CONTINUOUSCONTINUOUSCONTINUOUSCONTINUOUS TISSUE TISSUETISSUE TISSUE EXPANSION EXPANSION EXPANSION EXPANSION AnAn effective effective method method for for enhanced enhanced lowerlower extremity extremity wound wound healing healing

American Society of Podiatric Medical Assistants AmericanAmerican SocietyQuarter Society ofTwo Podiatricof - 2010Podiatric Medical Medical Assistants Assistants Introduction:QuarterIntroduction:Quarter Two- Two- Andrew2010 2010 Rader DPM - Memorial Hospital, Jasper IN Tissue expansion is an important technique for reconstruction of soft TissueTissue expansion expansion is an is important an important technique technique for reconstructionfor reconstruction of soft of soft tissuetissue defects.defects. ItIt isis commonlycommonly usedused inin thethe carecare ofof burns,burns, breastbreast re- tissuereconstruction defects. It is and commonly pediatric used plastic in thesurgery. care of The burns, phenomenon breast re- of constructionconstruction and andpediatric pediatric plastic plastic surgery. surgery. The The phenomenon phenomenon of tissue of tissue tissue expansion is well known and observed in pregnancy. Skin expansionexpansion is well is well known known and andobserved observed in pregnancy. in pregnancy. Skin Skin expands expands expands in response to tension generated by the increased in responsein response to tension to tension generated generated by theby increasedthe increased abdominal abdominal volume volume Figure 1: Excisional debridement of the abdominal volume during pregnancy. This response has been found Figure 1: Excisional debridement of the duringduring pregnancy. pregnancy. This This response response has hasbeen been found found to be to a be metabolically a metabolically wound with undermining of the wound to be a metabolically active process resulting in increased mitotic wound with undermining of the wound activeactive process process resulting resulting in increased in increased mitotic mitotic activity activity and andvascularity vascularity of of marginsmargins activity and vascularity of the expanded skin.1 the expandedthe expanded skin.1 skin.1 Tissue expansion for medical purposes was first reported in 1905 by TissueTissue expansion expansion for medicalfor medical purposes purposes was was first first reported reported in 1905in 1905 by by Codvilla who attempted to lengthen tissue in the hip area.2 CodvillaCodvilla who who attempted attempted to lengthen to lengthen tissue tissue in the in hipthe hiparea.2 area.2 Neuman Neuman , , in 1957,Neuman,in 1957, used used in controlled 1957, controlled used tissue controlled tissue expansion expansion tissue with expansion with a rubber a rubber with ball balloon a rubberoon to aid to aid 3 in reconstructionballoonin reconstruction to aid ofin anreconstruction of ear an defect.3ear defect.3 of Interest an Interest ear indefect. tissue in tissue expansionInterest expansion in thentissue then wanedexpansionwaned until until the then latethe waned late1970’s. 1970’s. until Techniques the Techniques late 1970’s. were were developed Techniques developed for were breastfor breast reconstructiondevelopedreconstruction forover breast over the coursethe reconstruction course of the of nextthe over next decade. the decade. course Pioneering Pioneering of the nextthis this 4 techniquedecade.technique was Pioneering was Radovan Radovan thisin 1982.4 techniquein 1982.4 Since was Since that Radovan that time, time, tissuein 1982. tissue expa expa Sincensionnsion that has time,hasbecome become tissue an accepted expansionan accepted standard has standard become technique technique an accepted in providing in providingstandard soft technique soft tissue tissue in providingcoverage ofsoft increasingly tissue coverage complex of increasingly wounds. complex wounds. coverage of increasingly complex wounds. FigureFigure 2: Application 2: Application of skin of skinanchors anchors

TissueTissue expansion expansion in the in thefield field of lower of lower extremity extremity wound wound care care has hasalso also undergoneundergone an evolutionan evolution over over the thepast past several several decades. decades. Mechanical Mechanical skinskin stretching stretching was was attempted attempted with with devices devices such such as the as theSure Sure Clo- ClosureClo- sureSkinsure Skin SkinStretching Stretching Stretching System. System®.5 System®.55 However, However, However, the therigors rigorsthe of rigors adjusting of adjusting of adjusting the device the proveddevicethe device provedto be proved an to obstacle be to an be obstacle an to obstacleits continued to its to continued its use.continued Recently use. use. Recently a Recentlydevice a a devicehasdevice hasbeen hasbeen developed been developed developed that that provides that provides provides continuous continuous continuous tissue tissue expansion tissue expansion expansion for for enhancingfor enhancing lower lower extremity extremity wound wound healing. healing. The The inconvenience inconvenience of of adjustingadjusting the thedevice device has hasbeen been eliminated eliminated and and the thepreliminary preliminary results resultsresults are areencouraging. encouraging. The The device device is marketed is marketed under under the thetrade trade name name Der- Der- maCloseDermaClose®maClose RCTM. RCTM. RC. (Wound Care Technologies – Chanhassen MN)

