Closure of Difficult Wounds by External Tissue Expansion icult

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Closure of Difficult Wounds by
External Tissue Expansion
Eli S. Schessel, MD;1 Ralph Ger, MD (retired)
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Address correspondence to:
Eli S. Schessel, MD
108-33 70th Rd.
Forest Hills, NY 11375
Phone: 718-793-1822
Email: [email protected]
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From the 1Flushing Hospital &
Medical Center, New York, NY
Abstract: The open nonhealing wound is a persistent challenge to
physicians. Infections, foreign bodies, osteomyelitis, and skin coverage of repaired structures remain problems. As the body ages, the elderly are prone to the development of pressure sores and foot ulcers,
particularly patients with diabetes. Many elderly patients will have
comorbid conditions making closure of these wounds difficult. The
authors have more than 100 combined years of experience treating
wounds. Throughout their long careers the authors have treated
numerous wounds with various types of methods. Antibiotics were
introduced during World War II; specially developed colloidal dressings, growth factors, and negative pressure wound therapy were introduced to expedite epithelial coverage of wounds. The plastic surgery
field was developed through the introduction of flaps to close wounds.
In the last 12 years, we have closed most wounds with an external tissue expansion device usually in 1 to 2 weeks. A quickly closed wound
improves the quality of life for the patient and reduces the cost to the
healthcare system.
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WOUNDS 2010;22(6):151–157
he open nonhealing wound continues to challenge the physician.
Infections, full-thickness skin coverage, involvement of bone, the presence of foreign bodies, and ischemia are common underlying factors.
Elderly patients often have comorbid conditions that facilitate pressure, leg,
and foot ulcer development, creating wounds that are difficult to close. The
literature abounds with methods for closure of nonhealing wounds that continue to challenge the physician.
In general, morbidity has increased. The main culprit is the alarming escalation of patients with diabetes mellitus where an incidence of 85% of amputations is due to infected foot ulcers.1 Likewise, an increasing incidence of
pressure sores is presently associated with more than 60,000 annual deaths,2
not to mention the care and expense connected with the management of
these patients.
An open nonhealing wound presents the physician with a basic decision:
wound management or wound closure. Traditionally, the wound has been
managed to promote epithialization by creating a moist wound environment. More recently, negative pressure wound therapy has been used to
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remove exudate and infectious materials, reduce edema,
and provide a better wound-healing environment. These
modes of therapy are used to expedite epithelial migration to cover the wound. Unfortunately, these methods
require a lot of time, cover the wound with scar tissue,
and the results remain to be improved. It is worth examining the current situation more critically to ascertain
which method or combination of methods can or cannot
improve treatment results.
In the 1990s, skin expansion was achieved using
external skin expanders. This technique has been shown
to be simple to use and to successfully close wounds
over most of the body. Two main devices were available,
the Sure-closure and the Proxiderm. The former discontinued activities after a short while, but the Proxiderm
(Progressive Surgical Products, Westbury, NY; [Figure 1])
is presently available. Both authors during the past 12
years have closed more than 650 chronic or dehisced
wounds following a simple philosophy: control infection, and close the wound with a minimally invasive surgical technique that includes the use of an external tissue
expansion wound closure device.This approach has produced the best results and will serve as the basis of this
overview.
At the outset, it should be noted that patients with vascular issues are not included in this overview.These cases
require referral to a vascular service for evaluation and
treatment.
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Figure 1. Proxiderm wound closure device.
finger dissection. In a subacute wound this maneuver
may not be necessary. In lower limb lesions non-weight
bearing is essential for heel and plantar ulcers. A partial
ostectomy of the non-weight bearing calcaneus is recommended to facilitate closure of heel ulcers. The closure of transmetatarsal or a below the knee amputations
may require fashioning the wound into a fishmouth
shape to facilitate closure.
Infection. The prevention of infection or its eradication is essential for a successful result. Infected wounds
should not be closed. The latter will entrap infected
material, cause dehiscence, and result in debridement
and a larger open wound. The causes of persistent discharge or the presence of inflammation must be ascertained and treated prior to wound closure. When infection and inflammation are controlled, the wound is ready
for closure.
