Treatment of limb skin defect with self-made skin distractor

Treatment of limb skin defect with self-made skin distractor | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Treatment of limb skin defect with self-made skin distractor Gao Lei, Li Kai, Zhang Yanlong, Wang Hongrun, Liu Shibo, Wang Yong, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5131608/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Dec, 2024 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted 4 You are reading this latest preprint version Abstract Objective To investigate the effect of self-made skin distractor in the treatment of limb skin defects. Methods From September 2018 to January 2020, 15 cases of limb skin defects (16 wounds) were treated with self-designed skin distractor, including 13 males and 2 females, with an average age of 42 years (range, 9-73 years). The smallest area of skin defect was 6cm×3cm, the largest was 32cm ×7cm, with an average of 72.4cm 2 . The wound healing was observed, complications and the time of use of the distractor were recorded. Results All patients were followed up for 6-12 months with an average of 9.2 months. Of the 16 wounds in 15 patients, 2 wounds were closed in one stage during operation, 13 wounds were delayed in primary closure. Skin incision occurred in 1 case, but the wound closure was not affected；One wounds were not closed completely, because the skin was cut by Kirschner wire, and could not be stretched continously. The remaining wounds were closed by skin grafting. Another case also had skin cutting was occurred in another case, but the wound closure was not affected. No skin stretch was terminated due to pain. All wounds were healed. The elasticity and color of the skin on the wound surface were not different from the surrounding skin. The movement of the adjacent joints was basically normal. Conclusion The self-made skin stretcher is simple in structure and easy to use. It provides a reliable and effective method for the treatment of skin defects of limbs. Skin Defect Distractor Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Large-scale skin defects following trauma are a common clinical challenge for orthopedic trauma surgeons. These defects often involve complex situations such as open wounds with soft tissue loss, skin defects following fasciotomy for compartment syndrome, and donor site defects after skin flap transplantation. The goal of surgical treatment is to close the wound, prevent infection, and restore limb function. Current methods for treating skin defects include split-thickness skin grafts, vascularized or free flap transplants, skin expansion techniques, and skin distraction methods. Split-thickness skin grafts often result in poor elasticity, contraction, hyperpigmentation, and scarring at graft junctions due to the incomplete skin structures transferred. Donor sites can develop extensive scarring and poor durability, with a tendency to blister or rupture due to the loss of epidermis. Vascularized or free flap transplants, suitable for cases with exposed tendons, vessels, or bones, offer good extensibility and durability. However, large flaps may require additional split-thickness skin grafts for donor site closure, and free flaps require high surgical skill and carry a risk of necrosis. In 1976, Barrer first used a skin distractor to repair small skin defects, a method also known as skin distraction [1] . Over more than 40 years, various skin distraction devices have been developed, such as the Sureclosure®, Dermaclose®, and TopClosure® [2] . Despite their advantages, these devices also have drawbacks, such as complex structures and high costs. The basic principle of skin distraction involves utilizing the viscoelastic and mechanical stretch properties of the skin. By applying continuous mechanical tension, the skin on either side of the wound is pulled towards the center, effectively repairing the defect. This method is simple, effective, and results in high-quality wound repair, with the texture, durability, sensation, and function of the repaired skin closely resembling that of adjacent normal skin, without damaging the donor area and sometimes avoiding the need for flap repair [3] . To overcome the shortcomings of traditional skin distractors, from September 2018 to January 2020, the authors developed an improved version, the mini adjustable skin distractor (Figure 1, produced by Hebei Hengshui Zengli Medical Instruments Co., Ltd., patent number: 201720872132.2), and applied it clinically to repair large-scale skin defects in 15 patients after trauma. This mini adjustable skin distractor has proven to be easy to operate, cost-effective, and efficient. This study retrospectively analyzes this data with the objectives of: (1) exploring the feasibility of using the mini adjustable skin distractor for repairing large-scale skin defects post-trauma; (2) evaluating the clinical efficacy of the mini adjustable skin distractor in the repair of these defects; (3) summarizing the precautions needed when using the mini adjustable skin distractor for such repairs. Materials and Methods I. Inclusion and Exclusion Criteria Inclusion Criteria: 1. Skin defects on limbs or torso following trauma. 2. Good patient compliance. 3. Healthy soft tissue surrounding the wound. 4. Minimum follow-up duration of 12 months. Exclusion Criteria: 1. Severe infection of the wound or surrounding scarring. 2. Patients with thin skin. Based on these criteria, this study included 15 patients (16 wounds) with limb skin defects. There were 13 males and 2 females, aged between 9 and 73 years, with an average age of 42 years. Skin defect locations included the forearm (2 cases), thigh (3 cases), bilateral knees (1 case), lower leg (5 cases), ankle (1 case), and heel (3 cases). Causes of the initial injuries included traffic accidents (6 cases), machinery injuries (3 cases), falls (1 case), infections requiring surgical debridement (5 cases), and decompressive fasciotomy for compartment syndrome (1 case). Wound sizes ranged from 6cm x 3cm to 32cm x 7cm, with an average size of 72.4cm². The study was approved by the Ethics Committee of the Third Hospital of Hebei Medical University (approval number: 2017-007-1), and all patients provided informed consent. All surgeries were performed by the same surgeon(Table 1). Table 1 Summary of case data NO SEX AGE Site of wound Wound size (cm2) Causes of injury Stretcher time (days) Follow-up time (months) complication 1 MALE 9 left leg 8×7 traffic accidents injury 23 8 NO 2 MALE 37 Left lateral malleolus 10×4 infection of internal fixator 21 6 NO 3 FEMALE 61 Both knees L：10×6 R：8×4 Infection after sealing operation L：21 R：18 11 NO 4 MALE 46 left thigh 16×6 Machine wound 21 12 NO 5 MALE 27 right forearm 12×4 Machine wound 16 8 NO 6 FEMALE 73 Left heel 5×4 traffic accidents injury 28 12 Kirschner wire cut 7 MALE 34 Right heel 6×3 traffic accidents injury 49 10 NO 8 MALE 49 Right leg 20×5 Fall 24 10 NO 9 MALE 55 Left leg 25×7 Osteofascial syndrome after tension reduction 20 12 NO 10 MALE 49 left thigh 22×6 psoas abscess 28 6 NO 11 MALE 26 left thigh 10×4 traffic accidents injury 18 6 NO 12 MALE 27 right forearm 32×7 Machine wound 21 6 Kirschner needle incision,secondary skin grafting 13 MALE 53 Right heel 6×3 diabitic foot 27 12 NO 14 MALE 45 Right leg 10×6 traffic accidents injury 21 10 NO 15 MALE 32 Right leg 10×4 traffic accidents injury 20 6 NO II. Surgical Methods Debridement of the Wound The procedure was performed under continuous epidural or brachial plexus block anesthesia with the patient in a supine position. Initial thorough debridement was conducted to remove all necrotic tissue, followed by disinfection with povidone-iodine, application of sterile drapes, and changing into fresh surgical attire and instruments. Installation of the Skin Distractor At 1cm from the wound edge, a 2.0mm Kirschner wire was inserted through the skin surface into the junction between the dermis and subcutaneous tissue. The Kirschner wire could either tunnel subcutaneously for 2-3cm before emerging from the skin and re-entering, or continue subcutaneously until emerging at the other end of the wound. The same procedure was applied on the opposite side of the wound. The tails of the two Kirschner wires on the same side were attached to two sliders on the same distractor, which were then