External tissue stretching for closing skin defects in 22 patients

Efficacy and safety of external tissue expansion technique in the treatment of soft tissue defects: a systematic review and meta-analysis of outcomes and complication rates

Background

Currently, various external tissue expansion devices are becoming widely used. Considering the scarcity of relevant application standards, this systematic review was performed to explore the effectiveness and safety of external tissue expansion techniques for the reconstruction of soft tissue defects.

Method

A systematic review and meta-analysis on the efficacy and safety of external tissue expansion technique was conducted. A comprehensive search was performed in the following electronic databases: PubMed/Medline, Embase, Cochrane Library (Wiley Online Library), and Web of Science. Studies reporting patients with soft tissue defects under the treatment of external tissue expansion technique were included.

Results

A total of 66 studies with 22 different types of external tissue expansion devices met the inclusion criteria. We performed a descriptive analysis of different kinds of devices. A single-arm meta-analysis was performed to evaluate the efficacy and safety of the external tissue expansion technique for different aetiologies. The pooled mean wound healing time among patients with defects after fasciotomy was 10.548 days [95% confidence interval (CI) = 5.796-15.299]. The pooled median wound healing times of patients with defects after excisional surgery, trauma, chronic ulcers and abdominal defects were 11.218 days (95% CI = 6.183-16.253), 11.561 days (95% CI = 7.062-16.060), 15.956 days (95% CI = 11.916-19.996) and 12.853 days (95% CI=9.444-16.227), respectively. The pooled wound healing rates of patients with defects after fasciotomy, excisional surgery, trauma, chronic ulcers and abdominal defects were 93.8% (95% CI=87.1-98.2%), 97.2% (95%CI=92.2-99.7%), 97.0% (95%CI=91.2-99.8%), 99.5% (95%CI=97.6-100%), and 96.8% (95%CI=79.2-100%), respectively. We performed a subgroup analysis in patients with diabetic ulcers and open abdominal wounds. The pooled median wound healing time of patients with diabetic ulcers was 11.730 days (95% CI = 10.334-13.125). The pooled median wound healing time of patients with open abdomen defects was 48.810 days (95% CI = 35.557-62.063) and the pooled successful healing rate was 68.8% (95% CI = 45.9-88.1%). A total of 1686 patients were included, 265 (15.7%) of whom experienced complications. The most common complication was dehiscence (n = 53, 3.14%).

Conclusions

Our systematic review is the first to demonstrate the efficacy and safety of external tissue expansion in the management of soft tissue defects. However, we must interpret the meta-analysis results with caution considering the limitations of this review. Large-scale randomized controlled trials and long-term follow-up studies are still needed to confirm the effectiveness and evaluate the quality of healing.

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.

Intraoperative and delayed wound approximation in closure of skin defects in different areas

OBJECTIVE

Wound approximation device is an interesting reconstructive option but not well popularised. In this study we present a simple device that can be used for immediate or delayed closure of large dermal wounds in different anatomical areas.

METHOD

Patients with acute and chronic wounds were recruited and underwent immediate intra-operative wound approximation and/or delayed wound approximation, with a home-made wound approximation device.

RESULTS

Approximation time in the immediate closure group ranged from 20-140 minutes. Satisfactory scars were obtained in 19 patients (76%) and adherent scars developed in 6 patients. Delayed wound approximation was used successfully in closure of 9 defects.

CONCLUSION

This simple dermal wound approximation device can be used intraoperatively to successfully close large difficult wounds, located on the trunk and thigh, with minimal complications. The device can also be used to approximate delayed wounds located in regions where closure is particularly problematic, like the lower leg, foot, and scalp. Some modifications of the device are needed to improve its safety and efficacy. Wound tension is detrimental to adequate wound healing and tensile strength, another basic principle that should not be overlooked to avoid wound dehiscence. Wound approximation is adding to reconstructive options, not replacing them, and they must always be considered.

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.

