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1. Tissue expanders in oral
and maxillofacial surgery
Asok kumar RS OMFS

2.  INTRODUCTION
 HISTORY
 PHYSIOLOGIC PROPERTIES AND MORPHOLOGIC CHANGES
 ADVANTAGES
 DISADVANTAGES
 INDICATION
 CONTRA INDICATION
 TISSUE EXPANSION DEVICE
 RULE OF 1
 APPLICATION
 SELF INFLATING OR OSMOTIC EXPANDER
 COMPLICATION
 CONCLUSION Asok kumar RS OMFS

3.  TISSUE EXPANSION refers to the prolonged expansion of skin during an interval of
days to weeks.
 Defined as, “The ability of at least some living tissue such as skin, mucous membrane to
accommodate a slowly enlarging mass beneath it by increase in surface area” [AUTSAD]
 Reconstructive surgical procedure that provide space for the development of additional
tissues
 Insertion of tissue expander in defect site allows the enlargement of soft tissues to provide
adequate soft tissue closure.
 Offers a unique potential to preserve both form and function.
Asok kumar RS OMFS

4.  During the past decade reconstructive surgical procedures have been developed to
provide functional and aesthetic benefit.
 MAJOR BENEFITS - Correction of cutaneous defects and ability to use tissue
that are optimally matched in color, texture, thickness and hair-bearing qualities.
 It may also obviate the need for multiple flaps or grafts and avoids creation of a
second defect at a distant area to correct the primary deformity.
 Expansion of tissue is a dynamic process producing adequate amount of tissue
available for flap transfer.
Asok kumar RS OMFS

5. History
 1900 - Modern use of tissue expansion was first introduced
 1957 - NEUMANN described the use of a latex balloon to expand the skin for reconstruction
of an ear.
 1970 - RADOVAN AND AUSTAD independently began studying the use of tissue expansion
to repair soft tissue defects using silicone expander.
 1975 - AUSTAD AND ROSE Described self-inflating expander and established the basis for
understanding of the tissue response to expansion.
 1993 - WEISE Introduced self-inflating osmotically active soft tissue expander.
Asok kumar RS OMFS

6. Asok kumar RS OMFS

7.  Certain populations employed tissue expansion to
decorate, enhance or mutilate facial or body structures.
 MURSI TRIBE OF ETHIOPIA- Giant decorative
plate in lower lip
 KAYAN WOMEN MYANMMAR- Series of ring
around neck to enhance linear growth
 WAORANI TRIBE ECUADOR – Large wooden spool
to widen the ear lobe
Asok kumar RS OMFS

8.  GIBSON studied the properties of skin and described its
inherent extensibility.
 Skin could stretch beyond its inherent extensibility and called
this mechanical creep.
 It attributed to displacement of interstitial fluids and
mucopolysaccharide ground substance, parallel alignment of
randomly oriented collagen fibers and migration of tissue.
 Biologic creep as the gradual stretching of skin overlying a
slowly expanding subcutaneous structure.
Gibson T. The physical properties of skin. In: Converse JM, editor. Reconstructive plastic surgery, vol. 1. Philadelphia: WB Saunders; 1977.
Asok kumar RS OMFS

9.  Composed of stratified squamous epithelium of the keratinized
type.
 Increase in thickness during skin expansion.
 Active basal layer of the epidermis increases in density and
thickness.
 Basal layer normally composes 10% of the thickness of the
epidermis but during expansion increases to 40%.
Asok kumar RS OMFS

10.  VAN RAPPARD ET AL - Observed during skin
expansion , epidermal thickness increases and no
histologic change in the layers of the epidermis.
 Increase in the cellular mitotic rate in the stratum basal
of expanded skin and showed a net gain in donor tissue.
 Initial stretching of the epidermis from inflation of an
expander increases the intercellular spaces, which in turn
probably signals the cells to increase mitotic activity
van Rappard JHA, Bauer FW, Grubben MJAL, et al. Epidermopoiesis in controlled tissue expansion. In: van Rappard JHA, editor. Controlled tissue
expansion in reconstructive surgery. Nijmegan, Netherlands: SSN; 1988.
Asok kumar RS OMFS

