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Clinical and experimental wound closure using a skin stretching device
Melis, P.
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Melis, P. (2003). Clinical and experimental wound closure using a skin stretching device
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Download date: 14 Jun 2017
C h a p t e rr
22
Revieww of the literature
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I I II RAH KI
REVIEWW OF THE LITERATURE
Onee of the earliest reports of wound closure was the use of large soldier ants by
Southh American Indians long before the first Portuguese and Spanish explorers
discoveredd the great Amazon basin.' Eciton Buehelli ants were placed on margins
off open wounds and dug their claws promptly into the wound. The edges of the
woundd were then drawn together and the rear claws of the ants dug in the other
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woundd closed because the ants did not release their grip, even when dead (Fig. 1).
Figuu re 1. The jaws of the Eciton buehelli holding together the edges of a wound (left) in an experiment
onn a dead rat. In the second step of the clamping process (right), the body of the ant is twisted off.
Scalee in mm.
Graduall tension may induce expansion of the skin and subcutaneous tissue as is
demonstratedd physiologically during pregnancy, obesity and growth. Among the
firstfirst applications of non-physiological skin stretching have been neck-stretching
customss of Padaung women in Burma2 (Fig. 2) and stretching of the lips and earlobes
byy means of wooden disks or rings by women in the village of Madecongo in the
Territoryy of Chad in French Equatorial Africa,3 as has been described in the National
Geographicc Magazine (Fig. 3).
Inn 1920, sir Harold Gillies described closure of a war injury of the left cheek by
meanss of skin stretching. Approximation of the skin edges was performed with dress
21 1
CHAPTERR 2
hookss sewn to pieces of blanket flannel fixed
withh collodium to each edge of the wound and
thenn united by rubber bands.4
Inn 1957, Neumann"1 described the principle
off tissue expansion by gradual application of
pressuree with a subcutaneous rubber balloon. An
areaa of skin was expanded for ear reconstruction.
Itt was not until the 1980s that Radovan''"
reintroducedd the technique of skin expansion in
reconstructivee surgery to overcome shortage of
skinn tissue and this study was followed by the
studiess of Austad and Rose,s Argenta,9 and
Manderss et al.10 Since then, skin expansion has
becomee a well-accepted technique for closing
largee defects.
Itt was the pioneering contribution of Gibson
andd Kennedi""13 to the understanding of biomechanicall properties of skin that made plastic
surgeonss increasingly familiar with the
applicationn of engineering principles in their
reconstructivee work. Exploitation of the
viscoelasticc properties of skin, known as
mechanicall creep and stress relaxation, enables
largerr delects to be closed primarily. Mechanical
Figuree 2. A Padaung woman with
creepp occurs when a constant stretching force is
multiplee rings to stretch her neck.
appliedd to skin. The skin will gradually extend
beyondd the limits of its inherent extensibility. Stress relaxation, the corollary of creep,
occurss when skin is stretched over a given distance and that distance is held constant,
whereass the force required to keep the skin stretched gradually decreases.
Hirshowitzz et al. were the first to describe a method to gain skin tissue for
woundd closure by stretching.14 It became possible to gain skin tissue without disrupting
edgess of skin flaps by hooks. It appeared that the most efficient way to stretch skin
withh the use of skin hooks was cycle loading, intermittent stretching of skin followed
byy short periods of relaxation.'' '4
Besidess undermining the skin edges of wounds, other techniques were developed
onn the basis of mechanical creep to close larger skin defects. In 1986, Liang et al.1'
22 2
R ll VIEW Ol Till I ITERATURE
describedd a techniquee ofpresuturing the skin with nylon sutures one day before
excision.. As a result, a significantly lower force was required to close 8 x 8 cm
largee standard-size wounds in pigs without undermining surrounding skin. To gain
tissuee by expansion in a shorter period of time, Sasaki161, reported an intraoperatively-sustainedd limited expansion to exploit the biomechanical properties
off skin. When expanding skin Haps adjacent to defects to facilitate wound closure,
aa surface increase up to 30 percent was obtained. However, it was questioned
whetherr skin stretching with this technique was merely the result of undermining
woundd edges.1*'9 MacKay et al.1S demonstrated a significantly decreased wound
closuree tension in undermined wounds as compared with not undermined wounds
butt differences were not observed in undermined wounds versus intraoperative
tissuee expansion. Tension decrease depends primarily on the extent of skin
mobilizationn and not on short-term expansion. Therefore, it was not considered to
bee a result of "creep** behavior.11'
23 3
CHAPTERR 2
Thee use of skin traction beyond a 'normal' degree of tension for the treatment
off acute military wounds has been reported by Bashir20 who inserted 4 Kirschner
pinss in the edges of a wound and looped silver wires around their points of crossing.
Thee wires were twisted on a daily basis. Furthermore, staples were applied to the
skinn edges to which rubber bands were attached.21
Inn 1993, Hirshowitz et al.22 introduced a skin-stretching device for wound
closure,, the Sure-Closure system. This new device was designed to harness
viscoelasticc properties of skin by incremental traction and can be employed
preoperatively,, intraoperatively and postoperatively. After the first application of
thee Sure-Closure skin-stretching system, many clinical studies followed, that gave
moree insight in the possibilities of this technique.2, :>1 A series of indications were
formulatedd to apply the Sure-Closure skin-stretching system after excision of
tumors22"266 and tattoos,22 for scar revisions,22-24-25-27 for closure of traumatic injuries
involvingg skin loss,22-24-26-2*-29 open fasciotornies,2224293') amputations'1 and for
intraoperativee closure of free-flap donor sites.-12-"
Besidess the Sure-Closure system, which is the most popular skin-stretching
device,, various other intradermally-used skin-stretching devices have been designed
andd used for skin stretching such as the Frechet Extender,'4 the External Tissue
Extender"-^^ and the Proxiderm.^41 These systems have been applied successfully
forr wound closure in clinical settings but animal studies have not been reported
yett to objectively determine the usefulness of these skin-stretching devices. The
Sure-Closuree system is in comparison with the other devices the only device that
cann be used intraoperatively in a time span of 30 minutes to close a large defect.
Thee other skin-stretching devices are applied for at least several days up to many
weekss postoperatively. Therefore we have selected the Sure-Closure system to
establishh what the effects are of intraoperative skin stretching for the closure of
largee defects.
24 4
RtVIliWW Hl
IIH I 111 RATI Rf
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22 Weeks, G. S. Into the heart of Africa. Natl. Geogr. Mag. 110: 257, 1956.
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