Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_764_Библиотеки_им_академика_М_И_Перельмана
.pdf
508
https://t.me/medicina_free
V. Ramella et al.
References
1. Grayson ML, Gibbons GW, Balogh K, Levin E,
Karchmer AW. Probing to bone in infected pedal
ulcers: a clinical sign of underlying osteomyelitis in
diabetic patients. JAMA. 1995;273(9):721–3.
2. Valencia IC, etal. Chronic venous insufciency and
venous leg ulceration, 2001.
3. Youn YJ, Lee J.Chronic venous insufciency and varicose veins of the lower extremities. Korean J Intern
Med. 2019;34(2):269–83.
4. Venermo M, etal. Vascular laboratory for critical limb
ischaemia. Scand J Surg. 2012;101(2):86–93.
5. Mandell JC, Khurana B, Smith JT, Czuczman GJ,
Ghazikhanian V, Smith SE. Osteomyelitis of the
lower extremity: pathophysiology, imaging, and classication, with an emphasis on diabetic foot infection.
Emerg Radiol. 2018;25(2):175–88.
6. Vlajinac H, Marinkovic J, Maksimovic M, Radak
D. Factors related to venous ulceration: a crosssectional study. Angiology. 2014;65:824–30.
7. Tam M, Moschella SL.Vascular skin ulcers of limbs.
Cardiol Clin. 1991;9:555–63.
8. Holloway GA Jr. Arterial ulcers: assessment and diagnosis. Ostomy Wound Manage. 1996;42(46–8):50–1.
9. Kirsner RS, Vivas AC. Lower-extremity ulcers:
diagnosis and management. Br J Dermatol.
2015;173(2):379–90.
10. Alavi A, Sibbald RG, Mayer D.Diabetic foot ulcers:
part I. Pathophysiology and prevention. J Am Acad
Dermatol. 2014;70(1):1.e1–18.
11. Lavery LA, Armstrong DG, Harkless
LB. Classication of diabetic foot wounds. Ostomy
Wound Manage. 1997;43(2):44–8.
12. Brodsky JW.Classication of foot lesions in diabetic
patients. St. Louis: Elsevier; 2007.
13. Braun LR, Fisk WA, Lev-Tov H, Kirsner RS, Isseroff
RR.Diabetic foot ulcer: an evidence-based treatment
update. Am J Clin Dermatol. 2014;15(3):267–81.
14. Oluwasanmi JO, Alao MO, Ofodile FA. Tropical
ulcers. Plast Reconstr Surg. 1979;64(1):41–6.
15. Ghaly P, Kim YD, Iliopoulos J, Ahmad M.The management of malignant lower limb ulcers: clinical considerations. Br J Nurs. 2020;29(15):S34–40.
16. Situm M, Kolic M.Atypical wounds: denition and
classication. Acta Med Austriaca. 2012;66(Suppl
1):5–11.
Part VIII
https://t.me/medicina_free
Ulcer Management Further Issues
Wound Care inAesthetic Surgery
https://t.me/medicina_free
ValerianoVinci, RiccardoDi Giuli,
AnaPaulaFontouraAndradeReis,
andMarcoKlinger
44
44.1 Wound Healing: AnAesthetic
Perspective
44.1.1 Scar Outcome
Accurate wound care is a highly relevant aspect
of achieving an aesthetically pleasing scar. The
wound-healing process is marked by three
phases: inammation, proliferation, and remodeling phase. These phases rather than being
strictly time dened, fade on each other in a
continuous process, settling, together with
external modiable factors, the basis for a satisfactory scar. Basic modiable factors of incisional scars are general physical health,
smoking, nutrition, comorbidities, preoperative
incision plan, intraoperative atraumatic handling of soft tissue, hemostasis, asepsis techniques, and tension- reducing approaches in the
short and long-term periods [1]. Local and systemic factors need to be consistently addressed,
commencing before surgery and extending for
V. Vinci
Humanitas University, Milan, Italy
e-mail: valeriano.vinci@hunimed.eu
R. Di Giuli · M. Klinger (*)
University of Milan, Milan, Italy
e-mail: marco.klinger@humanitas.it
A. P. FontouraAndradeReis
Humanitas Clinical and Research Center– IRCCS,
Milan, Italy
months into the remodeling phase, long after
suture and dressing removal.
