Building a Multidisciplinary Clinic Dedicated to Upper-Extremity Limb Loss.

Complete care of the patient with upper limb loss mandates a long-term, multifaceted approach. Increased functionality and quality of life require collaborative efforts between the patient's surgeon, prosthetist, hand therapists, mental health professionals, and peers. An individual surgeon may find that initiating and maintaining a practice offering total integrated treatment for upper-extremity amputees is a formidable task, but with specific, actionable recommendations, the process can be demystified. The upper-extremity surgeon must be facile with operative techniques such as targeted muscle reinnervation (TMR), regenerative peripheral nerve interface (RPNI), and soft tissue reconstruction and focus on team recruitment strategy and promotion of the clinic within the community. Consistent communication and team decision-making shape each patient's preoperative and postoperative course. We aim to relay effective interventions at each step of recovery from each clinic member and describe clinic workflow designed to reinforce holistic care. We present a blueprint for creating a functional and comprehensive multidisciplinary center for patients with upper-extremity limb loss for those providers interested in providing care, but who are missing the logistical roadmap for how to do so.

Vascularized Bone Grafting Versus the 2-Stage Masquelet Technique for Upper-Extremity Bone Reconstruction: A Meta-Analysis.

PURPOSE: Vascularized bone grafting (VBG) has been described as the technique of choice for larger bone defects in bone reconstruction, yielding excellent results at the traditional threshold of 6 cm as described in the literature. However, we hypothesize that the 2-stage Masquelet technique provides equivalent union rates for upper-extremity bone defects regardless of size, while having no increase in the rate of patient complications. METHODS: A systematic literature review was conducted using PubMed and Scopus for outcomes after VBG and the Masquelet technique for upper-extremity bone defects of the humerus, radius, ulna, metacarpal, or phalanx (carpal defects were excluded). A meta-analysis was performed to compare outcomes following VBG and the Masquelet technique at varying defect sizes. RESULTS: There were 77 VBG (295 patients) and 25 Masquelet (119 patients) studies that met inclusion criteria. Patients undergoing the Masquelet technique had defect sizes ranging from 0-15 cm (average 4.5 cm), while patients undergoing VBG had defect sizes ranging from 0-24 cm (average 5.9 cm). The union rate for Masquelet patients was 94.1% with an average time to union of 5.8 months, compared to 94.9% and 4.4 months, respectively, for VBG patients. We did not identify a defect size threshold at which VBG demonstrated a significantly higher union rate. No statistically significant difference was found in union rates between techniques when using multivariable logistic regression analysis. CONCLUSION: There was no statistically significant difference in union rates between VBG and the Masquelet technique in upper-extremity bone defects regardless of defect size. Surgeons may consider the Masquelet technique as an alternative to VBG in large bone defects of the upper extremity. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

First Carpometacarpal Joint Denervation: A Systematic Review.

PURPOSE: The first carpometacarpal (CMC) joint is a frequent location of osteoarthritis in the hand. The denervation of the first CMC joint has gained traction as a viable treatment for CMC arthritis. This study reviewed literature on CMC denervation for first CMC arthritis. METHODS: A systematic review of papers and abstracts was conducted. The preferred reporting items for systematic reviews and meta-analyses guidelines were followed. Articles including the results of CMC denervation were included. We compiled data on patient demographics, preoperative testing, intraoperative technique, and postoperative outcomes. Anatomic literature was also reviewed to assess agreement on the innervation of the first CMC joint. RESULTS: Six anatomic studies and 9 clinical studies were included in this systematic review. Pinch strength, grip strength, and Kapandji scores increased on average in patients. Pain relief was noted on average in patients in 5 studies that reported pain outcomes. In studies that reported postoperative complications, the most frequent complications were radial paresthesias, hypoesthesia dorsal and/or distal to the surgical site, and wound infection. CONCLUSIONS: The innervation of the CMC joint is controversial. This is reflected in clinical practice, wherein varied surgical approaches are used. Carpometacarpal denervation shows promise as an option to treat patients with CMC arthritis without joint instability, but its results vary. Additional clinical studies with longer-term follow-up and control groups are necessary to better determine its longevity and efficacy. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

External Tissue Expansion in Complex Extremity Reconstruction.

