- Email: [email protected]
The application of dermatotraction for primary skin closure
The American Journal of Surgery 190 (2005) 123–126
How I do it
The application of dermatotraction for primary skin closure Daniel J. Marek, M.D.a, G. Edward Copeland, M.D.b, Michael Zlowodzki, M.D.a, Peter A. Cole, M.D.a,* a
Department of Orthopaedic Surgery, University of Minnesota, Regions Hospital, 640 Jackson St., St. Paul, MN 55101, USA b Department of Orthopaedic Surgery, University of Arkansas, 4301 W. Markham St., Little Rock, AR 72205, USA
Abstract Management of an open wound is a problem frequently encountered in the treatment of fractures. Skin grafting, rotational flaps, free flaps, and healing by secondary intention add a considerable amount of morbidity and cost to the patient. Therefore, it is ideal to obtain primary closure when possible. This communication describes a technique that uses spinal needles, using towel clips and the natural stretching ability of the skin to enable primary closure of wounds. The technique described uses dermatotraction to stretch the skin is a cost-effective way to achieve primary closure of large wounds with supplies that are readily available in every operating room. © 2005 Excerpta Medica Inc. All rights reserved. Keywords: Dermatotraction; Mechanical creep; Stress-relaxation; Swelling; Wound closure
Management of an open wound is a problem frequently encountered in the treatment of fractures. Traditional methods other than primary closure include skin grafting, rotational flaps, free flaps, and healing by secondary intention. These methods add a considerable amount of cost, time, and morbidity to the patient. Therefore, it is ideal to obtain primary closure when possible. Primary closure may be assisted using the viscoelastic properties of the skin. The viscoelastic properties of mechanical creep and stress relaxation in skin were described ⬎40 years ago [1,2]. If skin is stretched with a constant force, it will expand with time as long as it is kept under tension, a phenomenon known as “mechanical creep.” In contrast, if the skin is stretched to a constant distance, it will expand and lead to a decrease in the force or tension on the skin with time, a phenomenon known as “stress–relaxation.” Surgeons have recently applied these stretching properties to close large wounds that previously would have undergone secondary closure. Recently, load cycling has been identified in the literature as another skin stretching technique based on mechanical creep principles. Load cycling is the incremental elongation of the skin when intermittent tension is applied [3]. Tension applied for approximately 3 minutes is followed by a load-free period of 30 to * Corresponding author. Tel.: ⫹1-651-254-1513. fax: ⫹1-651-2541519. E-mail address: [email protected]
60 seconds. A load is reapplied for an additional 3 minutes, and the cycle continues until the desired elongation of skin has occurred. Load cycling has been shown to dramatically aid in skin stretching and typically occurs within 15 minutes [4,5]. In 1993, Hirshowitz et al [5] first described a skinstretching device that later became known as the SureClosure skin-stretching system (Zimmer, Warsaw, Indiana). The device uses the principles of mechanical creep and stress–relaxation to apply tension along the entire wound to stretch the skin and minimize the tendency for the skin to recoil. Once the skin has stretched to approximate the wound edges, either sutures or staples may be used for closure. However, availability of this device is variable and it adds considerable cost to any procedure. This article will describe a technique that uses the natural stretching ability of the skin to enable primary closure of wounds. This method is cost-effective and employs supplies that are readily available in every operating room.
Surgical Technique The required equipment includes 2 18-gauge spinal needles and 2 towel clips. The spinal needles are inserted subdermally at approximately 5 mm from the wound margins. The tongs of the clamps are then placed with the tips around the spinal needles, 1 clamp on each end of the
0002-9610/05/$ – see front matter © 2005 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2005.05.038
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D. J. Marek et al. / The American Journal of Surgery 190 (2005) 123–126
Fig. 1. Oblique (top) and anterior–posterior (bottom) radiographs of the forearm demonstrating a ballistic injury resulting in an ulna fracture.
wound. The skin edges are advanced slowly using the clamps: 1 notch equals 1 load cycle. Mild skin blanching will subside as the skin undergoes stress–relaxation. If there is concern regarding lack of capillary refill, the skin can be tested by checking with a fine needle for bleeding. After 10 to 15 minutes of stress–relaxation, the tension will have decreased, and the towel clips may be gradually advanced. It is not recommended or necessary to undermine the skin because this has been shown to decrease local blood supply [6]. Once the skin edges are approximated, the wound is closed using either sutures or staples.
