Introduction

Complex wounds involve extensive skin loss associated with infection, lack of viability of superficial tissues, or systemic diseases. These wounds do not follow the expected, orderly, and timely repair sequence and do not present anatomical and functional integrity restoration after three months of proper treatment. They are more common in trauma, diabetes, pressure ulcers, and chronic venous ulcers with necrosis or autoimmunity.^1,2 They carry a high risk of complications, including amputations and death.²

In this regard, achieving safe, functional, aesthetic, and system-friendly outcomes requires creativity in making technical decisions between treatment options, with a special emphasis on cost reduction.¹

In addition to flaps and grafts, tissue expansion is an alternative closure method. In reconstructive surgery, this model maintains the form and function of the affected site. As such, elastic sutures and traction wires, such as Kirschner wires (KWs) and steel wires, can successfully close complex wounds.³

Elastic sutures (ESs) involve placing elastic threads between knots tied at the wound edges, creating a crisscross effect similar to a shoelace knot, with continuous tension. Two to three days after placement, the surgeon increases the elastic tension by stretching and tying the elastic thread. This adjustment allows for gradual wound closure with reduced morbidity and may be an alternative to grafts or microsurgery. However, despite its applicability in fasciotomies and laparotomies, its use in larger wounds remains uncertain, mainly due to the small number of studies.⁴

Dermotraction involves the subdermal placement of steel wires, such as KW, parallel to the wound edges. Next, tension bands are placed around the two interposed steel wires to apply an evenly distributed traction to approximate the wound edges. Retraction can occur every 24 to 48 hours, often within 24 hours. Wire removal occurs after edge approximation with no tension.⁵ This technique has been described as being used in wounds resulting from infection, bone fractures, fasciotomies, pressure ulcers, flap closure (potentially avoiding the use of a graft or flap), and in one case of bilateral mastectomy undergoing intraoperative traction.⁶ However, established guidelines and indications for this technique are still lacking.

Objectives

The present study aimed to report the outcomes of patients with complex wounds who underwent dermotraction using steel wires and ES, including the treatment’s cost-effectiveness and the length of postoperative hospital stay. Moreover, the study aimed to describe the surgical technique used at a referral trauma hospital and analyze the progress and outcomes of patients who used steel wires for the gradual closure of complex wounds compared with those who used other materials.

Materials and Methods

The Research Ethics Committee CEPSH-SESA/HT approved the current study under number CAAE 64890722.0.0000.5225.

Sixty-four patients underwent treatment at the Department of Plastic Surgery of Complexo Hospitalar do Trabalhador from 2012 to 2022. The study included patients aged 18 or older undergoing complex wound treatment with dermotraction using steel wire or ES, who had signed the free informed consent form (ICF). We excluded underage subjects and those who did not undergo dermotraction with KW or ES.

From the selected sample, we performed a retrospective, descriptive cross-sectional study by collecting and reviewing data from electronic medical records of patients admitted to Complexo Hospitalar do Trabalhador for complex wound treatment with dermotraction. Complex wounds included fasciotomies, pressure, diabetic, venous, venous insufficiency, and infected ulcers, or lesions with a closure period longer than 3 weeks.

We collected the following data from medical records: medical record number, age, gender, wound etiology, wound classification, lesion size, lesion location, exposure time before plastic surgery intervention, type of surgery, material used in surgery (thread), anesthesia, number of surgical approaches, number of cycles for tension increase, time until closure, length of hospital stay, whether the closure was successful, associated complications, comorbidities (diabetes, systemic arterial hypertension [SAH], venous insufficiency, HIV, autoimmune disease, heart failure, coagulopathy), cost of materials, and case outcome.

Data analysis included descriptive and exploratory statistics, with calculations of absolute and relative frequencies, measures of central tendency (mean and median), and dispersion (standard deviation). This analysis was performed using the IBM SPSS Statistics for Windows (IBM Corp.) software, version 25.0.