Physiology: Physiology:Physiology: FigureFigure 3: 4.5mm 3: 4.5mm barbs barbs of the of skin the skinanchor anchor engageengage the subcutaneous the subcutaneous tissue tissue SkinSkin has hasthree three important important physical physical properties properties that that make make tissue tissue expan- expan- sionexpansionsion possible. possible. possible.Skin Skin tension tensionSkin is tensiona isfunction a function is a offunction the of elasticthe ofelastic the fiber elastic fiber network. network.fiber Thisnetwork.This is the is phenomenonthe This phenomenon is the phenomenonsurgeons surgeons see surgeonsseewhen when making seemaking when a skin a makingskin incision incision a skin andincision andseeing seeing the and contractionthe seeing contraction the ofcontraction the of woundthe wound of edges the edges wound away away edgesfrom from the away incision.the from incision. Skin extensibility is the response of skin to mechanical forces. An ex- Skinthe extensibility incsion. Skin is theextensibility response ofis theskin response to mechanical of skin forces. to mechanical An ex- ample of this is the stretching of skin over the elbow as the arm flexed ampleforces. of this An is example the stretching of this of is skinthe stretchingover the elbow of skin as over the a therm elbowflexed and extended. The final property is viscoelasticity. This is creep and andas extended. the arm flexedand The final extended.property is Theviscoelasticity. final property This is is viscoelasticity. creep and stress relaxation. As tissue is stretched, less force is required to main- stressThis relaxation. is creep and As stresstissue relaxation.is stretched, As less tissue force is is stretched, required lessto main- force is tain that stretch over time. tainrequired that stretch to maintain over time. that stretch over time. Traditional tissue expansion happens in one of two ways. Prolonged TraditionalTraditional tissue tissue expansion expansion happens happens in one in one of two of two ways. ways. Prolonged Prolonged tissue expansion (PTE) occurs over 1-6 weeks. Rapid intraoperative tissuetissue expansion expansion (PTE) (PTE) occurs occurs over over 1-6 1-6weeks. weeks. Rapid Rapid intraoperative intraoperative FigureFigure 4: Tightening 4: Tightening of tensioning of tensioning device device with withnylon nylon line engagingline engaging the skin the skinanchors anchors

Page 27 2nd Quarter www.aspma.orgwww.aspma.org ASPMA ASPMA tissue expansion (RITE) occurs entirely in the operating room CONTINUOUS TISSUE EXPANSIONtissue expansion (RITE) occurs entirely in the operating room CONTINUOUS TISSUE EXPANSIONsetting. RITE depends entirely on the viscoelastic properties of setting. RITE depends entirely on the viscoelastic properties of the skin in response to load cycling.6 PTE induces changes in the skin in response to load cycling.6 PTE induces changes in vascularity and cellular activity of the expanded skin. The epi- vascularity and cellular activity of the expanded skin. The epidermis dermis initially thickens slightly as the dermis and adipose tissue An effective method for enhancedinitially thickens slightly as the dermis and adipose tissue thins.7 The thins.7 The expanded skin then becomes hyperemic resulting in expanded skin then becomes hyperemic resulting in a hardier flap a hardier flap than one produced from nonexpanded skin.1 It has 1 lower extremity wound healingthan onealso produced been found from that nonexpanded the expanded skin. skin Itflap has isalso more been resistant found to that thebacterial expanded invasion skin flap than is randommore resistant cutaneous to bacterialflaps.8 invasion than random cutaneous flaps.8 American Society of Podiatric Medical Assistants Technique: Technique: Figure 5: Locked tension device engaged on Introduction:Quarter Two- 2010 skin anchor The DermaClose RCTM kit contains a tension controller con- Tissue expansion is an important technique for reconstruction of soft The DermaClose®taining a 52cm RC loop kit containsof nylon aline, tension 10 skin controller anchors, containing a skin sta apler tissue defects. It is commonly used in the care of burns, breast re- 52cm loopand aof staple nylon remover line, 10 pack.skin anchors, Wounds a suitable skin stapler for application and a staple of construction and pediatric plastic surgery. The phenomenon of tissue removerthis pack. technique Wounds include suitable noninfected for application foot ulcers, of this surgical technique wounds expansion is well known and observed in pregnancy. Skin expands includeand non-infected traumatic wounds.foot ulcers, surgical wounds and traumatic wounds. in response to tension generated by the increased abdominal volume Figure 1: Excisional debridement of the during pregnancy. This response has been found to be a metabolically wound with undermining ofAnesthesia the wound is administered and the area is prepped in the usual active process resulting in increased mitotic activity and vascularity of margins Anesthesiasterile is manner. administered When and used the on area a chronic is prepped wound, in the fibrotic usual sterilemargins the expanded skin.1 manner.of Whenthe wound used are on exciseda chronic and wound, the wound fibrotic margins margins are ofundermined the wound0.5-1.0 are excised cm. Thisand wound releases margins the margin are undermined of the skin to0.5-1.0 begin cm.creep. Tissue expansion for medical purposes was first reported in 1905 by This releases(Figure the 1) Aftermargin obtaining of the skin hemostasis, to begin creep.the skin (Figure anchors 1) are After ap - Codvilla who attempted to lengthen tissue in the hip area.2 Neuman , obtainingplied hemostasis, by pressing the them skin into anchors the skin. are applied(Figure by2) pressing The skin them anchors in 1957, used controlled tissue expansion with a rubber balloon to aid into thehave skin. a pair (Figure of flat 2) Theangulated skin anchors barbs 4.5 have mm a inpair length. of flat The barbs angulated barbs 4.5mm in length. The barbs are inserted 1-1.5 cm in reconstruction of an ear defect.3 Interest in tissue expansion then are inserted 1-1.5 cm from the margin of