Skin grafting and flap-based reconstruction have been the conventional treatments for complex extremity wounds. However, these methods can be associated with relatively high complication rates and involve increasing levels of complexity. External tissue expansion has recently emerged as an attractive alternative to its conventional counterparts. It is a technically simple and low-morbidity technique for complex wound reconstruction. This article provides a review of internal and external tissue expansion with a focus on the evolution, indications, and recent successes of external expansion for soft tissue coverage.

The extent of brachial plexus injury: an important factor in spinal accessory nerve to suprascapular nerve transfer outcomes.

Objective: The purpose of this study was to assess the association between extent of brachial plexus injury and shoulder abduction/external rotation outcomes after spinal accessory nerve (SAN) to suprascapular nerve (SSN) transfer.Methods: A systematic review of the literature was conducted according to PRISMA guidelines. Inclusion criteria were studies reporting outcomes on patients undergoing SAN to SSN nerve transfer. Patients were excluded for the following reasons: age under 18, nerve transfer for reanimation of the shoulder other than SAN to SSN, and less than 12 months of follow-up postoperatively. Pooled analysis was performed, and primary outcomes were Medical Research Council (MRC) score and range of motion (ROM) for shoulder abduction and external rotation. Univariate logistic regression analysis was used to assess the association between extent of brachial plexus injury and shoulder abduction/external rotation outcomes after SAN to SSN transfer. A multivariate logistic regression analysis model including age, injury to surgery interval, and extent of injury as factors was also created.Results: Univariate logistic regression analysis showed greater extent of injury to be a predictor of poorer shoulder abduction outcomes (OR: 0.502; 95% CI: 0.260-0.971, p = 0.040). Multivariate logistic regression analysis confirmed this association (OR: 0.55; 95% CI: 0.236-0.877, p = 0.019). Extent of injury was not significantly associated with external rotation outcomes on univariate analysis (OR: 0.435; 95% CI: 0.095-1.995, p = 0.284) or multivariate analysis (OR: 0.445; 95% CI: 0.097-2.046, p = 0.298). Age and injury to surgery interval were not significantly associated with postoperative outcomes.Conclusions: More extensive brachial plexus injuries are associated with inferior outcomes after SAN to SSN transfer. A potential explanation for this finding includes lost contribution of muscles from the shoulder girdle that receive innervation from outside of the upper brachial plexus. The relationship between extent of injury and postoperative outcomes is important to recognize when determining and discussing operative intervention with patients.

Incisional Negative Pressure Wound Therapy Augments Perfusion and Improves Wound Healing in a Swine Model Pilot Study.

BACKGROUND: A commonly used treatment for open wounds, negative pressure wound therapy (NPWT) has recently been used to optimize wound healing in the setting of surgically closed wounds; however, the specific mechanisms of action by which NPWT may benefit patients after surgery remain unknown. Using a swine wound healing model, the current study investigates angiogenesis as a candidate mechanism. METHODS: Multiple excisional wounds were created on the dorsa of 10 male Yorkshire pigs and closed by primary suture. The closed wounds underwent treatment with either NPWT dressing or control dressings in the absence of negative pressure. Dressings were maintained for 8 days followed by euthanasia of the animal. Scar evaluation of the wounds by photographic analysis was performed, and wounds were analyzed for angiogenesis markers by enzyme-linked immunosorbent assay and immunohistochemistry. RESULTS: Scar evaluation scores were observed to be significantly higher for the NPWT-treated sites compared with the control sites (P < 0.05). The enzyme-linked immunosorbent assay results demonstrated increases for vascular endothelial growth factor (VEGF) staining at the incision site treated with NPWT compared with other treatment groups (P < 0.05). In addition, an approximately 3-fold elevation in VEGF expression was observed at the NPWT-treated sites (2.8% vs. 1%, respectively; P < 0.0001).). However, there was no significant difference in immunohistochemistry staining. CONCLUSIONS: The use of NPWT improves the appearance of wounds and appears to increase VEGF expression after 8 days in the setting of a closed excisional wound model, suggesting that improved angiogenesis is one mechanism by which NPWT optimizes wound healing when applied to closed surgical wound sites.

A 3D Mammometric Comparison of Implant-Based Breast Reconstruction With and Without Acellular Dermal Matrix (ADM).

