Regenerative Closure of Palmar Wound Defects
Roger Khouri, MD, FACS1; Calva Daniel, MD, FACS2; Raul A Cortes, MD, FACS2
1Miami Breast Center, Key Biscayne, FL; 2Miami Breast Center, Miami, FL
Palmar skin is specialized and its loss difficult to replace. Treatment with conventional flaps is based on the principle of “Borrow from Peter to pay Paul”. Could we instead allow Paul to regenerate? From the observation that palmar wound defects in the 1mm range heal in a regenerative fashion without a scar, we hypothesized that stacking tens of these gaps would add up to enough tissue regeneration to close sizeable wounds.
Materials & Methods: Under regional block anesthesia and tourniquet exsanguination the contractures or the wound defect edges are placed under extreme tension. We use a lead hand for contracture release and approximating clamps for wound defects. Then, with an 18G hypodermic needle, we perform in an orderly fashion a staggered alternating pattern of punctures starting distally and progressively moving centrally. Tension is crucial to the differential cutting property of the needle. Needle nicks under tension will preferentially snap the tensed restrictive fibers and spare the looser neurovascular structures. This generates a mesh pattern (similar to the mesh expansion of a skin graft) that expands the surrounding tissues to completely release the contracture or to close the wound under no tension. To regenerate the subcutaneous fat in cases of full thickness tissue loss, we also loosely inject sedimented lipoaspirate under the released skin. After tourniquet release we apply an extension splint/dressing. A week later the punctures are imperceptible and gentle hand use is allowed.
Results: 85 palmar cutaneous defects requiring flaps were treated with this technique. (68 digital, 11 first webspace, 6 palmar). 72 were contracture releases and 13 were acute wound defects. We learned that the safe expansion pattern is only 1:1.25/1:1.3. That is to regenerate 1cm we need to mesh 3-4cm. More aggressive needling occasionally lead to necrosis of the meshed tissues. No intact tendons were severed and no digits became ischemic. We had only 5 neuropraxias that completely resolved. In our last 50 consecutive cases, all contractures were near totally released and all wound defects healed uneventfully. The missing tissue regenerated to heal the wound gap and the needle punctures left no scar.
Conclusion: Regenerative closure is based upon our innate capacity to regenerate across tiny gaps. Stacking up a large number of gaps can safely mesh expand the tissues surrounding a defect and avoid the potential complication and morbidity of flaps. Adding fat grafting is useful to regenerate the significant full thickness tissue defects.
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