The presurgical incision plan is often performed based on relaxed skin tension lines. A
proper understanding of skin tension lines in preoperative planning is crucial since skin tension is
highly associated with scar formation. A relaxed
skin tension line (RSTL) is a furrow created
when the skin is pinched and relaxed in the
absence of local tension. Clinically, the skin is
maximally extensible perpendicular to
RSTL.When the tension along the incision is too
high, there is a higher attempt of the body to keep
the wound closed, resulting microscopically in an
increase of collagen deposition and consequently
a hypertrophic scar. Therefore, scars are minimized if the incision is done along RSTL [1].
Although the role of mechanical tension is
known to have a relevant impact on scar outcome, the role of chemical factors has been
extensively explored and yet not so well dened.
Some studies suggest that mechanical tension
may lead to an immune response. Nonetheless,
inammation is a normal phase of wound healing although an excessive inammatory response
is correlated to the formation of hypertrophic
and unsightly scars [2].
Collagen brillar arrangements, maturation,
and extracellular matrix (ECM) remodeling play
an essential role in scar outcome. During the
remodeling phase, myobroblasts replace hyaluronic acid with proteoglycans, such as decorin,
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
https://doi.org/10.1007/978-3-031-45453-0_44
511
512
https://t.me/medicina_free
V. Vinci et al.
which regulates collagen brillogenesis and
assures a spatial arrangement of the collagen
brils [2]. Decreased production of decorin or
functionality has been reported to have a role in
the formation of hypertrophic scars. Hence,
there has been an active interest in the study of
this proteoglycan to provide new specic wound
therapy [2]. Furthermore, in the remodeling
phase, some cross-linking compounds of collagen bers, such as pyridinoline, are correlated to
oxygen radical activity and have been reported
in hypertrophic scars. In this regard, antioxidants
appear to be benecial for scar reduction in these
cases [2]. Lastly, occlusion hydration of the stratum corneum reduces the signaling effects of
keratinocytes on collagen synthesis and release,
promoting scar maturation by ECM remodeling,
less inammatory response, and balanced protease activity. Thus, the hydration of the stratum
corneum minimizes transepidermal water loss
(TEWL) and the most effective barrier for TEWL
is silicone both in the form of sheets and gels,
which has been widely employed in the practice
of optimizing scars’ appearance [2].
The role of the suture is to provide wound
edge approximation with reduced tension, in
order to promote cellular responses and organized collagen ber deposition [1]. In this regard,
there has been an effort for the development of
new devices for surgical closure. Adhesive strips
are thought to have lower rates of wound infection and prevent “railroad track” scars when used
in place of supercial sutures [3]. However, it has
been reported that these adhesive strips when
applied on the skin of the back parallel to each
other and perpendicular to the wound edges may
provoke the development of cutaneous blisters
due to the increased shearing effect, as a solution,
the authors proposed a parallel to the wound
strips positioning to reduce this complication [3].
In addition, adhesive strips are associated with a
lower incidence of wound inammation and represent a faster and safer closure technique in
small incisions, thus reducing intraoperative
time. However, there is not enough evidence on
adhesive strip implications in wound dehiscence,
and the need for resuturing to draw nal conclusions on their effectiveness [4].
The evaluation of a new wound closure device,
named 3M Steri-Strip S® surgical skin closure
(3M, MN, USA), demonstrates that the use of
this device can substantially decrease surgical
time while maintaining scar quality in abdominal
incisions [5]. Furthermore, a comparative study
between the use of tissue adhesive (Dermabond®,
Ethicon Inc., Johnson & Johnson, NJ, USA) and
adhesive strips (3M Steri-Strips®) indicates that
the latter seems to have a better cosmetic outcome for the closure of laparoscopic port-site
incisions in children, as well as a less-expensive
technique [6].
