Simplifying soft tissue closure of the large meningomyelocele defect: a technical note.

The surgical management of large neural tube defects not amenable to primary closure poses a significant challenge. As a result, large residual skin defects often prompt excessively aggressive primary closure, complicated skin incisions, or flap advancements. However, our experience with the purse-string closure of a large meningomyelocele skin defect demonstrates that this technique can effectively provide coverage of very large meningomyelocele defects with minimal residual deformity. Here, we discuss the successful coverage of a large 5 x 5 cm meningomyelocele skin wound via staged purse-string closure spaced 2 weeks apart.     

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.     

A comparison of three methods of skin closure following repair of Achilles tendon rupture

Meticulous skin closure is required to avoid wound problems after Achilles tendon surgery. The purpose of our study was to compare postoperative complication rate, operation time, clinical outcome and patient satisfaction with the wound among two topical skin adhesives (2-octyl cyanoacrylate and n-butyl cyanoacrylate) and conventional nylon skin sutures in Achilles tendon repair surgery. We retrospectively reviewed the records 122 consecutive patients (40 patient in nylon skin suture, 43 patients in 2-octyl cyanoacrylate and 39 patients in n-butyl cyanoacrylate) who underwent surgical repair for acute Achilles tendon rupture between 2012 and 2016. The primary outcome measure was the development of complications in the wound. Secondary outcome measures included the operative time, the Achilles Tendon Total Rupture Score (ATRS) and patient satisfaction with the wound. There was no difference in complication rate in the wound (p = 0.694) and in ATRS (p = 0.824) among patients in the three groups. Mean operative time in nylon skin suture group was significantly longer than in the 2-octyl cyanoacrylate group and n-butyl cyanoacrylate group (p = 0.018 and p = 0.002, respectively). Patient satisfaction in the 2-octyl cyanoacrylate and n-butyl cyanoacrylate groups was significantly higher than in the nylon skin suture group (p = 0.015 and 0.018, respectively). The use of 2-octyl cyanoacrylate and n-butyl cyanoacrylate topical skin adhesives for skin closure following repair of Achilles tendon rupture has equivalent effectiveness and safety compared to conventional nylon skin suture, but higher patient satisfaction. Despite its higher cost, these topical skin adhesives are viable alternatives for wound closure in patients who regard cosmetic outcomes as important.     

Severe Abdominal Wall Necrosis After Ultrasound-Assisted Liposuction

The complicated case of a 44-year-old white female following ultrasound-assisted liposuction of the entire abdomen is presented. In this case the postoperative course was complicated by hematoma, treated conservatively. During following weeks extensive cutaneous necrosis over the abdomen developed. After four weeks the patient presented to our institution with purulent discharge. After surgical revision, requiring excision of the abdominal wall necrosis, a significant residual abdominal wall defect remained. After three further revisions, removal of residual necrotic fat, irrigation, and temporary coverage with a synthetic dressing, infection cleared. At this point, split thickness skin grafting was possible. The healing in of the skin grafts was complete, eventually enabling wound closure and successful reconstruction of the abdominal wall.     

Skin incisions and wound closure

The siting of an incision and the choice of wound closure may have profound effects upon the success of an operation and the patients lasting perception of their surgeon. This article discusses site and method of skin incision, access to the abdominal cavity, wound healing, choice of sutures and needles, suture techniques, fascial and skin closure techniques and difficult wound closure. With this information the reader should be able to make a tailored decision about incision and closure technique to achieve the best outcome for the patient.     

A safe and simple technique using the distal pedicled reversed upper arm flap to cover large elbow defects.

