Wound coverage using modified tissue expansion

Primary Closure of Wide Fasciotomy and Surgical Wounds Using Rubber Band-Assisted External Tissue Expansion: A Simple, Safe, and Cost-effective Technique

BACKGROUND

Although decompressive fasciotomy is a limb-saving procedure in the setting of acute compartment syndrome, it leaves a large wound defect with tissue edema and skin retraction that can preclude primary closure. Numerous techniques have been described to address the challenge of closing fasciotomy wounds. This study reports our experience with fasciotomy closure using rubber bands (RBs) for external tissue expansion.

METHODS

Patients were informed about RB closure and split-thickness skin graft options. Only patients who opted for RB closure and had wounds that could not be approximated using the pinch test underwent the procedure. Starting from the apex and progressively advancing, the RBs were applied to the skin edges at 3 to 4 mm intervals using staples. The RBs were advanced by twisting back-and-forth to create a criss-cross pattern. One week after application, fasciotomy wounds were closed primarily or underwent further RB application, based on clinical assessment of adequacy of skin advancement, compartment tension, and perfusion. Review of a prospectively maintained database was performed, including demographics, comorbidities, etiology, wound and operative details, hospital stay, and complications.

RESULTS

Seventeen consecutive patients with 25 wounds (22 fasciotomy and 3 other surgical wounds) were treated using the RB technique. Average wound length and width measured 15.7 cm (range, 5-32 cm) and 5.2 cm (range, 1-12 cm), respectively. Locations of wounds included forearm (n = 12, 48.0%), leg (n = 7, 28.0%), hand (n = 4, 16.0%), elbow (n = 1, 4.0%), and hip (n = 1, 4.0%). Eighteen of 25 wounds (72.0%) were closed primarily after 1 RB application. Additional RB application was required for 5 wounds to achieve primary closure. Between stages, patients were discharged home if they did not have other conditions requiring in-hospital stay. No complications were observed, and no revision surgeries were required. Patient satisfaction was 100%, and all indicated that they would choose the RB technique over skin grafting.

CONCLUSIONS

The modified RB technique is a simple, safe, and cost-effective alternative for treating fasciotomy and other surgical defects resulting in high patient satisfaction and good cosmetic outcome, without the need for split-thickness skin graft or flap coverage.

Progressive Tightening of Pulley Sutures for Primary Repair of Large Scalp Wounds

Supplemental Digital Content is available in the text.

Scalp defects greater than 2 cm in diameter are not usually amenable to primary closure and require local tissue rearrangement, grafting, tissue expansion, or prolonged second intention healing. Scalp flap reconstruction is a significant undertaking that requires elevation of a total flap surface area that is 3–6 times the size of the defect, often involves profuse bleeding, and can be challenging to perform without conscious sedation or general anesthesia. Anticoagulated and medically complex patients pose additional challenges and limit options for treatment. The pulley suture uses the mechanical advantage of the pulley to distribute tension across a wound and is useful in areas of high tension such as scalp wounds. For scalp wounds greater than 2 cm, pulley sutures are placed along the length of the wound. An assistant exerts equal tension on the pulley sutures, and the surgeon sequentially ties the sutures. The sutures are tightened and retied weekly until complete scalp closure is achieved. The pulley sutures can be used for rapid primary closure of scalp wounds up to 2.5–3.0 cm in diameter under local anesthesia. For scalp wounds larger than 3 cm, we have also found that pulley sutures can be progressively tightened yielding additional tissue expansion every week. Scalp wounds greater than 3.0 cm can be easily closed via primary repair and weekly tightening of pulley sutures without the need for flap reconstruction, traditional tissue expander placement, or second intention healing.

Selective Scalp Nerve Block: A Useful Technique With Tissue Expansion in Postburn Pediatric Alopecia

BACKGROUND

Scalp defects can be reconstructed either with skin graft, local flaps, free flaps, or tissue expansion. Tissue expanders have been proved to be fruitful in the pediatric population. Scalp expansion has proved to be useful in the reconstruction of posttraumatic and postburn alopecic defects. Selective nerve block can be added for attenuation of sympathetic stimulation and decrease surgical stress in cranial surgeries. In this study, a comparison was done between using selective nerve block and without selective nerve block in both stages of tissue expansion procedure.

