INTRODUCTION

Skin possesses unique properties, which allow it to confirm to the shape depending on the external or internal forces applied. Using few of its properties such as creep and elasticity aids in an important aspect of plastic surgery, which is wound coverage. Two types of skin expansion have been described: internal and external tissue expansion. Various external tissue expansion devices are available. In this article, we would like to share our experience of innovative use of ziplock as external tissue expansion.

MATERIALS AND METHODS

This study was conducted in a tertiary care hospital in June 2019.

The patient was a 65-year-old gentleman, a known case of diabetic and hypertensive, chronic liver disease, and portal hypertension with thrombocytopenia. He had a chronic nonhealing ulcer over the dorsum of the right foot for 1-month duration.

Even after wound bed preparation with medical and surgical methods, the wound bed could not be covered, due to his thrombocytopenia, which made him unfit for major surgery.

Hence while optimizing the patient general condition, we thought of innovative method of using commercially available ziplock tags for using as external skin expansion device.

Materials required

1. Commercially available 15 cm ziplock tags, 2. polypropylene suture material, 3. instruments for suturing. The cost of each ziplock tag was INR 5 [Figure 1].

Close

Figure 1

Equipments required

Export to PPT

Steps

The lock end of the ziplock was cut and it was sutured to the normal skin around the ulcer on one side [Figure 2]. The zip tag end was sutured to the opposite side of the lock end and it was locked [Figures 3 and 4]. As we were waiting for the patient general condition to improve, the ziplock was tightened and advanced on a daily basis by few millimeters. This way, the size of the wound, which was 15 cm × 7 cm on admission, had reduced to 10 cm × 5 cm [Figure 5]. It was applied to prevent expansion of wound margins as well as to bring them together. It was used as adjuvant therapy in multimodality wound bed preparation. Once the patient improves, the wound will be covered.

Close

Figure 2

Lock end of the zip ties being cut

Export to PPT

Close

Figure 3

Ends being sutured to the wound edges

Export to PPT

Close

Figure 4

Post application of ziplock tags

Export to PPT

Close

Figure 5

Decrease in wound size post application of ziplock tags

Export to PPT

DISCUSSION

Immediate, primary closure of wounds is the best solution for soft tissue defect closure because of its simplicity and satisfactory outcome, yet it might not be possible always.[1] Various factors, both wound related (due to a big raw area) and patient related (general condition being unfit for surgery) will not permit early closure, either primarily or by grafts and flaps. In that case external tissue expansion plays a major role.

Skin is a dynamic tissue, which has unique biochemical properties that allow it to protect and conform to the body that it covers. They are (a) stress, (b) strain, (c) creep, (d) elasticity, (e) extensibility, (f) viscosity, (g) anisotropy, and (h) viscoelasticity.[2]

Tissue expansion was described first by Neumann,[3] who related the use of a rubber balloon placed subcutaneously in the postauricular region. This was a form of internal tissue expansion. Since then various research has been undertaken and tissue expansion has gained widespread popularity

In recent days, the same techniques that have used the creep and stress relaxation phenomena of skin used in internal expansion has been extrapolated to gain tissue for wound coverage in the form of external tissue expansion. Various commercial devices are available for external wound expansion. But they neither are they easily available, nor are they cost-effective (INR 5000 for a single application). To circumvent those issues, ETEWC technique using hooks and rubber bands which can be used for wound closure have been described.[4]

In a similar manner, we have described the use of ziplock eternal tissue expansion, which is cost-effective (INR 5/piece). It is also easily available, and can be sterilized easily using ETO or gamma radiation.

The advantages of this method is that, while waiting for the general condition of the patient to get optimized, we can reduce the wound size and thereby decrease the size of graft or flap used. It is based on the principle that, the given pressure exerted through a smaller area will be much higher than the same pressure exerted through a larger area. Hence it is much better than sutures used to approximate the edges of a wide wound. The prerequisite is that the wound margins are healthy enough to sustain the tension. It can also be used as an effective dressing holder, which prevents the dressing from getting dislodged.

The disadvantages are that it cannot be used in an inflamed skin margin because it will shear the skin.

CONCLUSION

External skin expansion using ziplock tags is easy to apply, cost-effective, can be applied bed side and results are comparable with commercially available external expansion devices. A controlled, large sample size study with statistical analysis is required to substantiate the results.