This retrospective study utilizes 3D imaging and mammometrics to compare implant-based breast reconstruction with and without the use of ADM. Previous studies have suggested improved aesthetic outcomes with the use of ADM, but none have been able to quantify this difference. Images were obtained at early and late time points following the expander-implant exchange procedure. Measurements included the point of maximum projection, the superior, inferior, medial and lateral volumetric distribution, and the distance from the point of maximum projection to the inframammary fold along the breast meridian. The patients' demographic information, implant size, and complication rate between the two cohorts were similar. In the early post-operative period, the patients with ADM demonstrated higher medial pole volume; however, this difference did not persist in the late post-operative period. Patients with ADM demonstrated a small but statistically significant greater point of maximum projection and length of lower pole curvature in comparison with the non-ADM cohort. In summary, the results of this study demonstrate improved mammometric measurements when ADM is used in implant-based breast reconstruction, supporting superior aesthetic outcomes in early and late post-operative time points. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Technique for Tripartite Reconstruction of Fingertip Injuries Using the Thenar Flap With Bone and Nail Bed Grafts.

Fingertip amputation is the most common amputation encountered by hand surgeons. Treatment decisions are multifactorial, based on mechanism, level of injury, tissue loss, associated injuries, and patient preference, among others. In this article, we present use of the thenar flap in combination with bone graft and split-thickness nail bed graft to address the tripartite loss of distal phalanx, soft tissue, and nail bed. This method allows for a full-length and functional reconstructed fingertip that is aesthetically satisfactory and does not require microsurgical techniques.

The Effect of Nasal Tip Rotation on Upper Lip Length.

Background: Increasing the nasolabial angle (NLA) with tip rotation generates the appearance of a lengthened lower facial third. In particular, the upper lip show seems increased following elevation of the nasal tip. Objectives: The purpose of this study is to quantify the impact of tip rotation on upper lip length (ULL), and to establish a predictable correlation between the two. Methods: A retrospective cohort study of rhinoplasty patients with increased tip rotation, using either caudal septal extension graft (CSEG) or columellar strut graft (CS), was performed. Three-dimensional photos were obtained and analyzed anthropometrically and used to measure the ULL and NLA. The deltas between NLA and ULL at the various time points, was then compared using linear regression with P < .05 recognized as statistically significant. Results: One-hundred and fifty patients were identified and 88 patients met inclusion criteria. CS and CSEG were used in 40% (n = 36), and 60% (n = 52), respectively. Three-dimensional assessment showed that as the NLA positively correlated with the ULL in both cohorts. The CSEG group created a greater NLA and ULL compared to the CS cohort. Both NLA and ULL decreased over time, but remained statistically increased as compared with preoperative measurements. For every one degree of NLA increase, the ULL increases by 0.05 mm. Conclusions: Increasing nasal tip rotation in rhinoplasty results in greater upper lip show. Both CS and CSEG can effectively increase tip rotation and ULL. A predictable correlation of nearly 0.05 mm of ULL for every 1 degree of tip rotation is shown. Level of Evidence: 4.

Cleft Palate Repair Using a Double Opposing Z-Plasty.

Cleft palate is a common congenital defect with several described surgical repairs. The most successful treatment modality remains a controversy. The goals of repair focus on achievement of normal speech and optimizing velopharyngeal function while minimizing both fistula formation and facial growth restriction. In this video, the authors demonstrate use of the double opposing Z-plasty technique in the repair of a Veau II type cleft palate. The video demonstrates the marking, incisions, dissection, and repair of the cleft. It also examines the use of von Langenbeck-type relaxing incisions and demonstrates a specific approach to the repair of this particular cleft. The authors believe that the Furlow double opposing Z-plasty with the von Langenbeck relaxing incision can provide the best postoperative outcome by combining the benefits of each individual operation. The Z-plasty technique works to correct the aberrant muscle of the soft palate while increasing the length of the palate. The authors believe that this results in better velopharyngeal function.

Aesthetic breast shape preferences among plastic surgeons.

