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Soft Tissue Injury Management With a Continuous External Tissue Expander

Santiago, Gabriel F. MD*; Bograd, Benjamin MD*; Basile, Patrick L. MD*†‡; Howard, Robert T. MD*†; Fleming, Mark DO*; Valerio, Ian L. MD, MS, MBA*†‡

doi: 10.1097/SAP.0b013e31824a4584
Clinical Papers

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 cm2. Mean wound size was 262.7 cm2. 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.

From the *Walter Reed National Military Medical Center, Bethesda, MD; †Division of Plastic and Reconstructive Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA; and ‡Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Baltimore, MD.

Received January 6, 2012, and accepted for publication, after revision, January 9, 2012.

Presented at the 28th Annual Meeting of the Northeastern Society of Plastic Surgeons, Amelia Island, FL, October 20–23, 2011.

Conflicts of interest and sources of funding: Neither Dr Valerio nor his associated coauthors have received anything of value from or owns stock in a commercial company or institution related directly or indirectly to the subject of this article. Views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, nor the US Government.

Reprints: Ian L. Valerio, MD, MS, MBA, Plastic and Reconstructive Surgery Service, Walter Reed National Medical Center, 8901 Wisconsin Ave, Bethesda, MD 20889. E-mail:;

© 2012 Lippincott Williams & Wilkins, Inc.