Results

Table 1 shows the clinical characteristics, demographics, and outcomes of patients undergoing dermotraction with each technique.

Table 1 - Clinical characteristics, demographics, and outcomes of patients undergoing dermotraction with each technique

The study included 58 patients undergoing dermotraction, 50 with KW, 6 with ES, and 2 with KW plus ES. The sample comprised 12 women and 46 men, with a mean age of 37.88 years (± 13.27), ranging from 19 to 75 years old. The average age per technique was 37.88 years (± 12.91; range: 19-75) for KW, 35.6 years (± 17.67; range: 19-58) for ES, and 43.5 years (range: 35-48) for KW plus ES. Regarding comorbidities, among the patients undergoing elastic suture, 2 had systemic arterial hypertension (SAH) and 1 had type-2 diabetes mellitus (DM). Of those who underwent dermotraction with KW, 2 had SAH, 1 had type-2 DM, 1 had type-1 DM, 1 had Crohn’s disease, 1 had grade-II obesity, 1 had had a stroke, and 1 had chronic arterial disease and an acute myocardial infarction with previous revascularization.

Wound etiology included 28 cases of traumatic soft-tissue injuries, 19 fasciotomies, 5 surgical wound infections, 3 nonsurgical soft-tissue infections, 1 burn, 1 dog bite, 1 surgical access, and 1 flap donor site complication. Therefore, approximately 80% of the injuries presented a traumatic origin.

Lesion location in patients receiving KW included 36% cases on the left lower limb, 28% on the right lower limb, 6% on the right foot, 6% on the chest, 4% on the abdomen, 4% on the head, 4% on the left upper limb, 2% on the right upper limb, 2% on both lower limbs, 2% on the left foot, and 2% on the sacrum. In subjects receiving ES, 50% of the wounds were on the left lower limb, 33.3% on the right lower limb, and 16.67% on the left foot. In patients undergoing both techniques, one case affected the left lower limb and another, the right lower limb.

The mean documented wound length was 17.7 ± 5.68 cm in patients undergoing dermotraction with KW, 15.33 ± 8.08 cm in subjects undergoing ES, and 22 cm in patients submitted to the combined technique. The mean preoperative time until dermotraction plastic surgery was 22.76 days in subjects receiving KW, 34 days in those receiving ES, and 41.3 days in patients undergoing dermotraction with KW plus ES.

Regarding hospitalization time, the average length of stay was 82.54 days for patients undergoing dermotraction with KW, 26.8 days for those undergoing dermotraction with ES, and 20 days for those receiving both KW and ES. However, 50% of patients treated with KW plus ES required admission to the intensive care unit (ICU) compared with 16.6% of those treated with ES and 28% of cases using KW. In addition, 42% of wounds treated with KW traction presented with a previous infection, compared with 50% of those treated with ES and 100% of those undergoing treatment with KW plus ES.

Furthermore, regarding the number of surgical procedures, patients who underwent traction with KW had an average of three surgical procedures and one outpatient procedure. Patients undergoing ES treatment had on average three surgical procedures, and none of them required outpatient treatment in the emergency room. The number of traction procedures using KW plus ES was two, while patients who underwent KW and ES underwent, on average, one wire traction procedure during treatment.

Concerning complications, subjects treated with KW presented traction loss in 6% of cases, suture dehiscence in 2%, and femoropedal deep vein thrombosis (DVT) in 2%. There were no complications in patients undergoing ES or KW plus ES treatment. All subjects presented complete wound closure (►Fig. 1).

Fig. 1 - Percentage of supplementary therapies associated with dermotraction techniques with Kirshner wires, elastic suture, or both.

Fig. 1 - Percentage of supplementary therapies associated with dermotraction techniques with Kirshner wires, elastic suture, or both.