BACKGROUND: There has been little discussion in the plastic surgery literature regarding breast shape preferences among plastic surgeons, despite strong evidence that such aesthetic preferences are influenced by multiple factors. Much effort has been focused on delineating the objective criteria by which an "attractive" breast might be defined. This study aimed at providing a better understanding of the presence and significance of differences in personal aesthetic perception, and how these relate to a plastic surgeon's demographic, ethnic, and cultural background, as well as practice type (academic vs private). METHODS: An interactive online survey was designed. Modifiable ranges of upper pole fullness and areola size were achieved via digital alteration, enabling participants to interactively change the shape of a model's breasts. The questionnaire was translated into multiple languages and sent to plastic surgeons worldwide. Demographic data were also collected. Analysis of variance was used to elucidate plastic surgeon's breast shape preferences in respect to sex and age, geographic and ethnic background, as well as practice type. RESULTS: The authors gathered 614 responses from 29 different countries. Significant differences regarding preferences for upper pole fullness, areola size in the natural breast, and areola size in the augmented breast were identified across surgeons from the different countries. Further, significant relationships regarding breast shape preferences were distilled between the age and sex of the surgeon, as well as the practice type. No differences were found in respect to the surgeons' self-reported ethnic background. CONCLUSIONS: Country of residence, age, and practice type significantly impact breast shape preferences of plastic surgeons. These findings have implications for both patients seeking and surgeons performing cosmetic and reconstructive breast surgery. In an increasingly global environment, cultural differences and international variability must be considered when defining and publishing new techniques and aesthetic outcomes. When both the plastic surgeon and the patient are able to adequately and effectively communicate their preferences regarding the shape and relations of the breast, they will be more successful at achieving satisfying results.

Simulated surgery and cutting guides enhance spatial positioning in free fibular mandibular reconstruction.

INTRODUCTION: The free fibular flap is the workhorse for mandibular reconstruction. Three-dimensional (3D) planning, with use of cutting guides and prebent plates, has been introduced. The purpose of this study is to evaluate the interfragmentary gap size and symmetry between conventional freehand preparation versus those using 3D planning. METHODS: A retrospective review was performed. Conventional free form and 3D planned fibular reconstructions performed by the senior authors at a single institution were included. Reconstructions were further subdivided into "body only" and "complex." Demographic and intraoperative data were collected. Postoperative CT scans were analyzed using Materialize software. Interfragmentary gap distances (mm) and symmetry (degrees) were assessed. RESULTS: Nineteen fibular reconstructions met inclusion criteria, ten conventional free form, and nine 3D planned reconstructions. Interfibular gaps measured 0.36 ± 0.50 mm in the 3D group versus 1.88 ± 1.09 mm in the non-3D group (P = 0.004). Overall symmetry (a ratio between right and left angles) measured versus 1.027 ± 0.08 in the 3D-planned versus 1.024 ± 0.09 in the non-3D group in (P = 0.944). Within only mandibular body reconstructions, symmetry was similar between the two techniques: 1.05 ± 0.12 in the 3D group versus 0.97 ± 0.05 in the non-3D group (P = 0.295). CONCLUSIONS: 3D planning lessens interfibular gap dimensions and may enhance axial symmetry. Space between native mandible and fibula is not appreciably altered using planning. Future efforts will focus on the accuracy and reproducibility of the 3D planned to actual results as well as clinical significance and efficiency benefits.

Alar-columellar and lateral nostril changes following tongue-in-groove rhinoplasty.

BACKGROUND: Repositioning the medial crura cephalically onto the caudal septum (tongue-in-groove; TIG) allows alteration of the columella, ala, and nasal tip to address alar-columellar disproportion as seen from the lateral view. To date, quantitative analysis of nostril dimension, alar-columellar relationship, and nasal tip changes following the TIG rhinoplasty technique have not been described. The present study aims to evaluate post-operative lateral morphometric changes following TIG. MATERIALS/METHODS: Pre- and post-operative lateral views of a series of consecutive patients who underwent TIG rhinoplasty were produced from 3D images at multiple time points (≤2 weeks, 4-10 weeks, and >10 weeks post-operatively) for analysis. The 3D images were converted to 2D and set to scale. Exposed lateral nostril area, alar-columellar disproportion (divided into superior and inferior heights), nasolabial angle, nostril height, and nostril length were calculated and statistically analyzed using a pairwise t test. A P ≤ 0.05 was considered statistically significant. RESULTS: Ninety-four lateral views were analyzed from 20 patients (16 females; median age: 31.8). One patient had a history of current tobacco cigarette use. Lateral nostril area decreased at all time points post-operatively, in a statistically significant fashion. Alar-columellar disproportion was reduced following TIG at all time points. The nasolabial angle significantly increased post-operatively at ≤2 weeks, 4-10 weeks, and >10, all in a statistically significant fashion. Nostril height and nostril length decreased at all post-operative time points. CONCLUSION: Morphometric analysis reveals reduction in alar-columellar disproportion and lateral nostril shows following TIG rhinoplasty. Tip rotation, as a function of nasolabial angle, also increased. These results provide quantitative substantiation for qualitative descriptions attributed to the TIG technique. Future studies will focus on area and volumetric measurements, and assessment of long-term stability. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

PDE-5 inhibition improves skin flap viability in rats that are exposed to nicotine.

