A new partly external device for extension of skin before excision of skin defects

Clinical study on a skin stretching technique with adjustable external fixators to treat skin defects

The aim of this study was to determine the effectiveness of a skin stretching technique with adjustable external fixators in treating skin defects.Eighteen patients treated with a skin-stretching technique with adjustable external fixators for skin defects from April 2017 to October 2019 were included. Visual Analogue Scale (VAS) scores were collected during therapy. The skin defects gradually became smaller until they were completely resolved according to the blood flow of the affected limb and wound skin (the color, temperature, elasticity, and capillary response). The defect sizes ranged from 4 cm × 2 cm to 20 cm × 6 cm.The 18 adjustable external fixators were dismantled in 2 to 9 days (mean, 4.05 days) after the operation, and the defects were completely closed and the sutures were removed after 2 to 3 weeks. The average VAS score was 5.97. The follow-up period was 4 to 12 months (mean, 6.3 months); 17 patients healed well with linear small scar, and no infections or patients of necrosis were observed. Sensory recovery was assessed using the Medical Research Council scale, and all the sensation scores were S3+. Eight patients were healed after the first stage. Nine patients were closed totally while small sinus or skin defect were observed after sutures were removed; 3 patients were healed after the second debridement, and 6 patients finally healed after the dressings were changed. Patellar osteomyelitis recurred in 1 patient who was transferred to the Orthopedic Department for further treatment, and a flap graft procedure was performed.The operation was simple and obviously reduced the course of the disease, the costs, and the damage to the donor site, and it is also significantly superior to skin graft or flap transplantation procedures in terms of the resulting skin sensation, color, texture, elasticity, and appearance.

Multidisciplinary Application of an External Tissue Expander Device to Improve Patient Outcomes: A Critical Review

Significance: Continuous external tissue expansion (CETE) is a versatile tool in soft tissue injury management, and could be an addition to the traditional reconstructive ladder.

Recent Advances: This critical review discusses the principles and application of CETE, covering a company-sponsored consensus meeting on this emerging technology and highlighting the DermaClose^® (Synovis Micro Companies Alliance, Inc., Birmingham, AL) device's unique approach to soft tissue injury management. There is clinical evidence to support the use of CETE in the management of a number of wound types, including fasciotomy, trauma, amputation, and flap donor sites. The device can be applied to open wounds, potentially avoiding the need for a skin graft or other more complex or invasive reconstruction options. DermaClose applies constant tension without restricting blood flow and does not require repeated tightening.

Critical Issues: CETE is becoming more widely used by surgeons of different specialties, and numerous reports describing its efficacy and safety in wound management have been published. Surgeons using CETE must follow the correct technique and select patients carefully to achieve optimal outcomes. However, there is no single source of information or consensus recommendations regarding CETE application.

Future Directions: Prospective evidence on the efficacy and safety of CETE in clinical practice is required to communicate the best techniques and share important experiences. This will help to solidify its place in the reconstructive ladder as a valuable additional option for surgeons.

[Application of self-made chronic wound closure device in the repair of scarred lower extremity wounds]

Objective

To investigate the effectiveness of self-made limb chronic wound closure device in the treatment of scarred lower limbs and complex skin and soft tissue defects.

Methods

Between January 2014 and January 2017, 29 patients with complex fractures of the lower extremities and skin and soft tissue defects were treated. There were 19 males and 10 females with an average age of 31.1 years (range, 21-66 years). The causes of injury included 14 cases of traffic accidents, 5 cases of falling from height, 4 cases of heavy object crushing injury, 4 cases of mechanical crushing injury, and 2 cases of exposed steel plate after fracture. There were 26 cases of calf fracture and skin defect, 3 cases of metatarsal bone fracture and skin defect of the foot. The skin defect ranged from 5 cm×3 cm to 18 cm×8 cm. The time from injury to admission was 5-31 days, with an average of 14.3 days. All patients underwent a thorough debridement, open wound drainage, self-made chronic wound closure device combined with Ilizarov stretching technique for a slow skin and soft tissue traction. After the wound was cleaned up and the granulation tissue was freshened, the skins on both sides were closed, and then proceed to the second stage operation of skin grafting or direct suture closure based on the size of the wound.