Case Reports
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Case 1. A 64-year-old hospitalized patient developed a
sacral pressure ulcer measuring 8.6 cm x 9.6 cm, which
was treated conservatively for 3 months (Figures 2A–H).
The patient was transferred to a nursing home and treated for 3 months without any improvement.After debridement of the necrotic tissue and wound cleansing, a series
of paired 2-0 nylon sutures are placed 2 cm–3 cm from
the wound margins and 2 cm apart, the ends are left 7 cm
long. One suture of each pair is tied and passed through
rubber booties; the adjacent suture is left untied secured
by Steristrips and tied at the first dressing change. The
tied sutures decrease the size of the wound and assist in
obliteration of dead space. Proxiderms are applied
approximately 2 cm–3 cm apart and the long ends of the
previously tied sutures are looped around the expanders
and tied to secure the expanders to the patent. Combines
are placed under the ends, between, on the side, and over
the expanders. Elastoplast and/or adhesive tape is placed
over the combines and secured to the patient about 5 cm
from the wound margins. The patient was placed on an
air flotation bed. Sacral pressure ulcers necessitate daily
evaluation to prevent fecal soiling of the wound and any
pressure necrosis of skin by the wound care devices. On
postoperative day 1, the wound was cleansed, untied
sutures were tied, and the wound was irrigated. An additional application of expanders was indicated. This
process of suture and expander application should be
repeated until there is an abundant amount of tensionfree tissue to allow for primary closure by suture. After 6
daily applications of expanders followed by 2 days of
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Four case reports are used to illustrate the wound closure technique. The wounds were rendered as clean as
possible, and inflammation and infection were controlled. In many chronic wounds the skin inverts and is
adheres to underlying structures in an effort to close the
wound. In these instances the edges of the wound are
either sharply or gently undermined, the latter usually by
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Figure 2. A) A 64-year-old patient with a sacral pressure ulcer measuring 8.6
cm x 9.6 cm of 6 months duration. B) A series of paired 2-0 nylon sutures are
placed, the ends being left 7 cm long. One suture of each pair is tied and
passed through rubber booties; the adjacent suture is left untied, secured by
steristrips. C) Application of Proxiderms. The long ends of the previously tied
sutures are looped around the expanders and tied to secure the expanders to
the patient. D) Combines are placed beneath the ends, between and over the
Proxiderms. Expanders and dressings are secured to the patient with
Elastoplast and/or adhesive tape. E) Appearance at postoperative day 1.
Untied sutures are tied; wound is irrigated. F) Five days of expansion followed
of irrigation. Final closure of the wound is by suture of well-vascularized,
tension-free tissue whose skin edges are freshened. A catheter is placed
subcutaneously and the wound is irrigated. G) Appearance at 14 months, no
recurrence. H) Patient ambulatory 2 weeks post closure.
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intensive local wound care therapy and irrigation, the
skin edges are freshened, and the wound was well vascularised and tension-free. Sutures were used for final
closure. A catheter is placed subcutaneously and the
wound is irrigated with an antimicrobial solution for
approximately 2 days to eliminate anaerobic microorganisms. An additional 1-day application of expanders
allows the wound to heal in a tension-free environment.
Case 2. A 21-year-old man sustained a gunshot wound
to the left groin, which severed the femoral artery
(Figures 3A–C). After the femoral artery was repaired, a
diagnosis of compartment syndrome was made and a fasciotomy was performed to decompress the anterior compartment. Three days later the necrotic and devascularized muscles of the anterior compartment were excised.
Appearance post fasciotomy revealed exposed tendon
with significant tissue and muscle loss. Initially, the physician used Proxiderm (model PS 460), which were spaced
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Figure 3. A) A 21-year-old sustained a gunshot wound of the groin, which severed the femoral artery. After the femoral
artery was repaired, a fasciotomy was performed. Three days later the necrotic and devascularized muscles of were
excised. Appearance post fasciotomy reveals exposed tendon with significant tissue and muscle loss. B) Application of
expanders. C) Appearance at 16 days.