INTRODUCTION: Nicotine causes ischemia and necrosis of skin flaps. Phosphodiesterase-5 (PDE-5) inhibition enhances blood flow and vasculogenesis. This study examines skin flap survival in rats exposed to nicotine that are treated with and without PDE-5 inhibition. MATERIALS AND METHODS: Eighty six rats were divided into five groups. Group 1 received saline subcutaneous (SC) once per day. Group 2 received nicotine SC 2 mg/kg day. Group 3 received sildenafil intraperitoneal (IP) 10 mg/kg day. Group 4 received nicotine SC 2 mg/kg and sildenafil IP 10 mg/kg day. Group 5 received nicotine SC 2 mg/kg day and sildenafil IP 10 mg/kg two times daily. After 28 days of treatment, modified McFarlane flaps were created, silicone sheets were interposed, and flaps were sutured. Photographs were taken on postoperative days 1, 3, and 7 and fluorescence angiography was used on day 7, both to evaluate for skin flap necrosis. Rats were euthanized and flaps were harvested for Vascular Endothelial Growth Factor (VEGF) Western blot analysis. Images were analyzed by three blinded observers using ImageJ, and necrotic indices were calculated. RESULTS: The nicotine and PDE-5 inhibition twice-daily group showed a 46% reduction in flap necrosis when compared to saline only (P < 0.05) and a 54% reduction when compared to nicotine only (P < 0.01). Fluorescence angiographic image analysis revealed reductions in flap necrosis (P < 0.01). VEGF analysis trended toward increased VEGF for all sildenafil-treated groups (P > 0.05). CONCLUSIONS: PDE-5 inhibition exhibits a dose-dependent reduction in skin flap necrosis in rats exposed to nicotine. This suggests that PDE-5 inhibition may mitigate the ill effects of smoking on skin flaps.

Does phosphodiesterase inhibition lessen facial flap necrosis in tobacco cigarette users?

Tobacco cigarette smoking remains a serious risk factor for necrosis of local facial skin flaps. To date, no pharmacological therapies exist for cigarette smoke-induced impairment of skin flap tissue survival. Accumulating evidence suggest that phosphodiesterase-5 (PDE-5) inhibitor therapy may counteract the negative effects of cigarette smoke on flap survival. Here, we evaluate skin flap survival in a series of consecutive tobacco cigarette users treated with the PDE-5 inhibitor, sildenafil, who underwent local flap facial reconstruction. We included 11 patients (5 females; median age: 64) with a significant smoking history. Seventeen facial flaps were performed for 14 defects. All patients received sildenafil in the postoperative setting. One complication of necrosis of the flap distal margin was encountered. Follow-up was available for all patients. Our results demonstrate that facial reconstruction in tobacco cigarette smokers can be performed with improved success and that sildenafil therapy may mitigate the deleterious effects of smoking on flap survival.

The incidence of burns among sex-trafficking victims in India.

Sex trafficking remains a flagrant violation of human rights, creating many public health concerns. During the initiation period, these victims experience acts of violence including gang rapes, subjecting them to traumatic injuries that include burns. Furthermore, lack of access to health care, particularly surgical, keeps them from receiving treatment for these functionally debilitating contractures caused by burns. This piece provides an overview of burns among sex-trafficked victims in India and the efforts by Cents of Relief to address the associated surgical burden of disease.

Comparison of Intramedullary Screw Fixation, Plating, and K-Wires for Metacarpal Fracture Fixation: A Meta-Analysis.