The reconstruction of large soft-tissue defects at the elbow is hard to achieve by conventional techniques and is complicated by the difficulty of transferring sufficient tissue with adequate elasticity and sensate skin. Surgical treatment should permit early mobilisation to avoid permanent functional impairment. Clinical experience with the distal pedicled reversed upper arm flap in 10 patients suffering from large elbow defects is presented (seven male, three female; age 40-70 years). The patient sample included six patients with chronic ulcer, two with tissue defects due to excision of a histiocytoma, and one patient with burn contracture. In the two cases of histiocytoma, defect closure of the elbow's ulnar area was achieved by using a recurrent medial upper arm flap. In the eight other patients we used a flap from the lateral upper arm with a flap rotation of 180 degrees. Average wound size ranged from 4 to 10 cm, average wound area from 30 to 80 cm(2). Flap dimensions ranged from 15 x 8 cm for the lateral upper arm flap to 29 x 8 cm for the medial upper arm flap. The inferior posterior radial and ulnar collateral arteries are the major nutrient vessels of the reversed lateral and medial upper arm flaps. Perforating vessels are identified preoperatively using colour Doppler ultrasonography. Flap failure did not occur. Secondary wound closure became necessary due to initial wound healing difficulties in one patient. Mean operation time was 1.5 h and mean follow-up period 12 months. Good defect coverage with tension-free wound closure was achieved in all cases. Stable defect coverage led to long-term wound stability without any restriction of elbow movement. The lateral and medial upper arm flaps represent a safe and reliable surgical treatment option for large elbow defects. The surgical technique is comparatively simple and quick.     

The Keystone Design Perforator Island Flap in reconstructive surgery

Background: A surgical technique for closing skin defects following skin cancer (particularly melanoma) removal is described in the present paper. Its use is illustrated in five patients. The technique has been used in 300 cases over the past 7 years and is suitable for all areas of the body from scalp to foot. We have coined the term Keystone Design Perforator Island Flap (KDPIF) because of its curvilinear shaped trapezoidal design borrowed from architectural terminology. It is essentially elliptical in shape with its long axis adjacent to the long axis of the defect. The flap is based on randomly located vascular perforators. The wound is closed directly, the mid‐line area is the line of maximum tension and by V‐Y advancement of each end of the flap, the ‘islanded’ flap fills the defect. This allows the secondary defect on the opposite side to be closed, exploiting the mobility of the adjacent surrounding tissue. The importance of blunt dissection is emphasized in raising these perforator island flaps as it preserves the vascular integrity of the musculocutaneous and fasciocutaneous perforators together with venous and neural connections. The keystone flap minimizes the need for skin grafting in the majority of cases and produces excellent aesthetic results. Four types of flaps are described: Type I (direct closure), Type II (with or without grafting), Type III (employs a double island flap technique), and Type IV (involves rotation and advancement with or without grafting). The patient is almost pain free in the postoperative phase. Early mobilization is possible, allowing this technique to be used in short stay patients. Results: In a series of 300 patients with flaps situated over the extremities, trunk and facial region, primary wound healing was achieved in 99.6% with one out of 300 developing partial necrosis of the flap. Conclusions: The technique described in the present article offers a simple and effective method of wound closure in situations that would otherwise have required complex flap closure or skin grafting particularly for melanoma.     

Use of a Living Dermal Equivalent for a Refractory Abdominal Defect after Pediatric Multivisceral Transplantation

BACKGROUND: Primary closure is not always possible after pediatric multivisceral transplantation. Reepithelialization may require extended periods of postoperative time, which can be associated with significant morbidity. OBJECTIVE: The objective was to accelerate secondary wound closure thereby minimizing infection or further complications in a pediatric multivisceral transplant patient. METHODS: Five applications of human fibroblast-derived dermis (Dermagraft, Smith and Nephew) were applied to the postsurgical defect of a pediatric multivisceral transplant patient over the course of 8 months. Routine wound care and observation was performed between human fibroblast-derived dermis applications. RESULTS: Human fibroblast-derived dermis stimulated healing and accelerated reepithelialization. Signs of clinical rejection or infection were not observed. CONCLUSION: Reepithelialization can be aided in the postoperative period in pediatric multivisceral transplant patients with human fibroblast-derived dermis, thereby helping to deter complications associated with secondary wound closure. We have illustrated the successful use of a human fibroblast-derived dermis as an adjunct for wound healing in a complicated surgical defect.     