11.  Sheet of connective tissue underlying and supporting the
epidermis
 Composed of the papillary layer and the reticular layer.
 PAPILLARY LAYER - Contains finer collagen fibers
than the reticular layer and contains numerous elastic
fibers.
 RETICULAR LAYER - Composed of dense, irregular
collagen fibers. Responsible for the lines of tension
Asok kumar RS OMFS

12.  During tissue expansion, a rapid decrease in dermal thickness is
observed [20%].
 Amount of thinning depends on the rate of expansion.
 Expanded dermis contains large bundles of collagen fibers and
active fibroblasts.
 Increase in collagen synthesis.
 Collagen fiber bundles become parallel to the skin surface noted for
6 months after cessation of the expansion process.
 Melanin production increases causing a temporary
hyperpigmentation of the skin. Asok kumar RS OMFS

13.  Composed of fat, loose connective tissue, collagen, arteries, veins, nerves,
lymphatics, hair follicles and sebaceous glands.
 Thickness of the subcutaneous layer is diminished by 50%
 PASYK ET AL - Noted that thickness of sub cutaneous tissue becomes
greater than normal thickness of the subcutaneous tissue within 2 years
after removal of expanders
 During skin expansion, there is a marked decrease in the number of fat
cells within the subcutaneous tissue.
Pasyk KA, Austed ED, McClatchey KD, et al. Electron microscopic evaluation of guinea pig skin and soft tissues “expanded” with a self-
inflating silicone implant. Plast Reconstr Surg 1982;70:37.
Asok kumar RS OMFS

14.  Increase in the interlobular spaces and increase in the collagen content within
these spaces.
 Fat necrosis.
 Hair follicle morphology remains the same during and after skin expansion.
 Follicles become separated during expansion
 Hair shock is common and manifested by conversion of follicles to their telogen
phase resulting in temporary alopecia.
 Sebaceous glands show little change and blockage of glandular ducts.
Asok kumar RS OMFS

15.  Sensitive to tissue expansion.
 Increase in the number and size of mitochondria, number of vesicles and amount of
sarcoplasm.
 Number of muscle cells remains unchanged.
 Striated pattern of muscle cells decreases and necrotic.
 Hyalinization of muscle cells followed by calcification.
 Decrease in muscle function and strength in the region of tissue expansion.
 SASAKI ET AL- Reported visible muscle atrophy and weakness after tissue
expansion, but permanent sequelae are rare.
Sasaki GH. Expansion of extremities. Presented at the Plastic Surgery Educational Foundation International Tissue Expansion Symposium, San Francisco,
October 1987. Asok kumar RS OMFS

16.  Tissue expansion stimulates the proliferation of blood vessels
 Creates highly vascular tissue
 Distention of capillaries is noted first followed by an increase in the number of
venules and arterioles.
 Barium angiography demonstrates a dense vascular pattern in expanded tissue.
 STARK ET AL - Demonstrated a rapid elongation of arteries and veins with no
loss of vessel wall diameter or intimal integrity.
 CHERRY ET AL - Demonstrated that flaps raised from expanded tissue have a
17% increase in survival length compared with random pattern flaps raised in
nonexpanded skin.
Cherry GW, Austed ED, Pasyk KA, et al. Increased survival and vascularity of random pattern skin flaps elevated in controlled expanded skin. Plast Reconstr Surg
1983;72:680.
Asok kumar RS OMFS

17.  Tolerate expansion well without demyelination or necrosis of nerve
tissue.
 Elongation of peripheral nerves by use of an expander has been
successful.
 MANDERS ET AL - Described the expansion of peripheral nerves and
monitored the intraluminal pressure of expanders while measuring nerve
response to expansion with electroneuromyography.
 No neurologic changes in response to expansion if the intraluminal
pressure of expanders remained below 40 mm Hg.
Manders EK, Saggers GC, Diaz-Alonso P, et al. Elongation of peripheral nerve and viscera containing smooth muscle. Clin Plast Surg 1987;14:551
Asok kumar RS OMFS

18.  Dense fibrous capsule develops around tissue expanders
 Composed of elongated fibroblasts that are active in collagen production.
 Granulation tissue consisting of macrophages, fibroblasts and lymphocytes
observed followed by development of a double-layered capsule within 7
days after an expander is implanted.
 Inner layer consists of macrophages and the outer layer eventually becomes
rich in collagen fibers
 Histologic remnants of the capsule can be found up to 1 year after removal
of an expander
 Myofibroblasts are also present in the capsule and if capsule left intact may
lead to stretchback. Asok kumar RS OMFS

