A Substitute for Skin Grafts, Flaps, or Internal Tissue Expanders in Scalp Defects Following Tumor Ablative Surgery
January 2014 | Volume 13 | Issue 1 | Original Article | 48 | Copyright © 2014
Moris Topaz MD,a,b Narin-Nard Carmel BSc,c Guy Topaz BSc,c Isaac Zilinsky MDd
aPlastic Surgery Unit, Hillel Yaffe Medical Center, Hadera, Israel
bDepartment of Chemistry, Bar Ilan University, Ramat Gan, Israel
cMedical Student, Sackler Medical School, Tel-Aviv University, Tel-Aviv, Israel
dMohs Micrographic Unit, The Department of Plastic & Reconstructive Surgery, Sheba Medical Center at Tel Hashomer, Israel
BACKGROUND: The skin of the scalp is relatively thick, minimally mobile, with distinct hair distribution.
TopClosure® is a novel device for skin stretching and secure wound closure.
OBJECTIVES: To evaluate the efficacy of the TopClosure® system in primary closure of moderate and large scalp defects, as a substitute for skin grafts, flaps, and tissue expanders.
METHODS: We report a retrospective series of 8 patients requiring resection of 9 scalp tumors resulting with moderate to large size defects that otherwise would have required reconstruction with skin grafts, flaps, or tissue expanders. TopClosure® was applied for intraoperative cycles of stress-relaxation, followed, when indicated, by additional steps of mechanical creep and scar secure.
RESULTS: Skin defects, averaging 3.5 cm, were managed by TopClosure®, enabling, primary closure in all wounds. Immediate wound edge approximation was reached through stress-relaxation in 2 wounds by heavy tension sutures within one hour. Further skin stretching by mechanical creep was required in 7 wounds, achieving staged primary closure in an outpatient setting. TopClosure® was further applied to secure the skin for up to 3 weeks following surgery.
CONCLUSIONS: The TopClosure system, effectively, aided closure of moderate and large scalp defects by stress-relaxation and mechanical creep and serving as a topical tension-relief platform for tension sutures, allowing mobilization of skin and subcutaneous tissue without undermining or need of drainage, for early, direct wound closure. Local complications were minimal and donor site morbidity was eliminated. Surgical time, hospital stay and costs were reduced, and post-operative wound aesthetics were improved.
J Drugs Dermatol. 2014;13(1):48-55.
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Scalp defects that cannot be primarily closed impose a significant challenge during tumor ablative and reconstructive surgery. Frequently, direct closure is not possible due to the limited elasticity of the scalp.1,2 The use of skin grafts, flaps, tissue expansion, or micro-vascular free tissue transfer may serve to reconstruct moderate and large scalp defects, yet may be complex and inflict significant morbidity and cost, frequently failing to achieve adequate cosmesis. Rapid or gradual sequential stretching of the skin by various skin stretching devices was advocated to enable substantial skin extension by harnessing the viscoelastic properties of the skin, thus minimizing tension and achieving primary closure of various skin defects.3,4,5,6 Through stress-relaxation, tension is acutely applied to the skin, leading to collagen and elastin fiber reorientation and elongation, with gradual reduction in stress.7 As a result, the skin is relaxed and additional tension can be applied in repeated cycles until the skin margins are brought into close approximation for suturing or stapling. Via mechanical creep, constant pressure is applied to the skin to create deformation, resulting in incremental elongation of the skin until wound margins are approximated for direct closure.
TopClosure® is a novel device that employs distribution of dynamic, selective, vector-oriented forces over a wide area of attachment, continuously or cyclically, in both non-invasive and invasive attachment to the skin, so that surrounding skin can be stretched, allowing safe primary closure of wound margins by conventional methods.8
The objective of our retrospective clinical evaluation was to assess the efficacy of the TopClosure skin stretching system in utilizing both stress-relaxation and mechanical creep for closure of moderate to large scalp defects that otherwise would have required coverage with flaps or skin grafting.
MATERIALS AND METHODS
Our retrospective study group included 8 consecutive patients (all men ranging in age from 17 to 95 years) with 9 ablative wound