INTRODUCTION
Extensive skin loss in the lower limbs presents great treatment challenges. These
lesions are caused by extensive trauma, exposed fractures, vasculopathies, and
neoplasms and are characterized by difficulty approximating wound edges, which
can lead to aesthetic and functional damage1.
The treatment options range from primary closure to reconstruction using distant
flaps. Some plastic surgeons specialize in this area and perform different
techniques to close the lesions depending on their extension. In this context,
the elastic suture was included in the therapeutic strategy for lower-limb
reconstruction, a technique divided into two surgical times: the aid of an
elastic sutured into the skin that approximates the wound edges; and the removal
of this elastic and the wound edges sufficiently approximated so only a simple
suture closes the wound. This mechanism uses the biomechanical properties of the
skin with the aid of only a sterile elastic band. The elastic suturing was
performed in two patients at the Independência Hospital of Porto Alegre, RS.
The present study aimed to describe the elastic suture technique and confirmed
its safe applicability in cases of skin loss in the lower limb based on the
description of two surgical cases and a literature review.
METHODS
The present study consists of two case reports of patients treated at the
Independência Hospital of the Divina Providência Group in Porto Alegre, RS, in
2017. Based on the surgical method used, a literature review was conducted using
the Google Scholar, PubMed, and Lilacs databases. The abstracts that were
relevant for the topics were initially identified and selected; subsequently,
the open access articles that clearly addressed the elastic suture treatment
were reviewed.
Two patients were selected for the two stages of the procedure. The first stage
includes the elastic suture and consists of debridement of the wound edges and
suturing of the sterile elastic into the most superficial layer of the skin. The
elastic was fixed to the skin with a mononylon thread, and was interlaced and
sutured back into the skin. This process was repeated until the wound edges were
approximated in all affected areas. One week after this first stage, the elastic
was removed and the wound was fully closed with mononylon 3.0 thread.
CASE REPORTS
G.L.S.N., 24-year-old man. The patient suffered a motorcycle accident
in October 2014 and required surgical treatment for a right tibial
shaft fracture. The postoperative course was successful and he was
discharged. In July 2017, the patient returned to the hospital
complaining of progressive exposure of the synthetic material with
signs of a site infection. Thus, the plaque was removed in July
2017. However, the patient had an extensive surgical wound that
required debridement and assessment by the plastic surgeon. The
lesion size in the anterior region of the right leg was 15 ×
4.3 cm (Figure 1). The patient
then underwent elastic suturing to cover the lesion. The first stage
of the procedure was performed in August 2017; in the second stage 1
week later, the wound already measured 15 × 1.1 cm, which
made the primary suturing possible, and the patient was discharged 4
days after the second surgery. The patient’s condition progressed
well, the surgical wound healed completely, and he was discharged
from the plastic surgery team’s outpatient clinic in February
2018.
Figure 1 - A: Skin lesion – preoperative view;
B: Elastic suture – immediate
postoperative view; C: First week
postoperative view; D: 2-month
postoperative view.
Figure 1 - A: Skin lesion – preoperative view;
B: Elastic suture – immediate
postoperative view; C: First week
postoperative view; D: 2-month
postoperative view.
N.D.S., 45-year-old woman. The patient was suicidal in October 2017
accidentally injured her left leg with a shotgun blast.
Consequently, she had an exposed fracture in the left tibia and
fibula with a lesion in the anterior region of the leg measuring 17
× 4.5 cm (Figure 2). An
orthopedic procedure to treat the fractures of both bones of the leg
using an external fixator was conducted and an assessment by the
plastic surgeon was requested. Elastic suturing was indicated and
performed in December 2017 in two stages, and the wound’s width had
decreased to 1.2 cm 1 week later. The patient progressed adequately
after plastic surgery and continues to be followed up at the
hospital outpatient clinic.
Figure 2 - A: Skin lesion – preoperative view;
B: Elastic suture - immediate
postoperative view; C: First week
postoperative view; D: 1-month
postoperative view.
Figure 2 - A: Skin lesion – preoperative view;
B: Elastic suture - immediate
postoperative view; C: First week
postoperative view; D: 1-month
postoperative view.
DISCUSSION
After the technique was performed, the lesion healed as well as with the use of
grafts and flaps since collagen is the main structure of the healing process, as
it is constantly produced and degraded by fibroblasts and exerts tensile
strength and supports the tissue. Throughout the basic stages, the produced
collagen is replaced by the formation of cross-links between the fibers2. Therefore, the elastic suture works at
this healing stage, facilitating and accelerating this wound tensile
process.
