External Tissue Expander for Closing Large Defects of the

CASE REPORT
External Tissue Expander for Closing Large Defects of the
Extremities and Trunk
Julia Kirschke, Dimitrios Georgas, Michael Sand, and Falk G. Bechara
Background: Direct closure is the reconstruction of choice for surface soft tissue defects; however, it may not be suitable for
larger defects due to extensive tension. A variety of techniques are available for achieving tension free closure, including skin grafts,
skin flaps, and internal or external tissue expansion.
Materials and Methods: The external skin expander developed by Blomqvist and Steenfos consists of single tissue expander
units that contain an atraumatic needle and two friction stoppers connected via a silicone string. Each device of the expander is
inserted under local anaesthesia on each side of the defect at a distance of about 2 cm from each other. Postoperative the silicone
strings have to be tightened at least once a day. After about 5 to 10 days a sufficient expansion is achieved and the defect can be
closed directly after expander removal.
Results: The external tissue expander developed by Blomqvist and Steenfos is an efficient, time-effective, easy-to-handle device
that can be inserted under local anesthesia, providing a good functional and satisfactory cosmetic outcome. Due to the
comparatively low complication rate, even outpatient treatment is possible. The major drawback of this technique is the possibility
of developing uncommon secondary scars under the plastic stoppers.
Contexte: La fermeture directe des plaies est la technique privilégiée de reconstruction des pertes de tissu mou superficiel;
toutefois, dans les cas de perte importante de substance, il n’est pas possible de procéder de la sorte en raison d’une trop forte
tension. Différentes techniques permettent de réaliser des fermetures exemptes de tension, notamment les greffes de peau, les
lambeaux cutanés et l’expansion tissulaire interne ou externe.
Matériel et méthode: L’expanseur cutané externe, conçu par Blomqvist et Steenfos consiste en des trousses séparées
d’expansion tissulaire, qui contiennent une aiguille non traumatisante et deux organes d’arrêt à friction reliés par une attache de
silicone. Chaque partie de l’expanseur est introduite sous la peau, sous anesthésie locale, de chaque côté de la perte de substance, à
une distance d’environ 2 cm l’une de l’autre. Après l’opération, il faut resserrer les attaches de silicone au moins une fois par jour. Au
bout de 5 à 10 jours, l’on obtient une expansion suffisante, et il est possible de procéder à la fermeture directe de la plaie après le
retrait du dispositif.
Résultats: L’expanseur tissulaire externe, conçu par Blomqvist et Steenfos est un dispositif efficace, temporellement efficient et
facile à manipuler, qui peut se glisser sous la peau, sous anesthésie locale, et qui donne de bons résultats tant fonctionnels
qu’esthétiques. Il est même possible de réaliser le traitement en ambulatoire en raison de son faible taux de complications
comparativement à d’autres techniques. Son principal désavantage est le risque de formation de cicatrices secondaires mais rares
sous les organes d’arrêt de plastique.
IRECT CLOSURE is the reconstruction of choice for
surface soft tissue defects; however, it may not be
suitable for larger defects due to extensive tension. A
variety of techniques are available for achieving tensionfree closure, including skin grafts, skin flaps, and internal
or external tissue expansion.1,2
Tissue expansion works by stretching the adjoining skin,
thus recruiting skin from the surroundings, and partly by
generating new cutis.3 The technique was first described in
1957 by Neumann to reconstruct ear defects in which local
skin was mobilized using a subcutaneously placed rubber
D
From the Department of Dermatology, Venereology and Allergology,
Ruhr-University Bochum, Bochum, Germany.
Address reprint requests to: Julia Kirschke, MD, Dermatologic Surgery
Unit, Department of Dermatology, Venereology and Allergology, RuhrUniversity Bochum, St. Josef Hospital, Gudrunstr. 56, 44791 Bochum,
Germany; e-mail: [email protected].
DOI 10.2310/7750.2013.13037
# 2013 Canadian Dermatology Association
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 17, No 6 (November/December), 2013: pp 423–425
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Kirschke et al
A
solution to be used without reaching toxic levels. After
anesthesia, each device is passed subcutaneously on each
side of the defect approximately 0.5 cm from the wound
edge. This is repeated at intervals of about 2 cm with every
ETE unit. Finally, the silicone strings are attached to the
holding bars. For the best possible cosmetic outcome, these
should be placed in different directions from each other.
The wound is covered with sterile dressing materials of
nongreasy consistency to prevent slippage of the silicone
string and subsequent loss of tension. Tension is maintained by pulling the strips gently once or twice a day. This
can be executed by the attending physician or the patient
after accurate instruction. After about 5 to 10 days,
depending on the initial size of the defect and skin tension,
the edges of the wound meet each other, allowing the
removal of the expander. The defect can then be closed
directly with interrupted or continuous sutures placed in
multiple layers. A suction drain can be placed under the
skin closure to prevent fluid accumulation; alternatively,
open drainage is possible (Figure 2).