Case Report A 23-year-old man presented to the emergency room after a gunshot wound to the left forearm at close range. Radiographs revealed an isolated midshaft ulna fracture (Fig. 1). The patient was taken to the operating room and underwent open reduction and internal fixation of the ulna through a dorsal incision (Fig. 2). The patient had marked swelling of the soft tissues, and the skin edges could not be easily approximated. The distal 2 cm and proximal 4 cm of the wound underwent primary closure. At this point, an 18-gauge spinal needle was placed subdermally on each side of the open wound as described previously (Fig. 3). Two towel clips were then placed on the outside of the spinal needles near the ends of the wound (Fig. 4). The skin edges were slowly advanced 1 ratchet at a time. This process was executed during a 20-minute period until the skin edges were brought together (Fig. 5). The subcutaneous tissues were loosely approximated with 4-0 vicryl sutures, and the skin was closed with 3-0 nylon sutures. The towel clips and spinal needles were subsequently removed (Fig. 6).
Fig. 2. Anterior–posterior (top) and lateral (bottom) radiographs of the forearm demonstrating the fracture after open reduction and plate fixation of the ulna.
Comments The notion of using the viscoelastic properties of the skin to close large wounds is a relatively recent idea. In 1991, Almekinders [7] described a technique in which staples were placed along the skin edges, and half of each staple was embedded in the skin, whereas the other half acted as an eyelet for a large nylon suture. The suture was tightened daily, and primary closure was obtained after 5 to 10 days. Another study used staples and a rubber vessel loop instead
Fig. 3. Surgical incision in a massively swollen forearm demonstrating significant tension of the skin. Two 18-gauge needles were placed immediately subdermally on both sides of the wound approximately 5 mm from the wound margins.
D. J. Marek et al. / The American Journal of Surgery 190 (2005) 123–126
Fig. 4. Two towel clips were placed across the wound at the proximal and distal needles and slowly closed during a period of 20 minutes, thereby approximating the edges of the incision. The skin is stretched and expands, leading to a decrease in the force or tension on the skin with time (stress–relaxation).
of a large suture to apply tension across the skin edge [8]. Unfortunately, these methods do not apply an evenly distributed tension across the entire wound, typically take several days, and/or multiple trips to the operating room for progressive closure. Hirshowitz et al [5] described a technique that used 2 pins embedded intradermally and attached to a skin-stretching device. This technique distributes tension more evenly along the wound edge. The investigators discovered that stretching occurred within 20 to 30 minutes when both subcutaneous and cutaneous tissues were normal. However, stretching was considerably slowed by chronic edema and fibrosis secondary to the pace at which collagen fibers realign [5]. As mentioned previously, this device has been marketed as the Sure-Closure skin stretching-system (Fig. 7). Different investigators have applied this device to the closure of fasciotomies [9], diabetic ulcers [10], free-flap donor sites [11], and Mohs defects [12] with relatively good suc-
Fig. 5. After the wound edges are brought together with towel clips, the wound is closed with sutures.
125
Fig. 6. Closed incision immediately after surgery.
cess. One group, however, found increased compartmental pressures using the Sure-Closure skin-stretching system and encouraged close monitoring of these pressures during follow-up [13]. Abramson et al [14] described an alternative to the SureClosure skin-stretching system in a different setting that mimics the technique presented here. The method used a rib approximator and 2 18-gauge spinal needles to allow for primary closure in large cutaneous wounds. The 2 spinal needles were placed approximately 3 cm from the wound edges with the central portion of the needles exposed so the rib approximator could be hooked onto the needles. The rib approximator was progressively tightened until the skin edges aligned, and vicryl sutures were used to close the wound. Two main differences exist between Abramson’s technique and the method reported here. Abramson placed the spinal needles 3 cm from the wound edge. In our method, the spinal needles are placed only 5 mm from the wound edge. This allows for a greater surface area of skin to participate in stress–relaxation, less skin tension, and a
Fig. 7. Sure-Closure skin-stretching system as first described by Hirshowitz et al [5]. Here it shown applied to a lateral thigh wound.
