Guide Michigan Manual of Plastic Surgery

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Placement of incision or laceration within parallel to relaxed skin tension line 5. Minimal tension following closure e. Optimal surgical technique e.


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Definition: An abnormal wound healing endpoint in response to trauma, inflammation, burn, or surgery 1. Raised, erythematous, and often pruritic 2. Etiology 1. Major factors a.

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Amount and depth of trauma most commonly with burns b. Inflammation, infection c.

Contributing factors a. Areas of tension b. Darker skin tone C. Natural history 1. Worsens over 6 months 3. May cause contractures at joints 4. May take 1 to 2 years to mature scar will become less red, less tender, and less pruritic 5. May regress somewhat without any intervention at all D.

Histologic characteristics under standard light microscopy, hypertrophic scar and keloid are indistinguishable 1. Cigar-shaped nodules of blood vessels, fibroblasts, and collagen fibers that are arranged parallel to epidermis and oriented along tension lines normal skin: the basket-like woven pattern of collagen fibers 2.

Lower ratio of type I:type III collagen Type I:type III collagen ratio is 3. Treatment approach 1.


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  • Nonoperative a. Pressure garments i. Commonly used for hypertrophic burn scars ii. Induces local tissue hypoxia, reduces fibroblast proliferation and collagen synthesis iii. Compression of 24 to 30 mmHg to be effective b. Unclear mechanism of action—thought to increase hydration of remodeling scar ii. Corticosteroid injection 2.

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    Surgical excision a. Attention to atraumatic technique, excision of inflamed tissue, avoidance of nidus for inflammation e. Z-plasty tissue rearrangements to release contractures c. May require graft or flap reconstruction for coverage d.

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    Fractional ablative CO2 laser can be helpful adjunct. Definition: An abnormal wound healing endpoint in response to trauma, inflammation, burns, or surgery. May start as a raised, erythematous, and pruritic lesion 2. Increased levels of adenosine triphosphate within keloid B. Darker skin tone b. Genetic predisposition 2. Age peak just after puberty b. Hormones keloids worsen during puberty and pregnancy; postmenopausal women experience softening and flattening of keloids C.

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    Natural history: Evolves over time without a significant regression or quiescent phase D. Histologic characteristics under light microscopy, hypertrophic scar and keloid are indistinguishable 1. Thick and large collagen fibers haphazardly packed closely together 2. Pressure devices e. Silicone sheeting and topical silicone gel c. Corticosteroid injection d. Radiation therapy 2. Surgical a. Ehlers—Danlos syndrome 1.

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    Autosomal dominant transmission 2. Significant joint laxity, thin and friable skin, and severe skin hyperlaxity 3. Extreme risk for wound healing problems e. Should be discouraged from pursuing elective and aesthetic surgery B. Cutis laxa 1. Defective collagen synthesis results in hyperextensible skin 2. Can be autosomal dominant, autosomal recessive, or X-linked 3.

    Autosomal and X-linked variants have more generalized manifestations: Growth retardation, skeletal dysplasia, facial dysmorphia, emphysema, cardiovascular involvement, hernias, and hollow viscus diverticula 4. Scars typically widen over time. Some areas, such as the back or the legs, are especially prone to scar widening. Nicotine in any form smoking, patches impairs wound healing significantly due to vasoconstrictive effects 3. Macrophages are critical cells in wound healing and initiate the growth factor cascade, fibroblast proliferation, and collagen formation 4.

    Prior to considering scar revision, at least 1 year should pass to allow for complete scar remodeling. What is the difference between wound contraction and wound contracture? Wound contraction is a part of secondary healing beginning a few days after injury as myofibroblasts contract and reduce the size of the wound to be epithelialized. What is the difference between hypertrophic scar and keloid? They have much different type I:type III collagen ratios.

    Hypertrophic scars produce smooth muscle actin by myofibroblasts, whereas keloids do not. What are the factors that impair wound healing? Systemic conditions e. What are the types of nerve injury and their expected recovery? Which types require surgical intervention?

    T he basic science of wound healing. Plast Reconstr Surg. Fibroproliferative scars. Clin Plast Surg. PMID: Pathophysiology of nerve injury. Acute versus chronic see Fig. Origin and duration of wound a. Traumatic versus atraumatic i. Zone of injury is larger in high- versus low-impact traumas ii. Assessment of other associated injuries b. Timing: Injuries that are closed after 6 to 8 hours of remaining open have increased rate of infection.

    Extent of contamination i. Antibiotics are not needed for most wounds unless they demonstrate signs of active infection e. Bite wounds are always contaminated and have a high likelihood of infection. Tetanus prophylaxis see Table d.

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    Size of wound i. Assessment of patient local and systemic factors a. Presence of ischemia—reperfusion injury b. Hypoxia in the wound bed c. Bacterial load of the wound i. Contaminated: Bacteria present without proliferation ii. Colonized: Bacteria present and proliferating but without causing host response. General assessment 1.

    Overall health of the patient 2. Quality of tissue surrounding the wound. T he phases of wound healing. Radiation-induced chronic skin changes ii. Edema iii.