Stress-relaxation and tension relief system for immediate primary closure of large and huge soft tissue defects: an old-new concept: new concept for direct closure of large defects

Abstract

Stress-relaxation is a well-established mechanism for laboratory skin stretching, with limited clinical application in conventional suturing techniques due to the inherent, concomitant induction of ischemia, necrosis and subsequent suture failure. Skin defects that cannot be primarily closed are a common difficulty during reconstructive surgery. The TopClosure tension-relief system (TRS) is a novel device for wound closure closure, providing secured attachment to the skin through a wide area of attachment, in an adjustable manner, enabling primary closure of medium to large skin defects. The aim of this study was to evaluate the efficiency of the TopClosure TRS as a substitute for skin grafting and flaps for primary closure of large soft tissue defects by stress-relaxation. We present three demonstrative cases requiring resection of large to huge tumors customarily requiring closure by skin graft or flaps. TRS was applied during surgery serving as a tension-relief platform for tension sutures, to enable primary skin-defect closure by cycling of stress-relaxation, and following surgery as skin-secure system until complete wound closure. All skin defects ranging from 7 to 26 cm in width were manipulated by the TRS through stress-relaxation, without undermining of skin, enabling primary skin closure and eliminating the need for skin grafts and flaps. Immediate wound closure ranged 26 to 135 min. TRS was applied for 3 to 4 weeks. Complications were minimal and donor site morbidity was eliminated. Surgical time, hospital stay and costs were reduced and wound aesthetics were improved. In this case series we present a novel technology that enables the utilization of the viscoelastic properties of the skin to an extreme level, extending the limits of primary wound closure by the stress-relaxation principle. This is achieved via a simple device application that may aid immediate primary wound closure and downgrade the complexity of surgical procedures for a wide range of applications on a global scale.

Conflict of interest statement

The authors have no funding and conflicts of interest to disclose.

Figures

FIGURE 1

Reconstruction of a huge soft tissue defect in right flank (REPRESENTATIVE CASE 1) by the tension-relief system. A. Large ulcerated squamous cell carcinoma in the right flank. B. Ablative tumor resection resulted in a defect of 15 × 25 cm. C. Immediate primary closure of wound within less than 30 min. D. Post-operative day 1, a small, limited dehiscence. Wound edges are secured by tension sutures, avoiding complete dehiscence of surgical wound. E. Six months following surgery, uneventful recovery, with minor widening and depression of the scar and additional skin tumor to be excised.

FIGURE 2

Reconstruction of a large soft tissue defect in the Lt. scapular region after wide ablation of malignant melanoma (REPRESENTATIVE CASE 2). A. Post-incomplete excisional biopsy of malignant melanoma lesion in scapular area. B. Tumor ablation resulted in a defect of 7 × 11.5 cm. C. Immediate primary closure was achieved; utilizing 3 TopClosure® 8 mm sets. D. Six weeks following surgery, acceptable aesthetic result, mild, partial hypertrophic scar. E. Eighteen months following surgery, mild widening of scar is observed.

FIGURE 3

Reconstruction of a huge soft tissue defect in the right supraclavicular region, extending to the base of the neck by the TopClosure® tension-relief system (REPRESENTATIVE CASE 3). A. Large recurrent tumor of the right cervical/supraclavicular region, 18 × 25 cm. B. Coronal MRI section demonstrating the extent of tumor. C. Twenty-six centimeter wide defect following tumor ablation. D. Immediate, direct primary closure was achieved in just over 2 hours. E. Post-operative day 23, uneventful recovery. F. Ten months following surgery, slight widening of scar is observed.