Adjustable, Skin-Stretching External Fixation Device and Negative Pressure Wound Therapy Application for Infected Full-Thickness Skin Defects

A Case Series Study

Ye Peng, MD; Wei Zhang, MD; Faran Bokhari, MD; Zuo Cao, MD; Gongzi Zhang, MD; Shuwei Zhang, MD; Lihai Zhang, MD


Wounds. 2021;33(7):178-184. 

In This Article

Abstract and Introduction


Introduction: Skin defects—especially infected, massive full-thickness defects—can be challenging to manage. Traditionally, defects are repaired using free flaps or musculocutaneous flaps. Many side effects and complications are associated with flaps, however, such as infection, pain, donor site pain, and poor cosmesis.

Objective: This case series evaluates the use of an adjustable, skin-stretching external fixation device and negative pressure wound therapy (NPWT) to repair soft tissue defects.

Materials and Methods: In this retrospective series, 7 patients with skin defects were treated with an adjustable, skin-stretching external fixation device and NPWT between January 2014 and December 2017. All patients were followed until complete healing was achieved. Each patient's age, sex, defect size, mechanism of injury, healing time, results, and complications were recorded.

Results. The average patient age was 37.43 years ± 10.47 SD (range, 26–55 years). The average skin defect area was 14.5 cm2 ± 5.26 * 23.25 ± 9.01 cm2 (range, 7–15 cm2 * 10–30 cm2), and average healing time was 3.29 months ± 1.60 (range, 1–6 months). All defects healed, and 2 patients developed ulcers.

Conclusions: This series showed the adjustable, skin-stretching external fixation device and NPWT to be a simple, safe, and effective means of managing skin defects, with minimal complications.


Soft tissue defects are a common problem and remain challenging to manage. These defects occur from a variety of mechanisms, including trauma, open fracture, Morel-Lavallée lesion, burns, extensive tumor resection, soft tissue infection, and pressure injury. Massive soft tissue defects often occur with infection. Several techniques for covering soft tissue defects have been described, including free flaps, muscle flaps, and engineered bilayered skin products. In recent years, flap coverage has been considered the criterion standard. In a multicenter retrospective review, Cho et al[1] reported a muscle flap thrombosis rate of 17%, loss rate of 13%, and salvage rate of 58% in patients with lower extremity trauma. In patients with infected defects, however, the efficiency and safety of free flap coverage, particularly for large defects, remains unclear. The complication rate increases with the size of the soft tissue defect, with defects 200 cm2 or larger especially at risk for complications related to flap coverage.[2] The failure rate of free flaps is estimated to be between 1% and 21%,[3–6] with early complications in approximately 7% of patients and delayed complications in 33%.[2] Muscle flaps are also at risk for complications such as pain and musculoskeletal dysfunction at both the donor and graft sites.[7] Engineered skin is costly and time-consuming to produce, and the results of its use are uncertain.

The stretching technique was first introduced by Ilizarov, and it can be used for bone, soft tissue, and skin.[8] In this technique, soft tissue and skin are gradually stretched using an external fixation device to reduce the wound size and achieve complete coverage of the defect. The technique is easy to apply, and it avoids the need for a donor site as well as associated donor site complications. It can promote epithelial regeneration and wound granulation, lessen the inflammatory reaction, and control superficial soft tissue infections.[9]

In this case series, the authors reported the outcomes of using a modified technique with an adjustable, skin-stretching external fixation device and negative pressure wound therapy (NPWT) to repair full-thickness skin defects.