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D. J. Marek et al. / The American Journal of Surgery 190 (2005) 123–126
theoretical decrease in risk of increased compartment pressures. Additionally, Abramson used 1 rib approximator to apply tension to the spinal needles. The tension in the middle was greater than at the ends of the spinal needle. Our technique using 2 towel clips allows for a more evenly distributed tension along the 2 needles. Like Abramson’s technique, our method allows for primary closure of substantial wounds without using the SureClosure skin-stretching system, avoids unnecessary costs, and saves substantial time. The Sure-Closure skin-stretching system is relatively expensive ($450.00/device), whereas each spinal needle costs approximately $1.55. Most operating rooms are equipped with 18-gauge spinal needles and towel clips, whereas availability of the Sure-Closure device is more variable. Our method also requires less operating room time compared with secondary closure. There are some limitations to the technique described here. First, there is no built-in monitoring system, transducer, force-limiting applicator, or other safety mechanism. Capillary refill is not a great indicator in determining the application of the next load. Capillary refill does provide information about the blood supply, but it does not give any indication as to the architecture of the dermis itself. Second, the dermis thins at a rate of 6%/decade, with less ground substance present in aged skin [15]. Therefore, elderly patients may not have as much skin to participate in the stretching. Third, neither the Sure-Closure device nor the technique reported here can easily incorporate the principles of load cycling. Finally, like the Sure-Closure and other “homemade” skin-stretching methods, the load is not completely distributed evenly. The load at the site of the towel clips is greater than at the middle of the spinal needles. Other skin- stretching techniques, such as presuturing [16], allow for a more evenly distributed tension, but they require significantly more time and are not applicable in the trauma setting. In the trauma setting, the technique described here must be employed with good judgment because the integument may be compromised, muscle tissues may be threatened, and compartment edema may be substantial. Good judgment requires experience, and an applicable conservative working rule is to stop pressure if concern for skin dehiscence or compartment syndrome even enters the mind of the surgeon. A compartment measurement to obtain a simple
pressure reading can help guide decision making during the learning curve of this technique. This technique will allow surgeons to avoid the relatively high cost of the SureClosure skin-stretching system and lengthy procedures to achieve primary closure of large wounds.
References [1] Gibson T, Kenedi RM, Craik JE. The mobile microarchitecture of dermal collagen: a bioengineering study. Br J Surg 1965;52:764 –70. [2] Neumann CG. The expansion of an area of skin by progressive distension of a subcutaneous balloon. Plast Reconstr Surg 1957;19: 124 –30. [3] Gibson T. The physical properties of skin. In: Converse JM, editor. Reconstructive Plastic Surgery. Vol. 1. Philadelphia, PA: Saunders; 1977:70 –7. [4] Hirshowitz B, Kaufman T, Ullman J. Reconstruction of the tip of the nose and ala by load cycling of the nasal skin and harnessing of extra skin. Plast Reconstr Surg 1986;77:316 –9. [5] Hirshowitz B, Lindenbaum E, Har-Shai Y. A skin-stretching device for the harnessing of the viscoelastic properties of the skin. Plast Reconstr Surg 1993;92:260 –70. [6] Melis P, Noorlander ML, van der Klejj AJ, et al. Oxygenation and microcirculation during skin stretching in undermined and nonundermined skin. Plast Reconstr Surg 2003;112:1295–301. [7] Almekinders LC. Gradual closure of fasiotomy wounds. Orthop Rev 1991;20:82– 4. [8] Harris I. Gradual closure of fasciotomy wounds using a vessel loop shoelace. Injury 1993;24:565– 6. [9] Narayanan K, Latenser BA, Jones LM, et al. Simultaneous primary closure of four fasciotomy wounds in a single setting using the Sure-Closure device. Injury 1996;27:449 –51. [10] Armstrong DG, Wunderlich RP, Lavery LA. Reaching closure with skin stretching: applications in the diabetic foot. Clin Podiatr Med Surg, 1998;15:109 –16. [11] Futran ND. Closure of the fibula free flap donor site with the SureClosure skin-stretching device. Laryngoscope 1996;106:1487–90. [12] Marrero GM, Dufresne RG Jr. An intraoperative skin-stretching device to close wounds in Mohs defects. Dermatol Surg 1996;22:546 –50. [13] Hussmann J, Kucan JO, Zamboni WA. Elevated compartmental pressures after closure of a forearm burn wound with a skin-stretching device. Burns 1997;23:154 – 6. [14] Abramson DL, Gibstein LA, Pribaz JJ. An inexpensive method of intraoperative skin stretching for closure of large cutaneous wounds. Ann Plast Surg 1997;38:540 –2. [15] Branchet MC, Boisnic S, Frances C, et al. Skin thickness changes in normal aging skin. Gerontology 1990;36:28 –35. [16] Liang MD, Briggs P, Heckler FR, et al. Presuturing-a new technique for closing large skin defects: clinical and experimental studies. Plast Reconstr Surg 1988;81:694 –702.