Results

All patients were followed up 8-20 months, with an average of 13 months. Twenty-nine patients were treated with self-made chronic wound closure device combined with Ilizarov technique for 1-2 times with an average of 1.3 times, then the wound infection was controlled and the granulation tissue grew well. In the course of treatment, the pain was not obvious and the patients had good compliance. All patients' wounds healed clinically without skin traction complications and formed linear or flaky scars.

Conclusion

The self-made chronic wound closure device is effective in repairing complex scarred wounds of lower extremities, and it is easy to operate.

[Application of modified adjustable skin stretching and secure wound-closure system in repairing of skin and soft tissue defect]

Objective

To investigate the application of modified adjustable skin stretching and secure wound-closure system in repairing of skin and soft tissue defect.

Methods

Between March 2016 and April 2017, 21 cases of skin and soft tissue defects were repaired with the modified adjustable skin stretching and secure wound-closure system (the size of regulating pressure and the times of adjustment were determined according to the color, temperature, capillary response, and swelling degree of the skin edge). There were 11 males and 10 females, with an average age of 49.2 years (range, 21-67 years). Among them, 1 case was the residual wound after amputation of leg; 18 cases were the wounds after traumatic injury operation, including 4 cases in the lower leg, 3 cases in the knee joint, 7 cases in the upper limb, and 4 cases in the foot; and 2 cases were diabetic feet. The skin defect area ranged from 4.0 cm×2.5 cm to 21.0 cm×10.0 cm.

Results

Skin defect wounds closed directly in one stage in 4 cases; 12 cases were closed after continuously stretching for 5-14 days (mean, 10 days); 5 cases were reduced to less than one-half area, and the wound healed after the second skin grafting or flap repairing. All the 21 patients were followed up 3-12 months (mean, 5.2 months). The wound was linear healing with small scar, and no invasive margin, poor blood flow, necrosis, and poor sensory function happened.

Conclusion

The modified adjustable skin stretching and secure wound-closure system can reduce the skin and soft tissue defects or close the wound directly, and even replace the skin graft and skin flap repairing. It was a good method for the treatment of skin and soft tissue defect.

Easy and cheap way to prepare skin extenders

Skin extender is a very useful method to repair wounds when oedema and skin retraction make a direct suture impossible. We have developed a new, simple and cheap way to prepare skin extenders based only on elastic vessel loops and metal clips stapler commonly used for skin suture and available in any operating room. This simple method can be performed both in the operating room and at the patient bedside, even under local anaesthesia, causes no bleeding and appears to be inexpensive and rapidly usable and should be made readily available in any hospital.

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.

External tissue expander for closing large defects of the extremities and trunk

BACKGROUND

Direct closure is the reconstruction of choice for surface soft tissue defects; however, it may not be suitable for larger defects due to extensive tension. A variety of techniques are available for achieving tension free closure, including skin grafts, skin flaps, and internal or external tissue expansion.

MATERIALS AND METHODS

The external skin expander developed by Blomqvist and Steenfos consists of single tissue expander units that contain an atraumatic needle and two friction stoppers connected via a silicone string. Each device of the expander is inserted under local anaesthesia on each side of the defect at a distance of about 2 cm from each other. Postoperative the silicone strings have to be tightened at least once a day. After about 5 to 10 days a sufficient expansion is achieved and the defect can be closed directly after expander removal.

RESULTS

The external tissue expander developed by Blomqvist and Steenfos is an efficient, time-effective, easy-to-handle device that can be inserted under local anesthesia, providing a good functional and satisfactory cosmetic outcome. Due to the comparatively low complication rate, even outpatient treatment is possible. The major drawback of this technique is the possibility of developing uncommon secondary scars under the plastic stoppers.

