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Rapid intraoperative tissue expansion example

Rapid intraoperative tissue expansion (RITE) is a technique for stretching skin when the surgeon is confronted with skin loss after skin cancer excision. By stretching the skin, often skin flaps, skin grafts, and second intent healing can be avoided. This saves the surgeon time and risk, retains more closures in their practice, and offers patients another option for how their wound is closed.

How Does RITE Work?

Tissue expansion is a well-described technique used by surgeons for many years. Human skin has viscoelastic properties that allow for tissue expansion. Part of the skins’ response to stretch is elastic, like a rubber band. After being stretched, parts of the skin fibers snap back to its original size and shape. But the skin also has a viscous component, like warm taffy, in that the skin will not snap back to original size and shape but remain at the new stretched length. During RITE, skin is stretched to its maximum within a given time. After the sustained stretch used in RITE, a wound that at first was not able to be closed linearly is now smaller and, in most cases, can be closed linearly. Thus, RITE helps avoid skin flaps, grafts, and second intent healing. RITE gives surgeons and patients a fourth option for closing skin cancer defects.

Mechanisms of Action

The strength in human skin is derived from the collagen rich dermis. Type I collagen fibers in the dermis are arranged in a somewhat random fashion, though they may more often run parallel to Langer’s lines, otherwise known as relaxed skin tension lines (RSTLs). When significant force is applied to human skin, it can be lengthened by as much as 50% in less than 30 minutes. This lengthening occurs by parallelization and stretch of the dermal elastin and collagen fibers, and from extrusion of fluid the dermal extracellular matrix.

Rapid intraoperative tissue expansion example

Applied force (stress) causes lengthening (strain) in 3 phases (Figure). In the first two phases, the skin can recover to original length quickly. However, in the third phase, structural change in the skin (i.e. skin “creep”) occurs. RITE must reach the third stage to be maximally effective. It is reached optimally when a sustained (rather than an intermittent cycled) force is applied in one direction.

RITE Made Simple with SUTUREGARD® Device

The strength in human skin is derived from the collagen rich dermis. Type I collagen fibers in the dermis are arranged in a somewhat random fashion, though they may more often run parallel to Langer’s lines, otherwise known as relaxed skin tension lines (RSTLs). When significant force is applied to human skin, it can be lengthened by as much as 50% in less than 30 minutes. This lengthening occurs by parallelization and stretch of the dermal elastin and collagen fibers, and from extrusion of fluid the dermal extracellular matrix.

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References

Johnson TM, Brown MD, Sullivan MJ, & Swanson NA. (1990). Immediate intraoperative tissue expansion. Journal of the American Academy of Dermatology, 22, 283–287.
Lear W, Mustoe T et al. (2018). Rapid Intraoperative Tissue Expansion of the Scalp Using a Novel Suture Retention Device. Manuscript submitted for publication.
Neumann, CG. (1957). The expansion of an area of skin by progressive distension of a sub-cutaneous balloon. Plastic and Reconstructive Surgery, 19, 124–130.
Sasaki, GH. (1987). Intraoperative sustained limited expansion (ISLE) as an immediate reconstructive technique. Clinics in Plastic Surgery, 14, 563–573.

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