Reducing Opposed Multilobed Flap Repair, a New Technique for Managing Medium-Sized Low-Leg Defects Following Skin Cancer Surgery

BACKGROUND: Following skin cancer excision, skin defects on the low leg between 10 and 35 mm in diameter can be problematic. Direct closure of the wound risks excessive wound tension and wound dehiscence. Skin grafts heal slowly and often remain unsightly. Traditional skin flaps have a limited role. OBJECTIVE: The objective was to develop a random-pattern skin flap that offers significant advantages over traditional techniques including grafting. METHODS: The reducing opposed multilobed flap involves a series of semicircular lobes extending both cephalic and caudal from the defect. The technique involves lobes most distant from the primary defect being transposed in turn closer to the defect. The technique does not result in the unnecessary excision of Burrows triangle skin. RESULTS: The reducing opposed multilobed (ROM) flap reduces skin tension concerns, lowers the risk of flap necrosis, and allows for quicker and more aesthetic healing. After 20 cases, we have yet to experience dehiscence, infection, or delayed healing. The healing wound is resistant to contraction and invariably produces an acceptable aesthetic outcome. CONCLUSION: The ROM flap repair allows the dermatologic surgeon an additional option when faced with a medium-sized lower leg defect following skin cancer excision.     

Primary skin closure of large groin defects after inguinal lymphadenectomy for penile cancer using an abdominal cutaneous advancement flap

PURPOSE Large groin defects may be created after inguinal lymphadenectomy for bulky metastatic penile cancer. We describe a new method of primary closure of a large groin skin defect.MATERIALS AND METHODS In 3 patients with large volume inguinal lymph node metastases with skin breakdown and secondary infection extensive inguinal lymphadenectomy was done with wide surgical excision of skin and subcutaneous tissue. The procedures resulted in a large groin defect. Sartorius muscle was transferred to cover the femoral vessels. An abdominal advancement cutaneous flap was placed for soft tissue and skin coverage of the wound.RESULTS Primary closure of a large skin defect was possible using an abdominal advancement flap. In all patients the wound healed primarily with good cosmesis. A single patient underwent postoperative external beam radiation therapy to the flap site with no untoward effect on graft survival.CONCLUSIONS Large groin skin defects can be closed primarily using an abdominal advancement flap. This technique may also be used for bilateral groin defects. Compared with other types of flaps advocated for this purpose the main advantages of the procedure are simplicity, lower morbidity and superior cosmetic results.     

Comparison of clips versus sutures in orthopaedic wound closure

A prospective randomised trial was conducted to compare the use of skin clips versus interrupted nylon sutures in uncomplicated orthopaedic wound closure. Non-blinded wound assessment for complications and outcome (cosmesis) was performed on day 13 when the clips/sutures were removed. Average time for removal of each clip/suture was calculated for each wound. Also, an assessment of patient pain during removal was made using a patient-completed visual analogue scoring system (VAS). No statistically significant difference was found in wound healing and cosmesis between the clip and suture group at follow-up. Clip removal with the special clip remover was found to be quicker and less painful (p=0.001). There was good patient satisfaction with the use of skin clips over nylon sutures. We recommend the use of skin clips, using an assistant to evert the wound edges, as an efficient form of wound closure in most uncomplicated orthopaedic procedures.     

