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Update on Technology and Evidence-Based Management of Scars 237
radiation with intralesional excision. It acts via inhibiting collagen synthesis and
inducing apoptosis of proliferating cells, which might rebuild a balance between
keloid degeneration and collagen synthesis. It is given in doses of 15–30 Gy,
ranging from 3 to 40 Gy investigators as Ragoowansi et al. (2003) and Ogawa et al.
(2019). Have supported the use of immediate postoperative radiotherapy.
Large-scale clinical trials are required to investigate a dose–respon se correlation
among different races. Using radiotherapy as an adjuvant has revealed good scar
resolution rates from 67 up to 98%. Yet, the retrospective study design, different
follow-up intervals, and lacking universal clinical evaluation have weakened this
success rate.
Photodynamic Therapy (PDT)
The cytotoxic effects of PDT (with methyl amino levulinate and amino levulinic
acid) were investigated in different keloid lesional sites. One study concluded that
the success of PDT depends on the photosensitizer precursor, the location and the
number of fibroblasts at the lesion site. A beneficial effect of topical application of
methyl-amino levulinate PDT was initially observed in a patient with resistant
keloid. There is a case series with twenty keloid patients were examined for the
effect of PDT. The results showed that PDT reduced pain and pruritus scores,
reduced flow of blood, improved pliability and reduced levels of collagen in keloid
and resulted in a decrease of volume of keloid without recurrence over the
follow-up period (9 month) (Ud-Din et al. 2013). These findings direct potential
utility of PDT in the management of keloid and necessitate a further high quaintly
clinical trial to confirm the safety and efficacy of photodynamic therapy.
Electrical Stimulation
Electrical stimulation (ES) was investigated in relieving the keloid symptoms, such
as pruritis and pain. Lately, a new in-vitro system examined the efficacy of various
ES types on collagen expression in keloid fibroblasts and revealed that ES could
inhibit formation of collagen I in keloid. Case series confirmed the efficacy of
degraded wave ES in few patients with painful keloids and the regimen exhibited
significant amelioration of the symptoms (Ud-Din et al. 2013). Large-scale studies
are needed to confirm the effectiveness of PDT-ES combination therapy.
Surgical Strategies
Contracture release creates a large skin defect, and the aim of surgery is to restore as
far as possible a full skin obtains after surgery and to prevent recurrence.
238 L. Téot et al.
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Z Plasties
Z plasty is the most frequently realised surgical technique (Crawford 1995). Based
on the principle of skin disponibility and softness of adjacent areas, the triangles
designed by the Z shape incisions break the linear scar contracture with a new scar
without any mechanical tension. The cosmetic result is usually acceptable. Linear
contractures are better managed using Z plasties, multiple Z plasties. Web contracture may be treated using W-Y 5 plasties combing 2 Z plasties and an
advancement flap, or omega plasties using the contracted skin but needing two
small full skin grafts on the edges.
Skin Grafts
Skin grafts are by definition free skin transfers from one site to another without any
vascular connection. Depending on their thickness, skin grafts form two different
techniques, partial thickness skin grafts limited to epidermis and a thin layer of
dermis (PTSG), harvested using a dermatome and full thickness skin grafts, which
include the epidermis and the entire dermis; harvested with a scalpel and needing a
defatting before application. The donor sites of PTSG heal by rapid reepithelialisation (like a superficial abrasion) while the donor site of FTG must be closed
primarily for healing, so thei r use is limited to smaller defects. The main disadvantage of STG is the lack of dermal component, meaning a risk of recurrence
higher than when using a flap. Some authors would keep a layer of fibrotic dermis
to overgraft using PTSG.
Dermal Substitutes
Since three decades the introduction of acellular dermal substitute has changed the
profile of skin grafting. The dermal component brought by the use of collagen (and
elastin) inside the dermal substitute limits the secondary retraction of the thin skin
graft applied to cover it, even if some shrinking is sometimes observed. Different
devices are proposed, with or without elastin, the collagen coming from different
animals like cows, shark, veal, with different combination with elastin, and with or
without a protective film in silicone, depending if the product is immediately
covered by skin graft or secondarily after three weeks, the device being slowly
incorporated in the new dermis before skin coverage. Hori et al. recently compared
the contraction capacity, pores size and shape of the different proposed devices
(Hori et al. 2016) which may induce a secondary contraction.
Flaps
Large contractures will be more candidates to excision and replacement using
different types of flaps.
Random skin flaps are frequently used, coming from the adjacent area when scar
free, but pedicled fasciocutaneous flaps bring a rich vascular network. Branches
from this plexus reach the skin as direct or indirect perforators. They can be used
locally or regionally, and rotated into the defect (Tsuge et al. 2020).
Update on Technology and Evidence-Based Management of Scars 239
Perforator flaps, more recently developed, are based on a fine dissection of the
perforator vessels going through the fascia to vascularize the overlying skin island.
This increases the range of motion of these pedicled flaps and it reduces significantly the donor site morbidity.
