Closure Of Large Skin Defects Research Articles

Reverse-traction skin-stretching device for primary closure of large skin defects.

The tension in the skin margin of a wound is the major determinant for wound healing. The difficulty of primary closure for large skin defects due to excessive wound tension has long been a clinical challenge. In this study, we designed and fabricated a reverse-traction skin-stretching device (RT-SSD) to relieve the skin tension of a large skin defect and thereby allow primary wound closure. The novel RT-SSD designed in this study drives the fixing device fixed on the skin edge of the wound by rotating the pulling device, thus exerting a reverse tensile force on both sides of the wound, causing creep and stress relaxation, thus reducing the skin tension. Through the tension analyses; microcirculation detection; clinical scores; and a series of histological staining in vivo, it is verified that intraoperative application of RT-SSD can stretch and straighten collagen and fragment elastin, thus effectively reducing skin tension of large skin defect of miniature pigs. In addition, its special linear and planar traction protects the subcutaneous microcirculation of the wound site. The evaluation of wound healing confirmed that RT-SSD had negligible negative impact on wounds, reduced the incidence of complications, and promoted the healing of large skin defects. Therefore, this study provides a new safe and effective device for the primary closure of large skin defects.

HOW WE DO IT: the Keystone flap for large skin defects: our experience with 30 consecutive cases

Background The keystone perforator-based fasciocutaneous island flap is a method of locoregional skin defect reconstruction, consisting of two conjoined V to Y advancement flaps. In this article, we report a series of 30 consecutive cases in various body parts with the aim to demonstrate the versatility of the keystone flap in the reconstruction of various skin defects after removal of a suspected malignant skin lesion and evaluate our clinical experience while maintaining oncological safety and good aesthetic results. Methods Patients who underwent keystone flap reconstruction between January 2016 and January 2021 were retrospectively reviewed. Their demographics, operative details, oncological data and postoperative details were obtained from the institution’s internal electronic patient records system. Results The majority of the skin defects were the result of an oncologic resection (97%, n = 29) and were located in the pretibial region (47%, n = 14). In five cases (17%) there was a need for a double keystone flap to cover the skin defect. One or more risk factors (hypertension, smoking, anticoagulation, …) were identified in 22 patients (73%). Minor complications (partial wound dehiscence, effusion or surgical site infection) occurred in ten cases (33%) which were resolved with conservative wound management or systemic antibiotics. There were no major postoperative flap-related complications such as flap failure or need for re-surgery. Conclusion In our experience, the keystone island flap is an effective and reliable technique to attain a single stage tension-free closure of large skin defects. Due to its low technical complexity and high success rate, we consider it a feasible alternative to other reconstructive flaps and grafts for direct closure of secondary defects.

Relaxation Systems of the Skin for the Closure of Large Mammary Defects

In MAMMARY tumors that are large relative to breast-size, complex reconstructive methods are required. We describe an alternative system of closure. In circumstances such as this, primary closure of this skin defect may be enabled by stress relaxation of the skin and the use of a tension-relief system. Tension-relief systems secures immediate primary closure of large skin defects in patients with large for breast-size tumors by placing the tension away from the skin edges. This enables early skin closure and rapid mobilization with good functionality. Optimal healing facilitates postoperative radiotherapy on time without reconstruction failure.

Sistemas de relajación de la piel para el cierre de grandes defectos mamarios

In mammary tumors that are large relative to breast-size, complex reconstructive methods are required. We describe an alternative system of closure. In circumstances such as this, primary closure of this skin defect may be enabled by stress relaxation of the skin and the use of a tension-relief system. Tension-relief systems secures immediate primary closure of large skin defects in patients with large for breast-size tumors by placing the tension away from the skin edges. This enables early skin closure and rapid mobilization with good functionality. Optimal healing facilitates postoperative radiotherapy on time without reconstruction failure.

229: Use of tissue grafts for in-utero spina bifida closure of large skin defects

