Case 1. Twenty-year-old Ms. Q was admitted for a 10 cm x 8 cm, partially necrotic and bleeding cutaneous tumor in her left groin (see Figure 1a). Before she came to the center, only 2 months had elapsed for her lesion to develop from a small eczema-like plaque to the present status. She had not received any previous treatment, had no other self-reported health conditions or comorbidities, and none were identified during presurgical health screening. Computer tomography (CT) scan indicated a solid, homogeneous tumor without involvement of the left femur artery, vein, or nerve (see Figure 1b). Biopsy result indicated small cell carcinoma. A multidisciplinary surgical team was assembled comprising an orthopedic oncology surgeon and a plastic and reconstructive surgeon. Before surgery, the patient’s ipsilateral and contralateral inferior epigastric arteries were located by noninvasive Doppler sensor, and a potential deep inferior epigastric perforator (DIEP) flap was designed to address the defect (see Figure 1c). Radical resection of the tumor then was completed, leaving a huge groin skin and soft tissue defect (see Figures 1d,e). A 16 cm x 8 cm contralateral DIEP flap was harvested and transferred to cover the wound (see Figures 1f–1h). The donor site margins were sutured, and 3 pair of APs were invasively placed along the suture line and interconnected by a long, flexible AS to relax the tension (see Figure 1i).
All of Ms. Q’s presurgical and postsurgical care was provided by the plastic surgeons and nurses at the center. After the operation, her gauze dressing was changed and the wound evaluated every 2 days. The suture line was disinfected with benzalkonium chloride and the sutures and adjacent skin assessed to evaluate the risk of rupture or skin trauma (ie, pressure ulcer) under the APs. The APs were carefully adjusted to gradually loosen the skin while protecting the sutures from excessive tension. At 4 weeks, Ms. Q’s wound was firmly closed and the sutures and APs were removed (see Figure 1j).
Because the pathology report indicated the lesion was a nonHodgkin’s lymphoma and positron emission tomography (PET) CT scan indicated several suspicious lymph nodes, Ms. Q was transferred to the Department of Hematology to receive chemotherapy.
Case 2. Mr. K is a 53-year-old man whose left foot and ankle were crushed in a traffic accident by the wheel of a heavy truck, causing a 10 cm x 8 cm skin and soft tissue avulsion on the ankle joint and dorsal site. Mr. K had no other self-reported health conditions or comorbidities; presurgical health screening indicated no other positive findings except for a smoking index of 600 (60 cigarettes per day times 10 years).
To cover this defect, right anterolateral thigh, free-flap transplantation was performed in the Orthopedic Wound and Fracture Department. Simultaneously, the donor site, too wide for primary closure, was covered with a split-thickness skin graft. However, both the grafted skin and the transplanted flap became necrotic, leaving a 10 cm x 16 cm defect on the right upper leg (see Figure 2a,b). The orthopedic surgeon took a cotton swab sample from the donor site defect wound for microbiological culture; the result indicated Serratia marcescens infection (sensitive to most antibiotics). Mr. K then was transferred to the wound center for treatment of both wounds by a plastic surgeon. After careful physical examination and discussion, the plastic surgeons decided to perform stress relaxation and assisted closure. This involved complete surgical debridement, followed by installation of 3 pair of APs, invasively placed along the wound axis and interconnected by a long, flexible AS (see Figure 2c). The wound was initially covered with Vaseline gauze (Jiujiang Huada Medical Dressing Co, Ltd, Gongqing City Jiangxi Province, P.R. China) (see Figure 2d). Simultaneously, for the foot and ankle wound, the necrotic grafted flap was removed, exposing thrombosis of the drainage vein (see Figure 2e). After debridement, another split-thickness skin graft was used to cover the left foot ankle wound (see Figure 2f). The plastic surgeons first changed the dressing 3 days after the surgery, using SeaSorb-Ag dressing (Coloplast Group, Humlebaek, Denmark) to cover the wound and absorb wound exudate; the dressing was changed every 2 days thereafter. During each dressing change, the wound and skin were assessed and wound measurements obtained, and the skin was gradually stretched by adjusting the AS. During this procedure, great care was taken (including daily check, adjusting AS, and placing soft gauze beneath the APs) to avoid inducing pressure ulcers beneath the APs (see Figure 2g). Nineteen (19) days after surgery, the residual wound measured 2 cm and was filled with granulation tissue that blocked the APs and skin (see Figure 2h). At a second surgery performed 19 days after the first, excess granulation tissue was resected and the wound was sutured closed (see Figure 2i). Another 2 pair of APs were placed to relax the tension (see Figure 2j). Fifteen (15) days later, both the suture and APs were removed. The muscle and fascia defect was firmly closed, leaving only several superficial skin gaps that healed with regular wound care, comprising daily dressing change, disinfection, and assessment (see Figure 2k); a skin graft was applied to the left foot ankle wound (see Figure 2l). At the 6-month follow-up, slight scarring at the donor site and foot wound was observed (see Figure 2m,n).