PATIENTS AND METHODS

This study included 32 different children who underwent tissue expansions in the management of postburn alopecia. Pediatric patients presented with postburn alopecia of the scalp with mature scar were included in this work.

RESULTS

Postoperative analgesics were less in children who had received scalp block, whereas it was shorter in patients who did not receive any scalp block. Meperidine consumption was much more less in patients who received selective scalp nerve block. Pain score was markedly decreased in children who had received selective scalp nerve block in the immediate postoperative period. Children who received scalp block showed marked attenuation in the surgical stress responses with minimal changes in heart rate and mean arterial blood pressure after skin incision.

CONCLUSIONS

Scalp nerve block is considered an excellent choice for postoperative pain control with less need for opioid analgesia.

Definitive management of significant soft tissue loss associated with open diaphyseal fractures utilising circular external fixation without free tissue transfer, a comprehensive review of the literature and illustrative case

Accepted management of diaphyseal fractures associated with significant tissue loss is rigid intramedullary stabilisation with free or rotational musculocutaneous flap coverage. Circular external fixation is a powerful tool in the management of limb trauma and with recent advances has been developed to provide multiple techniques for which even massive tissue loss can be addressed without the need for free tissue transfer. Gradual and acute shortening, acute fracture deformation and gradual lengthening with restoration of deformity combined with distraction tissue histiogenesis can provide the surgeon with an array of options which can be precisely tailored to the particular personality of a severe open diaphyseal fracture.

Comparison of three skin-stretching devices for closing skin defects on the limbs of dogs

Our objective was to evaluate the effectiveness of skin-stretching devices for closing defects on the extremities of dogs. Antebrachial skin defects were created on the limbs of 24 dogs randomly divided into three groups. Skin stretchers included staples and sutures passing through them (group A), sutures and hypodermic needles (group B), and Pavletic device (group C). Wounds on the left were further undermined in all groups. Tension and blood perfusion were assessed. After removing the stretchers on day 3, the defects were sutured and wound healing was clinically scored. Histological variables evaluated were cellular infiltration, edema, collagen orientation, and thickness of epidermis. Significant differences in tension were found among groups (p < 0.0005) and between measurement times for undermined (p = 0.001) or non-undermined (p < 0.0005) wounds. In contrast, blood perfusion values did not differ significantly. Clinical scores for group B seemed to be better than those for groups A and C, but differences were not significant. Primary wound closure using the Pavletic device was not feasible. No significant differences in histological variables were found between groups. Skin stretching with staples or hypodermic needles resulted in successful wound management with minor side effects on skin histology and circulation.

Wound complications

This article discusses postoperative wound complications in detail, including host factors that predispose the patient to nonhealing, technical factors in surgery that can reduce the likelihood of infection and dehiscence, and recommendations for postoperative management that can prevent wound healing problems. This discussion includes the treatment of wound complications, ranging from local wound care to various wound coverage options.

Dynamic Wound Closure for Decompressive Leg Fasciotomy Wounds

Decompressive fasciotomy for preservation of lower extremity function and salvage is an essential technique in trauma. The wounds that result from the standard two incision four-compartment leg fasciotomy are often accompanied by a wide soft tissue opening that in the face of true compartment syndrome are often impossible to close in a delayed primary fashion. We describe a technique using a device that allows for dissipation of the workload across the wound margin allowing for successful delayed primary closure. Consecutive patients who presented to the 28th Combat Support Hospital in Baghdad, Iraq with a diagnosis of compartment syndrome of the leg, impending compartment syndrome of the leg, or compartment syndrome of the leg recently treated with fasciotomies were followed. All patients underwent placement of the Canica dynamic wound closure device (Canica, Almonte, ON, Canada). Eleven consecutive patients treated at a combat support hospital in support of Operation Iraqi Freedom underwent four-compartment fasciotomies for penetrating injuries. There were five patients that underwent a vascular repair [three superficial femoral artery (SFA) injuries and two below knee popliteal artery injuries] and six patients that had orthopedic injuries (three comminuted tibial fractures, two fibula fractures, and one closed pilon fracture). Patients returned to the operating room within 24 hours for washout and wound inspection. Mean initial wound size was 8.1 cm; mean postplacement size was 2.7 cm; average time to closure was 2.6 days. All patients were able to undergo primary wound closure of the medial incision and placement of the Canica device over the lateral incision. Ten of the 11 patients (91%) could be closed in delayed primary fashion after application of the device. In our series of patients with penetrating wartime injuries and compartment syndrome of the leg we have found the use of this dynamic wound closure device to be extremely successful and expedient.