connected by adjusting a screw. If the wound was long or irregular, it could be divided into smaller sections, each managed with one or multiple sets of distractors as described. Turning the screw shortened the distance between the two sliders, gradually bringing the wound edges together to close the wound (Figure 2). If the wound edges had adequate tension and normal blood supply and color, the wound could be closed directly, known as primary closure. If the blood supply to the wound edges was poor and the color pale, the distractor was stopped, and wound closure was achieved gradually, known as delayed primary closure. III. Postoperative Care Antibiotics were administered for 24-48 hours post-surgery, with dressings changed every 2-3 days. For wounds closed primarily, the skin distractor was removed after about 3 weeks, with sutures removed 2-3 weeks postoperatively. For wounds that could not be closed primarily, the screw was turned every other day starting 2-3 days postoperatively to shorten the distance between the two sliders by 0.5-1cm each time. The adjustment was made based on the patient's tolerance to pain and without compromising the blood supply to the skin edges. Once the wound edges were aligned, the wound was sutured intermittently. The skin distractor was retained for about 3 weeks. IV. Follow-Up and Observation Indicators Patients were followed up for 6-12 months to monitor for any recurrence of infection and to assess skin color, elasticity, and the function of adjacent joints. Results All patients were followed up for 6 to 12 months, with an average of 9.3 months. At the final follow-up, there was no recurrence of infection at the wound site. The color, elasticity, and sensitivity of the skin stretched by the distractor were almost identical to normal skin, and the function of adjacent joints was largely normal. Of the 16 wounds in 15 patients, 2 wounds closed during the initial procedure, and 13 underwent delayed primary closure. In one case, there was a cut in the skin caused by a Kirschner wire, but this did not affect the wound closure. In another case, severe skin cutting occurred when the wound was nearly closed, which prevented further stretching; the remaining wound area was healed by skin grafting. Typical cases are shown in Figures 3 to 6. Discussion I. The Evolution and Working Principle of Skin Expanders In the year 25 AD, Celsus first described the use of skin expansion to close wounds. In 1921, Codivilla and Putti observed the phenomenon of skin expansion accompanying the lengthening of the femur [4] . In 1946, Neumann was the first to use subcutaneously placed balloons to expand the skin for ear reconstruction [5] . In 1967, Gibson and Kenedi introduced the concepts of mechanical creep and stress relaxation in skin [6] . They discovered that under tension, skin could be stretched to three to four times its original length, a property that could be utilized to repair skin defects. In 1976, Radovan inserted silicone spheres filled with saline underneath the skin to expand it for the repair of soft tissue defects [7] . In 1988, Austad applied the principle of hypertonicity to skin expansion to repair soft tissue defects. Since then, the method of using internal skin expanders to repair skin and soft tissue defects has been widely accepted [8] . In 1976, Barrer invented the external skin distractor for the repair of small skin defects, a method termed as skin distraction [1] . In 1978, Hirschowitz expanded the use of this technique to repair facial skin defects with skin distractors [9,10] . Over more than 40 years of continuous development, skin distractors have ultimately been applied to the repair of limb skin defects. The working principle of all skin distractors involves utilizing the mechanical creep and stress relaxation properties of the skin. By applying continuous tension, the skin area gradually expands, thus closing the wound. Mechanical creep refers to the rapid expansion of the skin area under sustained tension. Stress relaxation describes the skin being stretched to a certain length under tension, with the tension gradually decreasing over time [11,12] . Mechanical creep and stress relaxation are immediate responses of the skin to applied stress, both of which result in direct wound closure. Under the external forces of distraction, the skin’s collagen and elastic fibers reorient in the direction of the force, and water and glycosaminoglycans within the extracellular matrix move along the alignment of the fibers, forming the histological basis for mechanical creep and stress relaxation [13] . During skin expansion, collagen fibers regenerate rather than break. Research has shown that during the skin expansion process, as the dermis thins, the epidermis significantly thickens, basal layer cellular mitosis increases, and there is a noticeable increase in small arteries, small veins, capillaries, fibroblasts, and collagen content, indicating an increase in collagen synthesis [14,15] . Ruzzak found that two years after skin expansion, the structural layers of the skin can return to normal. The implementation method for stress relaxation characteristics involves using the skin distractor to apply maximum traction to the skin for 3 minutes, during which time the skin edges become ischemic, followed by a 1-minute relaxation to allow blood circulation to recover. This cycle is repeated for about 30 minutes in total to expand the skin around the wound, thereby closing the wound directly [16] . Ryan’s research shows that under cyclic tension, the oxygen content and viability within the skin further increase [12] . Different reports on the method of stress relaxation vary; Topazm uses a skin distractor to close the wound edges, maintains it for 30 seconds, then releases the distractor for 1–2 minutes, repeating this cycle for 0.5-2 hours, ultimately achieving single-session closure of wounds measuring 25cm×15cm, 15cm×7cm, and 25cm×18cm [17] . Lei and others used the skin's stress relaxation properties in two surgeries, completely closing a 40cm×30cm proximal thigh wound within 9 days [18] . The skin distractor I developed consists of a threaded rod and two sliders (Fig. 1 ), with Slider A being a freely moving slider without threads, able to move along the rod, and Slider B being an adjustable slider with threads that can be rotated along the rod. By turning the rod clockwise, the distance between the two sliders is shortened, thus applying tension to the skin on both sides of the wound (Fig. 2 ). This product is lightweight (each set of distractors weighs only 40g), structurally simple, and easy to use. Among the 15 patients treated (16 wounds), wound sizes ranged from 6cm×3 cm to 32cm×7 cm. In 2 cases, the wounds were closed primarily with the assistance of the distractor; in 13 cases, closure was delayed primary, with one case experiencing a Kirschner wire cut in the skin, though it did not affect wound closure. One case (No. 12) had a large skin defect area and experienced skin cutting when the wound was nearly closed, with the remaining wound area closed by free skin grafting. The treatment results showed that no cases experienced necrosis of the wound edges, wounds healed well, and the overall treatment effect was satisfactory. Researchers report that the skin stretched by distraction has similar color and hair characteristics to adjacent normal skin [19] , and may functionally be better than skin transplants or local skin flaps [20] . Our follow-up results also show that the expanded skin is virtually indistinguishable from surrounding skin in terms of sensation and durability. II. Precautions for Using Skin Distractors The use of skin distractors is predicated on the surrounding skin of the wound having good elasticity. Thin skin around the wound, scarred tissue, inflammation, edema, or areas that have received radiation are contraindications for skin distraction [21] . Clinically, the mobility and flexibility of the skin around the wound can be assessed by pulling on it to make an approximate judgement [22] . When closing the wound, thorough debridement must first be performed to remove necrotic and poorly vascularized tissues before installing the distractor. There is no need for a free skin edge, as this can further compromise blood supply to the edges [23] . Mellis et al. conducted quantitative