Comparison of vacuum-assisted closure device and conservative treatment for fasciotomy wound healing in ischaemia-reperfusion syndrome: preliminary results

Ischaemia-reperfusion syndrome (IRS) is a condition that may require early fasciotomy. In the past, fasciotomies ultimately required prolonged hospitalisation. Vacuum-assisted closure (VAC) therapy system is an innovative method which promotes wound healing by reducing wound oedema, increasing microcirculation, and stimulation of granulation tissue. The aim of this retrospective study was to compare the VAC treatment with the conservative treatment of the fasciotomy wound until definitive surgical closure. The researchers retrospectively identified 15 patients, 3 females and 12 males, with a mean age of 69 years, who underwent a fasciotomy between January 2003 and December 2009 at the University Hospital of Geneva. All of the fasciotomies performed on the patients were on account of IRS. Seven patients were subjected to wound treatment using the VAC-system device and eight patients underwent treatment through the usual conservative method. The data were analysed by comparing the operative wound size, length of time for wound closure and duration of hospital stay in both groups. The number of days after fasciotomy until surgical wound closure in the VAC-system group (n = 7) ranged from 8 to 13 days with a mean of 11 days. The wound size at the day of closure was decreased in length by a mean of 58% (range 29-67%) and in diameter by a mean of 56% (range 33-75%). The duration of hospital stay for this group ranged from 12 to 18 days with a mean of 14 days. No signs of infections were observed and no re-operation was required after first closure. In the conservative group (n = 8), the time to wound closure ranged between 12 and 20 days with a mean of 15 days. The wound size was decreased in length by a mean of 40% (range 32-53%) and in diameter by a mean 46% (range 30-70%). The mean duration of hospital stay was 18·5 days. Three of the patients in the conservative treatment group manifested wound infection during the course of the treatment. VAC device could be a new standard for treatment of fasciotomy wound. VAC therapy is a recent innovation and becoming more and more a necessary complementary therapy to hasten wound healing. In our preliminary study, the VAC-system device showed significantly reduction of the wound size, decreased tissue oedema, duration of hospital days and improvement of granulation tissue.

Application of skin traction for surgical treatment of grade IV pressure sore: a clinical report of 160 cases

STUDY DESIGN

Retrospective clinical study.

OBJECTIVE

To assess the method of primary surgical closure of pressure sores developed by the Ruixin Hospital for burns.

SETTING

Nanjing, China.

METHODS

The study included 235 grade IV pressure sores of 160 patients, M:F = 119:41. Their age ranged from 19 to 93 years (mean = 47.4, s.d. ± 15.7). The primary disease was spinal cord injury in 141 patients (88.1%). The location of sore spread over ischial, sacrococcygeal and trochanteric regions. The largest pressure sore measured 15 × 25 cm(2). The time from onset of sore to admission ranged from 3 months to 22 years (mean = 35.5 months, s.d. ± 55.8). Local preoperative preparation included external skin traction using adhesive tapes, wound cleaning and change of dressing. General condition was checked and improved by supportive measures. Operation procedures included thorough debridement, excision of hidden minor scars, mobilizing opposing skin flaps and meticulous haemostasis before closure. Skin traction continued after the operation until the wound was healed.

RESULTS

All but 10 sores healed primarily. These 10 sores healed after a revision. The length of stay in hospital ranged from 20 to 140 days (mean = 45.1 days, s.d. ± 21.1). Follow-up period was 2-51 months (mean = 22 months, s.d. ± 12.5). Two ischial sores recurred owing to long sitting. They were cured with the same method. Three illustrative cases are presented.

CONCLUSION

The method is simple and enjoys a high success rate with a short stay in hospital and hence is cost effective. The recurrence is rare.

The use of an innovative device for wound closure after upper extremity fasciotomy

INTRODUCTION

The purpose of this paper is to evaluate the Silver Bullet Wound Closure Device (SBWCD, Boehringer Laboratories, Norristown, PA), a new device for delayed primary closure of fasciotomy wounds.

