Iain Whitaker

Cronfa at Swansea University

Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, e115ee116CORRESPONDENCE AND COMMUNICATIONKirschner wires: a novel techniqueto assist abdominal closure utilisingthe viscoelastic properties of skinFigure 2 Dermal K-wires and open towel clips have beenapplied to aid closure of the abdominal wound.Dear Sir:Abdominal wall closure following deep inferior epigastricartery perforator (DIEP) flap harvest often requires flexionof the operating table at the level of the patient’s hips inaddition to undermining of the superior flap to aid closure.During closure, the skin flaps are elongated through thestretching of collagen fibres, breaking of elastin anddisplacement of water.1,2 We describe a technique thatuses towel clips and K wires, improvised from a devicepreviously reported by Hirshowitz et al3 which harnessesthe phenomenon of mechanical creep. This techniqueallows wound closure in difficult cases, without the needfor table manipulation or consideration of alternativereconstruction options.TechniqueFollowing lower abdominal flap harvest, the superiorabdominal skin flap is undermined to the costal margins andxiphisternum (see Figure 1). If the donor site closure is tootight to allow closure, the following technique is employed.Figure 1 Abdominal wall following deep inferior epigastricartery perforator (DIEP) flap harvest. Superior flap has beenundermined. Maximal longitudinal extent of wound is 14 cm.1748-6815/$ - see front matterª 2008 Published by Elsevier Ltd on behalf ofdoi:10.1016/j.bjps.2008.09.007Four 2.7 mm single trocar K-wires, two in parallel on eachside of the wound, are longitudinally ‘weaved’ into thedermis 1 cm behind each wound margin. Each K-wireundergoes two passes out of the tissue exposing wires forapplication of towel clips or bone reduction forceps. Thetowel clips are hooked onto opposing exposed wires andleft open (Figure 2), bridging the gap between woundmargins. The finger holes of the medial towel clips arehooked by further towel clips, which are closed to furtherdraw the wound edges together (Figure 3). After fiveminutes, all the attached towel clips are closed and left inthis position for at least twenty minutes whilst the Scarpa’sfascia and dermis are sutured in the lateral extremes of thewound (Figure 4). Further Scarpa’s and dermal sutures areFigure 3 Additional towel clips are applied to the handles ofthe initial towel clips to aid apposition of the K-wires.British Association of Plastic, Reconstructive and Aesthetic Surgeons.Figure 5 After removal of the towel clips and K-wires, theskin has gained sufficient length to close the wound withouttension.Figure 4 Towel clips are closed, maximally opposing thewound edges.e116 Correspondence and communicationplaced between the towel hooks which are subsequentlyreleased to allow the completion of wound closure(Figure 5).DiscussionThe K-wires form opposing bars, which enable the spread oftension along the wound during application of the towelclips. The illustrated example, where the apparatus wasremoved in order to measure the extent of mechanicalcreep, showed a reduction of the longitudinal wound extentfrom 14 cm to 9 cm. At no point did the surrounding skinblanch during this process, nor was the table flexed at thehips. This has been an effective tool used on well over 100DIEP flap patients with no specific identifiable complica-tions. By utilising this simple method of wound edgeapposition which manipulates the viscoelastic properties ofskin, difficult wounds can be approximated without theneed for consideration of alternative techniques, such astable manipulation, additional equipment or the need forlocal flaps or grafting to achieve closure.Conflict of interest/fundingNone.References1. Wilhelmi BJ, Blackwell SJ, Mancoll JS, et al. Creep vs. stretch:a review of the viscoelastic properties of skin. Ann Plast Surg1998 Aug;41:215e9.2. Gibson T, Kenedi RM. Biomechanical properties of skin. Surg ClinNorth Am 1967;47:279.3. Hirshowitz B, Lindenbaum E, Har-Shai Y. A skin-stretchingdevice for the harnessing of the viscoelastic properties of skin.Plast Reconstr Surg 1993 Aug;92:260e70.Marcus JD WagstaffDepartment of Plastic Surgery,Sheffield Teaching Hospitals NHS Trust, Herries Road,Sheffield, S5 7AU United KingdomE-mail address: m.wagstaff@doctors.org.ukWarren M RozenJack Brockhoff Reconstructive PlasticSurgery Research Unit, Room E533,Department of Anatomy and Cell Biology,The University of Melbourne,Grattan St, Parkville 3050,Victoria, Australia.E-mail address: warrenrozen@hotmail.comIain S WhitakerDepartment of Plastic, Reconstructive and Burns Surgery,The Welsh National Plastic Surgery Unit, The MorristonHospital, Swansea, United Kingdom.E-mail address: iainwhitaker@fastmail.fmTobias N SchneiderDepartment of Plastic Surgery, University HospitalUppsala, 75185 Uppsala, Sweden.E-mail address: tschneider@fastmail.com.auThorir AudolfssonRafael AcostaDepartment of Plastic Surgery, Uppsala Clinic Hospital,75185 Uppsala, Sweden.E-mail addresses: thorir.audolfsson@akademiska.se,rafael.acosta.rojas@akademiska.se

Kirschner wires: a novel technique to assist abdominal closure utilising the viscoelastic properties of skin

Abstract

Similar works

Full text

Available Versions

Cronfa at Swansea University