plastic surgery for scars
cosmetic surgery for acne scars
cosmetic surgery for scars
cosmetic surgery on scars
cosmetic surgery for scar removal
Skin resurfacing treatments help to restore a more youthful, beautiful complexion by removing the most damaged outer layers of skin to reveal the healthier-looking skin beneath and encouraging new, healthy skin cell growth.
Over time, our skin’s outer layers start to show wear and tear from aging, injury, and environmental factors in the form or wrinkles, scars, age spots and discoloration. Skin resurfacing treatments help to reverse these signs of aging and stress, helping you look younger, and even healthier, in the process.
Cosmetic surgeons use a variety of techniques for skin resurfacing to address a myriad of skin concerns. Choose from the list below to learn more about your options:
- Who should perform skin resurfacing treatments?
- Non-Surgical Facial Rejuvenation: an Infographic Guide
- Skin Resurfacing Treatments
There are literally hundreds of different skin resurfacing treatments available in the U.S., which are marketed under their own brand names. While most of these are excellent technologies, it is important to remember that the component of cosmetic medicine that has the biggest impact on your results is your provider. This goes for non-surgical skin resurfacing treatments as well as cosmetic surgery.
Certain skin resurfacing treatments should only be performed by a board certified cosmetic surgeon. These include deep chemical peels and certain ablative laser treatments. Other treatments, such as microneedling, light peels, and microdermabrasion, can be safely and effectively performed by a highly trained registered nurse or licensed aesthetician.
The credentials required to perform skin resurfacing treatments vary from state to state, but regardless of what is allowed in your area, you should always choose a provider who is licensed for his or her position, works under the supervision of a qualified cosmetic surgeon (if the provider is a nurse or aesthetician) and is very experienced in medical skin care. When you consult with potential providers, ask how many times he or she has performed the specific treatments you are considering. Additionally, ask about the provider’s experience working with patients with your skin type and concerns. This is essential for your safety and to ensure the treatments you receive will be effective in achieving your goals.
The best place to start is to contact a board certified cosmetic surgeon in your area and set up a consultation with that surgeon and/or their skin care director. You can use our Find-A-Surgeon Tool to locate cosmetic surgeons near you.
Non-surgical facial rejuvenation includes injectable fillers, neurotoxins, and skin tightening as well as skin resurfacing. Many cosmetic surgeons will combine treatments to achieve optimal, long-lasting results. The guide below outlines all of your options.
Lasers use highly concentrated beams of light energy to improve the skin’s tone, texture and appearance.
How can laser skin resurfacing improve my skin?
- Minimize fine lines or wrinkles
- Treat brown spots, redness or discoloration for more balanced skin tone
- Tighten skin and encourage collagen production
- Remove acne or surgical scars
- Remove unwanted facial or body hair
Ablative lasers remove outer layers of skin and encourage new skin to heal in its place. How deep the laser penetrates depends on the wavelength of the light; your cosmetic surgeon will determine the best laser application for you depending on your skin type, your goals, and the nature of the problem you wish to address. Today, more cosmetic surgeons are using fractionated lasers, which only remove a fraction of the skin in the treatment area. This allows the laser to safely penetrate into the deeper layers of skin to achieve more dramatic results with minimal downtime.
Some lasers do not break the skin’s surface; these are called non-ablative. They work instead by heating up the skin below the surface to encourage new collagen growth and help restore the skin’s natural firmness and tone. While they work more gradually than ablative lasers, these treatments typically require no downtime and can have lasting results for rejuvenating the appearance.
The improvements possible with laser resurfacing are long-lasting and can be dramatic, but they will not appear overnight. It takes several months for the full effects of new skin cell and collagen growth to take shape, and residual after-effects of treatment, such as skin that appears pink at the treatment site, can take a few weeks to subside. However, every patient is a little different. Your cosmetic surgeon will help you learn what type of results you might expect from different laser resurfacing treatment options.
Another way to resurface the skin is to apply a chemical solution that causes the outer layers of skin to peel away. This is what cosmetic surgeons call a chemical peel. Chemical peels are usually performed in a cosmetic surgeon’s office, either by the cosmetic surgeon or a specially trained aesthetician or nurse. During treatment, a solution is brushed or swabbed onto your skin, where it will be left for a certain period of time. Over the days following treatment, the affected layers of skin will gradually peel away, revealing a smoother, younger-looking complexion.