the wound and 2-3 cm Figure 6: 48 hours of continuous dynamic waned until the late 1970’s. Techniques were developed for breast from thefrom margin each ofother. the wound Because and of 2-3 the cmlength from of each the barbs,other. the Because subcuta - tension resulting in expanded skin and reconstruction over the course of the next decade. Pioneering this of the lengthneous tissueof the isbarbs, engaged the subcutaneousfor eventual migration. tissue is engaged The anchors for are smaller wound size technique was Radovan in 1982.4 Since that time, tissue expansion eventualsecured migration. with twoThe skinanchors staples. are secured (Figure with 3) two skin staples. has become an accepted standard technique in providing soft tissue (Figure 3) coverage of increasingly complex wounds. Figure 2: Application of skinThe anchors tension controller has a rotary knob with a clutch and an The tensionadapted controller line chute has that a rotary fits overknob the with hooked a clutch end and of onean adaptedof the Tissue expansion in the field of lower extremity wound care has also line chuteskin that anchors. fits over The the enclosed hooked line end is of placed one of over the theskin hooked anchors. edge undergone an evolution over the past several decades. Mechanical The enclosedof the anchors line is placed and the over knob the is hooked tightened. edge (Figure of the anchors4,5) The and skin stretching was attempted with devices such as the Sure Clo- the knobtension is tightened. controller (Figure cannot 4,5) be overThe tensiontightened controller because cannotof a clutch be sure Skin Stretching System®.5 However, the rigors of adjusting over tightenedmechanism. because The of knob a clutch will “slip”mechanism. on the clutchThe knob when will a force“slip” of the device proved to be an obstacle to its continued use. Recently a on the 1.2clutch kg iswhen obtained. a force The of 1.2 device kg is is obtained. then locked. The 1.2device kg of is forcethen device has been developed that provides continuous tissue expansion locked.will 1.2 be kg maintained of force will on bethe maintained line until the on devicethe line is until removed the device or for enhancing lower extremity wound healing. The inconvenience of is removedall of or the all line of theis retracted line is retracted back into back the intotension the controller.tension This adjusting the device has been eliminated and the preliminary results controller.eliminates This eliminates any need forany retightening need for retightening the device the and device provides and for continuous dynamic tension on the wound margins resulting are encouraging. The device is marketed under the trade name Der- provides for continuous dynamic tension on the wound margins Figure 7: Retention sutures applied after maClose RCTM. resultingin expansionin expansion of theof the surrounding surrounding tissue. tissue. This This expanded expanded tissue tissue is fully expanded to cover the original tissue migrates to the wound providing coverage. (Figure(Figure 6)6) NoNo deaddead wound. Physiology: Figure 3: 4.5mm barbsspace of isthespace produced skin isanchor produced since the since subcutaneous the subcutaneous tissue istissue mobilized is mobilized with the engage the subcutaneousskin margins. tissuewith the skin margins. Skin has three important physical properties that make tissue expan- sion possible. Skin tension is a function of the elastic fiber network. A primaryA primary dressing dressing is applied is applied that will that manage will manage wound wound exudate.The exudate. This is the phenomenon surgeons see when making a skin incision The wound under tension from the DermaClose RCTM device wound under tension from the DermaClose® RC device tends to and seeing the contraction of the wound edges away from the incision. tends to have increased exudate initially and extra absorbant have increased exudates initially and extra absorbant dressings are Skin extensibility is the response of skin to mechanical forces. An ex- dressings are suggested. Secondary dressings are chosen based suggested. Secondary dressings are chosen based on the anatomy of ample of this is the stretching of skin over the elbow as the arm flexed on the anatomy of the area. The tissue expander stays in place the area. The tissue expander stays in place for 1-7 days and extended. The final property is viscoelasticity. This is creep and for 1-7 days depending on the size of the wound and the elastic- depending on the size of the wound and the elasticity of the tissue stress relaxation. As tissue is stretched, less force is required to main- ity of the tissue being mobilized. being mobilized. tain that stretch over time. When the device is removed several retention sutures are applied When the device is removed several retension sutures are applied to Traditional tissue expansion happens in one of two ways. Prolonged to maintain the tissue expansion over the next couple of weeks. maintain the tissue expansion over the next couple of weeks. (Figure Figure 8: Two weeks after presentation with tissue expansion (PTE) occurs over 1-6 weeks. Rapid intraoperative Figure 4: Tightening of tensioning(Figure device 7) This effectively results in the physiologic changes partial thickness wound remaining with nylon line engaging7) This theexpected skineffectively anchors with results PTE. inPrimary the physiologic wound healing changes has expected not been with our PTE. Primary wound healing has not been our

Pagewww.aspma.org 28 2nd Quarter ASPMA www.aspma.orgPage 28 2nd Quarter ASPMA typical treatment goal, however the rate to complete epitheliali- zation has been rapid utilizing this wound reduction technique. (Figure 8,9)