histological studies on piglet skin and found that free skin edges have little effect on reducing skin tension, but they can increase complications such as edge necrosis and hematoma [24] . Skin expansion can be applied preoperatively, intraoperatively, and postoperatively. Before the removal of skin hemangiomas, neurofibromas, or keloids, to ensure primary closure of the postoperative wound, skin distractors can be applied preoperatively. With 1–2 weeks of traction, the skin around the lesion becomes relaxed, allowing the wound to be directly closed postoperatively [25] . Intraoperative use of skin distractors allows for immediate closure if the wound tension is low; for wounds with higher tension, delayed primary closure can be performed. Starting 2–3 days postoperatively, the tension is increased every two days, with adjustments based on the patient's tolerance to pain and without noticeable changes in the color of the skin edges. After the wound is closed, the skin is sutured intermittently, and the distractor is kept in place for 2–3 weeks before being removed, to prevent elastic recoil and reduce scar formation. Sometimes, postoperative wounds can be closed in one go without a distractor, but with significant tension. To prevent the wound from reopening, a skin expander is used after suturing the wound to reduce tension and ensure smooth healing. Conclusion The mini adjustable skin distractor that I have developed is simple in structure, easy to use, cost-effective, and has satisfactory therapeutic effects. The main limitation of this article is the small sample size, which was not compared with similar products. In the future, the sample size should be increased to accumulate more experience. Declarations Acknowledgements None. Author contributions Gao Lei and Li Kai contributed equally to this work. Zhang Yanlong proposed the idea and conceived the project with Wang Hongrun, Liu Shibo, Wang Yong. designed and conducted the experiments, analyzed the data, and wrote the manuscript. Peng Aqin provided important pieces of advice on this study. All authors reviewed and approved the manuscript. Funding No funds were received for this study. Data availability The datasets used and/or analyzed during the current study are available fromthe corresponding author upon reasonable request. Ethics approval and consent to participate The study was approved by the Ethics Committee of the Third Hospital of Hebei Medical University (approval number: 2017-007-1), and all patients provided informed consent. All procedures were performed in accordance with the ethical principles of the Declaration of Helsinki. Consent to participate All patients provided comprehensive written informed consent to use their medical data anonymously for publication. Consent for publication Not applicable. Competing interests The authors declare no competing interests. References Barrer S, Pavlides CA, Matsumoto T. Ideal laparotomy closure: comparison of retention sutures with new retention bridging devices[J]. Am Surg , 1976, 42(8): 582-584. DOI:10.1016/0002-9610(76)90202-6. Wang X, Zhu Z, Zhao Y, et al. The effect of TopClosure® TRS in the treatment of large abdominal wall defect[J]. European Journal of Plastic Surgery , 2019, 42(6): 603-610. DOI:10.1007/s00238-019-01516-y. Parrett BM, Matros E, Pribaz JJ, et al. Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures[J]. Plast Reconstr Surg , 2006, 117(4): 1315-1322; discussion 1323-1314. DOI:10.1097/01.prs.0000204959.18136.36. Putti V, Peltier LFJCO, Research R. The Operative Lengthening of the Femur[J]. 1990, &NA;(250). DOI:10.1097/00003086-199001000-00002. NEUMANN, Charles GJP, Surgery R. The expansion of an area of skin by progressive distention of a subcutaneous balloon; use of the method for securing skin for subtotal reconstruction of the ear[J]. 1957, 19(2): 124-130. DOI:10.1097/00006534-195702000-00004. Gibson T, Kenedi RMJSCNA. Biomechanical properties of skin[J]. 1967, 47(2): 279-294. DOI:10.1016/S0039-6109(16)38180-4. Radovan CJP, Surgery R. Tissue expansion in soft-tissue reconstruction[J]. 1984, 74(4): 482. DOI:10.1097/00006534-198410000-00005. Austad, Eric. Evolution of the Concept of Tissue Expansion[J]. Facial Plastic Surgery Fps , 1988, 5(04): 277-279. DOI:10.1055/s-2008-1064763. Hirshowitz B. The two-stage face lift[J]. British Journal of Plastic Surgery , 1978, 31(2): 159-164. DOI:10.1016/S0007-1226(78)90070-X. Hirshowitz B, Lindenbaum E, Har-Shai Y. A skin-stretching device for the harnessing of the viscoelastic properties of skin[J]. Plast Reconstr Surg , 1993, 92(2): 260. DOI:10.1097/00006534-199308000-00010. Saulis AS, Lautenschlager EP, Mustoe TA. 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The TopClosure 3S System, for skin stretching and a secure wound closure[J]. European Journal of Plastic Surgery , 2012, 35(7): p.533-543. DOI:10.1007/s00238-011-0671-1. Topaz M, Carmel NN, Topaz G, et al. Stress-relaxation and tension relief system for immediate primary closure of large and huge soft tissue defects: an old-new concept: new concept for direct closure of large defects[J]. Medicine , 2014, 93. DOI:10.1097/MD.0000000000000234. Lei Y, Liu L, Du SH, et al. The use of a skin-stretching device combined with vacuum sealing drainage for closure of a large skin defect: A case report[J]. J Med Case Reports , 2018, 12(1). DOI:10.1186/s13256-018-1779-8. Melis P, Bos KE, Horenblas S. Primary skin closure of a large groin defect after inguinal lymphadenectomy for penile cancer using a skin stretching device[J]. Journal of Urology , 1998, 159(1): 185-187. DOI:10.1016/S0022-5347(01)64052-7. Samis AJ, Davidson JS. Skin-stretching device for intraoperative primary closure of radial forearm flap donor site[J]. Plast Reconstr Surg , 2000, 105(2): 698-702. DOI:10.1097/00006534-200002000-00034. Arain AR, Cole K, Sullivan C, et al. Tissue expanders with a focus on extremity reconstruction[J]. Expert Review of Medical Devices , 2018, 15(2): 145-155. DOI:10.1080/17434440.2018.1426457. Ismavel R, Samuel S, Boopalan PRJVC, et al. A Simple Solution for Wound Coverage by Skin Stretching[J]. Journal of Orthopaedic Trauma , 2011, 25(3): 127-132. DOI:10.1097/BOT.0b013e318206f556. Hirshowitz B, Lindenbaum E, Har-Shai Y. A skin-stretching device for the harnessing of the viscoelastic properties of skin[J]. Plast Reconstr Surg , 1993, 92(2): 260-270. DOI:10.1097/00006534-199308000-00010. Melis P, Noorlander ML, van der Horst CMAM, et al. Rapid Alignment of Collagen Fibers in the Dermis of Undermined and Not Undermined Skin Stretched with a Skin-Stretching Device[J]. Plastic Reconstructive Surgery , 2002, 109(2): 674-680. DOI:10.1097/00006534-200202000-00038. Topaz M, Carmel N-N, Silberman A, et al. The TopClosure® 3S System, for skin stretching and a secure wound closure[J]. European Journal of Plastic Surgery , 2012, 35(7): 533-543. DOI:10.1007/s00238-011-0671-1. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 30 Dec, 2024 Read the published version in BMC Musculoskeletal Disorders → Version 1 posted Editorial decision: Revision requested 30 Sep, 2024 Editor assigned by journal 25 Sep, 2024 Submission checks completed at journal 25 Sep, 2024 First submitted to journal 22 Sep, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5131608","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":360495314,"identity":"005acd42-e163-4df0-8568-dad475b2d484","order_by":0,"name":"Gao Lei","email":"","orcid":"","institution":"Trauma Emergency Center of Third Hospital of Hebei Medical University","correspondingAuthor":false,"prefix":"","firstName":"Gao","middleName":"","lastName":"Lei","suffix":""},{"id":360495317,"identity":"affc3d06-9e6c-4982-8c19-5388cc3507c7","order_by":1,"name":"Li Kai","email":"","orcid":"","institution":"Trauma Emergency Center of Third Hospital of Hebei Medical University","correspondingAuthor":false,"prefix":"","firstName":"Li","middleName":"","lastName":"Kai","suffix":""},{"id":360495320,"identity":"60473586-2224-4fe8-ba87-07485ec80a22","order_by":2,"name":"Zhang Yanlong","email":"","orcid":"","institution":"Trauma Emergency Center of Third Hospital of Hebei Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhang","middleName":"","lastName":"Yanlong","suffix":""},{"id":360495321,"identity":"98e3d4b9-dcb8-4059-af6c-a4c8fd4d29a3","order_by":3,"name":"Wang Hongrun","email":"","orcid":"","institution":"Trauma