How I do it
The application of dermatotraction for primary skin closure Daniel J. Marek, M.D.a, G. Edward Copeland, M.D.b, Michael Zlowodzki, M.D.a, Peter A. Cole, M.D.a,* a
Department of Orthopaedic Surgery, University of Minnesota, Regions Hospital, 640 Jackson St., St. Paul, MN 55101, USA b Department of Orthopaedic Surgery, University of Arkansas, 4301 W. Markham St., Little Rock, AR 72205, USA
Abstract Management of an open wound is a problem frequently encountered in the treatment of fractures. Skin grafting, rotational flaps, free flaps, and healing by secondary intention add a considerable amount of morbidity and cost to the patient. Therefore, it is ideal to obtain primary closure when possible. This communication describes a technique that uses spinal needles, using towel clips and the natural stretching ability of the skin to enable primary closure of wounds. The technique described uses dermatotraction to stretch the skin is a cost-effective way to achieve primary closure of large wounds with supplies that are readily available in every operating room. © 2005 Excerpta Medica Inc. All rights reserved. Keywords: Dermatotraction; Mechanical creep; Stress-relaxation; Swelling; Wound closure
Management of an open wound is a problem frequently encountered in the treatment of fractures. Traditional methods other than primary closure include skin grafting, rotational flaps, free flaps, and healing by secondary intention. These methods add a considerable amount of cost, time, and morbidity to the patient. Therefore, it is ideal to obtain primary closure when possible. Primary closure may be assisted using the viscoelastic properties of the skin. The viscoelastic properties of mechanical creep and stress relaxation in skin were described ⬎40 years ago [1,2]. If skin is stretched with a constant force, it will expand with time as long as it is kept under tension, a phenomenon known as “mechanical creep.” In contrast, if the skin is stretched to a constant distance, it will expand and lead to a decrease in the force or tension on the skin with time, a phenomenon known as “stress–relaxation.” Surgeons have recently applied these stretching properties to close large wounds that previously would have undergone secondary closure. Recently, load cycling has been identified in the literature as another skin stretching technique based on mechanical creep principles. Load cycling is the incremental elongation of the skin when intermittent tension is applied [3]. Tension applied for approximately 3 minutes is followed by a load-free period of 30 to * Corresponding author. Tel.: ⫹1-651-254-1513. fax: ⫹1-651-2541519. E-mail address: [email protected]
60 seconds. A load is reapplied for an additional 3 minutes, and the cycle continues until the desired elongation of skin has occurred. Load cycling has been shown to dramatically aid in skin stretching and typically occurs within 15 minutes [4,5]. In 1993, Hirshowitz et al [5] first described a skinstretching device that later became known as the SureClosure skin-stretching system (Zimmer, Warsaw, Indiana). The device uses the principles of mechanical creep and stress–relaxation to apply tension along the entire wound to stretch the skin and minimize the tendency for the skin to recoil. Once the skin has stretched to approximate the wound edges, either sutures or staples may be used for closure. However, availability of this device is variable and it adds considerable cost to any procedure. This article will describe a technique that uses the natural stretching ability of the skin to enable primary closure of wounds. This method is cost-effective and employs supplies that are readily available in every operating room.
Surgical Technique The required equipment includes 2 18-gauge spinal needles and 2 towel clips. The spinal needles are inserted subdermally at approximately 5 mm from the wound margins. The tongs of the clamps are then placed with the tips around the spinal needles, 1 clamp on each end of the
0002-9610/05/$ – see front matter © 2005 Excerpta Medica Inc. All rights reserved. doi:10.1016/j.amjsurg.2005.05.038
124
D. J. Marek et al. / The American Journal of Surgery 190 (2005) 123–126
Fig. 1. Oblique (top) and anterior–posterior (bottom) radiographs of the forearm demonstrating a ballistic injury resulting in an ulna fracture.
wound. The skin edges are advanced slowly using the clamps: 1 notch equals 1 load cycle. Mild skin blanching will subside as the skin undergoes stress–relaxation. If there is concern regarding lack of capillary refill, the skin can be tested by checking with a fine needle for bleeding. After 10 to 15 minutes of stress–relaxation, the tension will have decreased, and the towel clips may be gradually advanced. It is not recommended or necessary to undermine the skin because this has been shown to decrease local blood supply [6]. Once the skin edges are approximated, the wound is closed using either sutures or staples.
