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Role of Skin Stretch on Local Vascular Permeability in Murine and Cell Culture Models. Plast Reconstr Surg Glob Open 2022; 10:e4084. [PMID: 35186636 PMCID: PMC8849308 DOI: 10.1097/gox.0000000000004084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 11/29/2021] [Indexed: 01/15/2023]
Abstract
Excessive mechanical forces, particularly skin stretch, have been implicated in pathological cutaneous scarring. We hypothesize that this reflects, in part, stretch-induced vessel leakage that provokes prolonged wound/scar inflammation. However, this has never been observed directly. Here, a mouse model was used to examine the effect of skin flap stretching on vascular permeability. An in vitro model with pseudocapillaries grown in a stretchable chamber was also used to determine the effect of stretching on endothelial cell morphology and ion channel activity.
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Tong X, Lu J, Zhang W, Wang S, Huang R, Zhang X, Huang J, Zhu Y, Xiao S, Ji S, Xia Z. Efficacy and safety of external tissue expansion technique in the treatment of soft tissue defects: a systematic review and meta-analysis of outcomes and complication rates. BURNS & TRAUMA 2022; 10:tkac045. [PMCID: PMC9741868 DOI: 10.1093/burnst/tkac045] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/26/2022] [Accepted: 09/07/2022] [Indexed: 12/14/2022]
Abstract
Abstract
Background
Currently, various external tissue expansion devices are becoming widely used. Considering the scarcity of relevant application standards, this systematic review was performed to explore the effectiveness and safety of external tissue expansion techniques for the reconstruction of soft tissue defects.
Method
A systematic review and meta-analysis on the efficacy and safety of external tissue expansion technique was conducted. A comprehensive search was performed in the following electronic databases: PubMed/Medline, Embase, Cochrane Library (Wiley Online Library), and Web of Science. Studies reporting patients with soft tissue defects under the treatment of external tissue expansion technique were included.
Results
A total of 66 studies with 22 different types of external tissue expansion devices met the inclusion criteria. We performed a descriptive analysis of different kinds of devices. A single-arm meta-analysis was performed to evaluate the efficacy and safety of the external tissue expansion technique for different aetiologies. The pooled mean wound healing time among patients with defects after fasciotomy was 10.548 days [95% confidence interval (CI) = 5.796–15.299]. The pooled median wound healing times of patients with defects after excisional surgery, trauma, chronic ulcers and abdominal defects were 11.218 days (95% CI = 6.183-16.253), 11.561 days (95% CI = 7.062-16.060), 15.956 days (95% CI = 11.916-19.996) and 12.853 days (95% CI=9.444-16.227), respectively. The pooled wound healing rates of patients with defects after fasciotomy, excisional surgery, trauma, chronic ulcers and abdominal defects were 93.8% (95% CI=87.1-98.2%), 97.2% (95%CI=92.2-99.7%), 97.0% (95%CI=91.2-99.8%), 99.5% (95%CI=97.6-100%), and 96.8% (95%CI=79.2-100%), respectively. We performed a subgroup analysis in patients with diabetic ulcers and open abdominal wounds. The pooled median wound healing time of patients with diabetic ulcers was 11.730 days (95% CI = 10.334-13.125). The pooled median wound healing time of patients with open abdomen defects was 48.810 days (95% CI = 35.557–62.063) and the pooled successful healing rate was 68.8% (95% CI = 45.9-88.1%). A total of 1686 patients were included, 265 (15.7%) of whom experienced complications. The most common complication was dehiscence (n = 53, 3.14%).
Conclusions
Our systematic review is the first to demonstrate the efficacy and safety of external tissue expansion in the management of soft tissue defects. However, we must interpret the meta-analysis results with caution considering the limitations of this review. Large-scale randomized controlled trials and long-term follow-up studies are still needed to confirm the effectiveness and evaluate the quality of healing.