Emergency Center of Third Hospital of Hebei Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wang","middleName":"","lastName":"Hongrun","suffix":""},{"id":360495322,"identity":"3bac3596-4ff0-4c05-bb25-653f2dd1a72e","order_by":4,"name":"Liu Shibo","email":"","orcid":"","institution":"Affiliated Hospital of Chengde Medical College","correspondingAuthor":false,"prefix":"","firstName":"Liu","middleName":"","lastName":"Shibo","suffix":""},{"id":360495323,"identity":"bbbdf60a-bf90-47e6-a40d-74eb828880ab","order_by":5,"name":"Wang Yong","email":"","orcid":"","institution":"Trauma Emergency Center of Third Hospital of Hebei Medical University","correspondingAuthor":false,"prefix":"","firstName":"Wang","middleName":"","lastName":"Yong","suffix":""},{"id":360495324,"identity":"a74c6f0b-709d-4b58-a9c9-a82ae786b564","order_by":6,"name":"Peng Aqin","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAwUlEQVRIiWNgGAWjYPACCQZ+ZuaDD0jTItnOlmxAmj0G53nMBIhSac7ee/jFjzKLPOPDDGYMDDU20QS1WPacSwNiiWKzwwxpDxiOpeU2EHTPjRwzA942icRthxmOGzA2HCZCy/03ZoZ/gVo2NzO2SRCn5QaP8WOQLRuYmdmI02LZk2PGLHNOInHGYTZmgwRi/GLOfsb445uyusT+/vMfH3yosSHCYQwMbBIMbFBeAiHlUC3MH+BaRsEoGAWjYBRgAwA+Tz1IG0551QAAAABJRU5ErkJggg==","orcid":"","institution":"Trauma Emergency Center of Third Hospital of Hebei Medical University","correspondingAuthor":true,"prefix":"","firstName":"Peng","middleName":"","lastName":"Aqin","suffix":""}],"badges":[],"createdAt":"2024-09-22 08:47:51","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5131608/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5131608/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12891-024-08249-5","type":"published","date":"2024-12-30T15:56:51+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":72333851,"identity":"d56f427c-e288-45d6-b49a-bba47b7ec7d7","added_by":"auto","created_at":"2024-12-25 15:26:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":169537,"visible":true,"origin":"","legend":"\u003cp\u003eHomemade Skin Distractor. A is a freely sliding slider, without threads, allowing it to move freely along the rod; B is an adjustable slider, which contains threads inside, enabling the adjustment of the distance between the two sliders by turning the rod.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5131608/v1/f68d008e6cdc0569060234cd.png"},{"id":72333138,"identity":"3dae25d9-11ea-4759-a1c3-7312990e685b","added_by":"auto","created_at":"2024-12-25 15:18:44","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":71340,"visible":true,"origin":"","legend":"\u003cp\u003eWorking Principle of the Distractor: When the rod is turned clockwise, the two sliders move towards each other automatically.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5131608/v1/cadaf468d3259516f647cb32.jpeg"},{"id":72333852,"identity":"860a57dc-1a79-4016-9951-6ce6276694d4","added_by":"auto","created_at":"2024-12-25 15:26:44","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":357833,"visible":true,"origin":"","legend":"\u003cp\u003eMale patient, 49 years old, with an open fracture of the right tibia (Gustilo Type IIIB), initially stabilized with an external fixator at another hospital and transferred to our institution on day 12 post-operation. A: The anteromedial wound on the right lower leg measured 20cm x 5cm, with the fracture ends partially exposed; B: After debridement, the wound could not be sutured directly; partial closure left a skin defect measuring 18cm x 3cm; C: With the assistance of two sets of skin distractors, the wound was closed primarily, with the skin edges under minimal tension and normal in color; D: The distractors were removed on day 24 post-operation, and the wound had healed well.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5131608/v1/b3ecfa860ae423612b6a2720.jpeg"},{"id":72333140,"identity":"96de1704-95f6-482b-9788-ab2f278e80a8","added_by":"auto","created_at":"2024-12-25 15:18:44","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":292078,"visible":true,"origin":"","legend":"\u003cp\u003eMale patient, 54 years old, admitted due to pain in the left iliac region accompanied by high fever (39°C) for 3 days and confusion for 1 day. A: Diagnosed with a left iliopsoas abscess upon admission, the wound condition one month after repeated debridement; B: Removal of a VSD (Vacuum Sealed Drainage) system from the wound, with the wound freshly debrided; C: Due to high tension in the wound, the iliac wound could not be sutured directly and was closed primarily with the aid of a skin distractor; D: Two months post-discharge, follow-up showed good wound healing with no recurrence of infection.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5131608/v1/cd06690375c2629250a8e52e.jpeg"},{"id":72333139,"identity":"139d4fae-a69b-46bb-87ee-933da951e919","added_by":"auto","created_at":"2024-12-25 15:18:44","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":252005,"visible":true,"origin":"","legend":"\u003cp\u003eFemale patient, 73 years old, with an open fracture of the left calcaneus (Gustilo Type IIIB), transferred to our hospital one month after the injury. A: Partial necrosis of the skin on the left foot; B: After debridement, the wound was partially sutured on both sides, but a central skin defect of 10×3.5cm^2 remained; C: With the assistance of a skin distractor, the wound size was significantly reduced; D: 12 days post-surgery, the Kirschner wire cut through the skin, the distractor was removed, and the wound was sutured directly; E: 45 days post-surgery, the wound had essentially healed; F: Follow-up one year post-surgery showed good wound healing.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5131608/v1/89d44d624af73ac9eb4c3710.jpeg"},{"id":72333142,"identity":"b356e471-df67-4dfc-8183-8f23dc63cea2","added_by":"auto","created_at":"2024-12-25 15:18:44","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":2479714,"visible":true,"origin":"","legend":"\u003cp\u003eA: Male patient, 61 years old, suffered bilateral lower limb fractures due to a traffic accident, with fasciotomy for compartment syndrome performed on the left lower limb one week post-injury. B: Two sets of skin distractors installed, achieving significant wound closure. Under pressure, the long and short muscles of the fibula protrude outward. C: During surgery, the wound was pre-sutured with loose knots, and the protruding muscles were pressed back into the wound. As the wound size reduced, the sutures could be progressively tightened bedside; three days post-injury, the skin distractor was adjusted, and the sutures were tightened for the first time. The distractor was tightened every two days. D: Ten days post-surgery, the wound was nearly closed, the sutures on both sides of the wound were tied, and the distractor near the lower leg was removed. E: Fourteen days post-injury, the central part of the wound was closed. F: Thirty-five days post-injury, the wound was completely healed and sutures were removed.\u003c/p\u003e","description":"","filename":"floatimage6.png","url":"https://assets-eu.researchsquare.com/files/rs-5131608/v1/944f085d6f3c10fa8990768e.png"},{"id":73093101,"identity":"b651e233-1be3-4242-a1d9-ccb5f18297ab","added_by":"auto","created_at":"2025-01-06 16:02:22","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5069888,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5131608/v1/b4f7c4dd-0752-40ad-a0e5-65c7694c8c4a.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Treatment of limb skin defect with self-made skin distractor","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLarge-scale skin defects following trauma are a common clinical challenge for orthopedic trauma surgeons. These defects often involve complex situations such as open wounds with soft tissue loss, skin defects following fasciotomy for compartment syndrome, and donor site defects after skin flap transplantation. The goal of surgical treatment is to close the wound, prevent infection, and restore limb function. Current methods for treating skin defects include split-thickness skin grafts, vascularized or free flap transplants, skin expansion techniques, and skin distraction methods. Split-thickness skin grafts often result in poor elasticity, contraction, hyperpigmentation, and scarring at graft junctions due to the incomplete skin structures transferred. Donor sites can develop extensive scarring and poor durability, with a tendency to blister or rupture due to the loss of epidermis. Vascularized or free flap transplants, suitable for cases with exposed tendons, vessels, or bones, offer good extensibility and durability. However, large flaps may require additional split-thickness skin grafts for donor site closure, and free flaps require high surgical skill and carry a risk of necrosis.