In-utero spina bifida closure of large defects is often challenging, requiring tissue graft (acellular dermal matrix or bovine collagen materials) for watertight skin closure. Using the fMMC Consortium registry sponsored by NAFTNet, we compared risk factors for tissue graft utilization and outcomes of primary skin closure vs. tissue graft closure. The fMMC Consortium registry is an international prospectively collected dataset including 296 patients from 15 centers during the period 2011-2018. Overall inclusion for in-utero spina bifida closure adhered to MOMS study criteria. The decision for the use of a tissue graft or the type of tissue graft was at the discretion of the pediatric neurosurgeon at the respective site. The perioperative management protocol was also institution dependent. Data collected included maternal demographics, fetal preoperative evaluation, operative outcomes, use of patch, and neonatal and childhood outcomes to age 3 years. The comparative statistics were performed with p-value of <0.05 considered significant. Overall 23% (67/296) of patients required fetal spina bifida closure using a tissue graft for skin closure. The comparison between the two groups is illustrated in Table 1. The risk factors for the use of tissue graft included higher lesion level and no covering sac. There were no differences in maternal age, gravidity, parity, ventricular size, or gestational age at procedure. The rate of preterm premature rupture of membranes and the gestational age at delivery were similar in the two groups. The development of syringomyelia was 5-fold higher with use of tissue graft. Shunt placement was 1.3-fold higher with tissue graft but did not reach statistical difference. There was a trend towards high risk of tethered cord in the tissue graft group. The higher level lesions or myeloschisis are more likely to need tissue grafts for the closure of skin during in utero spina bifida closure. These children are at higher risk of developing syringomyelia at the repair site. Further exploration of the mechanisms and optimal methods of wound closure are urgently needed.

Studies on reconstruction of large skin defects following mammary tumor excision in dogs

Aim:The main objective of the study was to describe the use of skin fold advancement flaps (SFAFs) and other reconstructive techniques for closure of large skin defects following mammary tumor excision in dogs.Materials and Methods:Twelve dogs underwent reconstruction of large ventral skin defects following mammary tumor excision with wide margins. Skin fold flaps (flank fold flap and elbow fold flap) were elevated from the flank and elbow region, respectively, and transposed and sutured onto the large ventral skin defect following mastectomy in all the dogs. In addition to the skin fold flaps, other reconstructive techniques such as undermining, walking sutures, and tension-relieving suture techniques were followed during surgery in the closure of large skin defects without skin tension and compromising limb mobility. The skin flap viability was assessed subjectively by gross observation of the flap such as color, temperature, capillary perfusion, and cosmetic appearance, and scoring (1-4) was done. Tissue samples were collected from a surgical site on days 3, 6, and 12 post-operatively for histopathological evaluation and healing status of the skin flap.Results:All the surgical wounds healed primarily, without any major complications and the skin flap remained healthy throughout the healing process post-operatively. Distal flap necrosis was noticed in one case and necrosis of skin flap between two suture lines was noticed in another case in which the necrotized distal portion healed by secondary intention after 7 days. The mean survival of subdermal plexus flap in the above cases was 98% which was a subjective evaluation based on surface area of the skin defect measured by Image’ J software and the flap dimensions. The average healing of skin flap in days was 14.91±0.86.Conclusion:The SFAFs along with other reconstructive techniques help in the reconstruction of large ventral skin defects following mastectomy in dogs without much compromising limb mobility.

Defect closure with “8-shaped crisscross tensile suture” technique

BackgroundSutures and suturing techniques compose the basis of the surgery. Although many surgical methods such as the skin grafts or flaps has been described for the closure of large defects, proper primary suturing may sometimes yield very successful results and decrease the need of complicated procedures. In this article, a new combined skin-subcutaneous tissue suturing technique called as “8-shaped crisscross tensile suture (8CTS)” designed for the closure of large skin defects is presented. Patients and methodsOne hundred forty-nine patients with an age distribution between 14 and 65 y were operated for large skin defects by using the 8CTS technique. The most common etiology of the defects was free flap donor sites, and the most common defect localization was the anterolateral thigh region. The average defect width on the axis of primary closure was calculated as 14.6 cm. The 8CTS technique is a combination of both skin and subcutaneous layers suturation and may even involve deeper layers suturation according to the depth of the defect. ResultsEight complications including wound dehiscence, early recurrence of pilonidal sinus disease, seroma formation, skin-edge necrosis, and incisional hernia were observed. The wounds of 141 patients were treated successfully. ConclusionsThe 8CTS technique is a useful method for the closure of large defects eliminating the need of more complex procedures and providing acceptable cosmetic results while supporting both skin and subcutaneous tissue in one suture.

Neoskin development in the fetus with the use of a three-layer graft: an animal model for in utero closure of large skin defects

Objective: To assess the ability of a three-layer graft in the closuse of large fetal skin defects. Methods: Ovine fetuses underwent a large (4 × 3 cm) full-thickness skin defect over the lumbar region at 105 days’ gestation (term = 140 days). A bilaminar artificial skin was placed over a cellulose interface to cover the defect (3-layer graft). The skin was partially reapproximated with a continuous nylon suture. Pregnancy was allowed to continue and the surgical site was submitted to histopathological analysis at different post-operative intervals. Results: Seven fetuses underwent surgery. One maternal/fetal death occurred, and the remaining 6 fetuses were analyzed. Artificial skin adherence to the wound edges was observed in cases that remained in utero for at least 15 days. Neoskin was present beneath the silicone layer of the bilaminar artificial skin. Conclusions: Our study shows that neoskin can develop in the fetus using a 3-layer graft, including epidermal growth beneath the silicone layer of the bilaminar skin graft. These findings suggest that the fetus is able to reepithelialise even large skin defects. Further experience is necessary to assess the quality of this repair.