All wounds are contaminated, but an excessive number of bacteria and/or higher virulence
strains may impair wound healing. The damage
is obtained by several mechanisms. For instance,
the increased oxygen-derived radicals value is a
crucial process in microorganism killing by leukocytes [7]. The deciency of this “oxidative
burst” due to tissue hypoxia predisposes wounds
to infection. A stasis in the progression of a previously normally healing wound often indicates a
critical colonization or wound infection. Signs
and symptoms are increased pain in the wound
and adjacent area, tissue edema, malodorous discharge, and increased drainage or purulence [7].
This highlights the importance of dressings and a
sterile environment, avoiding foreign debris, to
accelerate and overall improve wound healing.
44.1.2 Dressings inAesthetic Surgery
Specic dressing materials, techniques, and management choices are relevant aspects when treating patients following aesthetic surgery. An
accurate postoperative wound management does
not only have cosmetic implications but is deeply
involved in the prevention of many post-surgical
complications.
44.1.2.1 Blepharoplasty
Dressing choice on upper eyelids following
blepharoplasty, when applied, is limited to the
application of adhesive strips along the suture
line [8]. Deep orbital hemorrhage with vision
loss is a rare but dreadful eyelid surgery compli-
44 Wound Care inAesthetic Surgery
https://t.me/medicina_free
513
cation. It usually occurs within 24h after surgery
up to a week [9]. Even though potentially tight
circumferential dressings could reduce oozing
and therefore orbital hemorrhage, there is evidence in the literature that orbital hemorrhage
diagnosis can be delayed if eyelids are bandaged,
postponing an early diagnosis of retrobulbar
hemorrhage crucial to blindness prevention [10].
Ice packs immediately after surgery and for 48h
post-operation, antibiotic and anti-inammatory
drops treatment are suggested for 4 days in both
upper and lower blepharoplasties. In lower
blepharoplasty, adhesive strips should be applied
with adequate compression of the lower eyelid
and the patient should be instructed to avoid
downward traction of the lower eyelid in any circumstance [8].
Additionally, due to adequate dressing management in blepharoplasties, other aspects
strongly inuence scar formation. Careful suturing of the incision with appropriate skin edge
eversion is one of the most important elements to
take into consideration along with the right time
for suture removal (usually performed 3–5days
postoperatively) for the nest outcome. Excessive
tension in lower blepharoplasty should be avoided
due to ectropion risk and scar imperfections.
Blepharoplasties are anatomically advantaged
regarding scar formation, leading to narrow and
imperceptible scars after surgery due to poor dermal thickness. A broad dermal layer is diffusely
known as an important risk factor for wide scar
formation [11].
44.1.2.2 Mammoplasty
Aesthetic breast surgery dressing starts with the
application of adhesive strips on the surgical
incision as an adjunct to conventional suture closures to achieve optimal wound tension and provide an appropriate skin barrier. Adhesive strips
should be maintained in place for a minimum of
21days post-surgery. In addition, bandages are
placed over the breast followed by a self-adherent compressive dressing to distribute tension
throughout the breast until the midaxillary line
bilaterally and to support the new shape of the
breast.
Dressing choice, placement, and management
account for not only the prevention of complications in breast aesthetic procedures but also for
the optimization of cosmetic breast appearance.
Reduction mammoplasty, for instance, can be
complicated by unfavorable scar formation along
incision lines [12]. In this regard, new technologies and devices have been designed, such as the
Dermabond Prineo® skin closure system, which
combines the skin adhesive 2-octyl cyanoacrylate
with a self-adhering polyester-based mesh, with
proposed benets such as watertight seal, easy
removal, microbial barrier, even distribution of
tension, and reduced wound closure time [12]. It
should be stated that allergic reactions have been
reported in the literature with these surgical closure systems. Therefore, accurate patient selection and caution of usage should be taken into
consideration in post-operative dressing
planning.