\u003c/p\u003e\n\u003cp\u003eIn 1976, Barrer first used a skin distractor to repair small skin defects, a method also known as skin distraction\u003csup\u003e[1]\u003c/sup\u003e. Over more than 40 years, various skin distraction devices have been developed, such as the Sureclosure\u0026reg;, Dermaclose\u0026reg;, and TopClosure\u0026reg;\u003csup\u003e[2]\u003c/sup\u003e. Despite their advantages, these devices also have drawbacks, such as complex structures and high costs. The basic principle of skin distraction involves utilizing the viscoelastic and mechanical stretch properties of the skin. By applying continuous mechanical tension, the skin on either side of the wound is pulled towards the center, effectively repairing the defect. This method is simple, effective, and results in high-quality wound repair, with the texture, durability, sensation, and function of the repaired skin closely resembling that of adjacent normal skin, without damaging the donor area and sometimes avoiding the need for flap repair\u003csup\u003e[3]\u003c/sup\u003e.\u003c/p\u003e\n\u003cp\u003eTo overcome the shortcomings of traditional skin distractors, from September 2018 to January 2020, the authors developed an improved version, the mini adjustable skin distractor (Figure 1, produced by Hebei Hengshui Zengli Medical Instruments Co., Ltd., patent number: 201720872132.2), and applied it clinically to repair large-scale skin defects in 15 patients after trauma. This mini adjustable skin distractor has proven to be easy to operate, cost-effective, and efficient. This study retrospectively analyzes this data with the objectives of: (1) exploring the feasibility of using the mini adjustable skin distractor for repairing large-scale skin defects post-trauma; (2) evaluating the clinical efficacy of the mini adjustable skin distractor in the repair of these defects; (3) summarizing the precautions needed when using the mini adjustable skin distractor for such repairs.\u0026nbsp;\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cstrong\u003eI. Inclusion and Exclusion Criteria\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion Criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1. Skin defects on limbs or torso following trauma.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2. Good patient compliance.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 3. Healthy soft tissue surrounding the wound.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 4. Minimum follow-up duration of 12 months.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion Criteria:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 1. Severe infection of the wound or surrounding scarring.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; 2. Patients with thin skin.\u003c/p\u003e\n\u003cp\u003eBased on these criteria, this study included 15 patients (16 wounds) with limb skin defects. There were 13 males and 2 females, aged between 9 and 73 years, with an average age of 42 years. Skin defect locations included the forearm (2 cases), thigh (3 cases), bilateral knees (1 case), lower leg (5 cases), ankle (1 case), and heel (3 cases). Causes of the initial injuries included traffic accidents (6 cases), machinery injuries (3 cases), falls (1 case), infections requiring surgical debridement (5 cases), and decompressive fasciotomy for compartment syndrome (1 case). Wound sizes ranged from 6cm x 3cm to 32cm x 7cm, with an average size of 72.4cm\u0026sup2;. The study was approved by the Ethics Committee of the Third Hospital of Hebei Medical University (approval number: 2017-007-1), and all patients provided informed consent. All surgeries were performed by the same surgeon(Table 1).\u003c/p\u003e\n\u003cp\u003eTable 1 Summary of case data\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"631\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eSEX\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003eAGE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eSite of wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eWound size (cm2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eCauses of injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eStretcher time (days)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 104px;\"\u003e\n \u003cp\u003eFollow-up time (months)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003ecomplication\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eleft leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e8\u0026times;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003etraffic accidents injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 55px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eLeft lateral malleolus\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e10\u0026times;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003einfection of internal fixator\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 55px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eFEMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eBoth knees\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003eL：10\u0026times;6\u003c/p\u003e\n \u003cp\u003eR：8\u0026times;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eInfection after sealing operation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003eL：21\u003c/p\u003e\n \u003cp\u003eR：18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 55px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eleft thigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e16\u0026times;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eMachine wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 55px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eright forearm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e12\u0026times;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eMachine wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 55px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eFEMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eLeft heel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e5\u0026times;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003etraffic accidents injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 55px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eKirschner wire cut\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eRight heel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e6\u0026times;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003etraffic accidents injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 55px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eRight leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e20\u0026times;5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eFall\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 55px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eLeft leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e25\u0026times;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eOsteofascial syndrome after tension reduction\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 55px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e49\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eleft thigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e22\u0026times;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003epsoas abscess\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 55px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eleft thigh\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e10\u0026times;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003etraffic accidents injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 71px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003e\u0026nbsp; NO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eright forearm\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e32\u0026times;7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003eMachine wound\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 