Debridement
Wound healing is optimized by removing all necrotic tissue by wound cleansing or sharp debridement and by excising a rim of fibro-cutaneous tissue from the wound margins .

Undermining of wound margins
Undermining may only be necessary when the edges of the ulcer are depressed, adherent to underlying structures or infolded as occurs when healing by secondary intention is carried out. Initially a scalpel is used, after which finger mobilization renders the tissue mobile enough to slide to a modest degree. Undermining is at the supra-facial or deep subcutaneous level approximately 5 -10 mm. from the margins, thereby preserving the integrity of the cutaneous vessels

Evaluation of wound
The Proxiderms are left in place and wound is evaluated on intervals of 2 to 3 days. Significantly contaminated wounds are evaluated daily. After assessment of the wound, the Proxiderm procedure is repeated. This process of wound evaluation and Proxiderm application is continued until the wound is closed.

Intermittent use of Proxiderms
During the procedure, if there are signs of ischemia of the wound edges, the onset of edema, maceration or inflammation, a temporary discontinuation of the application of the devices is required, the devices should be removed and the situation reassessed. When these conditions are controlled the Proxiderms may be reapplied. Approximately 15 to 20 % of Proxiderms procedures involve the intermittent use of Proxiderms.

Wound Closure and Healing
Upon apposition of the wound margins it is recommended that the Proxiderms be applied for an additional 2-3 days to allow to wound edges to form a strong resilient bond in a tension free environment.   Premature removal of the Proxiderms can result in regression of the wound closure.

Most wounds are closed in 7 to 14 days, but the principles of wound healing are still basic to achieving the ultimate goal, namely a well healed wound. Final healing is related to the patients general condition.

Small wounds under 2 cm

55 year old diabetic patient with a plantar ulcer of 6 months duration. Three applications of Proxiderms Complete healing 15 days.

Sutures are not used to close small wounds under 2 cm prior to tissue expansion with the Proxiderm, since this would encapsulate contamination and lead to wound breakdown. These wounds are closed by Proxiderm application only. Once the wound margins are together without tension the wound can be sutured or the final closure of the wound can be allowed to occur naturally.

Procedure for small wounds - Undermine wound margins when necessary and close  wound with one to two Proxiderms over a time period of one to three weeks.

Large wounds greater than 2 cm

Figure 1 Figure 2 Figure 3

Figure 1 - The technique for wounds greater than 2 cm is illustrated on a 68 year old diabetic patient with a recalcitrant plantar ulcer of 4 months duration.  A previous tissue flap procedure failed. 

Figure 2 - Initially the ulcer is sharply debrided under sedation and/or local anesthesia as necessary, removing all non-viable tissue and excising a rim of fibro-cutaneous tissue from the margins. After debridement, the wound measured 3.8 cm by 5 cm . The wound margins were undermined at a supra-facial or deep subcutaneous level approximately 5 -10 mm. from the margins

Figure 3 - #2/0 nylon sutures were placed and tied 1-2 cm from the wound margins at 2 cm intervals. The ends of the tied sutures are left long, later they will be looped around the Proxiderms for increased stabilization. The use of rubber ``booties" to diminish pressure on the skin by the tied sutures is optional. Additional #2/0 nylon sutures are placed between the tied sutures, and the ends are secured by steristrips; these sutures will be tied after 2-3 days of tissue expansion by the Proxiderms.

Figure 4 Figure 5

Figure 4 - Two Proxiderm model (D 460) are selected. When multiple devices are used, the spacing between the Proxiderms should be 2 cm. The Proxiderm has two tissue hooks that are manually separated. One tissue hook is placed through the skin into the subcutaneous tissue approximately 10 mm from the wound margins. The second tissue hook is inserted into the opposing side of the wound in a similar fashion. The long ends of the previously tied sutures are looped around the Proxiderm device and tied.

Figure 5 - Four by four dressings are placed between the Proxiderms to assist stabilization of the devices. Combines are placed beneath the edges of the devices and further combines over the devices. The Proxiderms and wound are lightly wrapped with a dry gauze (Kling) dressing and an Unna boot is then placed around the dressing to further stabilize the devices. The foot is placed on a posterior splint in the position of function. The patient cannot walk on or keep his foot in a dependent position

Figure 6 Figure 7 Appearance at 4 days

Figure 6 - The Proxiderms are left in place for periods of 2-3 days after which the dressings are removed and the wound evaluated. A significant advancement of the wound margins occurs in the first few days.  The wound is debrided and cleansed as needed and the previously untied sutures are tied.

Figure 7 - The above steps are repeated at intervals of 2-3 days until the wound margins are approximated.  Proxiderms are applied near the original puncture sites.

Appearance at 7 days Figure 8 Appearance at 4 months Figure 9 Appearance at 2 1/2 years Figure 10

Figure 8 - After the wound edges are freshened and approximated by suture, the Proxiderms are applied for an additional 2-3 days to allow the wound margins to form a strong resilient bond in a tension free environment.

Figure 9 - Wound care consists of saline soaks for 15 minutes followed by cleansing with half strength hydrogen peroxide.  Dressings are by the application of non-adherent gauze, combines and a large gauze dressing which were changed twice daily by the patient or care-giver.  In this patient the wound was stabilized in 21 days and the sutures were removed.  Examination of the wound at 4 months showed a well healed wound that had withstood weight bearing which commenced 21 days after treatment.

Figure 10 - Appearance at 2 1/2 years, No recurrence

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