Strategies to Minimize Surgical Scarring: Translation of Lessons Learned from Bedside to Bench and Back

Nature-Inspired Scarless Healing: Guiding Biomaterials Design for Advanced Therapies

The use of biomaterials in the treatment of skin wounds has been steadily increasing over the last two decades. The key to the successful application of biomaterials in scar reduction is the up-to-date knowledge of the actors involved in accelerated healing and the cellular factors that can be implemented in bioinspired materials. Natural models of scarless healing such as oral mucosa, fetal skin and the skin of amphibians, fish, and reptiles are a great source of information. By investigating their microenvironments, cellular factors, and inflammatory self-regulatory systems, a general model of scarless healing can be defined. This review introduces the basic and current concepts of skin wound healing and focuses on providing a detailed overview of the main processes of accelerated healing without scarring. The article outlines the common features and key points that develop and promote scar-free healing. The tissues and healing processes of the selected natural models are described individually (tissue organization, structural components, ratios of cellular factors such as Collagen and transforming growth factor and their mechanisms of regulation of inflammation and scar overgrowth). A comparative work of each natural model concerning healing in human skin is included in the discussion. Finally, the patterns identified through the analysis of each model and their differences from normal healing are presented to facilitate the knowledge for the implementation of new treatments.

Triangular Flap Insertion: An Option for Correction of Dog-Ears Deformity in High-Tension Areas

Dog-ear deformity is a common protrusion defect of skin tissue after the closure of a surgical wound, affecting patients' appearance and quality of life. The common methods for correcting dog ears involve the removal of excess tissue in different directions or shapes after extending the incision along the long axis of the original wound. However, the literature regarding tissue preservation techniques for dog-ear correction is poor, especially for areas with insufficient skin tissue or high tension. The authors modified the original design of direct excisions, which transferred excess tissue from the horizontal axis of the wound to the longitudinal axis, thereby absorbing longitudinal tension and relieving linear scar contracture. This technique provides a way to correct dog ears without removing excess healthy tissue, especially as an option for dog-ear correction in high-tension areas.

An approach to achieve tension-free closure and mitigate recurrence in the management of recurrent cervical keloids

Keloid is a burdensome condition that negatively affects patient's quality of life. It is influenced by a spectrum of risk factors, including tension. We propose an approach to address the tension-free closure and optimize surgical outcomes in neck keloid. A retrospective review of neck keloid patients who underwent surgical treatment between 2014 and 2022 was performed. Five patients underwent surgical interventions. Two patients had sufficient and three had insufficient tissue redundancy. The former underwent keloid excision with tension-free closure. The latter underwent keloid excision with full thickness skin graft for tension-free closure. One patient required re-excision with free flap coverage. All patients received postoperative low dose radiation. All patients were satisfied with the results and there were no signs of keloid recurrence during the follow-up period. Tension during closure following keloid excision is a modifiable risk factor. An appropriate algorithm providing tension-free closure can minimize the recurrence.

The Effect of Body Mass Index on Free Flap Breast Reconstruction

BACKGROUND

 Literature addressing the risks associated with increasing body mass index (BMI) for patients undergoing free flap breast reconstruction is limited. Often, an arbitrary BMI cutoff (i.e., BMI of 30 kg/m2) is used to determine candidacy for a free flap without substantial backing evidence. This study utilized a national multi-institutional database to analyze outcomes of free flap breast reconstruction and stratified complications by BMI class.

METHODS

 Using the 2010 to 2020 National Surgical Quality Improvement Program database, patients who underwent free flap breast reconstruction were identified. Patients were divided into six cohorts based on the World Health Organization BMI classes. Cohorts were compared by basic demographics and complications. A multivariate regression model was created to control for age, diabetes, bilateral reconstruction, American Society of Anesthesiologists class, and operative time.

RESULTS

 Surgical complications increased with each BMI class, with the highest rates occurring in class I, II, and III obesity, respectively. In a multivariable regression model, the risk for any complication was significant for class II and III obesity (odds ratio [OR]: 1.23, p < 0.004; OR: 1.45, p < 0.001, respectively). Diabetes, bilateral reconstruction, and operative time were independently associated with an increased risk of any complication (OR: 1.44, 1.14, 1.14, respectively, p < 0.001).