Cost effectiveness: tissue expansion (RITE) occurs entirely in the operating room typicalTheCONTINUOUS rate treatment of wound goal, healing however and thetime rate to toepithelialization complete TISSUE with EXPANSION setting. RITE depends entirely on the viscoelastic properties of typicalCONTINUOUS treatment goal, however the rate to complete TISSUEepitheliali- EXPANSION epitheliatizationcontinuous tissue has expansion been rapid in utilizing our wound this care wound clinic reduction lead us to the skin in response to load cycling.6 PTE induces changes in zation has been rapid utilizing this wound reduction technique. technique.perform(Figure a 8,9)(Figure relative 8,9) cost analysis of this device versus standard vascularity and cellular activity of the expanded skin. The epi- wound care. Reimbursement information was obtained from dermis initially thickens slightly as the dermis and adipose tissue CosttheCost hospitalEffectiveness: effectiveness:An managing effective our wound care center. Amethod 6 month cost for enhanced thins.7 The expanded skin then becomes hyperemic resulting in evaluation was made of the first diabetic foot ulcers, pressure a hardier flap than one produced from nonexpanded skin.1 It has TheulcersThe rate rate and of ofwound surgical lowerwound healing woundshealing and weand time used extremitytime to thetoepithelialization epithelializationDermaClose RCTM with with wound healing also been found that the expanded skin flap is more resistant to device on. The billing records were reviewed and those costs bacterial invasion than random cutaneous flaps.8 continuouscontinuous tissue tissue expansion expansion in inour our wound wound care care clinic clinic lead lead us usto to performwereperform compared a relative a relative to cost the cost analysis cost analysis associated of ofthis this devicewith device similar versus versus ulcers standard standard (size, depth, vascular status, location) during the 6 months prior to Americanwoundwound care. Societycare. Reimbursement Reimbursement of Podiatric information information Medical was Assistantswas obtained obtained from from Figure 9: Fully epithelialized wound at four Technique: Figure 5: Locked tension device engaged on our use of this device. Our standard wound care algorithm Quarterthethe hospital Two- hospital 2010 managing managing our our wound wound care care center. center. A Asix 6 month cost weeks after presentation skin anchor Introduction:was followed to help with this analysis. (Diagram 1) The evaluationevaluation was was made made of ofthe the first first diabetic diabetic foot foot ulcers, ulcers, pressure pressure The DermaClose RCTM kit contains a tension controller con- results are found in diagram 2. The use of the DermaClose taining a 52cm loop of nylon line, 10 skin anchors, a skin stapler Tissueulcersulcers expansion and and surgical surgical is an woundsimportant wounds we techniquewe used used the the DermaClose®for DermaClose reconstruction deviceRCTM of soft on. RCTMdevice deviceon. The resulted billing inrecords a 72% were overall reviewed dollar andsavings those com costs- and a staple remover pack. Wounds suitable for application of tissueThepared defects. billing to advanced recordsIt is commonly were moist reviewed wound used in technology andthe carethose of costs (AMWT). burns, were breast compared The re- to this technique include noninfected foot ulcers, surgical wounds constructionthewere cost comparedassociated and pediatric to with the plastic similarcost associated surgery. ulcers (size, The with phenomenondepth, similar vascular ulcers of (size, tissuestatus, savingsdepth, vascularby wound status, type location)were as follows: during the72% 6 months(Pressure prior ulcer to and traumatic wounds. expansionlocation) is duringwell known the 6 andmonths observed prior toin ourpregnancy. use of this Skin device. expands Our Figure 9: Fully epithelialized wound at four stageour use 3 and of this4), 78% device. (Diabetic Our standard foot ulcers), wound 71% care (Trauma) algorithm and in responsestandard to wound tension care generated algorithm by was the increasedfollowed toabdominal help with volume this weeks after presentation 60%was (Surgicalfollowed toWounds). help with The this sample analysis. only (Diagram included 1) our The first 12 Figure 1: Excisional debridement of the Anesthesia is administered and the area is prepped in the usual duringanalysis. pregnancy. (Diagram This 1) response The results has been are found found in to diagram. be a metabolically 2 The use wound with undermining of the wound applicationsresults are found of DermaClose in diagram RCTM, 2. The butuse theof the initial DermaClose results are sterile manner. When used on a chronic wound, fibrotic margins activeof theprocess DermaClose® resulting in RC increased device resulted mitotic activityin a 72% and overall vascularity dollar savof - margins encouraging.RCTM device resulted in a 72% overall dollar savings com- of the wound are excised and the wound margins are undermined the ingsexpanded compared skin.1 to advanced moist wound technology (AMWT). The 0.5-1.0 cm. This releases the margin of the skin to begin creep. pared to advanced moist wound technology (AMWT). The savingssavings by by wound wound type type were were as asfollows: follows: 72% 72% (Pressure (Pressure ulcer ulcer stage 3 (Figure 1) After obtaining hemostasis, the skin anchors are ap- Tissueand expansion 4), 78% (Diabetic for medical foot purposes ulcers), 71%was first(Trauma) reported and in60% 1905 (Surgical by stage 3 and 4), 78% (Diabetic foot ulcers), 71%Cost (Trauma) Effectiveness and - DermaClose plied by pressing them into the skin. (Figure 2) The skin anchors CodvillaWounds). who attemptedThe sample to only lengthen included tissue our in firstthe hip 12 area.2 Neuman , have a pair of flat angulated barbs 4.5 mm in length. The barbs 60% (Surgical Wounds). The sample only included our first 12 in 1957,applications used controlled of DermaClose® tissue expansion RC, but withthe initial a rubber results ball oonare to aid are inserted 1-1.5 cm from the margin of the wound and 2-3 cm in reconstructionapplications of of an DermaClose ear defect.3 RCTM, Interest but in thetissue initial expansion results thenare Figure 6: 48 hours of continuous dynamic encouraging. from each other. Because of the length of the barbs, the subcuta- wanedencouraging. until the late 1970’s. Techniques were developed for breast tension resulting in expanded skin and 14000 neous tissue is engaged for eventual migration. The anchors are smaller wound size reconstruction over the course of the next decade. Pioneering this secured with two skin staples. (Figure 3) technique was Radovan in 1982.4 Since that time, tissue expansion 12000 has become an accepted standard technique in providingCost Effectivenesssoft tissue - DermaClose ® The tension controller has a rotary knob with a clutch and an coverage of increasingly complex wounds. Figure 2: Application of skin anchors adapted line chute that fits over the hooked end of one of the 10000 skin anchors. The enclosed line is placed over the hooked edge Tissue expansion in the field of lower extremity wound care has also 14000 of the anchors and the knob is tightened. (Figure 4,5) The undergone an evolution over8000 the past several decades. Mechanical tension controller cannot be over tightened because of a clutch skin stretching6 was month attempted cost ($) with devices such as the Sure Clo- DermaClose $ mechanism. The knob will “slip” on the clutch when a force of 12000 sure Skin Stretching System®.56000 However, the rigors of adjusting AMWT $ 1.2 kg is obtained. The device is then locked. 1.2 kg of force the device proved to be an obstacle to its continued use. Recently a will be maintained on the line until the device is removed or device has been developed that10000 provides continuous tissue expansion all of the line is retracted back into the tension controller. This for enhancing lower extremity4000 wound healing. The inconvenience of eliminates any need for retightening the device and provides adjusting the device has been eliminated and the preliminary results 8000 for continuous dynamic tension on the wound margins resulting are encouraging. The device2000 is marketed under the trade name Der- Figure 7: Retention sutures applied after 6 month cost ($) DermaClose $ in expansion of the surrounding tissue. This expanded tissue tissue is fully expanded to cover the original maClose RCTM. 6000 AMWT $ migrates to the wound providing coverage. (Figure 6) No dead wound. 0 space is produced since the subcutaneous tissue is mobilized Physiology: Pressure DM Trauma FigureSurgical 3: 4.5mm barbs of the skin anchor Wound Type with the skin margins. 4000 engage the subcutaneous tissue Skin has three important physical properties that make tissue expan- A primary dressing is applied that will manage wound exudate. sion possible. Skin tension is2000 a function of the elastic fiber network. The wound under tension from the DermaClose RCTM device This is the phenomenon surgeons see when making a skin incision tends to have increased exudate initially and extra absorbant and seeing the contraction of the0 wound edges away from the incision. dressings are suggested. Secondary dressings are chosen based Skin extensibility is the response of skinPressure to mechanical forces.DM An ex- Trauma Surgical on the anatomy of the area. The tissue expander stays in place ample of this is the stretching of skin over the elbow as the armWound flexed Type for 1-7 days depending on the size of the wound and the elastic- and extended. The final property is viscoelasticity. This is creep and ity of the tissue being mobilized. stress relaxation. As tissue is stretched, less force is required to main- ® tain that stretchCost over effectivenesstime. comparison between DermaClose and Advanced Moist Wound Therapy. When the device is removed several retention sutures are applied to maintain the tissue expansion over the next couple of weeks. Traditional tissue expansion happens in one of two ways. Prolonged Figure 8: Two weeks after presentation with (Figure 7) This effectively results in the physiologic changes partial thickness wound remaining tissue expansion (PTE) occurs over 1-6 weeks. Rapid intraoperative Figure 4: Tightening of tensioning device expected with PTE. Primary wound healing has not been our with nylon line engaging the skin anchors Cost effectiveness comparison between DermaClose and Advanced Moist Wound Therapy. Page 28 2nd Quarter www.aspma.org ASPMA Page 29 2nd Quarter www.aspma.org ASPMA Summary:Summary: Summary: ContinuousSummary:Continuous tissue tissue expansion expansion offers offers the woundthe wound care care Continuous tissue expansion offers the wound care Summary:physicianSummary:physician a reproducible a reproducible and reliableand reliable method method of of physician a reproducible and reliable method of obtainingContinuousobtaining local localtissue donor donor expansion tissue tissue for offersrapid for rapid andthe durableand durable obtaining local donor tissue for rapid and durable ContinuousepithelializationwoundContinuousepithelialization tissue care physician expansion tissueof lower of expansion lower a extremityoffersreproducible extremity the offers wounds.wound andthewounds. carewound The The care epithelializationSummary: of lower extremity wounds. The physiciantechniquereliablephysiciantechnique a reproducible methoddescribed adescribed reproducible of takesobtaining and takes reliableadvantage and advantage local