71px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eKirschner needle incision,secondary skin grafting\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eRight heel\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e6\u0026times;3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003ediabitic foot\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 71px;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eRight leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e10\u0026times;6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003etraffic accidents injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 71px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 38px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 40px;\"\u003e\n \u003cp\u003eMALE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 39px;\"\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 70px;\"\u003e\n \u003cp\u003eRight leg\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 86px;\"\u003e\n \u003cp\u003e10\u0026times;4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 114px;\"\u003e\n \u003cp\u003etraffic accidents injury\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" style=\"width: 71px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 50px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"3\" style=\"width: 123px;\"\u003e\n \u003cp\u003eNO\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eII. Surgical Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDebridement of the Wound\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe procedure was performed under continuous epidural or brachial plexus block anesthesia with the patient in a supine position. Initial thorough debridement was conducted to remove all necrotic tissue, followed by disinfection with povidone-iodine, application of sterile drapes, and changing into fresh surgical attire and instruments.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInstallation of the Skin Distractor\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAt 1cm from the wound edge, a 2.0mm Kirschner wire was inserted through the skin surface into the junction between the dermis and subcutaneous tissue. The Kirschner wire could either tunnel subcutaneously for 2-3cm before emerging from the skin and re-entering, or continue subcutaneously until emerging at the other end of the wound. The same procedure was applied on the opposite side of the wound. The tails of the two Kirschner wires on the same side were attached to two sliders on the same distractor, which were then connected by adjusting a screw. If the wound was long or irregular, it could be divided into smaller sections, each managed with one or multiple sets of distractors as described. Turning the screw shortened the distance between the two sliders, gradually bringing the wound edges together to close the wound (Figure 2). If the wound edges had adequate tension and normal blood supply and color, the wound could be closed directly, known as primary closure. If the blood supply to the wound edges was poor and the color pale, the distractor was stopped, and wound closure was achieved gradually, known as delayed primary closure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIII. Postoperative Care\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAntibiotics were administered for 24-48 hours post-surgery, with dressings changed every 2-3 days. For wounds closed primarily, the skin distractor was removed after about 3 weeks, with sutures removed 2-3 weeks postoperatively. For wounds that could not be closed primarily, the screw was turned every other day starting 2-3 days postoperatively to shorten the distance between the two sliders by 0.5-1cm each time. The adjustment was made based on the patient\u0026apos;s tolerance to pain and without compromising the blood supply to the skin edges. Once the wound edges were aligned, the wound was sutured intermittently. The skin distractor was retained for about 3 weeks.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIV. Follow-Up and Observation Indicators\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePatients were followed up for 6-12 months to monitor for any recurrence of infection and to assess skin color, elasticity, and the function of adjacent joints.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAll patients were followed up for 6 to 12 months, with an average of 9.3 months. At the final follow-up, there was no recurrence of infection at the wound site. The color, elasticity, and sensitivity of the skin stretched by the distractor were almost identical to normal skin, and the function of adjacent joints was largely normal. Of the 16 wounds in 15 patients, 2 wounds closed during the initial procedure, and 13 underwent delayed primary closure. In one case, there was a cut in the skin caused by a Kirschner wire, but this did not affect the wound closure. In another case, severe skin cutting occurred when the wound was nearly closed, which prevented further stretching; the remaining wound area was healed by skin grafting. Typical cases are shown in Figures 3 to 6.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003e \u003cb\u003eI. The Evolution and Working Principle of Skin Expanders\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn the year 25 AD, Celsus first described the use of skin expansion to close wounds. In 1921, Codivilla and Putti observed the phenomenon of skin expansion accompanying the lengthening of the femur\u003csup\u003e[4]\u003c/sup\u003e. In 1946, Neumann was the first to use subcutaneously placed balloons to expand the skin for ear reconstruction\u003csup\u003e[5]\u003c/sup\u003e. In 1967, Gibson and Kenedi introduced the concepts of mechanical creep and stress relaxation in skin\u003csup\u003e[6]\u003c/sup\u003e. They discovered that under tension, skin could be stretched to three to four times its original length, a property that could be utilized to repair skin defects. In 1976, Radovan inserted silicone spheres filled with saline underneath the skin to expand it for the repair of soft tissue defects\u003csup\u003e[7]\u003c/sup\u003e. In 1988, Austad applied the principle of hypertonicity to skin expansion to repair soft tissue defects. Since then, the method of using internal skin expanders to repair skin and soft tissue defects has been widely accepted\u003csup\u003e[8]\u003c/sup\u003e. In 1976, Barrer invented the external skin distractor for the repair of small skin defects, a method termed as skin distraction \u003csup\u003e[1]\u003c/sup\u003e. In 1978, Hirschowitz expanded the use of this technique to repair facial skin defects with skin distractors \u003csup\u003e[9,10]\u003c/sup\u003e. Over more than 40 years of continuous development, skin distractors have ultimately been applied to the repair of limb skin defects.\u003c/p\u003e \u003cp\u003eThe working principle of all skin distractors involves utilizing the mechanical creep and stress relaxation properties of the skin. By applying continuous tension, the skin area gradually expands, thus closing the wound. Mechanical creep refers to the rapid expansion of the skin area under sustained tension. Stress relaxation describes the skin being stretched to a certain length under tension, with the tension gradually decreasing over time\u003csup\u003e[11,12]\u003c/sup\u003e. Mechanical creep and stress relaxation are immediate responses of the skin to applied stress, both of which result in direct wound closure. Under the external forces of distraction, the skin\u0026rsquo;s collagen and elastic fibers reorient in the direction of the force, and water and glycosaminoglycans within the extracellular matrix move along the alignment of the fibers, forming the histological basis for mechanical creep and stress relaxation\u003csup\u003e[13]\u003c/sup\u003e. During skin expansion, collagen fibers regenerate rather than break. Research has shown that during the skin expansion process, as the dermis thins, the epidermis significantly thickens, basal layer cellular mitosis increases, and there is a noticeable increase in small arteries, small veins, capillaries, fibroblasts, and collagen content, indicating an increase in collagen synthesis\u003csup\u003e[14,15]\u003c/sup\u003e. Ruzzak found that two years after skin expansion, the structural layers of the skin can return to normal.