Excisional biopsy of skin tumors

The most frequently encountered neoplasm in the US is skin cancer. More than 600,000 new cases of malignant skin tumors are diagnosed in the US each year. One standard method of treatment of skin tumors is excisional biopsy. There are seven technical considerations involved in the excisional biopsy of skin tumors: (1) aseptic technique, (2) examination and demarcation of skin lesion, (3) skin biomechanical properties, (4) anesthesia, (5) excisional biopsy, (6) wound closure, and (7) postoperative care.The physician must use aseptic techniques and wear a cap, mask, and powder-free gloves. Hair is a source of wound contamination, and removal of hair prevents it from becoming entangled in suture and the wound during closure. Because surgical electric clippers cut hair close to the skin surface without nicking the skin, we now use only electric clippers to remove hair. The physician's visualization of the wound can be enhanced by magnification (2.5x) loupes. The physician's plan for excisional biopsy is dictated by the suspected pathology of the skin lesion. The ultimate appearance and function of a scar after closure of excisional biopsy can be predicted by the static and dynamic skin tensions on the surrounding skin. Infiltration anesthesia is preferred over regional nerve block because it does not interfere with the muscle movement that causes dynamic tensions, which elongate the configuration of the defect. Most skin lesions are amenable to a circular excision. In these instances, it is worthwhile to use circular-shaped excisions. The reusable metal trephines have been replaced by disposable trephines that have ribbed plastic handles attached to 316 stainless steel circular cutting blades. Wound closure is accomplished in the same direction as the long axis of the elliptical defect by first approximating the midportion of the defect with a 4-0 synthetic CAPROSYN* monofila-ment absorbable suture attached to the swage of the laser-drilled, compound-curved reverse cutting edge needle. Additional interrupted dermal (subcuticular) sutures are placed in each wound quadrant to approximate further the divided edges of the dermis. Compound-curved reverse cutting edge needles have been specifically designed for dermal closure. Reinforced Steri-Strips are then applied transversly across the incision to facilitate further skin edge approximation. Rigorous follow-up examination is essential for any patient with a history of a skin cancer to detect recurrence and prevent further actinic damage. The use of wide diameter trephine biopsy instruments are still not widely used by physicians because most physicians do not have the technical skills to approximate the defect with dermal sutures. Consequently, this need for a rapid dermal skin closure technique that can be used by a primary care physician must be devised before the trephine excisional biopsy technique is widely used by the primary care physician. This goal can be achieved by developing a disposable stapler for subcuticular closure of the skin.     

应用封闭式负压引流及游离皮瓣治疗小儿肢体大面积软组织缺损

目的 探讨应用封闭式负压引流(VSD)及游离皮瓣治疗小儿肢体严重创伤性大面积软组织缺损的手术技巧及临床应用价值.方法 应用VSD及游离皮瓣治疗22例患儿,年龄3～10岁,均为四肢严重创伤后大面积软组织缺损,骨、肌腱等深部组织裸露或部分缺损,创面大小12 cm×8cm ～ 34 cm×25 cm,新鲜创面9例,感染坏死性创面13例.创面经彻底清创后,先行VSD覆盖创面.对合并不稳定骨折者,急诊行外固定支架固定骨折或克氏针内固定.5～9 d后去除VSD负压膜,根据软组织缺损及其深部组织损伤情况,再次清创后单纯行游离皮瓣移植修复8例,游离皮瓣加植皮修复14例.术后对皮瓣的存活情况和愈合质量进行随访.结果 合并深部组织裸露的肢体大面积软组织缺损的22例患儿,经负压封闭引流后,局部创面无明显感染,肌腱及骨外露区周围肉芽组织生长良好.再次清创后施行的游离皮瓣移植全部一期成活,未出现血管危象,感染控制良好,没有形成窦道.术后随访6～24个月,皮瓣质地柔软,外形良好,患肢功能恢复满意.结论 对于小儿严重创伤后深部组织裸露的肢体大面积软组织缺损,经彻底清创后,应用封闭式负压引流及游离皮瓣修复,可明显缩短治疗周期,提高手术成功率,最大限度恢复小儿患肢的功能.     