Free flaps enlarge even further the armamentarium for tissue transfer. In prin-
ciple, all axial flaps can be transferred as a free vascularized flap: the artery and the
vein (eventually also the nerve) are transected at the donor site and re-anastomozed
microsurgically with a recipient vessel at another part of the body (Teot et al. 2000;
Hifny 20181 ; Teot and Bosse 1994). Till recently, free fasciocutaneous flaps and
perforator flaps were most frequently used for coverage of contracture defects. Both
can however result in significant donor site morbidity by harvesting structurally
important fascia.
Scar Prevention
To develop preventive strategies for scar formation, it is essential to have an
overview of the complete wound healing process and not limit oneself to the
ultimate end result which is the scar. As describe d above, many subsequent and
overlapping processes influence number and activity of fibroblasts in the wound,
with scar formation as an end result.
Preventive measures should start early, already at the time of the injury or prior
to injury, e.g. in determining the position of the incision line before elective surgery. Mechanical stress is known to stimulate scar formation, and should therefore
be avoided as much as possible.
Early after wounding, preventive measures to avoid infection and overexpres-
sion of inflammatory mediators should be considered. Reduced levels of inflammation will eventually reduce the number of fibroblasts in wound tissue. This will
lead to lower levels of extracellular matrix production. Processes contr ibuting to
reduced inflammation are debridement of necrotic tissue, early wound closure and
adequate topical wound management, e.g. by establishing a moist wound healing
environment.
Sunscreens are topical products that will absorb or reflect part of the UV radi-
ation on the skin. The efficacy of sun protection will depend on skin type of user,
amount of product applied, A sunscreen thickness of 2 mg/cm
recommended as providing a high level of photoprotection. Studies have shown that
the best protection is achieved by application of sunscreens 15–30 min before
exposure followed by reapplication 15–30 min after begin of sun exposure.
Exposure to sun has been demonstrated as pro-inflammatory (Due et al. 2007;
Goutos et al. 2009) and induce pruritus.
2
on the skin is
240 L. Téot et al.
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Lasers
In case of elevat ed hypertrophic scars, series of ablative laser sessions have been
added to combined local therapies with promising results. The therapeutic principle
consists of abrading very thin layers of skin/scar in a programmed and reproducible
fashion. The effect on the scar is comparative to both the classical mechanical
dermabrasion and chemical peeling. The chromophore target is water. The degree
of scar surface denaturation is related to the type of laser, and the temperature–time
combination applied. Two types of ablative lasers are discussed: CO
and Erbium
2
lasers. Some indications of the use of ablative lasers in burns scars by specialised
teams have been proposed (Patel et al. 2019; Krakowski et al. 2016).
Postoperative Mechanotherapy
Mechanotherapy limits excessive scarring. Several medical devices have been
proposed since decades and are currently used in practice, from adhesive sutures to
negative pressure wound therapy.
Applying materials over the suture after surgery is a long time practice.
In 2001, the first international consensus on scar management emphasized the
positive role of silicone but did not pay too much attention to the adhesive tapes, the
first cheap device supposed to limit tension on the suture edges.
Adhesive sutures. Used since decades long term these paper tapes are placed
over the skin edges in order to maintain a minimal pressure. Forces exerted on the
suture are low, the adherence of the paper embedded with glue being solubilised or
detached either by the exudation liquids or the movements. Reiffel could demonstrate some superiority when adhesive sutures were placed longitudinally on the
edges instead of transversally as a scale (Reiffel 1995; Atkinson et al. 2005; Goutos
2017).
Self adherent smart silicone has been proposed as a solution offering a permanent
pressure exerted on the skin edges by a smart technology using adherent silicone
covering the suture, isolating the suture from any external contamination.
A mechanomodulating polymer device was utilized to manipulate the mechanical
environment of closed cutaneous wounds in red Duroc swine, by applying tension to
the edges through physical means (silicone with pre-tensioning of axial fibers
inserted in the layer) (Gurtner et al. 2011). During a surgical procedure, surgeons
strive to make incisions that follow the relaxed tension lines on the body, so-called
Langer lines. This strategy is used because tension is well known to increase scarring. The Embrace
®
device is designed to shield the healing incision from the natural
tension that is inherent in any break in skin that must be pulled toget her to close a
wound. Previous preclinical and first-in-human data initially demonstrated that this
mechanism of action was effective in scar mitigation in both pigs and humans.
A prospective RCT in abdominoplasty scar appearance was conducted on 36
healthy subjects compa red Embrace
®
device for the half of an abdominoplasty and
control (surgeon’s optimal methods) on the other half. Result was significant on the
scar appearence at 12 months after 5 weeks of application (VAS p = 0.027, POSAS
subject p = 0.02 and surgeon <0.001) (Longaker et al. 2014).
Update on Technology and Evidence-Based Management of Scars 241
The Zip®System
A new medical device was recently designed in order to reduce skin tension across
an incision line, the Zip
the two edges together and set the skin tension. The system may be used as an
alternative to superficial sutures. The medical device (Zipline
®
system. The originality of the system is its ability to bring
®
) has been developed
and is used clinically as a wound closure technique as an alternative to sutures in
many surgical procedures.
