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.pdf
Matthew P. Lungren
Michael R.B. Evans
Editors
Clinical Medicine
Covertemplate
Scars
Subtitle for
APractical Guide forScar
Clinical Medicine Covers T3_HB
Therapy
SebastianP.Nischwitz
Second Edition
Lars-PeterKamolz
LudwikK.Branski
Editors
123
123
Scars
Sebastian P. Nischwitz
Lars-Peter Kamolz • Ludwik K. Branski
Editors
Scars
A Practical Guide forScar Therapy
Editors
Sebastian P. Nischwitz
Division of Plastic, Aesthetic and
Reconstructive Surgery, Department of
Surgery
Medical University of Graz
Graz, Steiermark, Austria
Ludwik K. Branski
Division of Plastic Surgery, Department
of Surgery
The University of Texas Medical
Branch, Shriners Hospital for Children
Galveston, TX, USA
Lars-Peter Kamolz
Division of Plastic, Aesthetic and
Reconstructive Surgery, Department of
Surgery
Medical University of Graz
Graz, Steiermark, Austria
COREMED-Cooperative Centre for
Regenerative Medicine
JOANNEUM RESEARCH
Forschungsgesellschaft mbH
Graz, Steiermark, Austria
ISBN 978-3-031-24136-9 ISBN 978-3-031-24137-6 (eBook)
https://doi.org/10.1007/978-3-031-24137-6
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature
Switzerland AG 2024
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher,
whether the whole or part of the material is concerned, specically the rights of translation,
reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any
other physical way, and transmission or information storage and retrieval, electronic adaptation,
computer software, or by similar or dissimilar methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specic statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors, and the editors are safe to assume that the advice and information in
this book are believed to be true and accurate at the date of publication. Neither the publisher nor
the authors or the editors give a warranty, expressed or implied, with respect to the material
contained herein or for any errors or omissions that may have been made. The publisher remains
neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland
Contents
https://t.me/med1917
Part I Skin, Wounds and Scars
Anatomy and Physiology of the Skin . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Johann Zwirner and Niels Hammer
From Wound to Scar: Scarring Explained—Pathophysiology
of Wound Healing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Thomas Wild, Ahmed A. Aljowder, A. Aljawder, Joerg Marotz, and
Frank Siemers
Pathophysiology of Burn Wounds . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Sebastian P. Nischwitz, Hanna Luze, and Lars-Peter Kamolz
Mechanobiology and Mechanotherapy of Cutaneous Scarring . . . . . 35
Rei Ogawa
The History of Scar Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Frank Sander, Herbert L. Haller, Sebastian P. Nischwitz,
and Bernd Hartmann
Recent Advances in Scar Research and Unanswered Questions . . . . 61
Hanna Luze, Sebastian P. Nischwitz, and Lars-Peter Kamolz
Part II Scar Assessment and Prevention
Scar Assessment Scores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Dalia Barayan, Roohi Vinaik, and Marc G. Jeschke
Measuring Postoperative SCAR Quality . . . . . . . . . . . . . . . . . . . . . . . 89
Jean-Phillip Okhovat and Jonathan Kantor
Scar Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Alejandra Monte-Soldado and Juan P. Barret
v
vi
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Part III Scar Treatment
Intralesional Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107
Christian Tschumi and Jan A. Plock
Lasers and Energy-Based Devices in Scar Therapy:
A Practical Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Hugues Cartier, Francois Will, Thierry Fusade,
and Hans-Joachim Laubach
Surgical Scar Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Eva Koellensperger and Guenter Germann
Oral Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 195
Varitsara Mangkorntongsakul, Alan J. Cooper,
and Saxon D. Smith
Physical Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211
Thomas Koller
Management of Hypertrophic Scars
in Pediatric Burn Patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 237
Alen Palackic, Robert P. Duggan, Camila Franco- Mesa,
and Ludwik K. Branski
Contents
Part IV Scar Rehabilitation
Medical Tattooing for Aesthetic Optimisation . . . . . . . . . . . . . . . . . . . 249
Thomas Rappl, Mario Barth, Dominique Bossavy, Paul Wurzer,
Lars-Peter Kamolz, and Sebastian P. Nischwitz
Treatment and Rehabilitation of the Patient with a Scar . . . . . . . . . . 255
Lisa Martin and Fiona Wood
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Part I
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Skin, Wounds and Scars
Anatomy andPhysiology
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oftheSkin
JohannZwirner andNielsHammer
Core Messages
• The ve-layered epidermis is a constantly
renewing protection layer against physical,
chemical and biochemical inuences on the
human body.
