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The use of a tissue expansion technique in the reconstruction of the female genitalia in bladder exstrophy

A 23-year-old woman presented with deformity of the external genitalia resulting from bladder exstrophy and scarring due to multiple operations in the pelvis and abdomen. She had undergone previous surgery to excise the bladder remnant and to provide urinary diversion into an ileal conduit. There had also been several attempts to treat recurrent prolapse of the uterus including uterine suspension with a nylon sling, an anterior colporrhaphy and a gracilis muscle flap. All of these were unsuccessful but repair of the prolapse was eventually achieved using an halon sponge implant. An attempt had also been made to reconstruct the external genitalia using local flaps but it had failed due to a shortage of normal tissue. The labia majora were absent and the labia minora were deficient (Fig. 1). The clitoris, which had been bifid but was repaired, lay inside the introitus on its anterior aspect. The hairbearing skin in the pubic area was separated into two halves by a wide vertical scar in the midline. To improve the cosmetic appearance of the external genitalia she underwent further surgery using tissue expansion to provide adequate tissue for reconstruction. A longitudinal incision was made at the superior border of the hair-bearing skin on each side. Bilateral subcutaneous pockets were dissected beneath the hair-bearing skin and a tissue expander of nominal volume 160 ml and basal measurements 12 x 5 cm was inserted into each. The remote injection valves were located in the subcutaneous tissues on either side of the pelvis. A 50 ml volume of saline was injected into each expander at the conclusion of the procedure, sufficient to fill the dead space between the expander and the enveloping tissue of the subcutaneous pocket. Following wound healing she attended for weekly injections of an average of 20 ml of saline into each expander. Excessive tension on the skin was avoided to maintain a good blood supply during expansion. After 14 weeks each expander contained 250 ml. Despite the increasing swellings she experienced little discomfort and had been able to continue with her normal activities.