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Affiliation(s)
- Xirui Tong
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Jianyu Lu
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Wei Zhang
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Siqiao Wang
- Tongji University School of Medicine, Tongji University , Shanghai, 200092 , China
| | - Runzhi Huang
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Xianliang Zhang
- Hospital of the 92426 Troops of the Chinese People’s Liberation Army , Tsingtao, 266400 , China
| | - Jie Huang
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Yushu Zhu
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Shichu Xiao
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Shizhao Ji
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
| | - Zhaofan Xia
- Department of Burn Surgery, the First Affiliated Hospital of Naval Medical University , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
- Research Unit of key techniques for treatment of burns and combined burns and trauma injury, Chinese Academy of Medical Sciences , 168 Changhai Road, Yangpu District, Shanghai, 200433 , China
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3
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Laser-assisted indocyanine green imaging to assess perfusion of scalp closure in an infant. J Craniofac Surg 2015; 24:2004-6. [PMID: 24220391 DOI: 10.1097/scs.0b013e3182a249ba] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The current treatment of craniosynostosis is open surgical excision of the prematurely fused suture and cranial vault remodeling. Due to the change in skull morphology and the increase in volume, some tension on the skin flaps is noted with closure. Although complete wound breakdown is rare, it can be a devastating complication. We present our experience with the use of the SPY imaging system (Lifecell Corporation, Branchburg, NJ, USA) to visualize and record blood flow within the flaps of a 1-year-old patient with anterior plagiocephaly. Intraoperative indocyanine green angiography has the potential to be a significant advantage in such cases, providing a safe and objective method to assess intraoperative scalp perfusion, allowing the surgeon to take additional measures to ameliorate any ischemic problems.
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Verhaegen PDHM, Bloemen MCT, van der Wal MBA, Vloemans AFPM, Tempelman FRH, Beerthuizen GIJM, van Zuijlen PPM. Skin stretching for primary closure of acute burn wounds. Burns 2014; 40:1727-37. [PMID: 24746282 DOI: 10.1016/j.burns.2014.03.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Revised: 03/07/2014] [Accepted: 03/08/2014] [Indexed: 11/25/2022]
Abstract
BACKGROUND In burn care, a well-acknowledged problem is the suboptimal scar outcome from skin grafted burn wounds. With the aim of improving this, we focused on a new technique: excision of the burn wound followed by primary closure, thereby using a skin-stretching device to stretch the adjacent healthy skin. The short- and long-term effect of Skin Stretch was compared to split skin grafting (SSG) in a randomized controlled trial. METHODS Patients with burn wounds were randomized for SSG or primary wound closure using Skin Stretch. Follow-up was performed at 3 and 12 months postoperatively. The scar surface area was calculated and the scar quality was assessed, using subjective and objective measurement methods. RESULTS No significant differences between the SSG and the Skin Stretch group were found for scar surface area. In the Skin Stretch group, a significant reduction of the surface area from 65.4cm(2) (13.6-129.1) to 13.4cm(2) (3.0-36.6) was found at 3 months (p=0.028) and at 12 months postoperatively (65.4cm(2) (13.6-129.1) to 33.0cm(2) (8.9-63.7), p=0.046, Wilcoxon signed ranks test). CONCLUSIONS Skin Stretch for primary closure of acute burn wounds is a suitable technique and can be considered for specific circumscript full-thickness burn wounds. However, future research should be performed to provide additional scientific evidence.
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Affiliation(s)
- Pauline D H M Verhaegen
- Association of Dutch Burn Centers, Red Cross Hospital, Beverwijk, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Red Cross Hospital, Beverwijk, The Netherlands; Burn Center, Red Cross Hospital, Beverwijk, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, VU Medical Center, Amsterdam, The Netherlands.
| | - Monica C T Bloemen
- Association of Dutch Burn Centers, Red Cross Hospital, Beverwijk, The Netherlands; Burn Center, Red Cross Hospital, Beverwijk, The Netherlands
| | - Martijn B A van der Wal
- Association of Dutch Burn Centers, Red Cross Hospital, Beverwijk, The Netherlands; Burn Center, Red Cross Hospital, Beverwijk, The Netherlands
| | | | | | | | - Paul P M van Zuijlen
- Association of Dutch Burn Centers, Red Cross Hospital, Beverwijk, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, Red Cross Hospital, Beverwijk, The Netherlands; Burn Center, Red Cross Hospital, Beverwijk, The Netherlands; Department of Plastic, Reconstructive and Hand Surgery, VU Medical Center, Amsterdam, The Netherlands
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5
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Bollero D, Malvasio V, Catalano F, Stella M. Negative pressure surgical management after pathological scar surgical excision: a first report. Int Wound J 2013; 12:17-21. [PMID: 23418720 DOI: 10.1111/iwj.12040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 01/12/2013] [Indexed: 11/29/2022] Open
Abstract
Wound dehiscence is a surgical complication caused by the application of opposing and distracting forces tending to pull apart the suture line. In recent years, a novel negative pressure surgical management system has been developed to prevent surgical wound complications. This system creates a closed environment that removes exudates and other potentially infectious material, protects the surgical site from external contamination, provides support in holding the edges of the incision together and promotes wound healing. In this study, we describe our first experience with Prevena™, a closed incision negative pressure management system used on suture line following wide pathological scars excision for the prevention of postoperative wound dehiscence. Eight patients with wide and mature pathological skin scars were treated with Prevena™. The device was positioned directly after surgical correction for 8 days with a continuous application of -125 mmHg negative pressure. All treated patients had no postoperative surgical wound dehiscence. In one case, a limit of the device was represented by its poor adherence on hairy surface, hampering the maintenance of an appropriate local negative pressure. In another case, suture line was longer than Prevena™ foam and it was covered partially. Prevena™ system appears to be safe, easy to use and may represent a support technique to wide pathological skin scars surgical correction.