How can a chemical peel help improve my skin?
- Reduce or remove age spots, blotchiness, or discoloration
- Smooth fine lines & wrinkles on the skin’s surface
- Minimize or remove acne scars or milder scars from injury or surgery
- Tighten & tone the skin and brighten the complexion
- Remove keratoses or precancerous growths
Light vs. Deep Chemical Peels
Depending on the treatment, a peel will often be classified as light, medium, or deep. This refers to how many layers of skin are removed. Light chemical peels will typically reach partially through the epidermis (the outermost layers of skin) and use a milder acid solution such as glycolic acid, alpha hydroxy acid (AHA), salicylic acid, fruit enzymes, or a low concentration of trichloroacetic acid (TCA). Light peels can be safely applied by a trained, experienced aesthetician under the supervision of a cosmetic surgeon, and typically involve little to no downtime.
Deeper peels will reach further into the epidermis or even into the next layer, the dermis, and are recommended to address more advanced signs of aging, such as deeper wrinkles and extensive sun damage, or severe acne scars. Examples include phenol peels, stronger TCA peels, and croton oils. While medium to deep peels can produce more dramatic improvements, they are more involved treatments. Anesthesia may be needed to keep a patient comfortable during treatment, and several days of downtime are required to allow the skin to heal optimally.
Your cosmetic surgeon will recommend a peel based on your skin type, the specific issues you want to address, and how deep the peel needs to work to achieve the desired results. After the initial healing period following a chemical peel, some improvements will be immediately noticeable: brighter, tighter-feeling skin and a more even skin tone. However, the effects of a peel are cumulative, and many patients find repeating treatment periodically is needed for optimal results.
A third class of skin resurfacing treatments are those that involve mechanical exfoliation, where an instrument is used to slough off outer layers of skin to remove visible skin damage and reveal smoother, healthier and younger looking skin. Such treatments include microdermabrasion and dermabrasion. While they have similar sounding names, each of these treatments works quite differently.
Microdermabrasion is a relatively gentle procedure that can be used on the face, neck, hands or body. During treatment, the area is exfoliated by using a very fine tipped instrument or by applying a fine mist of abrasive particles. The exfoliated skin is then immediately vacuumed away. Unlike some other resurfacing treatments, microdermabrasion is safe for all skin types, carries very little risk for side effects, and requires no downtime.
What can microdermabrasion do to improve skin?
- Minimize fine lines & wrinkles, such as crow’s feet
- Help skincare products work more effectively
- Brighten skin & improve tone
- Reduce age spots or mild acne scars
Microdermabrasion can be performed in the same sessions as a peel or facial to enhance the results. While immediate improvements are usually noticeable, microdermabrasion treatments are often performed in a series to achieve optimal improvements. It is also essential to protect the treated area from the sun, as skin will be more sensitive to sun damage after microdermabrasion.
Dermabrasion is a more powerful mechanical resurfacing technique than microdermabrasion. During treatment, a cosmetic surgeon will use a rapidly rotating instrument or blade to precisely remove skin from the treated area layer by layer until the desired depth. Because it reaches more deeply into the skin’s surface, dermabrasion can affect skin pigmentation, and thus is not recommended for every skin type. Typically, patients will receive a topical anesthetic or local anesthesia to ensure comfort during and after the procedure.
What can dermabrasion do to improve skin?
- Minimize vertical lip lines, smile lines, or other facial wrinkles
- Remove acne scars and other blemishes
- Smooth the skin and balance complexion
The purpose of dermabrasion is to remove enough layers of skin to remove the visible concerns and encourage new cell growth. Therefore, the area will be tender and “raw” after treatment. It is essential to keep the area well protected from the sun and follow your cosmetic surgeon’s instructions for keeping the skin free from infection.
Under the care of a qualified, experienced cosmetic surgeon, skin resurfacing treatments can reverse the visible effects of aging to dramatically enhance a patient’s appearance.
Microneedling is a skin resurfacing technology that uses the skin’s natural healing process to reduce skin imperfections, treat sun damage, and restore a smoother, clearer complexion. Instead of removing layers of skin with heat or chemicals, microneedling creates microscopic “injuries” in the skin using an instrument containing dozens of very fine, short needles. The “injuries” are not visible to the naked eye, but they do trigger the natural healing response, prompting your skin to produce new collagen and elastin and regenerate new, healthy skin cells.