Meta-analysis of skin adhesives versus sutures in closure of laparoscopic port-site wounds

Objective  To analyze the effectiveness of skin adhesives and sutures in the closure of laparoscopic port-site wounds. Methods  Electronic databases were searched to find relevant randomized controlled trials and their data was analyzed to generate a summative outcome. Results  Seven trials on port-site wound closure after laparoscopic procedures encompassing 902 patients were retrieved from the electronic databases. Four randomized controlled trials on 404 patients qualified for the review according to inclusion criteria. In both fixed- and random-effects models, there was no difference between the two port-site wound closure techniques in terms of wound infection, wound dehiscence and, patient satisfaction. However, statistically tissue adhesives were quicker in port-site wound closure as compared with sutures. Conclusions  Based on this review, there is insufficient evidence that port-site wound closure technique by tissue adhesives is superior to traditional suture closure technique in terms of wound infection, wound dehiscence, and patient satisfaction. However, tissue adhesives are quicker in port-site wound closure. A multicentre randomized controlled trial is required in order to obtain stronger evidence.     

Radical Resection of Giant Congenital Melanocytic Nevus and Reconstruction With Meek-Graft Covered Integra Dermal Template

BACKGROUND: Giant congenital melanocytic nevi represent a surgical challenge, particularly in cases in which the size of the nevus exceeds certain extend and malignant transformations have to be considered. OBJECTIVE: To discuss through case report considerable surgical options when extensive giant congenital melanocytic nevi with malignant transformation are encountered. METHODS: We present an unusual case of a giant congenital melanocytic nevi of the entire back of a 44-year-old patient. To achieve radical resection with direct appropriate wound closure and acceptable outcome, the integument of the entire back was excised and covered with Integra, followed by split-thickness skin grafting after stable integration of the matrix. RESULTS: The approach resulted in a complete excision of the tumor and acceptable cosmetic and excellent biomechanical outcome. CONCLUSION: The introduced practice demonstrates a useful alternative to established methods, particularly if tumor excision in large areas and subsequent wound closure might be achieved in one procedure.     

Einzeitige Defektdeckung von denudiertem Knochen und freiliegenden Sehnen mittels MATRIDERM? und Spalthaut

Background

Full-thickness skin defects over functional structures (tendons, vessels) or deperiosted bones of the extremities usually require extensive soft tissue reconstruction to cover the defect. A new option for coverage of the defect is the application of MATRIDERM?, a bovine matrix consisting of collagen and elastin, as a neodermis underneath skin transplants. Can this combined one-stage surgical intervention successfully cover deperiosted bone or tendon?

Patients and methods

We performed this one-stage procedure in ten patients instead of soft tissue reconstruction. The success of wound coverage with the one-stage method and in combination with skin transplantation for defects generally associated with considerable loss of transplants (deperiosted bones and tendons without paratenons) was determined.

Results

In nine of ten patients, complete defect coverage could be achieved. A one-stage wound closure in extensive defects with exposed tendons in four of five locations could be achieved. In deperiosted bone defects the one-stage coverage was only successful in two of six patients. However, complete wound closure could be achieved with a second skin transplantation in a patient with exposed tendon and bone in three of the four locations.

Conclusion

As a one- or two-stage procedure, MATRIDERM? application with skin transplantation resulted in an effective defect closure without the need for a complex plastic reconstructive procedure. With regard to its functionality it cannot be considered as a substitute for skin flaps. In selected cases MATRIDERM? is an interesting and successful method in plastic reconstructive surgery.     

Wound Closure Following Intervention for Closed Orthopedic Trauma

The method of skin closure and post-operative wound management has always been important in orthopedic surgery and plays an even larger role now that surgical site infection (SSI) is a national healthcare metric for both surgeons and hospitals. Wound related issues remain some of the most feared complications following orthopedic trauma procedures and are associated with significant morbidity. In order to minimize the risk of surgical site complications, surgeons must be familiar with the physiology of wound healing as well as the patient and surgical factors affecting healing potential. The goal of all skin closure techniques is to promote rapid healing with acceptable cosmesis, all while minimizing risk of infection and dehiscence. Knowledge of the types of closure material, techniques of wound closure, surgical dressings, negative pressure wound therapy, and other local modalities is important to optimize wound healing. There is no consensus in the literature as to which closure method is superior but the available data can be used to make informed choices. Although often left to less experienced members of the surgical team, the process of wound closure and dressing the wound should not be an afterthought, and instead must be part of the surgical plan. Wounds that are in direct communication with bony fractures are particularly at risk due to local tissue trauma, resultant swelling, hematoma formation, and injured vasculature.     

