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Archive for the ‘wound healing’ Category

The Biology of Suture (Stitch) Extrusions and Abscesses in Plastic Surgery

Wednesday, August 8th, 2012

Whether it is the closure of a surgical incision or that of a laceration repair, a well-aligned wound approximation is the hallmark of a plastic surgeon. The best scar outcomes can only come from a beautifully closed wound. While good wound closure is not always a guarantee of a great scar result, poorly repaired tissue edges are a certainty to have a poor scar afterwards.

No matter how a wound is closed, it requires suture materials to do so. One of the classic plastic surgery suture techniques is that of the subcuticular or intradermal wound closure. While not exclusively done by plastic surgeons, it is more widely used by plastic surgery than any other surgical specialty. The other common method used in skin closure by plastic surgeons are interrupted buried dermal sutures. Usually they are done in combination for the dual effect of strength and gross approximation (interrupted dermal sutures) and meticulous skin closure. (subcuticular suture)

While these skin repair techniques provide excellent skin edge approximation and avoids undesired suture track marks, it does leave a fair amount of suture material at the most superficial layer of the tissues. While most of the suture material used for these closure techniques is resorbable, this does not mean that they always go away without causing some disturbing complications.

One of the most vexing wound problems from the incision line after surgery is the extruding suture/abscess. It is confusing for patients because of when it develops. Often not occurring for weeks to months after surgery, patients assume that they have an infection or a deeper wound problem. Patients understandably assume that wound healing is linear, meaning each day the wound appearance should continue to get better, but it isn’t. When an apparent well healed incision line develops an opening, drainage or a spot abscess weeks after surgery, patients are confused as to why it has occurred.

The spitting or extruding suture is a direct result of the intradermal and/or subcuticular wound closure techniques and is the ‘dark side’ to their use. They occur due to a combination of factors which includes the volume of suture material in the most superficial layer of the skin, the partial devascularization of the wound edges (with the subcuticular method) and the body’s inflammatory response to their materials and  their degradation. In essence, the body thinks the sutures are foreign materials and an inflammatory response develops which is how they eventually resorb.

If the sutures were deep in the tissues this bodily reaction would never pose a problem. But in the skin, a small pocket of fluid around the knotted suture develops (which may progress to a small abscess like a pimple or pyogenic granuloma) and it begins to show through the suture line. A ‘hot spot’ will develop which will usually erupt through the skin and drain. Because the resorption time of all sutures used for these wound closure methods takes often six months or longer, the body’s inflammatory response occurs far quicker than the suture’s ability to resorb. When these suture extrusions involve a subcuticular stitch, it can act as a wick spreading the infection a great distance along the wound closure line.

Treatment of extruding sutures and their abscesses ultimately requires that the suture be removed, or the problem will continue to fester. In some cases, the suture extrudes innocuously many months later without any inflammatory reaction. This can be harder to appreciate because many of these suture materials are colorless and the only sign is a small opening along the incision line.

The most likely problems with extruding sutures is on long incisions from body contouring procedures. Tummy tucks, breast reductions, thigh lifts and arm lifts, all which involve extensive wound closures, are the most common procedures where these types of suture reactions are most likely to be seen. Why some patients get none, experience just a few and others have large number of extruding sutures in these wound closures is not clear.  

Dr. Barry Eppley

Indianapolis, Indiana

The Four Sins After Plastic Surgery

Sunday, August 5th, 2012

The after care from major plastic surgery is obviously important. The plastic surgeon can do the operation perfectly but how one heals is another part of the equation that can lead to a satisfying result. While every operation has its own unique set of recovery instructions and things to do and not to do, all surgery shares some basic healing principles.

Over the years, I have been written to by e-mail and heard by phone or in person many patient questions. Most of them are incredibly common and some concerns are not going to make a difference in the outcome either way. But there are some common questions that inquire about what I consider to be the ‘Four Sins After Plastic Surgery’.