Case Report A 23-year-old man presented to the emergency room after a gunshot wound to the left forearm at close range. Radiographs revealed an isolated midshaft ulna fracture (Fig. 1). The patient was taken to the operating room and underwent open reduction and internal fixation of the ulna through a dorsal incision (Fig. 2). The patient had marked swelling of the soft tissues, and the skin edges could not be easily approximated. The distal 2 cm and proximal 4 cm of the wound underwent primary closure. At this point, an 18-gauge spinal needle was placed subdermally on each side of the open wound as described previously (Fig. 3). Two towel clips were then placed on the outside of the spinal needles near the ends of the wound (Fig. 4). The skin edges were slowly advanced 1 ratchet at a time. This process was executed during a 20-minute period until the skin edges were brought together (Fig. 5). The subcutaneous tissues were loosely approximated with 4-0 vicryl sutures, and the skin was closed with 3-0 nylon sutures. The towel clips and spinal needles were subsequently removed (Fig. 6).
Fig. 2. Anterior–posterior (top) and lateral (bottom) radiographs of the forearm demonstrating the fracture after open reduction and plate fixation of the ulna.
Comments The notion of using the viscoelastic properties of the skin to close large wounds is a relatively recent idea. In 1991, Almekinders [7] described a technique in which staples were placed along the skin edges, and half of each staple was embedded in the skin, whereas the other half acted as an eyelet for a large nylon suture. The suture was tightened daily, and primary closure was obtained after 5 to 10 days. Another study used staples and a rubber vessel loop instead
Fig. 3. Surgical incision in a massively swollen forearm demonstrating significant tension of the skin. Two 18-gauge needles were placed immediately subdermally on both sides of the wound approximately 5 mm from the wound margins.
D. J. Marek et al. / The American Journal of Surgery 190 (2005) 123–126
Fig. 4. Two towel clips were placed across the wound at the proximal and distal needles and slowly closed during a period of 20 minutes, thereby approximating the edges of the incision. The skin is stretched and expands, leading to a decrease in the force or tension on the skin with time (stress–relaxation).
of a large suture to apply tension across the skin edge [8]. Unfortunately, these methods do not apply an evenly distributed tension across the entire wound, typically take several days, and/or multiple trips to the operating room for progressive closure. Hirshowitz et al [5] described a technique that used 2 pins embedded intradermally and attached to a skin-stretching device. This technique distributes tension more evenly along the wound edge. The investigators discovered that stretching occurred within 20 to 30 minutes when both subcutaneous and cutaneous tissues were normal. However, stretching was considerably slowed by chronic edema and fibrosis secondary to the pace at which collagen fibers realign [5]. As mentioned previously, this device has been marketed as the Sure-Closure skin stretching-system (Fig. 7). Different investigators have applied this device to the closure of fasciotomies [9], diabetic ulcers [10], free-flap donor sites [11], and Mohs defects [12] with relatively good suc-
Fig. 5. After the wound edges are brought together with towel clips, the wound is closed with sutures.
125
Fig. 6. Closed incision immediately after surgery.
cess. One group, however, found increased compartmental pressures using the Sure-Closure skin-stretching system and encouraged close monitoring of these pressures during follow-up [13]. Abramson et al [14] described an alternative to the SureClosure skin-stretching system in a different setting that mimics the technique presented here. The method used a rib approximator and 2 18-gauge spinal needles to allow for primary closure in large cutaneous wounds. The 2 spinal needles were placed approximately 3 cm from the wound edges with the central portion of the needles exposed so the rib approximator could be hooked onto the needles. The rib approximator was progressively tightened until the skin edges aligned, and vicryl sutures were used to close the wound. Two main differences exist between Abramson’s technique and the method reported here. Abramson placed the spinal needles 3 cm from the wound edge. In our method, the spinal needles are placed only 5 mm from the wound edge. This allows for a greater surface area of skin to participate in stress–relaxation, less skin tension, and a
Fig. 7. Sure-Closure skin-stretching system as first described by Hirshowitz et al [5]. Here it shown applied to a lateral thigh wound.