• The epidermal-dermal junction is a highly
organized transition zone that can be considered an independent anatomical unit.
• The two-layered dermis contains the bulk of
the extracellular matrix of the skin, which
makes it the key layer for the biomechanical
characteristics of the skin as a composite
tissue.
• Highly specialized receptors enable the skin
to detect and mediate mechanical, thermal,
nociceptive and potentially chemical stimuli.
J. Zwirner
Institute of Legal Medicine, University Medical
Center Hamburg-Eppendorf, Hamburg, Germany
Department of Oral Sciences, University of Otago,
Dunedin, New Zealand
e-mail: j.zwirner@uke.de
N. Hammer (*)
Division of Macroscopic and Clinical Anatomy,
Gottfried Schatz Research Center, Medical University
of Graz, Graz, Austria
Department of Orthopaedic and Trauma Surgery,
University of Leipzig, Leipzig, Germany
Division of Biomechatronics, Fraunhofer Institute for
Machine Tools and Forming Technology,
Dresden, Germany
e-mail: niels.hammer@medunigraz.at
Introduction
The skin forms the outermost and largest organ of
the human body [1]. It makes up between 6 and
16% of the entire body weight depending on
whether subcutaneous fat is included in this calculation [2]. Strictly speaking, skin is composed
of two layers, the supercial epidermis and the
deeper dermis even though the subcutaneous fat
is frequently included as a third layer [1, 3]. Both
epidermis and dermis are composed of several
sub-layers. Studying the anatomy of the skin
forms the basis to understand why the epidermis
is predominantly a physical, chemical and biochemical protective barrier for the body and the
dermis is mostly responsible for the biomechanical characteristics of the skin [4, 5]. The detailed
anatomy including the thickness and development of the specic sub-layers of the skin varies
depending on several factors such as age, sex as
well as the respective anatomical site with its specic functional requirements and challenges [6].
As an example, the thin skin of the eyelid covers
the eye to prevent it from dehydration and protect
it from foreign bodies. It moves every time we
blink and is, therefore, a dynamic tissue. On the
contrary, the skin at the soles of our feet is oftentimes stressed by a multiple of the body weight.
This functional difference directly reects on the
morphology and the thicknesses of the various
layers involved in load distribution. The eyelid is
considerably thinner compared to the soles of our
feet, which is potentially both the least sophisti-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
S. P. Nischwitz et al. (eds.), Scars, https://doi.org/10.1007/978-3-031-24137-6_1
3
4
https://t.me/med1917
J. Zwirner and N. Hammer
cated as well as the most comprehensible way to
emphasize the relationship between the form and
function of the skin. Consequently, summarizing
the anatomy and physiology of ‘the skin’ as a
whole can be misleading. However, studying the
general anatomical and physiological characteristics of the skin is an essential starting point to
gain a basic understanding of this fascinating
organ. Basically, two different classes of skin can
be distinguished: thin hirsute (hairy) skin covering most of the body and glabrous (hairless) skin
covering the palmar and plantar regions extending to the digits [7].