Smoking. Many patients who smoke tobacco undergo plastic surgery, whether it is known to the plastic surgeon or not. Everyone knows that smoking is not good either because of its pulmonary effects on anesthesia or its negative impact on tissue healing. Refraining from smoking is required to be done three or four weeks before surgery and an equal number of weeks afterward.  While smoking does cause a greater detriment to certain plastic surgery operations, known as long skin flap procedures (e.g., facelift, tummy tuck and breast reduction/lifts), it affects wound healing even in more well vascularized procedures. (e.g., breast augmentation, liposuction) The after surgery questions often is…but what if I have just one or two cigarettes a day? It is far less than I usually smoke…

Drugs. Does the periodic and sporadic use of either marijuana or cocaine after surgery pose a problem? The question about cocaine use is almost always after a rhinoplasty for the obvious reason. Interestingly topical cocaine liquid is frequently used during a rhinoplasty when the septum and turbinates are being manipulated. Its vasoconstrictive properties are why and it is extremely helpful in creating less bleeding. But this is done in the face of normal septal mucosa and tissues. Placing cocaine on healing mucosa by snorting it a different issue, with higher concentrations than what is used during surgery and on damaged tissues. Suffice it to say that even a single application may cause a septal healing problem.

Marijuana seems less offensive and perhaps less injurious to healing tissues than tobacco smoke. The absence of nicotine makes it have theoretically less vasoconstrictive potential. But if it is less harmful than cigarette smoke it is likely so only so because it is a more infrequent habit with less total inhaled smoke. To some degree smoke is smoke.

Exercise. Physical activity after surgery is good…in moderation and at the right time. While many patients have a good exercise regimen before surgery that has been instrumental in keeping their weight at a good level and making them feel good, it can have a negative impact on healing. Suture line disruption, the creation of fluid accumulations and inducing prolonged swelling can make for some minor or even major setbacks in recovery. Patients frequently say they have a ‘hyper’ personality and have trouble sitting still and just can’t keep themselves down, but the reality is this is more mental than physical. I have yet to operate on a patient who was training for the Olympics or had a professional sporting event to participate in soon after their surgery. If in doubt, wait. There will be plenty of time left in life to get back into shape.

Sex. Like exercise, sex is an important activity that may even be more important to some patients. Unlike exercise, however, sex involves another partner who has not undergone surgery and is not recovering. Some argue that sex is safe after a procedure as long as one can find a position that does not cause pain or stress the surgery sites.

Many of the pleasures of life do come into conflict with healing and recovery after plastic surgery procedures. Following your doctor’s instructions is important and there is a reason why they exist and are written down. When in doubt, don’t and ask your plastic surgeon first.   

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery’s Did You Know? Scar Redness

Friday, June 15th, 2012

While everyone acknowledges that incisions and scars take time to heal and look better, the natural history of this process confuses most patients. Immediately after surgery or a laceration repair, the skin edges and scar line looks great and has a natural color. This will continue to look this way before it changes for the worse in the next few weeks. This is because healing involves the growing in of new blood vessels around and into the incision line/scar to carry nutrients to build collagen to mend the wound edges together. In the beginning this is known as inflammation which takes weeks to appear so on the outside. That is why incision and scars, which looked so good in the first few weeks, turn red, darker and more ugly as the blood vessels multiply and grow into the injured tissues. Patients often think this is a sign of infection or scar worsening, which it is not. It is a natural process. Only when the wound edges have grown back together sufficiently (months), do the blood vessels recede and the scar color starts to improve. Scar eventually turn white or have matured when all the blood vessels have returned to normal numbers. (up to one year) Some hastening of the red color fading can be done with certain pulsed light and laser therapies.

Plastic Surgery’s Did You Know? Smoking and Wound Healing

Monday, May 21st, 2012

Smoking not only induces medical disease but impacts wound healing significantly. Its negative effects are thought to be primarily related to its reduced levels of tissue oxygenation, a critical factor that helps surgical wounds heal. Two major smoke consitutents, nicotine and carbon monoxide, causes peripheral vasoconstriction and decreases the ability of hemoglobin in red blood cells to carry oxygen. Nicotine may also impair the function of fibroblasts and white blood cells to make collagen and fight infection respectively. If you smoke and want to undergo plastic surgery, you would be wise to refrain from smoking at least two weeks before and after surgery to improve your chances of a successful and uncomplicated result. In addition, your anesthesiologist will also appreciate it as the direct effects of cigarette smoke on the lungs are certainly not helpful for your anesthetic and the immediate recovery from it.  

Plastic Surgery’s Did You Know? Sutures and Wound Healing

Saturday, May 12th, 2012

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.

Matristem for Wound Healing and Graft Stimulation

Sunday, January 2nd, 2011

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. It may also be valuable in a wide variety of numerous reconstructive and cosmetic plastic surgery applications.

 

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 if mixed with platelet-rich plasma. (PRP)

 

Dr. Barry Eppley

Indianapolis, Indiana

 

 


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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