Tissue expansion as an alternative to skin grafting for closure of skin deficits

Use of a soft tissue expander before surgical treatment of clubfoot in children and adolescents

Primary closure of the skin after surgical correction of severe clubfoot is difficult, sometimes impossible. The authors describe a surgical technique with the use of a soft tissue expander prior to surgical treatment on clubfoot in children and adolescents. They operated on 13 feet (10 patients) with rigid clubfoot, with ages ranging from 3 to 16 years (average 10 years). Satisfactory skin healing with primary closure of the skin was obtained in 10 feet; the remaining 3 had complications such as infection, skin necrosis, and premature exposure of the expander. The authors conclude that soft tissue expansion before surgical correction of clubfoot in selected cases is a good alternative for the management of skin closure. Special attention should be given to surgical technique.

A clinical trial of wound closure by constant tension approximation

BACKGROUND

Wounds that heal slowly may pass through a subacute phase and proceed to reach a chronic situation. The latter may heal slowly, if at all. These wounds often heal by secondary intention with a single layer of epithelium that has a tendency to break down. Methods that expedite healing by full-thickness skin usually involve operative procedures. A nonoperative method of achieving coverage of tardy wounds with full-thickness skin, partial or complete depending on the wound, would be valuable.

PATIENTS AND METHODS

A device has been designed that approximates the wound margins by applying constant low-grade tension over a period of days or weeks. One or more devices have been applied to the wounds of 25 patients to date.

RESULTS

Healing has been obtained in those patients (20) where the devices were used optimally. In 5 patients, optimal use was not possible, mostly for socioeconomic reasons; the latter included noncompliance, insurance problems, economic difficulties, and personal considerations. In these 5 cases, healing was obtained in the 3 that were available for follow-up, full-thickness skin coverage being estimated by grid photography to be in the 80% to 90% range. One patient was lost to follow-up after the wound was 95% covered by full-thickness skin. One patient whose wound reduced in size declined further treatment after 12 days of treatment.

CONCLUSIONS

It appears that when constant-tension, low-grade force is applied to subacute and chronic wounds, healing is accelerated and, depending on the wound, a considerable number of ulcers can be closed by full-thickness skin.

Is soft tissue expansion in lower limb reconstruction a legitimate option?

From 1986 to 1994, a consecutive series of 34 patients had 37 expanders placed in their legs. Indications for expansion included removal of painful ro unstable scars, chronic post-traumatic ulcers and one benign skin lesion. In 13 patients the lesion or scar was greater than 5 cm in diameter. The area of expansion was mainly in the proximal and distal thirds of the lower limb. On three occasions two expanders were simultaneously used in the same patient. The treatment with this technique was ultimately successful in 23 patients (67.6%) but 15 of the 23 patients (44% of the 34 patients) had minor wound healing problems. Before 1990, technical complications such as leaking injection ports caused further small interventions in 6 patients without compromising the ultimate outcome. The goal was not achieved with the expansion technique in 11 patients (32%). 5 of these 11 patients could be treated successfully with another surgical modality. All 34 patients were re-evaluated with an average follow-up of 4.5 years. We conclude that tissue expansion is ideal for removal of localised areas of scar, repair of contour defects and excision of benign tumours. Contraindications of soft tissue expansion are, in general, extensive scarred areas with compromised blood supply after trauma, vascular disease and osteomyelitis. These conditions require reconstruction with well vascularised tissue such as muscle flaps. A compliant patient is essential for lower limb reconstruction with tissue expansion. In spite of the tempting simple method of tissue expansion, success in the lower limb depends not only on the indication but also on the operating technique of the plastic surgeon.