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Current Reconstructive Surgery PDF

Current Reconstructive Surgery PDF Free Download
Current Reconstructive Surgery PDF
Preface:

Achievement of adequate wound repair, resolution of healing, and prevention of pathologic scarring is dependent not only on a complete understanding of this process but also on an understanding of wound biomechanics. This chapter will fi rst focus on certain features of wound biology and biomechanics where early intervention may prevent healing complications and problem scarring. The fundamentals of wound repair, emphasizing choice of incision, suture, and technique will be explored to further enhance decision making at the time of tissue restoration. In some cases, failure of resolution of the normal proliferative response, which occurs at the resolution phase of normal wound healing, can lead to proliferative scarring; however, prevention steps are possible provided the surgeon is knowledgeable about the pathogenesis of hypertrophic scars. Due to the challenging treatment of hypertrophic scars and keloids, both surgical and nonsurgical treatments will be discussed in addition to prevention strategies. PRINCIPLES OF WOUND HEALING Wound Biomechanics The plastic surgeon must plan each case relative to the biomechanical properties of skin. The principle constituent of skin is collagen, which is a structural protein organized in sheets with distinct spatial structural components. Elastin fi bers are also present in smaller amounts, giving the skin both elasticity and viscoelastic properties. In other words, in response to constant force, the skin will stretch and not fully return to its unstretched state. Skin Tensions. Placement of skin incisions and resultant scar formation are dependent on both static and dynamic skin tensions. Static tension is the inherent force which stretches the skin over the underlying structures when the body is motionless. 1 The static tension varies enormously within individuals based on anatomic location—for instance, it is quite high over the sternum and minimal in the groin. As a person ages, not only does skin relax and lose elasticity, but the magnitude of tension also changes. As mentioned earlier, the collagen fi bers have a spatial orientation, and this organization is refl ected in static lines of maximal skin tension called Langer lines. An incision along one of these lines will result in a tensionfree closure with minimal static forces pulling against the scar. The outcome is a narrow, fi ne, camoufl aged scar. In contrast, placing an incision against the directional orientation of static skin tension will result in a wider, more visible scar. This is the sequela of continuous high-magnitude forces pulling at the healing wound margins.

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