Discussion

Indications for steel wire or elastic suture use

In plastic surgery, complex wounds are injuries requiring a longer time to heal (often with no spontaneous closure up to 3 months after trauma). These wounds may also present infection, compromised viability of superficial tissues, association with systemic diseases impacting proper wound healing (including DM and venous diseases), or significant and extensive loss of the integument.⁷

The first step in treating these extensive wounds is cleaning and debridement, followed by the creation of flaps or skin grafts. However, the need for a donor site for tissue removal often leads to local complications such as hypertrophic scars, skin retraction, local infection, or cosmetic deformities in a previously healthy area.⁸ In this context, the skin’s high elasticity can be an ally in the adoption of other therapeutic methods to aid the healing of large wounds, including the use of ES, since primary wound closure should be the first choice whenever possible.⁹

The ES suture technique involves attaching an elastic band to the wound edges with suture for skin traction due to its elasticity and cutaneous compliance, resulting in subsequent healing of the treated lesion. This technique is low-cost and relatively simple to perform, making it a good alternative for complex wounds.⁹ Anchoring the ES thread to the wound edges allows for better redistribution of forces during skin traction, minimizing tissue ischemia at the wound edges and, consequently, local necrosis. Furthermore, the tension applied to the skin enhances local metabolism, resulting in neovascularization and increased collagen fiber production, which in turn boosts the skin’s capacity for expansion. As such, the ES technique is widely indicated for medium to large complex wounds, especially in difficult-to-heal sites, including those with poor vascularization, as the distal third of the leg or the foot. Therefore, this technique is a good alternative for lesion resolution without the need to compromise another donor site for wound coverage.¹⁰

Another well-regarded, widely used technique for closing large, complex lesions is intermittent skin traction with KW. This technique is low-cost, has low morbidity, and is easy to apply. It offers good outcomes in preventing the development of new dysfunctional scars compared with flaps, which are more likely to result from ischemia and subsequent tissue necrosis, as well as in dysfunctional scars due to tissue retraction.⁹ Therefore, wire traction is a good technique for wound closure, especially in the lower and upper limbs, and it is also widely used for closing fasciotomies. The mechanism of action of wire traction is the drag forces applied to the skin’s collagen fibers, which elongate them and, when combined with displacement of the cutaneous ground substance, allow for an increase in the surface area for local coverage⁵ (►Fig. 2).

Fig. 2 - Male patient with Kirschner wire dermotraction on the left leg due to fasciotomy. (A) Fasciotomy defect. (B) Aspect after Kirschner wire dermotraction surgery. (C) Complete closure after dermotraction.

Fig. 2 - Male patient with Kirschner wire dermotraction on the left leg due to fasciotomy. (A) Fasciotomy defect. (B) Aspect after Kirschner wire dermotraction surgery. (C) Complete closure after dermotraction.

One of the key points for comparison when evaluating the applicability of steel wire traction with the ES technique seems to be the ability to use the steel wires in a controlled manner. The correct use of steel wires enables the adjustment of skin traction according to specific needs and potential for tissue expansion to accommodate the deformity. This approach helps minimize the risk that the inability of neovascularization to keep pace with tissue expansion will limit the effectiveness of the traction. As a result, this was the main reason why most patients included in the present study were candidates for wire traction rather than the ES technique.¹¹

Conclusion

Experience with dermotraction for complex wounds has demonstrated that both KW and ES are effective and viable alternatives for closing these lesions. Both techniques have yielded good functional and aesthetic outcomes, with a low complication rate and without the need for flaps or grafts in most cases.

The choice between techniques was closely related to the size and complexity of the wound, with steel wires being preferred in larger injuries or those requiring greater traction control, and ES use in smaller wounds, resulting in reduced hospital stay and good evolution.

Thus, our findings reinforce the cost-effectiveness of dermotraction as an initial approach for complex wounds, highlighting its safety, simplicity, and accessibility within SUS. Further comparative and prospective studies are recommended to standardize indications, techniques, and follow-up protocols for optimizing surgical outcomes and resource allocation.