19.  CHERRY noted that the capsule has four histologic zones:
 INNER ZONE—Adjacent to the expander.
 Contains fibrin like filaments and a cellular layer with macrophages.
 CENTRAL ZONE—Next to the inner zone.
 Contains elongated fibroblasts and myofibroblasts oriented parallel to the surface of the
implant.
 TRANSITIONAL ZONE—Outside of the central zone.
 Has loose bundles of collagen fibers.
 OUTER ZONE—Most superficial layer.
 Contains established vessels loosely interspersed with collagen fibers.
Asok kumar RS OMFS

20.  Simple surgical procedure
 Minimal complications and infections
 Usage of tissue with similar color, sensation, hair bearing capability texture as the adjacent tissues
 Minimal risk of trauma and incisional scarring.
 Short surgical period for reducing post-operative pain.
 Minimised donor site morbidity
 Low cost of surgery.
 Involves placement of small remote incision, at a distance from the area of expansion to reduce the
stress applied on the incision during expansion period and the risk of tissue expander extrusion.
Hallock GG. Tissue Expansion Techniques to Minimize Morbidity of the Anterolateral Thigh Perforator Flap Donor Site. J Reconstr Microsurg.
2013 Jun 19
Asok kumar RS OMFS

21.  Temporary deformity during expansion
 Excessive post-operative bleeding and scarring.
 Hypoxia due to the rapid expansion
 Allergic responses due to the use of injected fluids
 Infections
 Lack of expanded tissues.
Hallock GG. Tissue Expansion Techniques to Minimize Morbidity of the Anterolateral Thigh Perforator Flap Donor Site. J Reconstr Microsurg.
2013 Jun 19
Asok kumar RS OMFS

22.  Correction of post-traumatic or postoperative alopecia
 Treatment of male pattern baldness
 Expansion of forehead skin prior to forehead flap total nasal reconstruction
 Expansion of post- auricular skin prior to reconstruction of the external ear
 Expansion of cheek or neck skin to allow scar revision
 Burn excision
 When primary closure is not possible without undue tension.
 Augmentation of resorbed edentulous ridges.
 Cleft lip repair surgery
Baker SR, Swanson NA (1990) Tissue expansion of the head an neck: indications, technique, and complications. Arch Otolaryngol Head
Neck Surg 116:1147–1153 Asok kumar RS OMFS

23.  Unwillingness or medical inability to undergo 2 or more operations.
 Noncompliance.
 Mental disability.
 Poorly vascularized tissues from radiation therapy.
 Active infection or open wounds.
 Ongoing chemotherapy.
 Systemic diseases such as diabetes mellitus, bacterial pneumonia, chronic liver disease, renal
failure and hypertension.
Handschel J, Schultz S, Depprich RA, Smeets R, Sproll C, Ommerborn MA et al (2013) Tissue expanders for soft tissue reconstruction in the
head and neck area—requirements and limitations. Clin Oral Investig 17(2):573–578
Asok kumar RS OMFS

24. MATERIALS
 Silicon expander
 Hydrogel expander
 Hydroxyapatite and
 Chitosan.
 Hydroxyapatite and chitosan are hard tissue expander
 Silicon and hydrogel are soft tissue expanders.
Asok kumar RS OMFS

25.  Wide variety of expander styles, sizes and
shapes have been introduced.
 Custom-made expanders can also be used for
irregular defects or unusual areas.
 Standard Radovan expander - Silastic reservoir,
a self-sealing injection port and connecting
tubing.
 Choice for head/neck expansion is almost
always rectangular. Asok kumar RS OMFS

26.  STANDARD EXPANDERS
I. Cylindrical.
II. Rectangular.
III. Crescent.
IV. Cupola.
 CUSTOM BUILT EXPANDER
 DIFFERENTIAL EXPANDER
 ANATOMICAL EXPANDER
SPHERICAL RECTANGULAR
CYLINDRICAL CRESCENT
Asok kumar RS OMFS

27. Asok kumar RS OMFS

28.  Soft tissue expander - Silicone elastomer inflatable expander with a
remote silicone elastomer injection dome.
IDEAL REQUISITES OF EXPANDER:
1. Should be loosely bounded by a silicone envelope with extension
for the placement of a fixation screw and pores.
2. Should decreases its thickness after expansion due to stretching.
3. Size should be large enough to overcome the expansive forces
4. Provide required tissue augmentation
Asok kumar RS OMFS