Another study evaluated the efcacy of selfadherent dressing (Mepiform®; Molnlycke
Health Care, Gothenburg, Sweden) for the treatment of post-surgical hypertrophic scars.
Mepiform® has been shown to cause less damage
to the stratum corneum of the skin upon repeated
removal when compared to other adhesive dressings [13]. Patients treated with soft silicone
dressing after breast surgery experienced major
and faster improvements compared with nontreated patients [13]. Hence, the use of soft silicone dressing, applied as soon as possible after
surgical closure, is suggested as the rst-line prophylaxis to hypertrophic postoperative scars [13].
Lastly, following the removal of the self-adherent
dressing, the immediate use of a postmammoplasty bra without underwire is complementary
to postoperative wound care since it promotes the
reduction of tension on the wound, breast support, improves inframammary fold denition,
and therefore a better aesthetic outcome.
44.1.2.3 Rhytidectomy
A face-lift dressing is applied to put pressure on
the incision lines and surgical area to limit swelling and decrease the chance of uid collection.
Hematoma is the most common complication in
514
https://t.me/medicina_free
V. Vinci et al.
rhytidectomy. It varies from large collections of
blood able to compromise the airway to small
blood collections only evident after edema reduction [14]. Hematoma pressure on the overlying
skin aps may impair vascular perfusion, causing
venous congestion and scarring skin irregularities [15]. Many factors predispose to hematoma
formation, such as male gender, history of hypertension, and coagulopathy. In this regard, there
has been an effort to establish a reliable technique
for postoperative bleeding prevention and
management.
Tissue sealants are brin deposition boosters
composed primarily of brinogen derived from
either autologous or homologous human plasma
in combination with thrombin, clotting factors,
antibrinolytic agents, and calcium chloride [15].
Tissue sealants, which in rhytidectomy are aerosolized in the subcutaneous plane after soft tissue
dissection, promote a decreased dead space by
facilitating clot formation and creating adherence.
However, mixed results regarding effectiveness
have been reported [15]. Regardless, other studies
demonstrate that tissue sealant use was associated
with fewer hypertrophic scars, necrosis, and
wound dehiscence [15]. Another study suggests
that the use of brin glue demonstrates a signicant decrease in the rate of hematoma and ecchymosis by closing and sealing the dead space. Its
benets, which have been mostly observed in
males rather than females, combined with meticulous hemostasis and pressure dressings make
drains not necessary in this procedure [16].
Compression dressings, although common in
the practice to mitigate the accumulation of uid
collection, demonstrated no relevant difference
in hematoma rate incidence compared to patients
without postoperative dressing [15]. Foam tape
dressings and transparent lm revealed no incidence of skin complications and hematoma and
are commonly used [15]. It must be considered
when employing a head wrap with only an anterior opening that the surgical site is hidden by
the dressing and therefore it may delay detection
of complications. It is reasonable to consider
only a light, nonrestrictive dressing in the rst
postoperative hours to provide support and reassurance [15].
44.1.2.4 Lipoaspiration
Liposuction, like any other surgical procedure,
comprises a variety of possible complications.
Especially in lipoaspiration, compression garments have a crucial function in their prevention.
Appropriate use prevents the formation of edema,
ecchymosis, and hematoma. Garment application
should be performed in the immediate postoperative up to a period of 4–6weeks [17]. Another
method used to minimize edema formation is the
non-suture of the surgical incisions with the
application of a bulky absorbent dressing for the
rst 24–48h to allow the excess remnant uid to
ow out. Additionally, manual lymphatic drainage also shows benets [17].