The medical device is made up of two adhesive carboxymethylcellulose strips,
which have a central reinforcing core made up of polyurethane fibers, placed on the
suture edges. These strips are interconnected by tensors formed of a polyurethane
thread made up of nodes which are regularly distributed along the wire and finished
by collars allowing easy grasping for tensioning. The entire set resembles a ladder
with an adjustable length of bars. This tensor is firmly fixed and connected to the
central core of polyurethane fibers of one of the two strips and placed transversely
to bridge the scar zone. The tensor passes from the opposite side into a collar, and
the nodules serve as blockers to maintain the desired tension. The distance between
the two strips at rest is 1.5 cm and can be reduced to 0.5 cm. This movement is
reversible, allowing for a true adaptation of the tension based on local needs and the
wishes of the surgeons. The system can be positioned immediately after surgery and
maintained in situ during subsequent weeks (Tanaka et al. 2016).
The tension adjustment makes it possible to avoid even minimal edge spacing,
which is a source of bacterial penetration and secondary infection. Moreover, the
separation movements exerted longitudinally by the natural movements of the body
are blocked, and this limitation serves as a transverse but also longitudinal
immobilization. This is an essential factor in wound healing, limiting local
inflammatory phenomena. Once the tension is stabilised, the loops are cut at their
base (Fig. 3).
Fig. 3 Maintaining a reapproximation force on suture edges after multiple wide scar resection in a
5 years old child
242 L. Téot et al.
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Incisional Negative Pressure Wound Therapy
In recent years, the indication for negative pressure wound therapy (NPWT) has
been extended to include treatment of closed surgical incisions (incisional NPWT,
iNPWT). Some of the first studies were case series and observational studies (Tsuge
et al. 2020) using one of the existing NPWT devices (Mitwalli et al. 2016; Reddix
et al. 2010; Wilkes et al. 2012; Hyldig et al. 2016) designed for open wounds. Two
simplified NPWT devices became commercially available in 2010 (Prevena
and 2011 (PICO
™
; Smith and Nephew, Hull, UK). These NPWT devices consist of
™
; KCI)
a single ‐use battery‐powered negative‐pressure thera py device, an easy‐to‐place
dressing, and either a very small and easily portable canister, or no canister at all. In
the latter case, the liquid is removed by evaporation through a semipermeable
dressing. The mechanisms of action of this closed incision management have been
supported by biomechanical studies.
Biomechanical testing could experimentally demonstrate that a pressure of
80 mm Hg applied over a suture was enough to prevent 55% of tissue deformations
compared to a situation when no NPWT dressing is applied (Ragoowansi et al.
2003). Other authors suggested increased blood flow, decreased lateral and shear
stress at the suture lines with decreased risk of wound dehiscence; and increased
lymph clearance with reduced formation of haematoma/seroma. More evidence on
the effect of I NPWT on pathological scarring is expected soon.
Conclusion
Epidemiological studies are lacking and the literature is poor on the subject, and
hypertrophic and keloids do not seem to be a frequent problem in the elderly. The
absence of inflammation and tension on the scar is undoubtedly an explanatory
factor that perhaps merits more basic research. However persistent functional
problems lead aged patients to consult. The risk of malignant transformation over
persistent wounds or sites of a long lasting healing process. Cosmesis and their
impact on quality of life are less present in this population and do not constitute a
major concern for surgeons in general. The existence of underlying diseases can
reopen certain scars or pressure ulcers. The treatment must be adapted to the
comorbidities. The geriatrician sometimes has a role to play in establishing the
therapeutic plan.
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Surgical Flaps in Wound Healing—An
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Update on Evidence-Based
Management
Joon Pio Hong and Asli Datli
Abstract
Flap reconstruction for wounds are frequently considered in cases lacking
healing progress despite good wound care or complex wounds which timely
coverage will benefit the overall healing process. A flap is taking a section of
skin with an intact blood supply and placing it over the wound. It can be taken
near the defect (local flap) or remotely (free flap) will need microsurgical repair
of the vessels (recipient to donor artery and vein) to ensure blood flow into the
flap. Flaps play a major role in the healing of wounds with exposed structure.
Flap surgery can help prevent hospitalization and decrease morbidity. Flap
surgery is used to prevent and resolve complications, including surgical site
infections and other infections, dehiscence, recurrence, flap necrosis, nutrient
deficiencies, and prevention of future malignancy (Marjolin ulcer) and seroma or
hematoma. The flap reconstruction for soft tissue defects not only aim to provide
coverage but to restore function and acceptable form as well.
Keywords
Local FlapsFree flapsReconstructionChronic woundsMicrosurgery
J. P. Hong (&)
Department of Plastic Surgery, Asan Medical Center University of Ulsan, Seoul, Korea
e-mail: joonphong@amc.seoul.kr
A. Datli
Department of Plastic and Reconstructive Surgery, Istinye University School of Medicine,
Istanbul, Türkiye
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
R. Mani (ed.), Chronic Wound Management,
https://doi.org/10.1007/978-3-031-26110-7_12
247
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