29.  Should be more comfortable and does not provide any damage to adjacent tissues.
 Should be soft and easy to insert.
 Size of the soft tissue expander must be comparatively smaller than that of the defect area.
 Should be able to withstand the external stimuli, it should not dislocate from its position.
 Cost- effective with easy handling.
 Should be easy to adapt and easy to remove before and after surgical procedure.
 Sudden rapid expansion should be avoided since it leads to perforation of the tissues.
 Low and gradual expansion is advocated
Uijlenbroek HJ, Liu Y, Wismeijer D. Soft tissue expansion: principles and inferred intraoral hydrogel tissue expanders. Dent Oral Craniofac Res. 2015
Dec 6;1:178-85
Asok kumar RS OMFS

30.  RECTANGULAR EXPANDER - Large defect on the head or neck
area.
 CRESCENT-SHAPED EXPANDER - Reconstruction of round
defects.
 Rectangular expanders provided the most effective gain of surface
area in expanded skin [38%], [32%] crescent-shaped expanders and
[25%] round expanders.
 Less expansion is required to gain sufficient skin for repair when
custom-made expanders are used for reconstruction of irregularly
shaped defects.
 Base of expander to be same size as the defect to be reconstructed.
van Rappard JHA, Sonneveld GJ, Borghouts JMHM. Geometric planning and the shape of the expander. Facial Plast Surg 1988;5:287
Asok kumar RS OMFS

31.  Surface area of expanded skin would be twice the area of the base of
the expander used.
 Expander base should be 2.3 to 3 times the surface area of the defect
to be closed.
 Ratio expected increase in skin surface area and generally accepted
guideline
 FACTORS THAT INFLUENCE THE AMOUNT OF SKIN
GAINED : Amount of undermining performed and the inherent
extensibility of the skin.
Radovan C. Tissue expansion in soft tissue reconstruction. Plast Reconstr Surg 1984;74:482
Asok kumar RS OMFS

32. I. Tissue expanders can often be implanted with local anesthesia consisting
of 1% lidocaine with epinephrine (1 : 100,000 epinephrine concentration)
[larger expanders - general anesthesia]
II. ACCESS INCISION - Placed in area adjacent to the area to be
reconstructed usually made at the junction of normal tissue with the tissue
to be replaced.
 Design to made to preserve vascularity and nerve innervation of the area.
III. SUBCUTANEOUS TISSUE RECIPIENT POCKET - Implant is
placed beneath the subcutaneous tissue layer of the skin and placed deep
to the platysma mucle
 Scalp expansion - Expander is placed in a subgaleal pocket.
Asok kumar RS OMFS

33. IV. INJECTION PORT - Placed in an area where the overlying tissue has
sufficient thickness to avoid breakdown from and through the same incision
used for insertion of the expander
 Port can be easily palpated and accessible for saline injections.
V. CLOSURE - Closed in layer and should assists with counteracting wound
closure tension on the incision line during tissue expansion.
VI. SALINE INJECTION to obliterate the remaining dead space in the
subcutaneous pocket.
 Volume injected should not create tension on the suture line.
 To allow sufficient healing, inflation of the expander is commenced 2 weeks
after implantation. Asok kumar RS OMFS

34.  Injections of isotonic saline are performed every 1 to 7 days, depending on the
volume injected and the response of the tissue.
 Sterile 23-gauge or smaller needle is used to inject saline through the injection
port.
 Injection is continued until the skin overlying the expander feels tense or the
patient complains of discomfort.
 Skin perfusion over the expander may be tested by finger pressure to check
capillary refill.
 Relaxation of the inflated skin usually begins within 24 hours of injection and
periodic inflation of the expander is continued until sufficient skin is generated
 Skin generation takes 6 to 12 weeks once the expansion process is started.
Asok kumar RS OMFS

35. I. 10% filling is performed intra-operatively.
II. Postoperative filling is started at the 10th postoperative day.
III. 1/10th of the total capacity is filled in each filling session.
IV. The entire filling process is completed over 10 weeks.
V. 10% overfilling beyond the prescribed capacity is routinely performed.
Hudson DA, Grob M. Optimising results with tissue expansion: 10 simple rules for successful tissue expander insertion. Burns 2005; 31: 1-4.
Asok kumar RS OMFS