MATERIALS AND METHODS

A retrospective review was performed over a period of 36 months of all patients with an upper extremity fasciotomy that could not be closed primarily. Cases that underwent fasciotomy closure with the SBWCD were separated from the patients that had a split thickness skin graft (STSG).

RESULTS

Seven patients had their wound closed with the SBWCD within 10 days (mean of 7.4 days). The seven patients that underwent STSG had their wound closed in an average of 8.4 days. The average number of days between the day of the fasciotomy incision and the date of the placement of the SBWCD was 1.9 days. STSGs were placed on the fasciotomy wounds on an average of 10.3 days after the date of the fasciotomy incision. We found that the SBWCD allowed for starting to approximate the edges of the fasciotomy wound at an earlier time when compare to STSG (2.1 vs 10.3 days).

CONCLUSIONS

We feel that the SBWCD as a one-stage procedure provides a consistent and efficacious way to manage upper extremity fasciotomy wounds while minimizing the morbidity associated with STSG. Elimination of a second-stage procedure reduces hospital costs. Our findings may help to inform surgeons about an available alternative when an upper extremity fasciotomy wound is not amenable to primary closure.

[A simple tissue expansion device for scalp defect]

INTRODUCTION

The closure of scalp defects requires various procedures, but unfortunately with a high rate of sequels.

OBSERVATION

The authors report their experience regarding a large pilomatrixoma of the scalp. The closure of an 8 by 10 cm defect resulting from excision was achieved using a simple tissular extension device during 20 days. The scar aspect was very satisfactory. The device is derived from Cohn's model. It is made of simple and widely used material (vascular lacks, staples).

DISCUSSION

This simplicity and efficiency of tissular extension devices has been proved. Nevertheless, their use may be restricted. This limitation often results from a high cost and difficulty in applying the adequate tension to the wound edges. Excessive tension may lead to cutaneous necrosis. The use of a simple device derived from Cohn's model seems interesting considering its efficiency, reliability, and low cost.

[Uni-axial tissular extension for covering skin defects of the limbs. A 31 cases review]

INTRODUCTION

The skin property to adapt to external constraints is widely used in plastic surgery. Tissue expansion is the most known and codified application. Tissue extension appears to be an attractive alternative. The authors propose the usage of a simplified procedure to deal with skin loss in the superior or inferior members.

MATERIAL AND METHOD

Thirty-one patients underwent uni-axial traction between February 2000 and October 2003.

RESULTS

Closure of skin loss on the upper member has been obtained in 6 days and in 8 days on the inferior member.

DISCUSSION

Efficiency, reliability and no subsequent aftermaths are strong arguments in favor of the development of a simplified extension procedure.

CONCLUSION

The tissue extension procedure, although scarcely used is an attractive procedure for the coverage of skin losses.

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.

Long-Term Results of Wounds Closed under a Significant Amount of Tension

BACKGROUND

The authors present the long-term follow-up of scars on various locations up to 7 years postoperatively, after closure of large skin defects with the use of a skin-stretching device.

METHODS

In a prospective, nonrandomized study of 30 patients whose initial wound could not be closed primarily without using a significant amount of tension, a complete follow-up of 24 cases was possible. Patients were observed preoperatively, postoperatively, and at long-term follow-up (mean, 7 years) for wound control and scar evaluation.

RESULTS

In 28 cases (93 percent), successful closure of a large defect was achieved. In the other two cases, a split-thickness skin graft was needed for wound closure. With respect to long-term scar formation after 7 years (24 cases), scarring was observed mainly on the scalp (average, 56 percent), back (average, 52 percent), and shoulder (average, 53 percent). On the extremities, including thigh and groin, there was significantly less scarring (p = 0.0004; average, 10 percent). Three weeks after the operation, 23 percent of the total scar formation had already occurred, whereas 57 percent occurred by 3 months postoperatively and 83 percent occurred by 6 months postoperatively.