Anatomy oftheSkin
Epidermis
The epidermis forms the most supercial layer of
the skin that completely renews itself within the
time frame of 52–75days [8]. It is composed of
the following ve layers (or ‘strata’) from supercial to deep: stratum corneum, stratum lucidum,
stratum granulosum, stratum spinosum and stratum basale [9]. The epidermal cell renewal takes
place from the basal layer towards the stratum
corneum, so the layers are most logically studied
in this order. The basal cell layer (derived from
the Greek word ‘basis’ as ‘ground’ or ‘bottom’;
Fig. 1) is also called stratum germinativum and
consists of a single layer of columnar nucleated
basal cells and melanocytes [1]. The basal cells
form the earliest developmental stage of the later
keratinocytes and are comprised of two different
proliferative cells: stem cells with an unlimited
capacity of self-renewal and transit amplifying
cells, which withdraw from the cell cycle to enter
a transitional state between stem cells and a cell
that eventually differentiates following numerous
divisions [10]. Basal cells are connected to one
another and to the supercial squamous cells via
desmosomes and attached to the underlying basal
membrane via hemidesmosomes [1, 11]. These
cell-cell and cell-extracellular matrix links are of
key importance for the integrity and homeostasis
of the epidermis [12]. Melanocytes are present in
the basal layer of the epidermis and in hair follicles [13]. Throughout life, the ratio of melanocytes and keratinocytes stays constant at 1:10;
however, the reason for this is unknown [14]. The
spinous layer (derived from the Latin word
‘spīnōsus’ meaning ‘thorny’), also known as the
prickle cell layer (Fig.1), is the next and thickest
epidermal layer the keratinocytes have to proceed
through on their way to the surface. In this layer,
the keratinocytes increase in size and establish
strong intercellular connections through desmosomes [11, 15]. The strong interdigitation by
means of spinous extensions between the keratinocytes is what gives this layer its characteristic
name. Cells that are close to the basal layer remain
mitotically active and hence are similar to the
basal layer but are less basophilic [3]. The term
‘Malpighian layer’ summarizes the structural and
functional similarity between the two [3]. The
predominantly polyhedral-shaped keratinocytes
atten towards the granular layer and their cytoplasm becomes acidophilic [3]. Two types of bone
marrow-derived antigen-presenting dendritic
cells, the Langerhans cells, can be found in the
spinous layer with dendritic processes that can
reach up to the stratum corneum [16]. Type 1 is of
a classic dendritic shape with numerous ‘tennis
racket-shaped’ granules, also called Birbeck bodies, and small numbers of lysosomes and mitochondria [16, 17]. Type 2 describes a less dendritic
cell that can be found supra-basally or even in the
basal layer, which contains more mitochondria,
fewer Birbeck bodies and a more electron-dense
cytoplasm compared to the Type 1 cells [17]. The
granular layer (derived from the Latin word
‘granum’ meaning ‘grain’; Fig.1) comprises multiple layers of nucleated keratinocytes of a polygonal shape without a limiting membrane [3].
Lamellar membrane-bound lipid granules are the
characteristic cytoplasmatic feature that gave this
layer its name [3]. These keratohyalin granules
synthesize prolaggrin, which after proteolytic
processing to laggrin aggregates laments of
keratin into dense bundles [4, 18]. This is the reason for the progressive attening of the keratinocytes towards the surface [4]. High levels of
lysosomal enzymes are present in the granular
Anatomy andPhysiology oftheSkin
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Fig. 1 Fine structure of the epidermis and dermis. Layers, features and characteristic cell types are depicted. (Adapted
from [7])
5
layer, which are required for the elimination of
cell components of the resilient anuclear corneocytes as the terminally differentiated keratinocytes [1, 18]. The lucid layer (derived from the
Latin word ‘lūcidus’ meaning ‘clear’) is only
present in thick skin areas such as the palm of the
hand or the sole of the foot [3]. The keratinocytes
of the lucid layer are non-vital and contain the
clear intracellular protein eleidin as opposed to
the keratin in deeper layers [19]. The cornied
layer (derived from the Latin word ‘cornu’ meaning ‘horn’; Fig.1) forms the outermost epidermal
layer and consists of attened anucleated cells
that are lled with keratin [3]. The extracellular
matrix of the corneal layer contains mainly lipids
that are organized within characteristic lamellar
bilayers but also enzymes, antimicrobial peptides
and structural proteins [20]. Supercial corneocytes are continuously shed off and replaced
through an ongoing supply of corneocytes from
the granular or lucid layer [3, 9]. This lines up
with the fact that corneocytes of deeper layers are
more tightly interconnected with desmosomes
compared to supercial layers as desmosomes are
subjected to proteolytic degradation towards the
surface [1].
The Epidermal-Dermal Junction
The epidermal-dermal junction is a transitional
zone that anchors the epidermis onto the dermis
and can be considered an independent anatomical
unit [21]. From supercial to deep, it consists of
the following four components:
1. The dermal surface of the plasma membrane
of the epidermal basal cells:
Hemidesmosomes, which describe multiprotein complexes that link the epidermal basal
cells to the basal lamina, are the most signicant structures of this layer [21, 22].
2. The lamina lucida as an intermembranous
space: This layer is not to be confused with
the epidermal lucid layer. The similar name
originates from common microscopic features
between the two. In electron microscopy, light
can pass through this layer but the space does
not occur completely transparent as ne laments from hemidesmosomes cross on their
course between the epidermal basal cells and
the basal membrane [21, 23].
3. The basal lamina: It is a continuous band of
type IV collagen, laminin, nidogen, and per-
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