How to Close a Limb Fasciotomy Wound

Early fasciotomy is the gold standard of prevention and treatment of compartment syndrome; however, the resulting wounds may significantly increase morbidity. To address the challenge of timely and safe closure of fasciotomy wounds, numerous methods have been described. A thorough search of medical databases PubMed/MEDLINE, ScienceDirect, SCOPUS, EMBASE, and Google Scholar was conducted for articles published between 1976 and 2013 using the search terms “limb fasciotomy wound closure,” “open wound management,” “skin stretching,” and “fasciotomy complications.” A total of 49 articles on technique descriptions, case reports of 2 or more patients, and of complications and comparative studies regarding limb fasciotomy wound closure were included. Details of the duration of treatment, advantages and disadvantages, direct cost, and complications were data extracted for each technique from the 49 studies included in this overview. Thorough knowledge of available techniques and their comparative advantages is essential for their clinical implementation, careful selection of patients, management of possible complications, decreased morbidity, and hospital recovery time and is also crucial for optimization of functional and aesthetic outcomes.

Reverse tissue expansion by liposuction deflation for revision of post-surgical thigh scars

Scars hypertrophy and widen when stretching mechanical forces are applied to resilient newly formed collagen before it reaches final maturity marring the final result of many surgical procedures and resulting in a clinical problem for many patients. Scar revision by surgical excision remains the traditional treatment for hypertrophic or widespread scars. It relies upon recruitment of local tissues for closure of the ensuing defect. Providing tension-free skin closure is the best option to avoid recurrence. Although tissue expansion procedure is a valuable and reliable technique for scar revision, it has its own disadvantages and potential complications. We describe an alternative method for scar revision that may be applicable in certain situations. Instead of expanding the soft tissues to make available additional skin, deflation by liposuction may be affected to relax the skin envelope thus indirectly providing additional skin for scar revision. We call this method 'reverse tissue expansion'.

A simple solution for wound coverage by skin stretching

Viscoelastic properties of skin, ie, creep and stress relaxation, allow it to stretch beyond its normal state within a short period of time. Presented here is a technique of "wound coverage by skin stretching" that uses this principle. Kirschner wires were passed through the skin edges on either side of the wound margins. Dynamic traction was applied with traction bands improvised by the surgeon from surgical glove wrist rings. We used this method in eight patients to close 10 wounds that were not feasible to close with direct methods. We have found that this simple, economic, and effective method provides rapid functional wound closure when bone and other structures are exposed. It does not require specialized training or devices. Careful attention to the described surgical technique gives good results and few complications.

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.

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.

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.

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.

The management of pressure sores by constant-tension approximation

The management of pressure sores in medically compromised patients is problematic as they are seldom candidates for major surgical procedures. We treated 52 pressure sores in 49 patients (including three bilateral lesions) by constant-tension approximation. The lesions were distributed as follows: 21 sacral, two ischial, 13 trochanteric and 16 posterior heel. The average age was 75 years and there were 22 males and 27 females. All patients had significant co-morbid conditions that, except for one wheelchair-bound person,confined them to bed. Nine patients were insensate; in two comatose cases this state was temporary. The management regime consisted of excision of the pressure sore and expansion of the skin and subcutaneous tissue using devices that, by means of continuous low-grade tension, approximated the wound edges, together with rigorous wound toilet and the judicious use of sutures. In total, 38 pressure sores healed primarily without recurrence, including three wounds that partially reopened and healed; 11 of these patients died, with healed wounds, at varying times between 2 and 48 months after treatment. Nine patients whose lesions were closed died within a month of treatment, and five patients, three of whose lesions were completely closed and two partially closed, were lost to follow-up; their lesions were not regarded as healed. This minimally invasive technique used to close pressure sores in elderly patients with co-morbid conditions has a satisfactory success rate.

A new technique for delayed primary closure of fasciotomy wounds

Fasciotomy for compartment syndrome in the lower limb is a surgical emergency to preserve future limb function. The advised standard procedure involves both medial and lateral dermotomy in addition to the fasciotomy. There is often concern before and after performing fasciotomy about the cosmetic appearance and prolonged hospital stay if split skin grafting is required to cover the resultant skin defect. This is the case in over 50% of lower limb fasciotomies. We have used a technique of subcuticular prolene suture, first described for the delayed primary closure of contaminated abdominal wounds, in six patients who had undergone lower limb fasciotomies. In all of these cases delayed primary closure was easily achieved without the need for skin grafting. Experiments using a synthetic skin model have shown a 60% reduction in suture tension when compared with interrupted vertical mattress suturing. The subcutaneous prolene suture has the advantage of being both the method of approximation and final closure whilst spreading tension evenly across the wound edges without causing skin edge necrosis. It appears to be simpler and more economical than any technique so far described for the successful delayed primary closure of fasciotomy wounds.