Soft tissue injury management with a continuous external tissue expander

BACKGROUND: Blast exposure is a common cause of soft tissue injury within the battlefield setting, with the extremities often critically involved. The resulting injury pattern presents with massive soft tissue defects that may be further complicated by varying degrees of accompanying orthopedic and peripheral nerve damage. To address the severe soft tissue defect, various combinations of advanced reconstructive methods are typically required to achieve definitive wound coverage. Continuous external tissue expansion has been used by our institution to significantly reduce wound burden and provide for definitive wound closure in certain blast-injured patients. METHODS: The authors present an early series of 14 patients who suffered massive extremity soft tissue injuries and were treated with an external tissue expansion system (DermaClose RC). Outcome measurements included time to definitive closure and method of definitive wound closure. A 5-patient subset of this group was prospectively analyzed to determine measurements including initial wound surface area (WSA), percentage reduction in WSA, and related complications. RESULTS: Overall time to wound coverage ranged from 1 to 6 days, with mean time to wound coverage being 4.4 days. Of the 14 patients included in the series, 12 (85.7%) were able to undergo delayed primary closure, whereas 2 required split thickness skin grafting. In the 5-patient subgroup, WSA initially ranged from 20.25 to 1031.25 cm. Mean wound size was 262.7 cm. Decrease in WSA ranged from 44% to 93% of the initial WSA, with mean decrease being 74.3% (95% confidence interval, 57.33-91.3). CONCLUSIONS: In the management of large complex wounds, external tissue expansion has proven to be a valuable adjunct in achieving definitive wound closure. It can often aid in successful delayed primary closure of certain soft tissue wounds, has low associated morbidities, and can reduce the need for more complex or morbid procedures when used properly. The authors propose an algorithm for the use of continuous external tissue expansion system to achieve effective and successful wound closure, while potentially reducing the need for increased donor-site morbidities associated with more complex or larger reconstruction measures.