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2 cm apart. As the wound became smaller, Proxiderm
(model D 460) were utilized. Combines were placed
beneath the ends, between, and over the expanders to
assist in stabilization and to minimize external pressure.
The expanders and padding were wrapped with dry
gauze and/or Unna boot or Elastoplast and secured to the
patient using adhesive tape. The wound was evaluated
every 2 to 3 days. Expanders were replaced as required.
Tissue expansion lasted 15 days. The wound went on to
heal satisfactorily. The stretch marks disappeared in
about 3 months.
Case 3. A 51-year-old patient with diabetes presented
with a plantar ulcer of 2 years’ duration (Figures 4A–E).
After debridement, the wound measured 4.4 cm x 5.6
cm. Proxiderm expanders (models D460 and PS460)
were applied. Non-weight bearing with the expanders in
place is essential—this is best achieved through complete bed rest, and less optimally, crutches or wheelchair.
After 5 days of expansion followed by 2 days of irrigation
and 1-day of expansion, the exposed bone was resected
and the wound closed by suture. One-week post closure
a 2-mm dehiscence was closed by suture. A closed plantar wound will take approximately 2–4 weeks to bear the
ambulating weight of a 180 lb–200 lb patient. During this
time the patient should offload with crutches or wheel154
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chair.
Case 4. A 51-year-old insulin dependent patient was
admitted with toe necrosis (Figures 5A–F). Guillotine
trans-metatarsal procedure resulted in a defect measuring 9.6 cm x 5.6 cm with exposed bone. Below the knee
amputation was recommended. The wound was undermined deeply 1 cm–2 cm above the exposed bone, and a
deep subcutaneous thick flap was created before the
expanders were applied. A line of sutures were placed
and expanders were applied.The wound was closed with
sutures after 5 days of expansion and 3 days of irrigation.
A full-thickness skin graft was placed on a non-weight
bearing area measuring 1.5 cm x 5.2 cm.
Results
Six hundred-fifty (650) dehisced, chronic, and traumatic wounds were closed using external tissue expansion (Table 1). In some lower extremity wounds, a combination of tissue expansion and skin grafts on nonweight bearing areas were used to close the wounds.The
average wound closure time was 1–2 weeks. The principles of wound healing are still followed after wound closure to achieve a well-healed, stable wound. To the best
of the auhors’ knowledge there were 25 failures, the
majority of which were lower limb failures due to lack of
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Figure 4. A) A 51-year-old patient
with diabetes and a plantar ulcer of
2 years’ duration. B) After
debridement, the wound measured
5.6 cm x 4.4 cm. C) Application of
expanders. D) Appearance 30 days
post closure. E) Appearance at 5
months.
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Figure 5. A) A 51-year-old insulin dependent patient required a guillotine trans-metatarsal procedure leaving a defect
measuring 9.6 cm x 5.6 cm with exposed bone. B) A line of sutures is placed and expanders applied. Appearance at
second postoperative day 2. C) Application of expanders. D) Wound was closed by suture. Skin graft was placed on a
non-weight bearing area measuring 1.5 cm x 5.2 cm. E) Appearance at 5 weeks post closure. F) Patient weight bearing
at 4 weeks.
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Table 1. Patient and wound characteristics.
77
76.7
54.3
56
60.2
62.6
58.6
60
67
57
57.5
67.6
56.8
65.3
86
40.2
Average wound
closure (days)
7.2
11.6
11.1
7.4
7.8
3.4
6.9
8.5
6
7
6
14.6
14.5
5.7
11
6.2
8
8.8
7.1
8
7.5
5.4
5.1
7.9
4.5
6
5.1
4.6
2.9
1.9
2.6
1.6
Wound type
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
x
10.7
11.1
11.8
15.8
17.3
8.1
20.3
18.9
8.4
11.7
10.4
6.7
4.6
3.1
4.3
2.2
Sacral decubius
Trochanteric decubitus
Ischial decubitus
Abdominal
Chest
Back
Leg/fasciotomies
Thigh/groin
Knee
Below the knee amputations
Transmetatarsal amputations
Heel
Plantar
Ankle
Achilles
Metatarsal
been shown to be simple to use and successful for closing wounds over most of the body.
