It is common practice to have sutures from surgery or a laceration repair removed after 7 to 10 days, if one has stitches of the non-dissolveable type. But the main reason that external sutures are removed is to prevent a type of scarring known as tracking or railroad marks, not because the wound is actually healed very well. The outermost layer of the skin, known as the epithelium, bridges or joins back together quite quickly in a week or so. But the deeper layers of the wound have not joined back together by even three weeks after surgery, having about 10% of normal tissue strength. This is why plastic surgeons place deeper sutures on the underside of the skin which is where the real support in suture repair is created. These internal dissolveable sutures take months to break down, giving the wound plenty of time to knit together and develop more normal tissue strength.

Wound healing and the science behind it is an integral part of plastic surgery. No medical specialty is faced with more diverse wound healing challenges being a referral source for difficult and non-healing surgery sites and wounds. Plastic surgery offers a wide spectrum of wound healing methods from tissue flaps, skin and fat grafting to topical therapies. One exciting new technology is an advanced regenerative medical implant that can be used as a either a topical application, an injectable slurry or as a surgical implant. Developed by the Acell company, MatriStem technology is a bioscaffold material derived from porcine tissue. When MatriStem is implanted into a surgical site or wound, it is resorbed and replaced with new natural tissue and less scar than would normally occur if it was not used.

MatriStem is a non-synthetic implant that is completely resorbable and acellular. It is a unique implant because of the way it induces healing by triggering extensive new blood vessel formation and recruiting specific cell types to heal the wound site. These cells have the potential to become tissue that is natural to the specific tissue site rather than undifferentiated scar tissue. During the healing process, the implant material is completely resorbed, leaving behind natural tissue replacement and not just scar or an integrated but unnatural residual implant. While no implant yet exists that can completely eliminate scar tissue formation, Matristem substantially reduces the amount of scar that can form in any wound. Less scar means more natural tissue replacement which could show less visible white scar and more normal movement and function around the wound or surgery site.

MatriStem is currently available in both sheet and micronized particle form. (powder) The availability of these two forms allows the material to be applied in any conceivable wound application. It can be used for the treatment of a wide variety of either chronic non-healing wounds or in primary acute surgery to facilitate faster recovery and better results. Dr. Eppley has experience in a wide variety of reconstructive and cosmetic surgery uses and continues to develop new approaches and applications for this novel implant material.

How does the MatriStem implant work? Current scientific understanding is that the scaffold material provides stimulation to the recipient’s immune system to recruit specific cell types for a three-dimensional repair with tissue that is indigenous to the area. The MatriStem bioscaffold is distinguished from other extracellular scaffold technology by its unique two layer or bimodal surface structure. One surface consists of an intact basement membrane which is especially conducive to epithelial and endothelial cell attachment, proliferation, and differentiation. The opposite surface consists of organized connective tissue comprised of the urinary bladder lamina propria. This surface allows for integration into the recipient’s connective tissues and supports blood vessel ingrowth as well. MatriStem implants consist of a both structural and functional proteins (such as Laminin, Collagen type IV and VII) that are arranged in a three-dimensional ultrastructure that is very difficult to reproduce in any manufactured synthetic implant. Growth factors native to MatriStem implants include vascular endothelial growth factor (VEGF), transforming growth factor beta (TGF?), platelet derived growth factor (PDGF), bone morphogenic protein 4 (BMP4), and basic fibroblast growth factor. (BFGF) These are present as the implant resorbs and accounts for why new blood vessels and the recruitment of connective tissue cells occurs to facilitate the healing and tissue remodeling process.

For non-healing wounds, Matristem may be useful either alone or in combination with conventional surgical treatment methods. (debridement and wound closure or grafting) Scars may be improved by excision and interposition of the powder form between the wound edges at closure. Matristem offers promise as an adjunct to injectable fat grafting and open bone grafting. As a slurry, it may be also useful as an injectable method of collagen stimulation particularly iof mixed with platelet-rich plasma. (PRP) Whether Matristem and your wound healing problem may be right for you can be determined through a consultation at one of two Acell Wound Healing Centers in the Indianapolis area. (Indiana University Health Carmel 317.814.4100 or Indiana University Health Avon 317.217.2200)

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Amongst the many adverse effects of smoking on the body is its detrimental impact on wound healing. This phenomenon has been recognized since the late 1970s when a correlation between smoking and an increased risk of wound problems in surgery was established. This is quite important in plastic surgery where large skin flaps area raised, resulting in a decreased blood supply to the raised skin as the circulation is cut off from below and skin survival is dependent on blood flow coming in from raised skin only. Cosmetic plastic surgery procedures such as facelifts, tummy tucks, and breast reductions in particular, are particularly prone to healing problems from smoking.

 
For this reason, the identification of smoking on a patient’s history is very important. It is often one of the first things that I look for on the intake medical history after allergies and medications. Whether the amount of tobacco use listed is accurate is up for debate. I figure most patients put down what they would like it to be, not necessarily how much tobacco they are exposed to every day. I strongly urge patients that they must refrain from all tobacco use at least three to four weeks before and after surgery. Some plastic surgeons refuse to operate at all on smoking patients for certain procedures such as a tummy tuck. I even know some that get a nicotine level several days before surgery. I don’t go quite that far but I can understand this concern. No plastic surgeon wants to deal with avoidable complications. On the surface, no patient wants to either but the addiction of smoking is quite strong even in the face of making smart decisions when you are venturing thousands of dollars in an investment in your body.

 
There is little question that smoking affects wound healing. I have seen a disproportionate number of patients who said they stopped smoking, but when they developed wound problems such as a dehiscence (separation of the incision line), they casually admitted that they had not stopped completely or had slipped in a few in the past few days to ‘calm them down’. Although I have no scientific evidence to support it, my feeling is that the effects of smoking probably takes many months (not just 3 or 4 weeks) and even up to a year after quitting to become ‘normal’ from a wound healing standpoint.

 
A recent journal article in Plastic and Reconstructive Surgery (May 2008) now implicates smoking as a cause of increased infections as well. I must say I am not surprised.

 
Dr. Barry Eppley
http://www.eppleyplasticsurgery.com
http://www.ologyspa.com
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis