Utility of a Continuous External Tissue Expander in Complex Pediatric Wound Reconstruction

Bobby L. May, MD; Ben Googe, MD; Somer Durr, BS; Amber Googe, MD; Peter Arnold, MD, PhD; Ian Hoppe, MD; Ben McIntyre, MD

Disclosures

ePlasty. 2022;22(e10) 

In This Article

Abstract and Introduction

Abstract

Background: Soft tissue reconstruction following traumatic injury can be devastating. Reconstructive treatment modalities can prove to be complex. DermaClose (Synovis Micro Companies Alliance, Inc) is a relatively novel wound closure device that has gained popularity for continuous external tissue expansion (CETE).

Methods: A single-institution case series of 3 traumatic pediatric soft tissue injuries in which DermaClose was used for soft tissue reconstruction as an alternative to free tissue transfer was presented. A review of the literature to identify similar reported cases was also conducted.

Results: The authors report their success with the use of this continuous external tissue expander in the management of pediatric soft tissue injuries. Open tibial fractures were sustained by 2 patients, and 1 patient suffered an avulsion injury to the scalp; sequential DermaClose application was successfully utilized to achieve wound closure in all cases.

Conclusions: The minimal amount of data currently available in the literature that document the use of this continuous external tissue expander in pediatric patients suggest that its safety and efficacy are inadequately investigated in this population. The cases included in this report suggest DermaClose may be an alternative to traditional methods for complex soft tissue closure in pediatric patients. For larger wounds, repeat applications with sequential closure should be expected and is described in an algorithm within this report.

Introduction

Tissue expansion is a biological mechanism of the human body that has been documented in response to both physiological and pathological stimuli.[1] Examples can be seen within pregnancy, weight gain, expansion of skin over a growing tumor, and various cultural behaviors such as neck extension and lower lip expansion.[1] Though the mechanism of tissue expansion is not completely understood, studies have suggested the importance of cellular response to mechanical stress, extracellular and intracellular changes, proliferation of basal keratinocytes, collagens, growth factors, second messenger systems, integrins, ion channels, and cell-to-cell interactions.[2,3] Internal tissue expansion harnesses these concepts by implantation of an inflatable subcutaneous expander. This technique has gained popularity in areas of planned reconstruction such as breast expansion for implant placement, tissue expansion before flap transfer, or pediatric facial reconstruction for microtia.[4–6] A downside of internal tissue expansion, however, is the necessary planning that is needed that often prevents its use with traumatic wounds.[4]

A more novel technique, continuous external tissue expansion (CETE), has started to gain popularity in achievement of wound coverage.[7] Despite the variation in hardware usage, this technique utilizes anchoring along the wound's edge with mechanical tension of skin across the wound opening to facilitate wound closure.[7–10] In a recently published review of CETE by MacKay et al, 6 devices that have been utilized in external tissue expansion were compared against each other. One of the devices included in the review was DermaClose (Synovis Micro Companies Alliance, Inc). A common advantage of these devices was the utility in management of longstanding wounds. DermaClose was reported to only have 1 disadvantage, which was the need to undermine wound edges.[7]

DermaClose is a self-tightening external tissue expander that applies constant tension to wound edges (Figure 1) and is indicated in aiding the closure of full-thickness wounds of the skin.[7] The device has proven efficacious in healing of complex wounds, both as a result of incisional complications and trauma.[7,11–13] In several reports, the device was found to improve outcomes including fewer postoperative complications, decreased time to wound closure, and better aesthetic results when compared to more traditional methods such as skin grafts, flaps, and secondary intention with granulation.[7,14–16] The use of the device has predominantly been reported in the adult population within specialty areas including podiatry, orthopedics, and microsurgery.[7,8] The reported uses in the pediatric population, though minimal, have also demonstrated the safety of this device in achieving healing and closure of complex wounds.[17,18]

Figure 1.

a) Tension controller used to achieve appropriate tension across wound b) Skin anchors placed at wound edge for tension line to be threaded through.

This article presents 3 cases in which the DermaClose device was used in pediatric patients to achieve closure of complex wounds that resulted after traumatic injury. Their article also describes the steps taken to review the literature with a summary of findings.

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