36.  SCALP - Well suited for expansion due to vascularity and thickness.
 Allows expedient healing and a low rate of complications
 Enables the correction of defects with hair-bearing skin.
 Expander is placed in a subgaleal plane.
INDICATION:
 Defects or deformities up to half of the surface area of the scalp
 Defects of the scalp secondary to burns
 Avulsion-type injuries
 Defects resulting tumor removal
Asok kumar RS OMFS

37.  KABAKER - Described the use of expanders for the
treatment of male pattern baldness .
 Technique for implanting expanders and design of
expanded flaps that created a double Y-shaped wound
closure
 Minimum 6 weeks to 2 months scalp expansion is
required before the transfer of expanded advancement
flaps.
Kabaker SS, Kridel RWH, Krugman ME, et al. Tissue expansionin the treatment of alopecia. Arch Otyolaryngol 1986;112:720.
Asok kumar RS OMFS

38.  Forehead skin can tolerate expansion due to its thickness and
vascularity.
 Expansion produces more pain than expansion of other areas.
 Provides sufficient tissue for reconstruction.
 EXPANDER PLACEMENT: Subfascial plane, deep to frontalis
muscle and superficial to periosteum of frontal bone
 Temporal branch of the facial nerve has to be considered in incision
placement.
Asok kumar RS OMFS

39.  Expansion of the forehead and scalp results in
depression or “bathtub.” deformity in the underlying
soft tissue and bone
 Resorption of bone with thinning of the outer layer of
the calvarium.
 Deformity resolves with time
Asok kumar RS OMFS

40.  Expander placed in a superficial tissue plane in the face and neck .
 Can be placed directly over the vicinity of the facial nerve and
expansion performed without nerve impairment.
 Incisions placed in natural creases for enhanced long-term
aesthetic results.
 FACE AND NECK EXPANION- Periauricular facelift-type
incision
 Placed deep to the platysmal muscle in the neck.
Asok kumar RS OMFS

41. Asok kumar RS OMFS

42.  Expansion of the neck skin was recommended to replace traumatized
tissue and to add additional skin and soft tissue to the area of the
chin.
 Used to reconstruct traumatic defects of the mandible.
 Bone grafting also been used in conjunction with expanded neck flaps
and expanded oral mucosa to provide an improvement in the form and
function of the reconstructed mandible.
 Expander serves as a “spacer” preserving a cavity for subsequent
placement of a bone graft.
 Served as a stimulus to create additional soft tissue as a vascularized
recipient site for the bone graft. Asok kumar RS OMFS

43.  Myocutaneous flaps remain the preferred method for reconstruction of
large deformities which requires adequate thickness and coverage of an
open wound.
 Used as an aid to nasal reconstruction when forehead flaps are required
 Forehead skin expansion provides adequate availability of skin and the
ability to close the donor site without tension.
 Also been used for ear reconstruction.
 First use of an expander was for reconstruction of an auricle.
 Expander inserted beneath the postauricular skin.
Nordstrom REA, Salo HP, Rintala AE. Auricle reconstruction with the help of tissue expansion. Facial Plast Surg 1988;5:338.
Asok kumar RS OMFS

44. Milind S. Wagh, Varun Dixit.Tissue expansion: Concepts, techniques and unfavourable Results.Indian Journal of Plastic Surgery May-August 2013 Vol 46
Issue 2 Asok kumar RS OMFS

45.  Use of self-inflating or osmotic tissue expander has started to gain attention in
various surgical procedures.
 Recent advances in tissue expander technology have made it easier for successful
implantation of bone grafts or synthetic grafts and development of tissue with
matching color and texture to the area of defect.
 Optimal restoration of aesthetics, form and function can be achieved
 Play an important role in intra oral tissue reconstruction in the future.
Asok kumar RS OMFS

46.  Self-inflating tissue expander -First described by Austed and Rose in
1982.
 TIME TO EXPAND: 8 to 14 weeks.
 Semi-permeable membrane filled with hypertonic saline which leads to
the entrance of the water by osmotic forces from the surrounding tissues
into the expander.
 Wiese developed an osmotic self-inflating expander the NaCl solution
with hydrogel
 Used to expand orbit in management of enophthalmos, microphthalmos,
and cryptophthalmos. Asok kumar RS OMFS