Inappropriate usage of compression garments,
such as repeated removal or suboptimal tting,
can lead to seromas. Localized serous collection
detected by the end of the rst postoperative
week may be solved within 10 days by the application of additional padding inside the compression garment in the specic area [17]. Seroma
formation in the scrotum or labia most commonly
following abdominal or pubic fat liposuction may
be largely prevented by restricting excessive
mobility in the rst 3 days after surgery and
wearing a snug-tting undergarment over the
compression garment [17]. In addition, patients
with a higher probability of residual skin laxity
after liposuction must use compression garments
for a longer period (up to 8–12 weeks postsurgery) to enhance skin retraction [17]. Close
post-operative patient monitoring should prevent
the compressive garment itself from being the
source of new complications. For example, skin
irregularities may happen when there is a badtting garment associated with bad posture due
to the creation of folds and creases in the compression dressing [17]. Skin hyperpigmentation
is a described complication of excessive pressure
from compression garments [17]. Lastly, umbilical deviation, although unusual, has been reported
hypothesizing the drag exerted by the closure
device of the garment being the source of this
complication. The problem is easily overcome by
the garments with closures on both sides [17].
Although infections are rare in liposuction,
these may be caused by hematoma in subcutane-
44 Wound Care inAesthetic Surgery
https://t.me/medicina_free
515
ous tissues with secondary bacterial contamination. In cases of signs of aggressive infection, it
should be treated with culture-sensitive antibiotics and may also benet from negative pressure
wound therapy [17].
44.1.2.5 Abdominoplasty
In patients undergoing abdominoplasty, management of surgical incision starts intraoperative. It
is relevant to highlight that there is a multilayer
closure of the abdominal incision, of which the
most important is the Scarpa fascia (which is the
deep membranous layer of the supercial fascial
system) [18]. The closure of the Scarpa fascia
with permanent or long-lasting suture may reduce
the signicant tension generated on closure, preventing wound dehiscence and reduction of scar
widening [18]. The dressing is concluded with
adhesive strip application and a compression garment that is kept during the postoperative period.
Additionally, the patient should be placed, immediately post-surgery, in a supine position with
legs slightly raised to reduce tension in the surgical incision.
A recent study made an intra-individual surgical wound comparison between standard
dressing and octenidine-based hydrogel dressing, both applied immediately after abdominoplasty [19]. It was revealed that the use of
octenidine-based hydrogel led to a lower incidence of hypertrophic scars, improved reported
visual analog scale (VAS) pain scores during
dressing change, improved scar outcome, skin
elasticity, and TEWL in the 45 patients included
in the study [19].
Interestingly, in another study, a decellularization protocol for skin derived from abdominoplasties (processed with 1 M NaCl and 0.5%
sodium dodecyl sulfate followed by washing
steps, freeze drying, and radiation sterilization)
results in a novel biological dressing that
improves wound closure kinetics and scar maturation in the proliferative and remodeling phases
of wound healing [20]. Acellular dermal matrices
(ADM) have been shown to be satisfactory for
tissue reconstruction, burns, and hard-to-heal
wounds. This approach is appealing since abdominoplasty skin remains are easily accessible with
the increased frequency in this aesthetic surgery,
in contrast to other available human sources of
ADM which are manufactured from cadaveric
skin [20].
44.2 Wound Management
Currently, there are different techniques used in
the management of post-surgical scarring tissue.
These methods aim to not only prevent wound
complications such as infection, hematoma,
seromas, and wound dehiscence; but also to provide the best aesthetic results. Treatment can be
conservative or invasive. Among the conservative methods, there are appropriate dressing (as
previously mentioned), pressure therapy, scar
massage, and photoprotection. More invasive
methods rely on intralesional corticosteroid
injections, autologous platelet-rich plasma treatment, photobiomodulation, laser treatment,
radiation, Rigottomy with or without autologous fat grafting, and when necessary surgical
revision.
As mentioned before, dressing materials are
known to inuence wound healing and scar formation in the rst few days after surgery. The
length of dressing maintenance is highly discussed in the literature since it can impact the
overall postoperative care in many aesthetic surgeries. In breast surgery, self-adhesive dressing
is generally removed around 7 days postoperative in the postoperative visit. During dressing
removal, surgical site incisions should be evaluated for signs of infection and overall development of the wound. A study evaluating the
inuence of the time of dressing application
after breast augmentation on cutaneous colonization suggested that maintaining the dressing
for 6 days leads to lower cutaneous colonization
but does not inuence surgical site infection
rates [21].