The closure of large tissue defects can be achieved by a
variety of techniques, including skin grafts, skin flaps, and
skin expanders. Flap procedures require a high degree of
surgical skill and experience to ensure a good cosmetic and
functional outcome and to minimize possible damage to the
vascular system, lymphatic drainage, and surrounding nerves
due to the preparation and transfer of the flap. Furthermore,
B
Figure 1. A, Two of six separately packed sterile units from one ETE
unit. One unit consists of one atraumatic needle, one silicone string,
and two friction stoppers. B, Detailed view of one friction stopper
mounted on a silicone string.
balloon.4 However, this technique did not become popular
until 1976, when Radovan described an analogous subcutaneous tissue expander made of silicone for breast reconstruction following mastectomy.5 Since then, a variety of expander
devices have been developed to generate excess tissue. While
searching for an external tissue expansion technique that
could be performed while the patient is ambulant under local
anesthesia, with a low complication rate and an adequate
cosmetic and functional outcome, we came across the external
skin expander developed by Blomqvist and Steenfos (ETE,
Höjmed AB, Stockholm, Sweden).6 The external tissue
expander consists of single tissue expander units that contain
an atraumatic needle and two friction stoppers connected via
a silicone string (Figure 1).
After using aseptic techniques, local anesthesia is
infiltrated along the incision line and into the surrounding
areas. Due to the large size of the defects, we regularly
apply tumescent anesthesia, allowing large amounts of
424
A
B
C
D
E
F
G
H
Figure 2. A, Preoperative defect embracing the underlying muscle tissue after
excision of a squamous cell carcinoma on
the upper back. B, Intraoperative photograph after connecting the silicone strings
to the holding bars. C, Postoperative
result after tightening the silicone
strings (the skin expander was thereafter tightened once a day). D, Result 3
days after implantation of the expander. E, Condition after removal of the
expander (4 days after implantation)
and closure of the defect using an
interrupted 2-0 polyglactin 910 (Vicryl)
suture to attach the deep dermis to the
tension points, a running 3-0 subcuticular polydiaxanone suture, and interrupted vertical mattress sutures using
3-0 nylon (Ethilon) for skin closure. F,
Result 5 days after closure of the defect
with demarcated pressure marks in the
normal skin adjacent to the former
defect. G, At the time of suture removal
(10 days after defect closure), a central
dehiscence was seen but was left to allow
secondary healing. H, Follow-up 10
weeks after surgery with good functional
and satisfactory aesthetic results.
Canadian Dermatology Association | Journal of Cutaneous Medicine and Surgery, Vol 17, No 6 (November/December), 2013: pp 423–425
External Tissue Expander for Closing Large Defects
these complex and time-consuming procedures often
require general anesthesia, which results in higher rates of
postoperative complications, longer hospitalization periods,
and thus rising health care costs. Split-skin and full-thickness
skin grafts are easy and short procedures but result in scars of
minor quality and donor-site morbidity.1,6,7
When direct defect closure is not possible, the external
tissue expander developed by Blomqvist and Steenfos is an
efficient, time-effective, easy-to-handle device that can be
inserted under local anesthesia, providing a good functional
and satisfactory cosmetic outcome. Due to the comparatively
low complication rate, even outpatient treatment is possible,
with the accompanying financial benefits to the health
system.1,6,7 The expander can be used on excisions up to
400 cm2.6 The price is J200 ($260 US) per package of six
units (one unit contains one silicone string and two friction
stoppers) plus freight. The expander can even be applied in
regions of maximum motion and tension on the wound, as in
the upper back near the scapula. Depending on the region
affected and defect size, excision of the defect and closure of
the wound can be carried out after 5 to 10 days. Patients
frequently describe an unpleasant but usually not painful
tension following each expansion. Wound dehiscence can
occur but can be left for secondary healing without any
hesitation in most cases. The major drawback of this
technique is the possibility of developing uncommon
secondary scars in the normal skin due to the pressure
exerted by the plastic stoppers adjacent to the former defect.6,7
Acknowledgment
Financial disclosure of authors and reviewers: None
reported.
References
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reconstruction of head and face defects. Dermatol Surg 2007;33:864–
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physiologic influences of tissue expansion. Plast Reconstr Surg 2002;
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skin for subtotal reconstruction of the ear. Plast Reconstr Surg (1946)
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Reconstructive Surgeons; 1976; Boston.
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