126
D. J. Marek et al. / The American Journal of Surgery 190 (2005) 123–126
theoretical decrease in risk of increased compartment pressures. Additionally, Abramson used 1 rib approximator to apply tension to the spinal needles. The tension in the middle was greater than at the ends of the spinal needle. Our technique using 2 towel clips allows for a more evenly distributed tension along the 2 needles. Like Abramson’s technique, our method allows for primary closure of substantial wounds without using the SureClosure skin-stretching system, avoids unnecessary costs, and saves substantial time. The Sure-Closure skin-stretching system is relatively expensive ($450.00/device), whereas each spinal needle costs approximately $1.55. Most operating rooms are equipped with 18-gauge spinal needles and towel clips, whereas availability of the Sure-Closure device is more variable. Our method also requires less operating room time compared with secondary closure. There are some limitations to the technique described here. First, there is no built-in monitoring system, transducer, force-limiting applicator, or other safety mechanism. Capillary refill is not a great indicator in determining the application of the next load. Capillary refill does provide information about the blood supply, but it does not give any indication as to the architecture of the dermis itself. Second, the dermis thins at a rate of 6%/decade, with less ground substance present in aged skin [15]. Therefore, elderly patients may not have as much skin to participate in the stretching. Third, neither the Sure-Closure device nor the technique reported here can easily incorporate the principles of load cycling. Finally, like the Sure-Closure and other “homemade” skin-stretching methods, the load is not completely distributed evenly. The load at the site of the towel clips is greater than at the middle of the spinal needles. Other skin- stretching techniques, such as presuturing [16], allow for a more evenly distributed tension, but they require significantly more time and are not applicable in the trauma setting. In the trauma setting, the technique described here must be employed with good judgment because the integument may be compromised, muscle tissues may be threatened, and compartment edema may be substantial. Good judgment requires experience, and an applicable conservative working rule is to stop pressure if concern for skin dehiscence or compartment syndrome even enters the mind of the surgeon. A compartment measurement to obtain a simple
pressure reading can help guide decision making during the learning curve of this technique. This technique will allow surgeons to avoid the relatively high cost of the SureClosure skin-stretching system and lengthy procedures to achieve primary closure of large wounds.
References [1] Gibson T, Kenedi RM, Craik JE. The mobile microarchitecture of dermal collagen: a bioengineering study. Br J Surg 1965;52:764 –70. [2] Neumann CG. The expansion of an area of skin by progressive distension of a subcutaneous balloon. Plast Reconstr Surg 1957;19: 124 –30. [3] Gibson T. The physical properties of skin. In: Converse JM, editor. Reconstructive Plastic Surgery. Vol. 1. Philadelphia, PA: Saunders; 1977:70 –7. [4] Hirshowitz B, Kaufman T, Ullman J. Reconstruction of the tip of the nose and ala by load cycling of the nasal skin and harnessing of extra skin. Plast Reconstr Surg 1986;77:316 –9. [5] Hirshowitz B, Lindenbaum E, Har-Shai Y. A skin-stretching device for the harnessing of the viscoelastic properties of the skin. Plast Reconstr Surg 1993;92:260 –70. [6] Melis P, Noorlander ML, van der Klejj AJ, et al. Oxygenation and microcirculation during skin stretching in undermined and nonundermined skin. Plast Reconstr Surg 2003;112:1295–301. [7] Almekinders LC. Gradual closure of fasiotomy wounds. Orthop Rev 1991;20:82– 4. [8] Harris I. Gradual closure of fasciotomy wounds using a vessel loop shoelace. Injury 1993;24:565– 6. [9] Narayanan K, Latenser BA, Jones LM, et al. Simultaneous primary closure of four fasciotomy wounds in a single setting using the Sure-Closure device. Injury 1996;27:449 –51. [10] Armstrong DG, Wunderlich RP, Lavery LA. Reaching closure with skin stretching: applications in the diabetic foot. Clin Podiatr Med Surg, 1998;15:109 –16. [11] Futran ND. Closure of the fibula free flap donor site with the SureClosure skin-stretching device. Laryngoscope 1996;106:1487–90. [12] Marrero GM, Dufresne RG Jr. An intraoperative skin-stretching device to close wounds in Mohs defects. Dermatol Surg 1996;22:546 –50. [13] Hussmann J, Kucan JO, Zamboni WA. Elevated compartmental pressures after closure of a forearm burn wound with a skin-stretching device. Burns 1997;23:154 – 6. [14] Abramson DL, Gibstein LA, Pribaz JJ. An inexpensive method of intraoperative skin stretching for closure of large cutaneous wounds. Ann Plast Surg 1997;38:540 –2. [15] Branchet MC, Boisnic S, Frances C, et al. Skin thickness changes in normal aging skin. Gerontology 1990;36:28 –35. [16] Liang MD, Briggs P, Heckler FR, et al. Presuturing-a new technique for closing large skin defects: clinical and experimental studies. Plast Reconstr Surg 1988;81:694 –702.