval was provided by the medical ethics committee of Shanghai Jiao Tong University Medical School.All patients in this study signed the consent form to permit the use of their data for medical analysis and publication.

Consent for publication

All patients included in this study provided written informed consent to publish the data contained in this study.

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

Lin X:Writing-Original draft,Software.Gu S:Software,Visualization.Gao Y and Zhu H:Investigation,Data curation.Gu B,Xie F,Li Q,and Zan T:Clinical Practice.Li H:Writing-Reviewing and Editing.

Acknowledgements

This work was supported by grants from the National Natural Science Foundation of China (81501668),Two-hundred Talent (20161424),Shanghai“Rising Stars of Medical Talent”Youth Development Program(Outstanding Youth Medical Talents),and Shanghai Jiao Tong University“Chenxing”Youth Development Program(Associate Professor Type A).