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

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

Management of Giant Congenital Nevi With Artificial Skin Substitutes in Children

Giant congenital nevi are one of several skin conditions in the pediatric patient population whose treatment leaves the patient with large skin defects. The giant congenital nevus is a rare pigmented skin lesion that covers large skin areas or affects any major or difficult-to-treat region of the body, such as the face. Congenital nevi should be excised fully because of the increased risk for malignant transformation to melanoma, as well as cosmetic considerations. However, after excision patients are left with large wounds that are difficult to close. Traditionally these defects have been repaired with split-thickness skin grafts, full-thickness skin grafts, the use of tissue expanders, and a variety of flaps. However, each of these methods has its disadvantages and thus cannot be used in all cases. Recently, new methods have been developed for the closure of large skin defects in pediatric patients with the use of artificial skin substitutes. Advantages include coverage of large wounds, decrease or elimination of donor site pain and morbidity, and decreased scarring and wound contractures. The authors present these experiences through two case reports.

Wertigkeit des externen Hautexpanders (ETE®) beim sekundären Verschluß von Hautdefekten

Zusammenfassung Hintergrund: Beim Verschluß großer Hautdefekte, bei denen erhebliche Spannung auf den Wundrändern lasten kann, bedient man sich plastischer Methoden bis hin zum Einsatz von subkutanen Ballonexpandern. Wir machen mit dieser Arbeit auf die sehr einfache Methode der Sekundärnaht aufmerksam. Patienten und Methodik: Es wird ein verbessertes System zur sekundären Hautnaht, ein sog. External Tissue Extender (ETE™) vorgestellt. Dieser Hautexpander besteht im wesentlichen aus Silikonbändern und Stoppern, die eine gute Druckverteilung gewährleisten. Es werden mögliche Anwendungen in der operativen Dermatologie und unsere Erfahrungen beschrieben. Ergebnisse: Die Implantation und die Handhabung des Expanders sind ausgesprochen einfach und wenig zeitaufwendig. Die funktionellen Ergebnisse sind gut, die kosmetischen Ergebnisse zufriedenstellend. Invasivere chirurgische Maßnahmen können durch die Verwendung dieses Verfahrens vermieden werden. Der auffälligste Nachteil der Methode ist die mögliche Entwicklung von Drucknekrosen unter den Stoppern. Schlußfolgerung: Nach unseren Erfahrungen ist der Gebrauch eines externen Expanders bei bestimmten dermatochirurgischen Indikationen eine sinnvolle Alternative zu aufwendigeren Verfahren des Hautverschlusses.

An Intraoperative Skin-Stretching Device to Close Wounds in Mohs Defects

A skin-stretching device takes advantage of the viscoelastic properties of the skin by exerting incremental traction to aid in closing complex wounds. To evaluate the effectiveness of a skin-stretching device and determine the cosmetic results available when this device is used in Mohs surgery. 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. 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. 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.

Skin fold advancement flaps for closing large sternal and inguinal wounds in cats and dogs.

Skin fold advancement flaps can be created from the elbow and flank folds to close large wounds in the pectoral and inguinal regions of cats and dogs, respectively. The attachments of the laterally facing (outer) and medially facing (inner) layers of the skin fold to the adjacent limb are divided to produce a U-shaped pedicle graft attached to the trunk. This mobilizes skin that can be advanced over large wounds involving the ventral chest or abdomen, or both. The use of skin fold advancement flaps enables direct closure of large skin defects without undue tension and without compromising the mobility of the adjacent limb.

Presuturing--a new technique for closing large skin defects: clinical and experimental studies.

We have developed a new technique termed presuturing for aiding in the closure of large skin defects which may have otherwise required a skin graft or flap. This technique is based on biomechanical properties of skin (creep, stress relaxation) which allow skin to stretch beyond its inherent extensibility. Presuturing is performed under local anesthesia and consists of plicating intact skin over the area of planned excision the night prior to operation. Experimental studies in a pig model showed the decrease in force required to close a standard-sized wound to be 40.1 percent less than control (p less than 0.001). Fourteen patients who underwent wide excision of skin lesions had their wounds presutured. All but one wound could be closed primarily without undermining. Presuturing seems to be an easy and clinically useful technique in aiding the primary closure of large defects.

A “walking” suture technique for closure of large skin defects in the dog and cat

A “walking” suture technique for closure of large skin defects in the dog and cat