reliablemethod donorof the ofmethod of physi-the physi- of technique described takes advantage of the physi- obtainingtissueobtainingologic local for properties rapiddonor local and tissue donor ofdurable skin for tissue rapidplaced for and rapidunder durable and prolonged durable ologicologicContinuous properties properties tissue of of skin expansion skin placed placed offersunder under the prolonged prolonged wound care epithelializationepithelializationepithelializationtissue expansion of lower of of producinglower extremity lower extremity extremity increasedwounds. wounds. epidermalThe The tissuetissuephysician expansion expansion a reproducible producing producing andincreased increased reliable epidermal epidermal method of techniquemitosiswounds.obtainingtechniquemitosis described and Theenhancedand local described techniqueenhanced takes donor microcirculation. advantage tissuetakes microcirculation.described advantagefor ofrapid thetakes and physi-In of this durablethe In au-thisphysi- au- ologicmitosis propertiesthor’s and opinion, enhancedof skin these placed microcirculation. effects under synergistically prolonged In this resultau- in thor’sadvantagethor’sepithelializationologic opinion, opinion, properties of thesethe these physicologicof effects of lowereffects skin extremitysynergistically placedsynergistically properties under wounds. prolonged ofresult result The inin tissue expansionenhanced producingrapid healing increased of chronic epidermal wounds. enhancedskinenhancedtechniquetissue placed rapidexpansion rapid described under healing healing prolonged producing takesof of chronic chronic advantage tissue increased wounds. wounds. of theepidermal physi- mitosisexpansionologic mitosisand enhanced properties and producing enhanced microcirculation. of skin increased microcirculation. placed epidermalunder In thisprolonged au-In this au- thor’s opinion,The DermaClose these effects RCTM synergistically device is easilyresult appliedin ThemitosisThetissue thor’sDermaClose DermaClose expansion andopinion, enhanced RCTM RCTMtheseproducing microcirculation. effects device device increased synergisticallyis is easily easily epidermal applied appliedIn result in enhancedin rapidan outpatient healing setting.of chronic As wounds. an external device, the in thisinanmitosis enhancedan outpatient author’s outpatient and rapid enhancedopinion, setting. setting. healing these Asmicrocirculation. As anof aneffects chronicexternal external wounds. device, device, In this the the au- complications expected would be relatively low. complicationssynergisticallycomplicationsthor’s opinion, expected expected result these in effectswould wouldenhanced synergisticallybe be relatively relatively rapid low. low.result in The DermaCloseOur early analysisRCTM deviceof cost issavings easily whenapplied utilizing this OurhealingOurenhanced Theearly early DermaClose analysisof analysis chronicrapid healingof of wounds. costRCTM cost savingsof savings chronic device when when wounds. is easily utilizing utilizing applied thisthis in andevice outpatientdeviceindevice anis isencouraging.outpatient isencouraging. setting. encouraging. setting. As In anIn addition external additionIn As addition an toexternal todevice, cost cost to costeffective- effective- device,the effective- the complicationsThecomplicationsness, DermaClose the expected rapid expectedwound RCTMwould healing bedevicewould relatively timeisbe easily relatively and low. applieddurability low. ness,Theness, the DermaClose® the rapid rapid wound wound RC healing healing device time time is easilyand and durability durability Our earlyinOurshould an analysis earlyoutpatient result analysis of incost setting. lower savingsof cost morbidity.As an savingswhen external utilizing Scientificwhen device, utilizing this thestudies this shouldappliedshould result result in an in in outpatientlower lower morbidity. morbidity. setting. Scientific AsScientific an studiesstudies devicewillwill complications isdevicewillbe encouraging.be needed be needed isneeded encouraging. to toexpectedconfirm toconfirm In confirm addition would these Inthese additionthese to early be earlycost relatively early observations, effective-toobservations, costobservations, low. effective- external device, the complications expected ness,but thebut Ourthisness,but rapidthis earlydevicethis thedevice wounddevice analysisrapid would would healingwoundwould ofappear appearcost appear healingtime savings to to beand beto timeone onebewhendurability ofone andof the utilizingthe ofdurability fewthe few few this would be relatively low. Our early analysis shouldtruetrue device resultshouldtrueinnovations innovations innovations inis result encouraging.lower in in in morbidity.lower lower lowerin lower extremity In morbidity.extremity addition extremity Scientific wound woundto Scientific costwound studies care. care.effective- care. studies will beofness, willneeded cost bethe savings neededtorapid confirm whenwound to confirm theseutilizing healing early these timethis observations, device earlyand durability observations, is but thisencouraging.should butdevice this result woulddevice inIn appearloweradditionwould morbidity. toappear to be cost one to ofScientificbe theone few of thestudies few true innovationseffectiveness,willtrue be innovations needed in lowerthe to rapid confirmin extremity lower wound these extremity wound healing early care.wound observations,time care. andbut durability this device should would result appear in to lower be one of the few morbidity.true innovations Scientific in lower studies extremity will be wound needed care. to confirm these early observations, but this device would appear to be one of the few true innovations in lower extremity wound care.