The application of the expanders and minimally invasive techniques allow for dedicated wound care as the
wound closes, which stimulates angiogenesis6 and the
production of growth factors (Table 2).7 The expansion
of nearby skin creates additional soft tissue,8 which fills
the wound cavity with subcutaneous padding. Most
wounds can be closed via suture in 1 to 2 weeks by a
method that is minimally invasive and which can often
be carried out under local anesthesia and/or sedation, as
required. External tissue expanders are cost effective and
medically efficacious.9–11 Good wound care practices and
a small, dedicated team are necessary ingredients to
achieve optimal results.
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Table 2. Advantages of tissue expansion.
Average size
(cm)
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64
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12
28
12
4
5
16
22
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11
3
5
Average
age (years)
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Minimally invasive technique
Multi-stage closure of contaminated wounds
Better quality skin (epidermis, dermis, and
subcutaneous tissue)
Close wound quickly (7–14 days)
Stimulates angiogenesis and growth of additional
soft tissue
Stimulates production of growth factors
Local anesthesia
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Discussion
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patient compliance to non-weight bearing instruction.
Failure of pressure ulcers were in patients on ventilators,
tube feeding, dialysis, or who had an albumin level < 2.5.
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The authors look back at a more than 100 years of
experience in the management of traumatic wounds,
lesions of the lower extremities, and pressure ulcers, and
are distressed to see the poor results that many patients
can expect. As successful treatment modalities are available, the causes for these disappointing results require
explanation.
Skin expansion techniques were introduced in the
1950s. An inflatable subcutaneous balloon was used to
expand the overlying skin, after which the stretched skin
was used to close the wound. However, this procedure
was accompanied by such significant complications that
is has virtually been abandoned for treatment of chronic
wounds.3–5 In the 1990s, skin expansion was achieved
through external skin expanders. This technique has
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Conclusion
As the careers of both authors approach their termination, we have come to the conclusion that the ultimate
in wound therapy may well be external tissue expansion
or a combination of external skin expansion and the
principles of muscle transposition with skin grafts in
non-weight bearing areas and/or tissue flaps.
References
1.
2.
3.
Ellenberg M, Rifkin H. Diabetes Mellitus: Theory and
Practice. New York, NY: McGraw-Hill; 1970:890–911.
Kynes PM. A new perspective on pressure sore prevention. J Enterostomal Ther. 1986;13(2):42–43.
Manders EK, Oaks TE, Au VK, et al. Soft tissue expansion
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in the lower extremities. Plast Reconstr Surg.
1988;81(2):208–219.
Masser MR.Tissue expansion: a reconstructive revolution
or a cornucopia of complications? Br J Plast Surg.
1990;43(3):344–348.
Antonyshyn O, Gruss J, Mackinnon S, Zuker R.
Complications of soft tissue expansion. Br J Plast Surg.
1988;41(3):239–250.
Ger R, Schessel ES. Prevention of major amputations in
nonischemic lower limb lesions. J Am Coll Surg.
2005;201(6):898–905.
De Filippo RE, Atala A. Stretch and growth: the molecular
and physiologicic influences of tissue expansion. Plast
Reconstr Surg. 2003;109(7):2450–2462.
Austad ED, Thomas SB, Pasyk K. Tissue expansion: dividend or loan? Plast Reconstr Surg. 1986;78(1):63–67.
Schessel ES, Lombardi CM, Dennis LN. External constant
tension expansion of soft tissue for the treatment of
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ulceration of the foot and ankle. J Foot Ankle Surg
2000;39(5):321–328.
Schessel ES, Ger R.The management of pressure sores by
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constant-tension approximation. Br J Plast Surg.
2001;54(5):439–446.
Schessel ES, Ger R, Ambrose G, Rim R. The management
of the postoperative disrupted abdominal wall. Am J
Surg. 2002;18(3):263–268.
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