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Affiliation(s)
- Daniele Bollero
- Department of Plastic Surgery, Burn Center, CTO Hospital, Turin, Italy
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6
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Mermans JF, Peeters WJ, Dikmans R, Serroyen J, van der Hulst RRJW, Van den Kerckhove E. A comparative study of colour and perfusion between two different post surgical scars. Do the laser Doppler imager and the colorimeter measure the same features of a scar? Skin Res Technol 2013; 19:107-14. [DOI: 10.1111/srt.12014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/09/2012] [Indexed: 11/29/2022]
Affiliation(s)
- J. F. Mermans
- Department of Plastic; Reconstructive and Hand Surgery; Maastricht University Medical Centre; Maastricht The Netherlands
| | - W. J. Peeters
- Department of Plastic; Reconstructive and Hand Surgery; Maastricht University Medical Centre; Maastricht The Netherlands
| | - R. Dikmans
- Department of Plastic; Reconstructive and Hand Surgery; Maastricht University Medical Centre; Maastricht The Netherlands
| | - J. Serroyen
- Department of methodology and Statistics; Research School CAPHRI; Maastricht University; Maastricht The Netherlands
| | - R. R. J. W. van der Hulst
- Department of Plastic; Reconstructive and Hand Surgery; Maastricht University Medical Centre; Maastricht The Netherlands
| | - E. Van den Kerckhove
- Department of Plastic; Reconstructive and Hand Surgery; Maastricht University Medical Centre; Maastricht The Netherlands
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7
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Agha RA, Agha M. Skin Stretching for Burn Scar Excision - A Critically Appraised Topic. Ann Med Surg (Lond) 2012; 1:49-54. [PMID: 26257909 PMCID: PMC4523150 DOI: 10.1016/s2049-0801(12)70014-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 08/12/2012] [Indexed: 11/17/2022] Open
Abstract
Adults with burn scars are a clinical challenge, and the long term sequelae of burns can have a significant impact on the patient. Scar excision is thought to be the best treatment at present, as it results in a smaller scar. Scar stretching has shown promise in a previous study, as it may allow the surgeon to excise more burn scar. The goal of this study was to determine if good evidence exists for the use of burn scar stretching, in routine clinical practice, through the format of a critically appraised topic. A question was formulated using the Patient Intervention Comparator Outcome (PICO) method:-Patient - Adult burn victims-Intervention - Scar excision + skin stretching-Comparator - Scar excision-Outcome - Total remaining scar The PICO question was used to develop a search query: "stretch* burn scar" (where '*' represents a wildcard function). A search was then conducted using PubMed, SCOPUS, the Cochrane Library, and Trip Database. One paper was selected for critical appraisal following identification, screening, and eligibility evaluation. The paper was critically appraised using accepted methodology outlined by Straus et al. and reporting quality was assessed using the CONSORT statement for non-pharmacological trials. Areas of methodological or reporting weakness were highlighted. Burn scar stretching, using the device or technique in question, requires much further research before widespread usage in burns patients.
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Affiliation(s)
- Riaz A. Agha
- Department of Plastic Surgery, Queen Victoria Hospital, East Grinstead, West Sussex, UK
| | - Maliha Agha
- Department of Public Health, King's College London, London, UK
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8
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Verhaegen PD, Schouten HJ, Tigchelaar-Gutter W, van Marle J, van Noorden CJ, Middelkoop E, van Zuijlen PP. Adaptation of the dermal collagen structure of human skin and scar tissue in response to stretch: an experimental study. Wound Repair Regen 2012; 20:658-66. [PMID: 22882499 DOI: 10.1111/j.1524-475x.2012.00827.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 05/12/2012] [Indexed: 11/30/2022]
Abstract
Surgeons are often faced with large defects that are difficult to close. Stretching adjacent skin can facilitate wound closure. In clinical practice, intraoperative stretching is performed in a cyclical or continuous fashion. However, exact mechanisms of tissue adaptation to stretch remain unclear. Therefore, we investigated collagen and elastin orientation and morphology of stretched and nonstretched healthy skin and scars. Tissue samples were stretched, fixed in stretched-out position, and processed for histology. Objective methods were used to quantify the collagen orientation index (COI), bundle thickness, and bundle spacing. Also sections were analyzed for elastin orientation and quantity. Significantly more parallel aligned collagen bundles were found after cyclical (COI = 0.57) and continuous stretch (COI = 0.57) compared with nonstretched skin (COI = 0.40). Similarly, more parallel aligned elastin was found after stretch. Also, significantly thicker collagen bundles and more bundle spacing were found after stretch. For stretched scars, significantly more parallel aligned collagen was found (COI = 0.61) compared with nonstretched scars (COI = 0.49). In conclusion, both elastin and collagen realign in a parallel fashion in response to stretch. For healthy skin, thicker bundles and more space between the bundles were found. Rapid changes in extension, alignment, and collagen morphology appear to be the underlying mechanisms of adaptation to stretching.