WoundWound Care CareCenter Center algorithm algorithm utilized. utilized. DermaClose DermaClose therapy therapy was compared was compared to to WoundAdvanced Care Moist Center Wound algorithm Therapy utilized. utilizing DermaClose this algorithm. therapy was compared to AdvancedAdvanced Moist Moist Wound Wound Therapy Therapy utilizing utilizing this algorithm.this algorithm.

Wound CareWound Center Care algorithm Center algorithm utilized. utilized. DermaClose DermaClose therapy wastherapy compared was compared to to AdvancedWoundAdvanced Moist Care WoundCenter Moist algorithmTherapy Wound Therapy utilizingutilized. utilizing this DermaClose algorithm. this algorithm. therapy was compared to Advanced Moist Wound Therapy utilizing this algorithm.

References: References:References: 1. Cherry G, et al. Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin. Plast Recontr Surg 72(5): 680-687, 1983. 1. 2. 1. Cherry Codvilla Cherry G, et A, G,al. On etIncreased theal. meansIncreased survival of lengthening survival and vascularity and in vascularity the lower of random-pattern limbs, of random-pattern the muscles, skin and flapsskin the flaps elevated tissues elevated which in controlled, inare controlled, shortened expanded throughexpanded skin. deformity. skin.Plast PlastRecontr Am Recontr J OthopSurg 72(5): SurgSurg 72(5): 2:680-687, 353-369, 680-687, 1983. 1905. 1983. 2. 3. 2. Codvilla Neuman Codvilla A, C, On TheA, the On expansion means the means of oflengthening anof arealengthening of skinin the by in lower progressivethe lower limbs, limbs, distensionthe muscles, the muscles, of aand subcutaneous the and tissues the tissues balloon.which which are Plast shortened are Reconstr shortened through Surg through 19:deformity. 124, deformity. 1957. Am J Am Othop J Othop Surg 2:Surg 353-369, 2: 353-369, 1905. 1905. References: 3. 4. 3.References: Neuman Radovan Neuman C, C,The C,Breast expansion The reconstructionexpansion of an ofarea anafter ofarea skinmastectomy of byskin progressive by using progressive the distension temporary distension of expander. a subcutaneous of a subcutaneous Plast Reconstr balloon. balloon. Surg Plast 69(2): PlastReconstr Reconstr 195-208, Surg Surg1982.19: 124, 19: 1957.124, 1957. References: 4. 5. 4. Radovan Armstrong Radovan C, Breast D, C, Lavery Breast reconstruction L, reconstruction 1998 William after mastectomyafter J. Stickel mastectomy Silver using Award. using the temporary Mechanicallythe temporary expander. assisted, expander. Plast delayed PlastReconstr primaryReconstr Surg closure Surg69(2): of69(2): 195-208,diabetic 195-208, foot 1982. wounds. 1982. J Am Podiatr Med Assoc 1. Cherry G, et al. Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin. Plast Recontr Surg 72(5): 680-687, 1983. 5. 88(10):5.1. 483-488, Armstrong ArmstrongCherry 1998. D, G, Lavery et D, al. Lavery Increased L, 1998 L, 1998William survival William J. and Stickel vascularityJ. Stickel Silver Silver Award.of random-pattern Award. Mechanically Mechanically skin assisted, flaps assisted, elevateddelayed delayed inprimary controlled, primary closure closureexpanded of diabetic of skin.diabetic foot Plast wounds. foot Recontr wounds. J AmSurg JPodiatr Am72(5): Podiatr Med680-687, AssocMed Assoc1983. 2. 1. Codvilla Cherry A, On G,the et means al. Increased of lengthening survival andin the vascularity lower limbs, of random-pattern the muscles, and skin the flaps tissues elevated which in arecontrolled, shortened expanded through skin. deformity. Plast Recontr Am J OthopSurg 72(5): Surg 2:680-687, 353-369, 1983. 1905. 88(10):6. 88(10):2. 483-488, 483-488, Mackay Codvilla 1998. D, 1998. et A, al. On Stretching the means skin: of lengthening undermining in is the more lower important limbs, thanthe muscles, intraoperative and the expansion. tissues which Plast areReconstr shortened Surg through 86(4): deformity.722-730, 1990. Am J Othop Surg 2: 353-369, 1905. 3. 