Delayed primary closure of fasciotomy wounds with Wisebands, a skin- and soft tissue-stretch device

BACKGROUND

Fasciotomy incisions for limb compartment syndrome usually cannot be closed primarily. The conventional method of wound closure with split-thickness skin grafting is effective, but it results in an insensate and disfiguring wound and is associated with donor site morbidity. We present our experience in delayed primary closure of fasciotomy wounds with Wisebands (WB), a skin- and soft tissue-stretching device.

PATIENTS

Between 2000 and 2003, we treated 16 patients with extremity fasciotomy wounds for which primary closure was not feasible.

RESULTS

The Wisebands devices achieved controlled stretching of the wound edges, including skin and underlying soft tissue, until primary closure was feasible. Fourteen patients (88%) had successful wound closure, two patients (12%) had minor wound complications that did not necessitate the removal of the device, and two patients had local wound complications (infection, intractable pain) and their devices were removed prematurely. Delayed primary closure was achieved at the initial surgery using intraoperative skin stretching in 3 of the 14 cases (21%). After a 2-year follow-up (1.3-4 years), the treated area showed stable scarring with good aesthetic outcome and no functional deficit.

CONCLUSIONS

The Wisebands device facilitates closure of fasciotomy wounds with low complication rates and good functional and aesthetic outcome. Its application is simple and safe and requires a short learning curve. Nevertheless, appropriate patient selection, intraoperative judgment and close postoperative supervision are essential for optimal results.

An Improvised Wound Closure System

BACKGROUND

Skin stretching harnesses the same viscoelastic properties of the skin as expansion, with the difference that the forces are applied externally and not internally. An improvised system for wound closure is presented.

METHOD

The system is assembled using silicone vascular loops used as sutures and the flow controllers of intravenous sets as locking devices. The wounds are gradually closed by increasing the tension applied by the devices.

RESULTS

The system has been applied to nine traumatic wounds in six patients. The average size of the wounds was 70 cm; the average number of devices used was 4.3 (range, 1-9; median, 3); the average time to achieve closure was 1.55 days (range, 0-2 days; median, 2 days).

CONCLUSION

This system permits the closure of wounds not suitable for closure by primary intention and avoids the use of skin grafts or flaps.

Our Experience with Wisebands: A New Skin and Soft-Tissue Stretch Device

Complex wounds that involve skin and soft-tissue defects that are unsuitable for primary closure by conventional suturing are common in the field of surgery. Among the many surgical options available to overcome these problems are various mechanical devices that have recently been proposed for delayed primary closure of such wounds. The authors present their experience with a new complex wound closure device, Wisebands, a device uniquely designed for skin and soft-tissue stretching. During the last 2 years, the authors have treated 20 patients with 22 skin and soft-tissue wounds for which primary closure was not feasible. The Wisebands devices were applied to the wounds, stretching the skin and underlying soft tissue, gradually closing the defects until the edges were sufficiently approximated for primary closure. Successful wound closure was achieved in 18 patients (90 percent). The Wisebands devices were removed in two patients (10 percent) because of major wound complications. In two other patients (10 percent), minor wound complications had occurred that did not necessitate removal of the device. At a mean follow-up of 1 year (range, 10 months to 2 years), stable scarring with no functional or significant aesthetic deficit was achieved. The authors conclude that the Wisebands device facilitates closure of complex skin and soft-tissue wounds, with low morbidity and complication rates, and can provide the surgeon with another important tool for closing complex wounds. Nevertheless, appropriate patient selection, intraoperative judgment, and close postoperative care are essential to ensure closure and avoid undue complications.