Intraoperative acute tissue expansion revisited: a valuable tool for challenging skin defects

Golden Spirals and Scalp Whorls: Nature's Own Design for Rapid Expansion

This paper documents what began as an exercise in curiosity—logarithmic spiral designs abound in nature—in galaxies, flowers, even pinecones, and on human scalps as whorls. Why are humans the only primates to have whorls on the scalp? Is the formation of scalp whorls mechanical or genetic? A mechanical theory has long been postulated– the mechanical theory suggests that hair whorl patterning is determined by the tension on the epidermis during rapid expansion of the cranium while the hair follicle is growing downwards—however, this has never before, to the author's knowledge, been experimentally proven conclusively. We found, that under certain conditions, we were able to experimentally recreate spirals on the scalp to demonstrate that the basis of scalp whorls is indeed mechanical—and that logarithmic spirals may be nature’s own design for rapid expansion of organic tissues. Given our experiments only created whorls when certain conditions were satisfied (and not in others), they have given us great insight into the mechanical formation of skin whorls and the physiology of skin stretch. We believe that these findings will lead to many more advances in understanding skin dynamics and indeed the changes that occur in tissue when confronted by stretch.

Intraoperative acute tissue expansion for the closure of large myelomeningoceles

OBJECT

Skin closure has always been the main challenge in treating myelomeningoceles (MMCs). Most cutaneous defects can be treated with the simple undermining and primary suture of the wound edges. This is the ideal treatment, but it is not adequate in cases in which the lesions are greater than 5 cm in diameter. Numerous reconstructive procedures have been described and the results have been satisfactory. The need to mobilize large skin areas and the fact of excessive blood loss, however, are major problems in newborns. Moreover, the tissue undermining destroys most of the skin's vascularization and can harm the adaptation of the skin flaps. The authors describe a technique for primary closure of large MMC skin defects in which they use acute skin expansion during the surgical procedure.

METHODS

Skin expansion was achieved by traction of the wound edges with U-shaped sutures and without the need of skin flaps. Sixteen patients with MMCs greater than 5 cm in diameter were evaluated.

RESULTS

The MMC areas ranged from 30 to 64 cm2 (mean 45 cm2). Two suture systems were developed based on the quality of the skin edge and the size of the skin defect. Wound edge traction was performed in 10-minute periods. The edges were gradually approximated and this allowed the primary closure of the wound without undermining the tissue in all patients. In one patient skin necrosis developed, which was associated with compression of the malformed underlying vertebrae.

CONCLUSIONS

Simplicity, low cost, and satisfactory results were the main advantages of the method and an increase in operative time was a disadvantage. The goal of this technique is not to replace the other methods, but the technique constitutes an effective option in the treatment of large MMCs.

Tattoos: surgical removal

Surgical treatment of tattoos remains a useful tool for complete removal despite the availability of laser and other nonsurgical techniques. The procedures are in accordance with standard dermatosurgery used in aesthetic and oncologic therapies. Healing by primary intention or healing by secondary intention has its own indications. Skin defects can be closed by flaps, grafts, tissue extension, or tissue expansion.

Tissue Expansion in the Head and Neck

Tissue expansion can be a valuable adjunct in reconstruction of large defects of the head and neck and is particularly useful in the scalp and forehead region. This article discusses the differences between conventional long-term expansion and rapid intraoperative expansion. Careful expander selection and application can allow extensive reconstructions with adjacent tissues that might otherwise be impossible. Complications are rare and usually avoidable with careful attention and technique.