BACKGROUND: Metacarpal fractures are common injuries with multiple options for fixation. Our purpose was to compare outcomes in metacarpal fractures treated with intramedullary screw fixation (IMF), Kirschner wires (K-wires), or plating. METHODS: A systematic literature review using the MEDLINE database was performed for studies investigating metacarpal fractures treated with IMF, plating, or K-wires. We identified 34 studies (9 IMF, 8 plating, 17 K-wires). A meta-analysis using both mixed and fixed effects models was performed. Outcome measures included mean Disabilities of the Arm, Shoulder, and Hand (DASH) scores, total active motion (TAM), grip strength, time to radiographic healing, and rates of infection and reoperation. RESULTS: Patients with IMF had significantly lower DASH scores (0.6 [95% confidence interval [CI], 0.2-1.0]) compared with K-wires (7.4 [4.8-9.9]) and plating (9.8 [5.3-14.3]). Intramedullary screw fixation also had significantly lower rates of reoperation (4%, [2%-7%]), compared with K-wires (11% [7%-16%]) and plating (11% [0.07-0.17]). Grip strength was significantly higher in IMF (104.4% [97.0-111.8]) compared with K-wires (88.5%, [88.3-88.7]) and plating (90.3%, [85.4-95.2]). Mean odds ratio time was similar between IMF (21.0 minutes [10.4-31.6]) and K-wires (20.8 minutes [14.0-27.6]), but both were shorter compared with plating (52.6 minutes [33.1-72.1]). There were no statistically significant differences in time to radiographic healing, TAM, or rates of reoperation or infection. CONCLUSIONS: This meta-analysis compared the outcomes of metacarpal fixation with IMF, K-wires, or plating. Intramedullary screw fixation provided statistically significant lower DASH scores, higher grip strength, and lower rates of reoperation, suggesting that it is a comparable method of fixation to K-wires and plating for metacarpal fractures.

Use of the ostomy baseplate in negative pressure wound therapy.

The advent of the negative pressure wound therapy (NPWT) has been a significant advancement in wound-healing practices. However, as the therapy has gained popularity and increased usage in all areas of the body, obstacles have arisen. In certain areas of the body, namely those with crevices and folds, or an abundance of apocrine glands, the application of NPWT can be problematic. This study presents a novel technique for the application of the NPWT in the treatment of wounds in areas difficult to achieve an appropriate vacuum seal. This method eliminates the traditional problems encountered when applying the NPWT to areas with clefts and folds by utilising an ostomy baseplate to provide a more secure and accessible surface area. The patient is an 84-year-old male with a category IV sacral decubitus ulcer. Traditional methods of NPWT application initially proved inadequate due to difficulty sustaining negative pressure; however, subsequent use of an ostomy baseplate with NPWT successfully secured a seal and allowed for wound healing. Our technique allows for the preservation of a proper seal near clefted areas, provides ease of application, reduces the burden of dressing changes and reduces cost, benefiting both the patient and health care providers.

Tendon Transfer to Treat Radial Nerve Palsy Following COVID-19 Infection.

Multiple manifestations have been associated with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus. Among them are mononeuritis multiplex (MNM) and other neurological complications, whose connection to coronavirus disease 2019 (COVID-19) is still unclear. One of the most common sites of nerve injury is the radial nerve, which can be treated with both nerve or tendon transfer. In this case report, a patient who was afflicted with severe COVID-19 infection and developed mono neuritis multiplex after prolonged mechanical ventilation with radial nerve palsy was treated with multiple tendon transfers. This is a way to use an established mechanism of resolving the manifestations of radial nerve palsy to aid in the recovery of COVID-19-related mononeuritis multiplex.

The Treatment of Complex Extremity Wounds Using External Tissue Expansion: A Case Series.

SUMMARY: The goal of wound reconstruction is the approximation of soft tissue and re-establishment of an acceptable appearance with minimal risk of complications. For large wound closure in the extremities, skin graft and flap reconstruction are common treatments but are associated with a variety of complications. Comparatively, tissue expansion can provide the opportunity to reconstruct large wounds with native, durable, and sensate tissue without significant donor site morbidity. External tissue expansion is less invasive and avoids complications associated with internal expansion. The authors treated 11 patients with varying extremity wound types and sizes with an external tissue expansion device. Patient age ranged from 18 to 68 years with an average age of 43.7 years (SD, ± 13.1 years). Average wound surface area was approximately 235 cm 2 (SD, ± 135.3 cm 2 ). Devices were affixed and left for 7 to 11 days before closure of the wounds. Outcomes were assessed at 2 to 36 weeks postoperative follow-up. All wounds were fully closed after treatment without need for secondary reconstructive procedures. No patient experienced major complications. All patients demonstrated intact sensation within the area of reconstruction equivalent to surrounding tissues. External tissue expansion, an excellent treatment option in extremity reconstruction, is efficacious and associated with lower complication rates compared with internal tissue expansion, skin grafts, and flap reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.