A substantial role in wound management is to
control an occurring infection. The incidence of
surgical site infections (SSI) varies largely in aesthetic surgeries. Factors such as the site of surgery and patient risk factors (such as age, gender,
BMI, smoking, diabetes mellitus, and combined
516
https://t.me/medicina_free
V. Vinci et al.
procedures) may require attention for postoperative individualized wound care [22]. For instance,
in blepharoplasty, post-surgical infection is
uncommon, and the rate has been estimated to be
0.2%. However, necrotizing fasciitis from
Staphylococcus aureus or group A-B hemolytic
Streptococcus after blepharoplasty has been
reported in the literature [9]. Therefore, an infection should be managed according to clinical
ndings on regular outpatient visits following
surgery. In the case of blepharoplasties, culture is
often difcult to obtain, and empirical therapy
should be considered in suspected infections,
such as in patients with unexplained erythema
and pain.
In the rst 3 months following surgery, in a
normal wound-healing process, scar remodeling
reaches its peak [1]. Incision wounds may show
signs of hypertrophic response at this moment.
Continuing dressing with wound tape to
decrease wound tension may ameliorate results
in hypertrophic scars combined with an
increased postoperative visits’ frequency for
wound evaluation [23].
Hypertrophic scars and keloid scar formation
are the results of a lack of negative feedback on
the cessation of collagen synthesis, leading to the
continuous production of collagen bers in the
wound. Relevant clinical differentiation is performed by scar margin evaluation. While broproliferative behavior in hypertrophic scars is
within wound margins, keloid scars are shown to
be beyond the original wound margins.
Scar massage, as a conservative postoperative
treatment, is recommended when the tissue is
epidermized and able to support manual techniques at least 2 weeks after surgery. The massage is used to improve skin quality in terms of
exibility, adhesions, pruritus, and pain [24]. The
improvement in elasticity and cutaneous mobility
recommends massage in trauma, burns, and surgical incision scars [24]. After blepharoplasty,
visible scars in the lateral canthal region may
improve with massage in the rst few months
after surgery. In addition, steroid-containing ointments, such as uorometholone 0.1% or hydrocortisone 0.5% or 1%, may help to soften rm
scars and lessen erythema [9].
In clinical practice, different creams are indicated in addition to scar massage aiming for
enhanced results. One of the methods used to
promote better healing is topical avonoids.
Flavonoids are one of the vital classes of bioactive chemicals, abundantly found in plants. Their
pharmacological properties, including antioxidant, anti-inammatory, antiproliferative, photoprotective and depigmentation, are very
promising in the treatment of several skin disorders [25]. In a postsurgical setting, they are used
from the second postoperative week up to 6
months to soften scars and provide scar elasticity.
However, their efcacy is controversial in the literature [26].
Intralesional steroid injections are found to be
effective in hypertrophic scars, although more
frequently used in keloid treatments.
Corticosteroids are known to suppress inammation. Their effects on the wound are a reduction in collagen and glycosaminoglycans and an
increase in collagen degradation. Injections can
be repeated every month for 4–5months. This
treatment results in softer and atter scars with
symptom alleviation, despite a high recurrence
rate [26].
Autologous platelet-rich plasma (PRP) is a
treatment option that has gained popularity and is
commonly employed. Platelets are small unnucleated bodies in the blood that circulate near
vascular walls. When the vascular cell wall is disrupted, platelets are activated, and their α-granules
release approximately 300 bioactive molecules
involved in homeostasis and wound healing [27].
These α-granules contain growth factors that
when introduced intra-dermally promote a higher
skin quality through collagen synthesis and tissue
regeneration stimulation. A study to evaluate the
effects of PRP treatment on patients who underwent blepharoplasty revealed signicant
improvement in eyelid healing, reducing scar
thickness, and irregularity [27].