\u003c/p\u003e \u003cp\u003eThe implementation method for stress relaxation characteristics involves using the skin distractor to apply maximum traction to the skin for 3 minutes, during which time the skin edges become ischemic, followed by a 1-minute relaxation to allow blood circulation to recover. This cycle is repeated for about 30 minutes in total to expand the skin around the wound, thereby closing the wound directly\u003csup\u003e[16]\u003c/sup\u003e. Ryan\u0026rsquo;s research shows that under cyclic tension, the oxygen content and viability within the skin further increase\u003csup\u003e[12]\u003c/sup\u003e. Different reports on the method of stress relaxation vary; Topazm uses a skin distractor to close the wound edges, maintains it for 30 seconds, then releases the distractor for 1\u0026ndash;2 minutes, repeating this cycle for 0.5-2 hours, ultimately achieving single-session closure of wounds measuring 25cm\u0026times;15cm, 15cm\u0026times;7cm, and 25cm\u0026times;18cm\u003csup\u003e[17]\u003c/sup\u003e. Lei and others used the skin's stress relaxation properties in two surgeries, completely closing a 40cm\u0026times;30cm proximal thigh wound within 9 days\u003csup\u003e[18]\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eThe skin distractor I developed consists of a threaded rod and two sliders (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), with Slider A being a freely moving slider without threads, able to move along the rod, and Slider B being an adjustable slider with threads that can be rotated along the rod. By turning the rod clockwise, the distance between the two sliders is shortened, thus applying tension to the skin on both sides of the wound (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). This product is lightweight (each set of distractors weighs only 40g), structurally simple, and easy to use. Among the 15 patients treated (16 wounds), wound sizes ranged from 6cm\u0026times;3 cm to 32cm\u0026times;7 cm. In 2 cases, the wounds were closed primarily with the assistance of the distractor; in 13 cases, closure was delayed primary, with one case experiencing a Kirschner wire cut in the skin, though it did not affect wound closure. One case (No. 12) had a large skin defect area and experienced skin cutting when the wound was nearly closed, with the remaining wound area closed by free skin grafting. The treatment results showed that no cases experienced necrosis of the wound edges, wounds healed well, and the overall treatment effect was satisfactory.\u003c/p\u003e \u003cp\u003eResearchers report that the skin stretched by distraction has similar color and hair characteristics to adjacent normal skin\u003csup\u003e[19]\u003c/sup\u003e, and may functionally be better than skin transplants or local skin flaps\u003csup\u003e[20]\u003c/sup\u003e. Our follow-up results also show that the expanded skin is virtually indistinguishable from surrounding skin in terms of sensation and durability.\u003c/p\u003e \u003cp\u003e \u003cb\u003eII. Precautions for Using Skin Distractors\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe use of skin distractors is predicated on the surrounding skin of the wound having good elasticity. Thin skin around the wound, scarred tissue, inflammation, edema, or areas that have received radiation are contraindications for skin distraction \u003csup\u003e[21]\u003c/sup\u003e. Clinically, the mobility and flexibility of the skin around the wound can be assessed by pulling on it to make an approximate judgement\u003csup\u003e[22]\u003c/sup\u003e. When closing the wound, thorough debridement must first be performed to remove necrotic and poorly vascularized tissues before installing the distractor. There is no need for a free skin edge, as this can further compromise blood supply to the edges\u003csup\u003e[23]\u003c/sup\u003e. Mellis et al. conducted quantitative histological studies on piglet skin and found that free skin edges have little effect on reducing skin tension, but they can increase complications such as edge necrosis and hematoma \u003csup\u003e[24]\u003c/sup\u003e .\u003c/p\u003e \u003cp\u003eSkin expansion can be applied preoperatively, intraoperatively, and postoperatively. Before the removal of skin hemangiomas, neurofibromas, or keloids, to ensure primary closure of the postoperative wound, skin distractors can be applied preoperatively. With 1\u0026ndash;2 weeks of traction, the skin around the lesion becomes relaxed, allowing the wound to be directly closed postoperatively\u003csup\u003e[25]\u003c/sup\u003e. Intraoperative use of skin distractors allows for immediate closure if the wound tension is low; for wounds with higher tension, delayed primary closure can be performed. Starting 2\u0026ndash;3 days postoperatively, the tension is increased every two days, with adjustments based on the patient's tolerance to pain and without noticeable changes in the color of the skin edges. After the wound is closed, the skin is sutured intermittently, and the distractor is kept in place for 2\u0026ndash;3 weeks before being removed, to prevent elastic recoil and reduce scar formation. Sometimes, postoperative wounds can be closed in one go without a distractor, but with significant tension. To prevent the wound from reopening, a skin expander is used after suturing the wound to reduce tension and ensure smooth healing.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe mini adjustable skin distractor that I have developed is simple in structure, easy to use, cost-effective, and has satisfactory therapeutic effects. The main limitation of this article is the small sample size, which was not compared with similar products. In the future, the sample size should be increased to accumulate more experience.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eGao Lei and Li Kai contributed equally to this work. Zhang Yanlong proposed the idea and conceived the project with Wang Hongrun, Liu Shibo, Wang Yong. designed and conducted the experiments, analyzed the data, and wrote the manuscript. Peng Aqin provided important pieces of advice on this study. All authors reviewed and approved the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo funds were received for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available fromthe corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved by the Ethics Committee of the Third Hospital of Hebei Medical University (approval number: 2017-007-1), and all patients provided informed consent. All procedures were performed in accordance with the ethical principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients provided comprehensive written informed consent to use their medical data anonymously for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBarrer S, Pavlides CA, Matsumoto T. Ideal laparotomy closure: comparison of retention sutures with new retention bridging devices[J]. Am Surg\u003cem\u003e,\u003c/em\u003e1976, 42(8): 582-584. DOI:10.1016/0002-9610(76)90202-6.\u003c/li\u003e\n\u003cli\u003eWang X, Zhu Z, Zhao Y, et al. The effect of TopClosure\u0026reg; TRS in the treatment of large abdominal wall defect[J]. European Journal of Plastic Surgery\u003cem\u003e,\u003c/em\u003e2019, 42(6): 603-610. DOI:10.1007/s00238-019-01516-y.\u003c/li\u003e\n\u003cli\u003eParrett BM, Matros E, Pribaz JJ, et al. Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures[J]. Plast Reconstr Surg\u003cem\u003e,\u003c/em\u003e2006, 117(4): 1315-1322; discussion 1323-1314. DOI:10.1097/01.prs.0000204959.18136.36.\u003c/li\u003e\n\u003cli\u003ePutti V, Peltier LFJCO, Research R. The Operative Lengthening of the Femur[J]. 1990, \u0026amp;NA;(250). DOI:10.1097/00003086-199001000-00002.\u003c/li\u003e\n\u003cli\u003eNEUMANN, Charles GJP, Surgery R. The expansion of an area of skin by progressive distention of a subcutaneous balloon; use of the method for securing skin for subtotal reconstruction of the ear[J]. 1957, 19(2): 124-130. DOI:10.1097/00006534-195702000-00004.\u003c/li\u003e\n\u003cli\u003eGibson T, Kenedi RMJSCNA. Biomechanical properties of skin[J]. 1967, 47(2): 279-294. DOI:10.1016/S0039-6109(16)38180-4.\u003c/li\u003e\n\u003cli\u003eRadovan CJP, Surgery R. Tissue expansion in soft-tissue reconstruction[J]. 1984, 74(4): 482. DOI:10.1097/00006534-198410000-00005.