CONCLUSION

This study demonstrates the considerable difference in scar formation among scalp, back, and shoulder defects compared with those on the extremities, groin, and thigh.

Dermal traction on the Ilizarov frame

We report a technique of skin traction, which harnesses the biological and mechanical properties of skin. We have used this technique in open fractures to close or reduce the size of the wound, thereby avoiding the use of split skin grafts or free flaps and their resultant additional morbidity. This report summarises our early experience with this technique in seven patients. We describe the technique and the results so far.

Wound closure by dermatotraction after fasciotomy for acute compartment syndrome

Intramuscular pressure (IMP) was measured in 16 patients during secondary wound closure by dermatotraction with external tissue extension (ETE). Secondary wound closure was done 4-16 days after fasciotomy for acute compartment syndrome. The traction between wound edges was 2.5 N in the first six patients and 3.5 N in the following 10 patients. Mean (SD) IMP was 6.9 (3.5) mmHg before wound closure. It increased to 12.3 (1.4) mmHg in the 2.5 N group and to 24.7 (7.0) mmHg in the 3.5 N group when dermatotraction was applied. Mean (SD) leg perfusion pressure in the 2.5 N group decreased by 7% to 69.3 (10.9) mmHg and in the 3.5 N group by 23% to 62.2 (7.4) mmHg. None of the patients needed a skin graft. We conclude that dermatotraction by ETE raises IMP intraoperatively sufficiently to preserve adequate limb perfusion pressures.

Nonsurgical breast enlargement using an external soft-tissue expansion system

Less than 1 percent of the women interested in having larger breasts elect to have surgical augmentation mammaplasty with insertion of breast implants. The purpose of this report is to describe and test the efficacy of a nonsurgical method for breast enlargement that is based on the ability of tissues to grow when subjected to controlled distractive mechanical forces. Seventeen healthy women (aged 18 to 40 years) who were motivated to achieve breast enlargement were enrolled in a single-group study. The participants were asked to wear a brassiere-like system that applies a 20-mmHg vacuum distraction force to each breast for 10 to 12 hours/day over a 10-week period. Breast size was measured by three separate methods at regular intervals during and after treatment. Breast tissue water density and architecture were visualized before and after treatment by magnetic resonance imaging scans obtained in the same phase of the menstrual cycle. Twelve subjects completed the study; five withdrawals occurred due to protocol noncompliance. Breast size increased in all women over the 10-week treatment course and peaked at week 10 (final treatment); the average increase per woman was 98 +/- 67 percent over starting size. Partial recoil was seen in the first week after terminating treatment, with no significant further size reduction after up to 30 weeks of follow-up. The stable long-term increase in breast size was 55 percent (range, 15 to 115 percent). Magnetic resonance images showed no edema and confirmed the proportionate enlargement of both adipose and fibroglandular tissue components. A statistically significant decrease in body weight occurred during the course of the study, and scores on the self-esteem questionnaire improved significantly. All participants were very pleased with the outcome and reported that the device was comfortable to wear. No adverse events were recorded during the use of the device or after treatment. We conclude that true breast enlargement can be achieved with the daily use of an appropriately designed external expansion system. This nonsurgical and noninvasive alternative for breast enlargement is effective and well tolerated.

Scalp extension--a quantitative study

The authors have compared the results of scalp reductions with extenders with their earlier results of scalp reductions without extenders. The extenders seem to prevent "stretch-back" and provide 30 to 86% more effectiveness when a second reduction is performed 4 weeks later.

Clinical experiences with the external tissue extender

Forty one patients were operated on for different skin defects using the external tissue extender (ETE). The indications were similar to those in which ordinary tissue expanders were used with a prevalence of scars (n = 20, 46%) and previous skin grafts (n = 12, 28%). The ETE was used all over the body but mainly on the upper (n = 18, 42%) and lower (n = 12, 28%) extremities. The mean treatment time was eight days, and the complication rate was 8% compared with the reported 25% using ordinary tissue expanders. The advantages of the ETE compared to ordinary tissue expanders are that it saves time and money for doctors and patients, it is easy to handle, and it is almost always possible to operate under local anaesthesia.