An immediate intraoperative wound treatment
procedure is the injection of Botulinum neurotoxin type A.Studies revealed that it affects cell
cycle distribution, inhibits cell growth, and suppresses broblast-to-myobroblast differentiation [28]. Injections have been shown to improve
44 Wound Care inAesthetic Surgery
https://t.me/medicina_free
517
scarring 6 weeks after rhytidectomy. In addition,
it has been reported to be effective in hypertrophic scar and keloid treatment [28]. A randomized trial study on patients who underwent
epicanthoplasty and upper blepharoplasty
reported that early post-operative injection of
Botulinum toxin type A in the medial canthal
region efciently reduced hypertrophic scarring
and improved outcomes [28].
Rigottomy (or needleotomy) is a technique
used in contracted scar tissue to create a threedimensional meshing of the scar, aiming to
expand the hard brous tissue, releasing the contracture, and creating microcavities in which
regenerative fat grafts can survive by diffusion
until neovascularization occurs [29]. Rigottomies,
through an adequate graft-to-recipient interface,
transform the cicatrix into a matrix-receptive fat
graft [29]. This technique is useful in cases of
contracted scar tissue, such as seen in the breast
with infection, radiation scarring, and congenital
constriction bands seen in tuberous breasts [29].
Another technique that revealed satisfactory
results in hypoplastic lower breast poles is the
sting technique, creating a nice, round, and regular contour of the constricted inferior quadrants
[30]. Different from the rigottomy technique,
needles in the sting technique are not used to create a space for fat particles. This procedure consists of multiple full-thickness percutaneous
stings of the skin and gland that expand the lower
pole by releasing subcutaneous contracting bands
and creating a three-dimensional expansion
which is subsequently maintained by the breast
implant insertion [30].
Photobiomodulation (PBM) has shown benets in the rst stages of the postoperative healing
process [31]. PBM consists of low-intensity light
sources with non-ionizing irradiations in both the
visible band and infrared band, usually administrated at interval sessions [32]. Low doses of photobiomodulation were shown to reduce
inammatory cell reaction, promotion of cell
migration and proliferation, and stimulation of
collagen synthesis, angiogenesis, and tissue granulation. In a clinical investigation, photobiomodulation had an overall improvement in scar
quality in Caucasian patients in the rst and 6
months after abdominoplasty. However, these
benets were inconsistent at 1-year follow-up
[31].
Negative-pressure wound therapy (NPWT)
employment showed signicantly narrow scars,
reducing type III collagen density, and promoting
thinner bers. A comparative study evaluating
the efcacy of this method was conducted on 13
patients who underwent insertion of tissue expansion on two-stage breast reconstruction. Scars
were half-side treated with negative pressure
application; on the non-treated side was applied a
lm dressing alone. Dressings were changed
once per week until complete ination of the tissue expander and scars were evaluated 6 months
later [33]. The study reported that scars treated
with negative-pressure therapy were signicantly
narrower. In addition, treated scars revealed a low
density of collagen, with thin bers and scant
myobroblasts, with general major softness and
pliability [33]. Therefore, negative-pressure
wound therapy might be considered in early postsurgical scar management to improve scar quality
and appearance.
Pulsed dye laser (PDL) therapy is a device that
exploits 585-nm-wavelength laser beams to target and eliminate erythematous scars by destroying newly formed blood vessels. PDL causes
photothermolysis, in which light energy is
absorbed by hemoglobin leading to coagulative
necrosis [34]. In addition, it has been reported as
effective in hypertrophic scars as a result of broblast quantity and functional reduction [35]. PDL
treatment has been associated with improvement
in scar pliability, thickness, pruritus, and attening of hypertrophic scars [36].