In addition, during the first 24–36 hours, epithelial cells are produced and
migrate to the central area of the lesion and induce another force that favors
closure of the wound edges. However, the elastic suture is more effective during
the maturation stage of the wound healing process since the wound is then under
constant contraction due to the movement of all the surrounding thick skin,
reducing the area of the disordered scar tissue2.
The tensile suture technique helps prevent the excessive productions of collagen
and epithelial tissue, which cause scarring defects due to the differentiation
of fibroblasts to myofibroblasts. Moreover, use of the elastic suture in elderly
patients can overcome the lack of tissue flexibility, while the progressive
decrease in collagen production can be beneficial in the wound healing
maturation stage in diabetic patients since most wound healing stages are
impaired by high blood glucose levels3.
The biomechanical principle of tissue tensile strength is the main mechanism
explored in the elastic suture technique. The distribution of the tensile
strength of the skin increases metabolic activity, which promotes vessel
development and collagen fiber proliferation for tissue healing. Moreover, the
viscoelastic properties of the skin allow gradual extension by a continuous
traction–creep phenomenon3. Since primary
closure of lesions is the first treatment choice whenever possible, the healing
process associated with elastic suturing leads to this primary closure at the
end of the procedure.
The comparison of two techniques of elastic suturing demonstrated that fixation
of the elastic subcutaneously and in the superficial fascia spared the tissue
from necrosis. Raskin’s technique in 19934
proposed fixation of the interlaced elastic directly on the wound edges, whereas
the technique of Leite et al. in 19965 proposed fixation of the elastic subcutaneously and in the
superficial fascia3,6. We used Raskin’s technique in both cases
of the present study.
CONCLUSION
The outcomes of our two patients were very positive and corroborated findings
already described in the literature. This technique was effective, low cost,
fast, and safe and resulted in good wound healing. In addition, it did not leave
a second scar in the donor area as occurs with graft use.
COLLABORATIONS
|
DSF
|
Final manuscript approval, project administration, realization of
operations and/ or trials, supervision, writing - original draft
preparation, writing - review & editing.
|
|
ALP
|
Analysis and/or data interpretation, conception and design study,
data curation, final manuscript approval, realization of operations
and/or trials, writing - original draft preparation, writing -
review & editing.
|
|
YPS
|
Analysis and/or data interpretation, conception and design study,
data curation, final manuscript approval, formal analysis,
methodology, writing - review & editing.
|
REFERENCES
1. Magalhães MAB, Petroianu A, Martins SGO, Resende V, Alberti LR,
Barbosa AJA, et al. Fechamento de grandes feridas com fita elástica de borracha
em coelhos. Rev Col Bras Cir. 2015;42(1):56-61.
2. Tazima MFGS, Vicente YAMVA, Moriya T. Biologia da ferida e
cicatrização. Medicina (Ribeirão Preto). 2008;41(3):259-64. DOI: http://dx.doi.org/10.11606/issn.2176-7262.v41i3p259-264
3. Vidal MA, Mendes Junior CES, Sanches JA. Sutura elástica - uma
alternativa para grandes perdas cutâneas. Rev Bras Cir Plást.
2014;29(1):146-50.
4. Raskin KB. Acute vascular injuries of the upper extremity. Hand
Clin. 1993;9(1):115-30.
5. Leite NM, Reis FB, Cristian RW. Rev Bras Ortop. Tratamento de
ferimentos deixados abertos com o método de sutura elástica.
1996;31(8):687-9.
6. Santos ELN, Oliveira RA. Sutura elástica para tratamento de grandes
feridas. Rev Bras Cir Plást. 2012;27(3):475-7. DOI: http://dx.doi.org/10.1590/S1983-51752012000300026
1. Hospital Independência, Porto Alegre, RS,
Brazil
2. ULBRA, Canoas, RS, Brazil.
Corresponding author: Douglas Severo
Fraga Av. Andarai, nº 566, apto 1110 - Passo D’ areia, Porto Alegre,
RS, Brazil Zip Code 91350-110 E-mail: fragadp@ig.com.br /
drdouglasfraga@gmail.com
Article received: May 15, 2018.
Article accepted: November 11, 2018.
Conflicts of interest: none.