External device for tissue expansion: clinical evaluation of the skin extender

Tissue expansion is a well known way of repairing soft tissue defects. However, traditional tissue expanders have certain disadvantages such as the need for repeated outpatient visits for the filling of the expander and a long period of time required before the final result is achieved. A series of other devices have recently been developed. We have evaluated one of these, a skin extender developed by Blomqvist and Steenfos, in 10 lesions of the extremities in nine adult patients. The defects ranged from 3.5-10 cm wide and the extenders were inserted under local anaesthesia. The patients were taught how to tighten the extenders themselves, so there was no need for repeated visits to the outpatient department. Nine of the 10 defects were excised within 14 days; the remaining one developed a wound infection. The results show that this skin extender is a simple, fast, and economical device for repairing soft tissue defects, and in certain cases it is more suitable than a traditional tissue expander. Its major drawback is unsightly scars in the normal skin beside the previous defect.

An intraoperative skin-stretching device to close wounds in Mohs defects

BACKGROUND

A skin-stretching device takes advantage of the viscoelastic properties of the skin by exerting incremental traction to aid in closing complex wounds.

OBJECTIVE

To evaluate the effectiveness of a skin-stretching device and determine the cosmetic results available when this device is used in Mohs surgery.

METHODS

We applied a skin-stretching device to seven patients, each of whom had a large, complex wound defect following Mohs surgery. All of the patients had basal cell carcinomas. In one patient the carcinoma was on an upper extremity, and in the others the carcinoma was located on broad facial surfaces, including the temple and forehead.

RESULTS

Complete primary closure was accomplished in six patients. A maximum of three cycles of tissue stretching were applied during the period of tissue processing between Mohs layers. In one patient the defect was reduced in size by more than 75%, with final healing by secondary intention. In two patients minor complications developed: focal wound dehiscence occurred in one patient and in the second patient, an inconsequential hypertropic scar developed. In both cases, the problems resolved with acceptable cosmetic results. The remaining patients experienced no complications and the cosmetic results were excellent.

CONCLUSION

The skin-stretching device accomplishes effective primary closure of large skin defects by dramatically reducing the size of the defect. It allows a simpler closure where a full-thickness graft or local flap would have otherwise been utilized. The device is convenient to use with minimal complications, reduces operative time, and aids greatly in preserving tissue integrity.

External tissue stretching for closing skin defects in 22 patients

In this prospective study, we treated 12 women and 10 men with a newly developed skin-stretching system. The stretching device was used for the closure of 9 fasciotomies and for preoperative skin extension before excision of 6 tattooes, 7 splitskin transplants, 4 giant naevi, and 3 scars. The stretching device was placed under the skin, using local anesthesia. The patient stretched the skin. The mean stretching time was 4 (2-11) days. 20 patients completed the expansion successfully, with no pain or only slight discomfort. In 2 cases, we observed minor complications during the expansion. The external skin-stretching system can be used to obtain primary closure of defects where splitskin transplants otherwise would be necessary. The method can be applied in out-patients, using local anesthesia.

Extended free lateral arm flap with preservation of the posterior cutaneous nerve of the forearm

The free lateral arm flap has become a well-defined and reliable flap for various reconstructive purposes. Little attention has been paid, however, to the possibility of preservation of the posterior cutaneous nerve of the forearm (nervus cutaneus antebrachii posterior) sacrifice of which results in numbness of the dorsal part of the forearm. In this study, an anatomical dissection showed that in many cases it would be possible to preserve the nerve. We did 23 free lateral arm flaps in 22 patients during the period 1989-1994. The maximum flap length was 40 cm. Standard maximum width in most cases was 6 cm, and by using a new expansion technique it reached 10 cm in one case. Furthermore, with meticulous dissection the posterior cutaneous nerve of the forearm was either preserved or cut and rejoined in 21 patients, so minimising sensory loss at the donor site.