2. Neuman Codvilla C, The expansionA, On the meansof an areaof lengthening of skin by inprogressive the lower limbs,distension the muscles, of a subcutaneous and the tissues balloon. which Plast are shortened Reconstr throughSurg 19: deformity. 124, 1957. Am J Othop Surg 2: 353-369, 1905. 6. 7. 6.3. Mackay Pasyk MackayNeuman D,K, et D,al.C, et TheQuantitativeStretching al. expansion Stretching skin: analysis of skin:undermining an areaof undermining the of thickness skin is moreby is progressive of moreimportant human important skin distensionthan and intraoperativethan subcutaneous intraoperativeof a subcutaneous expansion. tissue expansion. following balloon. Plast controlledPlastReconstr Plast Reconstr Reconstr Surgexpansion Surg86(4): Surg with86(4): 19:722-730, a 124, silicone 722-730, 1957. 1990. implant. 1990. Plast Reconstr 4. 3. Radovan Neuman C, Breast C, reconstructionThe expansion ofafter an mastectomyarea of skin by using progressive the temporary distension expander. of a subcutaneous Plast Reconstr balloon. Surg Plast 69(2): Reconstr 195-208, Surg 1982. 19: 124, 1957. 7. Surg7.4. 81(4): Pasyk 516-523, PasykRadovan K, et K,al. 1988. C,et Quantitative al.Breast Quantitative reconstruction analysis analysis of afterthe of thickness mastectomythe thickness of human using of human theskin temporary andskin subcutaneous and expander.subcutaneous tissue Plast tissue following Reconstr following controlledSurg controlled 69(2): expansion 195-208, expansion with 1982. awith silicone a silicone implant. implant. Plast PlastReconstr Reconstr 5. 4. Armstrong Radovan D, Lavery C, Breast L, 1998 reconstruction William J. afterStickel mastectomy Silver Award. using Mechanically the temporary assisted,expander. delayed Plast Reconstr primary Surg closure 69(2): of diabetic 195-208, foot 1982. wounds. J Am Podiatr Med Assoc Surg8. Surg5.81(4): 81(4): 516-523, Barker Armstrong 516-523, D, 1988. et al. D,1988. Resistance Lavery L, of 1998 rapidly William expanded J. Stickel random Silver skin Award. flaps to Mechanically bacterial invasion. assisted, J Traumadelayed 27(9):primary 1061-1065, closure of 1987. diabetic foot wounds. J Am Podiatr Med Assoc 88(10): 483-488,5. 1998. Armstrong D, Lavery L, 1998 William J. Stickel Silver Award. Mechanically assisted, delayed primary closure of diabetic foot wounds. J Am Podiatr Med Assoc 8.88(10): 483-488, Barker 1998. D, et al. Resistance of rapidly expanded random skin flaps to bacterial invasion. J Trauma 27(9): 1061-1065, 1987. 6. 8. 88(10):6. Mackay Barker483-488, D, Mackay D,et 1998.al.et al. StretchingD, Resistanceet al. Stretching skin: of underminingrapidly skin: expanded undermining is more random important is more skin important flapsthan intraoperative to bacterialthan intraoperative invasion. expansion. J expansion.Trauma Plast Reconstr 27(9): Plast 1061-1065,ReconstrSurg 86(4): Surg 1987. 722-730, 86(4): 722-730,1990. 1990. 7. 6.7. Pasyk K, Mackay Pasyket al. QuantitativeK,D, et al. StretchingQuantitative analysis skin: of analysis the undermining thickness of the thicknessisof morehuman important of skin human and than subcutaneousskin intraoperative and subcutaneous tissue expansion. following tissue Plast following controlled Reconstr controlled expansion Surg 86(4): expansion with 722-730, a silicone with 1990. a implant. silicone implant.Plast Reconstr Plast Reconstr 7. Pasyk K, et al. Quantitative analysis of the thickness of human skin and subcutaneous tissue following controlled expansion with a silicone implant. Plast Reconstr Surg 81(4):Surg 516-523, 81(4): 516-523,1988. 1988. Surg 81(4): 516-523, 1988. 8. 8. Barker D, Barker et al. ResistanceD, et al. Resistance of rapidly of expanded rapidly expanded random skin random flaps skin to bacterialflaps to invasion.bacterial invasion. J Trauma J 27(9):Trauma 1061-1065, 27(9): 1061-1065, 1987. 1987. 8. Barker D, et al. Resistance of rapidly expanded random skin flaps to bacterial invasion. J Trauma 27(9): 1061-1065, 1987.

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