Propeller flap donor site closure by means of another propeller flap: A case report and literature review

Despite some ongoing criticisms, propeller flaps are still gaining popularity among plastic surgeons. The need of skin grafting of the donor site is one of those limitations that sometime affect the beauty and the efficacy of this reconstructive technique. Similar to a classic bi-lobed skin flap in which the second lobe of the same flap is mobilized to cover the donor site defect of the first lobe, a second, discrete propeller flap can be harvested adjacent to the first, in order to close the first donor site defect, thus avoiding the need for a skin graft. We applied this concept of “sequential” propeller flaps to cover a 4.5 × 4 cm full thickness soft tissue defect at the level of the heel in a 54-year-old patient who underwent melanoma excision and sentinel node biopsy.The first and second propeller flaps of 10 × 4.5 cm respectively were rotated on a distal and on a more proximal perforator of the posterior tibial artery (PTA) respectively, obtaining a tension free closure along the entire wound. The post-operative course was uneventful and the patient returned to full normal activities after 4 weeks. Follow up at 6 months showed a stable reconstruction with no functional deficit. This option, that relies on two separate perforator propeller flaps performed in sequence to obtain complete wound closure, may be kept in mind when dealing with soft tissue defects eligible for propeller flap reconstruction, as long as sizeable perforators in a favorable position are available. Moreover, a brief literature review on propeller flap use in flap donor site closure is also provided.     

Best-practice algorithms for the use of a bilayered living cell therapy (Apligraf®) in the treatment of lower-extremity ulcers

Tissue-engineered skin substitutes such as Apligraf have emerged over the past 20 years as among the most carefully studied and efficacious of the advanced wound modalities. These products have been proven as effective enhancements to general wound care, promoting wound closure particularly in instances where conventional wound care fails. Marketed for hard-to-heal wounds since 1998, Apligraf has become part of standard wound care in many wound centers across the United States. Despite this situation, few general wound care guidelines incorporate advanced and active wound-healing technologies, such as tissue-engineered skin products. Because of this deficiency, appropriate patient selection and proper use of these product remain largely unaddressed within the general wound care community. Here, we describe the development of guidelines surrounding optimal use of the bilayered living cell therapy, Apligraf, in the treatment of the two types of lower extremity ulcers for which the product is FDA approved: venous leg ulcer and diabetic foot ulcer. The guidelines detailed in this article focus on the identification and selection of patients who are at risk for failure of standard wound care therapy and thus appropriate for Apligraf treatment. The intended audience for these guidelines is the general wound care practitioner, for whom the developed treatment algorithms and accompanying figure legends should provide practical, user-friendly direction simplifying both patient selection and appropriate use of Apligraf within the context of good wound-healing practice.     

Sentinel node biopsy site used as full thickness skin graft donor for cutaneous melanoma

BACKGROUND: Wound defects after wide local excision (WLE) for cutaneous melanoma can occasionally require the use of skin grafts for closure. Harvesting the skin graft can result in an additional wound. METHODS: The increasing use of sentinel lymph node (SLN) biopsy in cutaneous melanoma at our institution has facilitated the development of an alternative technique for obtaining donor skin. The proposed method utilizes the skin overlying the SLN as the skin graft donor site. Sixteen patients underwent WLE of intermediate to thick melanomas with SLN biopsy and full thickness skin graft harvested from the SLN biopsy site. RESULTS: After a median follow-up of 12 months, there were no graft failures. There were 2 partial graft losses. There were no wound complications. There were no melanoma recurrences. CONCLUSIONS: In cases where primary closure is not technically feasible or cosmetically favorable, the use of the SLN incision site as a skin graft donor provides the surgeon with an effective repair and spares the patient an additional skin graft donor site defect.