External Skin Expansion

Sir: I was delighted to read the article by Daya and Nair confirming the concept of external skin expansion.1 I have been working on this principle for 8 years with engineers from Canica Design, Inc. (Almonte, Ontario, Canada), developing products to accomplish wound closure and presurgical external skin expansion in a safe and reliable way. There are two complications one may encounter in the skin with tape application under tension. The first is blistering from the shear forces at the skin adhesive junction.2 These blisters are painful and can cause scarring. Reinforced strips do not stretch, which means that when they are adhered under tension, all of the force on the tape is transferred to the skin beneath the strip. The skin is no longer compliant, as it is bonded to the reinforced fabric. The skin right at the end of the strip suffers the highest load. The second problem is pain. Dr. Dal Cin describes expanding the skin to close an 8-cm skin graft on a scalp with dynamic external forces over a period of 149 days. The patient lost enthusiasm at several points along the way because of discomfort. However, with the adjustable features of dynamic traction, gently stretching the scalp, the graft was excised and primary closure achieved.2,3 The Canica Design solution has been to simply use an elastomer between two strips of Micropore tape (3M, St. Paul, Minn.). This provides gentle relentless traction on the skin. The level of tension is set initially by a limiter controlling the stretch of the elastomer, which protects even the most easily damaged skin (e.g., leg ulcers in diabetics and in irradiated skin). Similarly, this mechanism of controlled tensioning reduces pain. It is noninvasive, repeatable, and very easily applied. The product is called DynaClose. It is licensed for wound closure and is currently being reviewed by the U.S. Food and Drug Administration for surgical skin expansion. It is approved in Canada for both uses. We believe this product offers benefits similar to the technique described by Daya and Nair in prestretching skin but will avoid the problems of skin irritation, breakdown, and pain. This is achieved by controlled elastic forces. As Daya and Nair state, the use of the external traction principle has many potential applications4–6: prestretching skin before surgical reconstruction, pain relief, and scar reduction. The Canica DynaClose tape can also be used in open wounds, which can be viewed directly through the transparent silicone sheeting, so that any infectious process would be directly evident (Fig. 1). This principle of dynamic closure is invaluable in closing unclosable wounds nonsurgically. DynaClose is the latest and simplest of the Canica family of Dynamic Wound Closure devices, which are well documented in the literature.7–10Fig. 1.: This fasciotomy was primarily controlled by DynaClose tape to prevent excessive retraction. The tapes were changed weekly to achieve delayed primary closure by 5 weeks, with no secondary intervention required. (Above) Photograph obtained on July 9, 2007. (Center and below) Photographs obtained on April 23, 2008.With my evident conflict of interest as a paid design consultant for Canica Design, I cannot participate in a valid study of these products, but I would encourage others to assess the benefits of this newly available technology in an objective fashion. Michael S. G. Bell, M.D. Plastic, Reconstructive, Cosmetic Surgery and Laser Resurfacing 1919 Riverside Drive, Suite 402 Ottawa, Ontario K1H 1A2, Canada [email protected]

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