CONCLUSION

 This study suggests that the risks of postoperative complications following free flap breast reconstruction are highest for patients with a BMI greater than or equal to 35 kg/m2, having nearly 1.5 times higher likelihood of postoperative complications. Stratifying these risks by weight class can help guide preoperative counseling with patients and help physicians determine candidacy for free flap breast reconstruction.

Evaluation of microMend wound closure device in repairing skin lacerations

BACKGROUND

microMend, a novel microstaple skin closure device, may be able to close simple lacerations. This study aimed to evaluate the feasibility and acceptability of using microMend to close these wounds in the ED.

METHODS

This was an open-label, single-arm clinical study conducted at two EDs within a large urban academic medical centre. Wounds closed with microMend underwent assessments performed at days 0, 7, 30 and 90. Photographs of treated wounds were rated by two plastic surgeons using a 100 mm visual analogue scale (VAS) and a wound evaluation scale (WES), which has a best possible score of 6. Participants rated pain during application and both participants and providers rated their satisfaction with the device.

RESULTS

Thirty-one participants were enrolled in the study: 48% were female and the mean age of participants was 45.6 (95% CI 39.1 to 52.1). The mean wound length was 2.35 cm (95% CI 1.77 to 2.92), with a range of 1-10 cm. Mean VAS and WES scores at day 90 as evaluated by two plastic surgeons were 84.1 mm (95% CI 80.2 to 87.9) and 4.91 (95% CI 4.54 to 5.29), respectively. The mean pain score with application of the devices was 7.28 mm (95% CI 2.88 to 11.68) on a scale of 0-100 mm using VAS. Local anaesthesia was used in 9 patients (29%, 95% CI 20.7 to 37.3) of participants (of whom 5 required deep sutures). Ninety per cent (90%) of participants rated their overall assessment of the device as excellent (74%) or good (16%) at day 90. There were no serious adverse events in any participants in the study.

CONCLUSION

microMend appears to be an acceptable alternative for closing skin lacerations in the ED, providing good cosmetic results, with high levels of satisfaction by patients and providers. Randomised trials are needed to compare microMend with other wound closure products.

TRIAL REGISTRATION NUMBER

NCT03830515.

Dynamic characteristics of skin reaction force in different body postures

Mechanical stress influences scarring of a surgical wound. Several lines have been proposed for the best excision direction. It is unknown if these lines still apply when the body posture changes. The objective is to measure the skin reaction force in four directions and determine the direction of least force. Secondary objective is to determine if the reaction force varies in a different body posture. Skin reaction force was measured with the compressiometer in 30 participants on four different locations (forearm/upper arm/shoulder blade/lower back) in four directions (0°-45°-90°-135°) and two body postures. The direction of least skin reaction force changed with a different body posture and was significant for the forearm (p < 0.01) and shoulder blade (p = 0.05) The skin reaction force in all four direction changed significantly in a different body posture, except the 45° line in the upper arm and shoulder blade. Our results demonstrate that the skin reaction force in four directions in four locations varies with change in body posture. Focus should therefore not only lay on choosing the right direction, but also on managing skin tension postoperatively.

TREATMENT WITH THERESIENöL OF SURGICAL DISEASES OF THE SKIN

Theresienöl is a 100 % natural product representing a mixture of animal and vegetable raw materials from Tyrol. Its exact recipe has been preserved untouched and in deep secret for more than six centuries yet, and has been passed down from generation to generation. Six patients were included in this case series one patient with malignant melanoma of the skin after re-excision with subsequent non-free skin surgical plastic, two patients with III degree skin burning and three patients with infected wound successfully treated with Theresienöl. All of them - before the application of Theresienöl - were treated with different operative methods. The treatment of scars from operative interventions with Theresienöl is very effective. That is why it must start directly after the operative intervention. The therapeutic effect of Theresienöl for postoperative scars is commensurable with and even better than the one of all applied until now local medicines, which makes it an agent of choice in those cases. Theresienöl represents a good alternative to the free skin surgical plastic for small burns of III degree. The local treatment of infected wounds with Theresienoil is more effective and economically sound than the treatment with all the rest types of dressings. The effects from the treatment of different surgical diseases with Theresienöl occur very rapidly, while there is a very good response to local hematomas, pain, and itchiness by the medicine, and there are no side effects from its administration.