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9
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Wollstein R, Carlson L, Bilonick RA, Rodgers J. Progression of surgical scars in the hand and wrist over time: A peak in scar-related symptoms. J Plast Surg Hand Surg 2012; 46:276-80. [DOI: 10.3109/2000656x.2012.698084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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10
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On the surgical treatment of hypertrophic scars: a comprehensive guideline for the surgical treatment of hypertrophic scars. Eur Surg 2012. [DOI: 10.1007/s10353-012-0074-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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11
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Abstract
The mechanophysiological conditions of injured skin greatly influence the degree of scar formation, scar contracture, and abnormal scar progression/generation (e.g., keloids and hypertrophic scars). It is important that scar mechanobiology be understood from the perspective of the extracellular matrix and extracellular fluid, in order to analyze mechanotransduction pathways and develop new strategies for scar prevention and treatment. Mechanical forces such as stretching tension, shear force, scratch, compression, hydrostatic pressure, and osmotic pressure can be perceived by two types of skin receptors. These include cellular mechanoreceptors/mechanosensors, such as cytoskeleton (e.g., actin filaments), cell adhesion molecules (e.g., integrin), and mechanosensitive (MS) ion channels (e.g., Ca(2+) channel), and sensory nerve fibers (e.g., MS nociceptors) that produce the somatic sensation of mechanical force. Mechanical stimuli are received by MS nociceptors and signals are transmitted to the dorsal root ganglia that contain neuronal cell bodies in the afferent spinal nerves. Neuropeptides are thereby released from the peripheral terminals of the primary afferent sensory neurons in the skin, modulating scarring via skin and immune cell functions (e.g., cell proliferation, cytokine production, antigen presentation, sensory neurotransmission, mast cell degradation, vasodilation, and increased vascular permeability under physiological or pathophysiological conditions). Mechanoreceptor or MS nociceptor inhibition and mechanical force reduction should propel the development of novel methods for scar prevention and treatment.
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Affiliation(s)
- Rei Ogawa
- Department of Plastic, Reconstructive and Aesthetic Surgery, Nippon Medical School, Tokyo, Japan.
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12
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Verhaegen PD, van der Wal MB, Bloemen MC, Dokter J, Melis P, Middelkoop E, van Zuijlen PP. Sustainable effect of skin stretching for burn scar excision: Long-term results of a multicenter randomized controlled trial. Burns 2011; 37:1222-8. [DOI: 10.1016/j.burns.2011.04.018] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2011] [Accepted: 04/26/2011] [Indexed: 10/18/2022]
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13
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Ibrahim AE, Dibo SA, Hayek SN, Atiyeh BS. Reverse tissue expansion by liposuction deflation for revision of post-surgical thigh scars. Int Wound J 2011; 8:622-31. [PMID: 21895976 DOI: 10.1111/j.1742-481x.2011.00842.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Scars hypertrophy and widen when stretching mechanical forces are applied to resilient newly formed collagen before it reaches final maturity marring the final result of many surgical procedures and resulting in a clinical problem for many patients. Scar revision by surgical excision remains the traditional treatment for hypertrophic or widespread scars. It relies upon recruitment of local tissues for closure of the ensuing defect. Providing tension-free skin closure is the best option to avoid recurrence. Although tissue expansion procedure is a valuable and reliable technique for scar revision, it has its own disadvantages and potential complications. We describe an alternative method for scar revision that may be applicable in certain situations. Instead of expanding the soft tissues to make available additional skin, deflation by liposuction may be affected to relax the skin envelope thus indirectly providing additional skin for scar revision. We call this method 'reverse tissue expansion'.
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Affiliation(s)
- Amir E Ibrahim
- Division of Plastic, Reconstructive and Aesthetic Surgery, Department of Surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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14
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Efficacy of Skin Stretching for Burn Scar Excision: A Multicenter Randomized Controlled Trial. Plast Reconstr Surg 2011; 127:1958-1966. [DOI: 10.1097/prs.0b013e31820cf4be] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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