Novembre 2007
Elasticum® device for large scar revision without blunt dissection
Sergio Capurro, Fabrizio Cecchi*, Armando Gabrielli*, Carlo Rava
*Division of Plastic Surgery S. Martino Hospital Genoa ItalyThe excision of large scars caused by burns or traumas often results in subsequent scar widening due to the high tension exerted on the edges of the suture after excision. In order to minimize scar widening, ample blunt dissection of the skin is performed and suturing is carried out in several layers. However, ample blunt dissection reduces the vascularization of the skin and subcutaneous tissue, thereby increasing the risk of necrosis. Moreover, sutures under tension damage the edges of the wound and cut into the tissues, allowing the scar to widen progressively. A scar under tension becomes hypotrophic as it widens, and within a few months may take on a similar appearance to that of the initial lesion.
In order to prevent scar widening in cases in which the usual plastic surgery techniques display scant efficacy, we utilized a new device, which enables the tension on the edges of the wound to be alleviated, without blunt dissection of the skin, for the time needed for optimal healing. This device consists of a sheathed elastic thread mounted on a two-tipped atraumatic needle; the needle is a modification of the two-tipped atraumatic needle (with eye) described in publications in 1984 and 1987 (1-2). This two-tipped needle was originally designed to enable traction and suspension to be applied in any direction and for any length, while creating only one 2 mm skin incision in order to bury the knot.
Our experimentation in facial suspension procedures, for example in cases of facial nerve paralysis or face-lifting without blunt dissection, did not meet with success. The nylon, polypropylene and polyester threads used inevitably cut into the tissues within a few weeks at the most. This experimentation prompted us to conclude that inelastic threads are not suitable for prolonged tissue traction or suspension.
Thus, in order to achieve permanent results, we designed an elastic thread made of silicone and sheathed with polyester. This thread (Elasticum®, Korpo srl Genova Italy) has solved the problems raised by the use of non-elastic threads. Indeed, its elasticity prevents, or at least minimizes, the cutting effect; moreover, even if some cutting effect does ensue, traction or suspension is maintained by the elastic component of the thread. The sheath, which consists of spirals of inelastic polyester, limits the extent of stretching of the thread, while at the same time enabling the thread to be attached firmly to the two-tipped needle. After a few weeks, the polyester spirals are colonized by connective cells. This transformation of the thread in to a “natural ligament” which stabilizes the result obtained is one of the advantages that this new surgical thread has over unsheathed elastic threads (3-4 ).
Materials and methods
Once the cutaneous scar has been excised, no blunt dissection is carried out. Subcutaneous suturing is performed with the Elasticum thread mounted on a 115 mm or 165 mm two-tipped needle. The diameter of the thread used will depend on the region of the body under treatment.
The two-tipped needle is inserted into the subcutaneous tissue at a point about 5 mm below the dermis at one edge of the wound and emerges through the skin on the same side at a distance of about 3 or 4 cm from the wound. The needle is not extracted completely. Once the mid-point of the needle emerges, the thread attachment becomes visible. The thread is then pulled through and placed under tension, and a “mosquito” is fixed to the end of the thread. The body of the two-tipped needle is marked with depth indicators. At the predetermined depth, the posterior tip (which is still in the subcutaneous tissue) travels back in the opposite direction and emerges parallel to the point of entry at the edge of the wound. The same procedure is then carried out at the opposite edge. Once the elastic thread has been knotted, the wound closes; there is no tension on the edges, which can then be joined by means of an intradermal or spiral suture. The elastic thread must not be removed, as the fibrotic colonization of its sheath stabilizes the result over time. As the thread has the same consistency as the subcutaneous tissue, it is not palpable.
Fig.1) Elastic thread
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Conclusions
The device has been used successfully in 52 excisions of large scars on the face and body, without blunt dissection; no complications have been recorded. Biocompatibility of the thread has proved to be very good. The fact that traction is exerted at a distance from the edges of the wound allows good-quality healing. This innovative thread and the two-tipped atraumatic needle open up new possibilities in plastic and esthetic surgery operations.
References
1) Capurro S.: Un ago a due punte. Riv. Ital. Chir. Plast.16: 1, 1984.
2) Capurro S.: The double-tipped needle.Plast.Reconst.Surg 79: 6, 1987
3) Nordström, R.E.A. The "Nordström Suture" - A New and Very Effective Device. In Proceedings of the 8th Congress of the European Section of IPRAS, Lisbon, Portugal, June 22-25, 19974) Nordström REA, discussion paper for The "Silicone Suture" for Non-expander's Tissue Expansion: A New Device For Repair Of Soft Tissue Defects After Burn by Jincai Fan, MD Ph.D. and Jiping Wang, M.D, Plastic and Reconstructive Surgery, 2:489-490, 2004.