44.3 Complications Management
44.3.1 Wound Dehiscence
andNecrosis
Accurate wound care cannot always guarantee
optimal wound closure and healing. Many factors
contribute to wound dehiscence, starting from
genetic predisposition, patient comorbidities
(such as diabetes), lifestyle (such as alcohol use
518
https://t.me/medicina_free
V. Vinci et al.
and smoking), poor circulation, inappropriate
suture, infection, inappropriate topic medications, and high-tension wounds. Different
approaches are described to deal with this complication. Wound dehiscence can benet from
precise cyclic wound dressing renovation and in
more severe cases from surgical revision. This
procedure should include accurate devitalized
tissue debridement and well-vascularized wound
edges approximation and suture.
In this regard, NPWT indication also extended
to closed surgical incisions (ciNPWT). The
underlying mechanisms comprise edema reduction, removal of wound uid rich in deleterious
enzymes, and due to mechanotransduction stimulation, increase growth factor release, matrix production, and cellular proliferation. Evidence
reveals that a pressure of 80mmHg applied over
a suture prevented 55% of tissue deformations
compared to a situation when no NPWT dressing
was applied [37].
Wound complications, including wound
dehiscence, are a relevant issue for patients who
underwent post-bariatric abdominoplasty. These
patients most often carry obesity-associated systemic and local factors not favorable to wound
healing. These procedures exhibit a rate of major
and minor complications of 68–80%, prolonging
hospitalization, and treatment-related costs [38].
In a retrospective case–control series, the use of
ciNPWT revealed a signicant reduction inlocal
complications with dry, well-vascularized, and
without signs of inammation incision [38].
Other authors, in a randomized study in reduction mammaplasty, investigated the effects of a
single-use NPWT device in preventing composite morbidity (as infection, dehiscence, and
delayed wound healing) [39]. Overall the complication rates after reduction mammaplasty are as
high as 53% [39]. In this study the complications
rate within 21days fell from 44.7% with standard
care to 39.7% with NPWT [39].
Among the common complications following cervicofacial rhytidectomies, such as motor
and sensory nerve injury, alopecia, and auricular deformity, hematomas are by far the most
seen in practice. Hematoma may lead to prolonged edema formation and consequently ap
necrosis. Flap necrosis management approach
includes surgical debridement, local administration of antibiotics, moist dressings, vitamin
injections, hydrober dressings and lastly healing by secondary intention [40]. Polyheal®
(Clal Biotechnology Industries Ltd., Tel Aviv,
Israel) is a water-based suspension of charged
polystyrene 5-μm microspheres (CPM) and is a
recent resource aimed at speeding up the
wound-healing process. CPM activated different cell populations at the wound bed, such as
inammatory cells, broblasts, and keratinocytes. This promotes the growth of granulation
tissue and remodeling of damaged skin tissue
with promising results in open wounds following ap necrosis due to hematomas in facial
rhytidectomy [40].
An important matter to take into consideration
during secondary breast augmentation follow-up
is the effects of silicone implant rupture on breast
scars. Silicone breast implant ruptures can be
intracapsular or extracapsular. Extracapsular rupture leads to silicone extravasation to surrounding tissues that often has an inltrative pattern
leading to a straightforward nonspecic foreign
body reaction, which results in typical macrophage invasion, giant cell formation, and eventually scarring [41]. Moreover, among the different
systemic and local complications associated with
silicone implant extracapsular rupture, there is a
retracting effect of the silicone on the cicatrix,
which must be considered during scar
management.
Surgical revision of the scar is performed
when other methods have not been sufcient to
achieve the expected outcomes. Surgical revision
through excision of the scar area and wound closure with proper undermining and eversion of
layers is the gold standard denitive treatment for
depressed scars. This method results in a new
wound healing without indentation [42]. Surgical
treatment of hypertrophic scars is done when
there is no response to other less invasive therapy.
It is aimed at creating a linear and tension-free
closure [42]. Z-plasty or W-plasty manages to
rearrange tension lines to redistribute skin tension. Surgical revisions should not be undertaken
before the rst year following surgery. Particular
Соседние файлы в папке Библиотека им академика М.И. Перельмана