\u003c/li\u003e\n\u003cli\u003eAustad, Eric. Evolution of the Concept of Tissue Expansion[J]. Facial Plastic Surgery Fps\u003cem\u003e,\u003c/em\u003e1988, 5(04): 277-279. DOI:10.1055/s-2008-1064763.\u003c/li\u003e\n\u003cli\u003eHirshowitz B. The two-stage face lift[J]. British Journal of Plastic Surgery\u003cem\u003e,\u003c/em\u003e1978, 31(2): 159-164. DOI:10.1016/S0007-1226(78)90070-X.\u003c/li\u003e\n\u003cli\u003eHirshowitz B, Lindenbaum E, Har-Shai Y. A skin-stretching device for the harnessing of the viscoelastic properties of skin[J]. Plast Reconstr Surg\u003cem\u003e,\u003c/em\u003e1993, 92(2): 260. DOI:10.1097/00006534-199308000-00010.\u003c/li\u003e\n\u003cli\u003eSaulis AS, Lautenschlager EP, Mustoe TA. Biomechanical and viscoelastic properties of skin, SMAS, and composite flaps as they pertain to rhytidectomy[J]. Plast Reconstr Surg\u003cem\u003e,\u003c/em\u003e2002, 110(2): 590-598. DOI:10.1097/00006534-200208000-00035.\u003c/li\u003e\n\u003cli\u003eRyan, T. J. Biochemical consequences of mechanical forces generated by distention and distortion[J]. J Am Acad Dermatol\u003cem\u003e,\u003c/em\u003e1989, 21(1): 115-130. DOI:10.1016/S0190-9622(89)70156-0.\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Reilly AG, Schmitt WR, Roenigk RK, et al. Closure of Scalp Defects Using External Tissue Expander[J]. Archives of facial plastic surgery: official publication for the American Academy of Facial Plastic\u003cem\u003e,\u003c/em\u003e2012, 145(2 Suppl): 1-4. DOI:10.1001/archfacial.2012.662.\u003c/li\u003e\n\u003cli\u003eKnight KR, Mccann JJ, Vanderkolk CA, et al. The redistribution of collagen in expanded pig skin[J]. British Journal of Plastic Surgery\u003cem\u003e,\u003c/em\u003e1990, 43(5): 565-570. DOI:10.1016/0007-1226(90)90121-F.\u003c/li\u003e\n\u003cli\u003ePasyk KA, Argenta LC, Austad ED. Histopathology of human expanded tissue[J]. Clinics in Plastic Surgery\u003cem\u003e,\u003c/em\u003e1987, 14(3): 435-445. \u003c/li\u003e\n\u003cli\u003eTopaz M, Carmel NN, Silberman A, et al. The TopClosure 3S System, for skin stretching and a secure wound closure[J]. European Journal of Plastic Surgery\u003cem\u003e,\u003c/em\u003e2012, 35(7): p.533-543. DOI:10.1007/s00238-011-0671-1.\u003c/li\u003e\n\u003cli\u003eTopaz M, Carmel NN, Topaz G, et al. Stress-relaxation and tension relief system for immediate primary closure of large and huge soft tissue defects: an old-new concept: new concept for direct closure of large defects[J]. Medicine\u003cem\u003e,\u003c/em\u003e2014, 93. DOI:10.1097/MD.0000000000000234.\u003c/li\u003e\n\u003cli\u003eLei Y, Liu L, Du SH, et al. The use of a skin-stretching device combined with vacuum sealing drainage for closure of a large skin defect: A case report[J]. J Med Case Reports\u003cem\u003e,\u003c/em\u003e2018, 12(1). DOI:10.1186/s13256-018-1779-8.\u003c/li\u003e\n\u003cli\u003eMelis P, Bos KE, Horenblas S. Primary skin closure of a large groin defect after inguinal lymphadenectomy for penile cancer using a skin stretching device[J]. Journal of Urology\u003cem\u003e,\u003c/em\u003e1998, 159(1): 185-187. DOI:10.1016/S0022-5347(01)64052-7.\u003c/li\u003e\n\u003cli\u003eSamis AJ, Davidson JS. Skin-stretching device for intraoperative primary closure of radial forearm flap donor site[J]. Plast Reconstr Surg\u003cem\u003e,\u003c/em\u003e2000, 105(2): 698-702. DOI:10.1097/00006534-200002000-00034.\u003c/li\u003e\n\u003cli\u003eArain AR, Cole K, Sullivan C, et al. Tissue expanders with a focus on extremity reconstruction[J]. Expert Review of Medical Devices\u003cem\u003e,\u003c/em\u003e2018, 15(2): 145-155. DOI:10.1080/17434440.2018.1426457.\u003c/li\u003e\n\u003cli\u003eIsmavel R, Samuel S, Boopalan PRJVC, et al. A Simple Solution for Wound Coverage by Skin Stretching[J]. Journal of Orthopaedic Trauma\u003cem\u003e,\u003c/em\u003e2011, 25(3): 127-132. DOI:10.1097/BOT.0b013e318206f556.\u003c/li\u003e\n\u003cli\u003eHirshowitz B, Lindenbaum E, Har-Shai Y. A skin-stretching device for the harnessing of the viscoelastic properties of skin[J]. Plast Reconstr Surg\u003cem\u003e,\u003c/em\u003e1993, 92(2): 260-270. DOI:10.1097/00006534-199308000-00010.\u003c/li\u003e\n\u003cli\u003eMelis P, Noorlander ML, van der Horst CMAM, et al. Rapid Alignment of Collagen Fibers in the Dermis of Undermined and Not Undermined Skin Stretched with a Skin-Stretching Device[J]. Plastic Reconstructive Surgery\u003cem\u003e,\u003c/em\u003e2002, 109(2): 674-680. DOI:10.1097/00006534-200202000-00038.\u003c/li\u003e\n\u003cli\u003eTopaz M, Carmel N-N, Silberman A, et al. The TopClosure\u0026reg; 3S System, for skin stretching and a secure wound closure[J]. European Journal of Plastic Surgery\u003cem\u003e,\u003c/em\u003e2012, 35(7): 533-543. DOI:10.1007/s00238-011-0671-1.\u003cstrong\u003e\u003cbr\u003e \u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Skin, Defect, Distractor","lastPublishedDoi":"10.21203/rs.3.rs-5131608/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5131608/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u0026nbsp; To investigate the effect of self-made skin distractor in the treatment of limb skin defects.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u0026nbsp; From September 2018 to January 2020, 15 cases of limb skin defects (16 wounds) were treated with self-designed skin distractor, including 13 males and 2 females, with an average age of 42 years (range, 9-73 years). The smallest area of skin defect was 6cm×3cm, the largest was 32cm ×7cm, with an average of 72.4cm\u003csup\u003e2\u003c/sup\u003e. The wound healing was observed, complications and the time of use of the distractor were recorded.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e All patients were followed up for 6-12 months with an average of 9.2 months. Of the 16 wounds in 15 patients, 2 wounds were closed in one stage during operation, 13 wounds were delayed in primary closure. Skin incision occurred in 1 case, but the wound closure was not affected；One wounds were not closed completely, because the skin was cut by Kirschner wire, and could not be stretched continously. The remaining wounds were closed by skin grafting. Another case also had skin cutting was occurred in another case, but the wound closure was not affected. No skin stretch was terminated due to pain. All wounds were healed. The elasticity and color of the skin on the wound surface were not different from the surrounding skin. The movement of the adjacent joints was basically normal.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eThe self-made skin stretcher is simple in structure and easy to use. It provides a reliable and effective method for the treatment of skin defects of limbs.\u003c/p\u003e","manuscriptTitle":"Treatment of limb skin defect with self-made skin distractor","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-12-25 15:18:39","doi":"10.21203/rs.3.rs-5131608/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-09-30T07:59:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-09-25T11:18:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-09-25T11:15:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Musculoskeletal Disorders","date":"2024-09-22T08:46:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-musculoskeletal-disorders","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bmsd","sideBox":"Learn more about [BMC Musculoskeletal Disorders](http://bmcmusculoskeletdisord.biomedcentral.com/)","snPcode":"","submissionUrl":"https://author-welcome.nature.com/12891","title":"BMC Musculoskeletal Disorders","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"d0cbbe93-fb01-4166-8de6-86425bc31c38","owner":[],"postedDate":"December 25th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-01-06T15:58:04+00:00","versionOfRecord":{"articleIdentity":"rs-5131608","link":"https://doi.org/10.1186/s12891-024-08249-5","journal":{"identity":"bmc-musculoskeletal-disorders","isVorOnly":false,"title":"BMC Musculoskeletal Disorders"},"publishedOn":"2024-12-30 15:56:51","publishedOnDateReadable":"December 30th, 2024"},"versionCreatedAt":"2024-12-25 15:18:39","video":"","vorDoi":"10.1186/s12891-024-08249-5","vorDoiUrl":"https://doi.org/10.1186/s12891-024-08249-5","workflowStages":[]},"version":"v1","identity":"rs-5131608","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5131608","identity":"rs-5131608","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}