47.  Osmotic self-filling expander - Made of polymeric methyl
methacrylate vinyl- pyrrolidone which gains volume by
absorbing body fluids
 Hydrophilic polymer solution inflate spontaneously by absorbing
body fluid at a known rate of up to a volume that is 10 to 12
times larger than its initial size
 Hydrogel is inserted into the self-filling tissue expander easily
without the need for external inflation
 AVAILABLE SIZES: 0.24, 0.25, 0.7, 1.3 or 2.1ml
Asok kumar RS OMFS

48.  25% - 48% complication rate
 Highest for expansion of the cheek and neck (69%) and forehead (50% ).
 Least risk of complications (17% ) – Scalp expansion
GENERAL COMPLICATIONS:
 Erosion of the overlying skin.
 Exposure of an implant
 Rapid tissue breakdown
 Infection
Manders EK, Schenden MJ, Furrey JA, et al. Soft tissue expansion: concepts and complications. Plast Reconstr Surg 1984;74:493.
Asok kumar RS OMFS

49.  Mechanical failure of the expander.
 Accidental puncture of expander.
 Injection port tube leakage.
 Postoperative bleeding
 Hematoma
 Seroma formation
Manders EK, Schenden MJ, Furrey JA, et al. Soft tissue expansion: concepts and complications. Plast Reconstr Surg 1984;74:493.
Asok kumar RS OMFS

50.  Development of tissue expansion enabled to manage defects that cannot be closed primarily
without undue tension.
 Concept of expansion was useful addition to the surgeon’s armamentarium of reconstructive
procedures.
 Only reconstructive procedure that offers the capability of increasing the number of cutaneous
cells available for incorporation into a skin flap currently.
 Expansion should be considered whenever other reconstructive surgical procedures will not
provide an acceptable functional or aesthetic result.
Asok kumar RS OMFS

51.  Bakers. Local flaps in facial reconstruction .3 edition
 Gibson T. The physical properties of skin. In: Converse JM, editor. Reconstructive plastic surgery, vol. 1. Philadelphia: WB
Saunders; 1977.
 van Rappard JHA, Bauer FW, Grubben MJAL, et al. Epidermopoiesis in controlled tissue expansion. In: van Rappard JHA,
editor. Controlled tissue expansion in reconstructive surgery. Nijmegan, Netherlands: SSN; 1988.
 Pasyk KA, Austed ED, McClatchey KD, et al. Electron microscopic evaluation of guinea pig skin and soft tissues “expanded”
with a self-inflating silicone implant. Plast Reconstr Surg 1982;70:37.
 Sasaki GH. Expansion of extremities. Presented at the Plastic Surgery Educational Foundation International Tissue Expansion
Symposium, San Francisco, October 1987.
 Cherry GW, Austed ED, Pasyk KA, et al. Increased survival and vascularity of random pattern skin flaps elevated in controlled
expanded skin. Plast Reconstr Surg 1983;72:680.
 Baker SR, Swanson NA (1990) Tissue expansion of the head an neck: indications, technique, and complications. Arch Otolaryngol
Head Neck Surg 116:1147–1153
 Hudson DA, Grob M. Optimising results with tissue expansion: 10 simple rules for successful tissue expander insertion. Burns 2005;
31: 1-4.
 Muhammad Saaiq.Tissue Expansion: A Valuable Adjunct to Reconstructive Surgery; Ann. Pak. Inst. Med. Sci. 2013; 9(3): 103-104
 Milind S. Wagh, Varun Dixit.Tissue expansion: Concepts, techniques and unfavourable Results.Indian Journal of Plastic Surgery
May-August 2013 Vol 46 Issue 2
 John et al Tissue expansion in reconstruction of maxillofacial defects. J. Maxillofac. Oral Surg. (2015) 14(Suppl 1):S374–S382
 Lakshana et al. Tissue expaner in periodontics. International Journal of Recent Scientific Research Research Vol. 11, Issue, 08 (B),
pp. 39498-39503, August, 2020
 Carolin Jacob et al.Tissue expander –A review International Journal of Advanced Research (2016), Volume 4, Issue 6, 1683-1693
Asok kumar RS OMFS

52. Asok kumar RS OMFS