What skin concerns can microneedling treat?
- Fine lines & wrinkles
- Acne or surgical scars
- Large pore size
- Sun damage, age spots and hyperpigmentation
- Stretch marks
- Rough patches & texture problems
Since microneedling does not remove layers of skin with chemicals or lasers, it is generally safe for all skin types, even darker skin. Additionally, microneedling requires no downtime for most patients, and does not require a post-treatment “peeling” period. However, results may not be as dramatic as what is possible with more aggressive treatments, and multiple microneedling treatments are usually needed to treat specific skin concerns in an area.
Intense pulsed light, or IPL, is a treatment similar to laser resurfacing in that it uses light to treat skin problems, particularly pigmentation problems, and rejuvenate the complexion. However, instead of a highly focused, single wavelength, IPL uses a broad spectrum of light wavelengths, delivered in brief pulses. This light helps the skin in two ways. First, the wavelengths in IPL absorb excessive pigment in the skin (reds and browns) to restore a more even complexion. To a lesser degree, IPL stimulates collagen production to improve overall skin tone. IPL is a non-ablative treatment (no skin is removed during treatment), and typically requires little to no downtime.
What skin concerns can IPL treat?
- Sun damage
- Age spots & freckles
- Spider veins
- Redness & rosacea
- Vascular lesions
- Texture problems
- Fine lines
IPL is marketed under many different names, including BBL (broad band light), photofacial, and photorejuvenation. However, while individual treatment platforms vary somewhat in their specifications, all use a broad-wavelength intense pulsed light technology—the skill of your provider makes a bigger difference in your treatment than the brand name of the treatment.
Scars: A New Point of View in Plastic Surgery
By Gustavo E. Prezzavento
Submitted: September 19th 2018Reviewed: January 3rd 2019Published: April 26th 2019
The issue of achieving esthetically pleasing surgical scars has gained prominence in recent years, with the emergence of the concept of the “imperceptible scar,” which is expected by patients of not only cosmetic but also reconstructive surgery. Current research in reconstructive surgery focuses on obtaining high-quality results in the minimum number of steps, with a view to “doing it right the first time.” However, there is no uniform approach to scar treatment, which is partly due to a lack of consensus regarding the most effective healing methods. This chapter aims at shedding new light to discussion by putting forward two different procedures that enhance scar results in cosmetic and reconstructive surgeries by applying a topical treatment with active ingredients and by combining cadaver and artificial skin as dermal substitutes, respectively. The effectiveness of these treatments is shown by means of objective, quantifiable data collected as a result of studies and postoperative follow-ups carried out at Hospital Alemán in Buenos Aires.
- surgical wound
- wound healing
- reconstructive surgery
- esthetic surgery
Scars are a natural part of dermal healing following lacerations, incisions, or tissue loss. Wound healing, which is a natural process of tissue repair, consists of three phases: inflammation, fibroplasia, and maturation. The healing tissue generates changes in the cutaneous architecture, which renders the skin surrounding the scar different from the rest of the skin in terms of color, thickness, elasticity, texture, and degree of contraction . In surgical procedures, scars, which are the only visible sequela of the intervention, result from the reparation process undergone by the skin to heal the wounds caused by surgery or trauma. Because of its impact in scarring, considerable importance is placed on the closure of a surgical incision, which is the final phase of the intervention . The ideal scar is narrow, flat, level with surrounding tissue, and difficult for the untrained eye to see due to color match and placement parallel to relaxed skin tension lines. In contrast, hypertrophic, keloidal, dyspigmented, widened, contracted, or atrophic scars can be unsightly and/or cause functional limitations, which patients often perceive as a problem.
Thus, when the scar has unfavorable characteristics, scar revision is often indicated. Furthermore, as poor-quality healing of an incision can constitute a disabling pathology , scar treatment should not be considered as a trivial part of the intervention. On the contrary, wound treatment and care after surgery of any kind, including esthetic or reconstructive interventions, should be initiated early. In order to arrive at an effective esthetic and functional outcome, surgeons must be familiar with the different scar treatments available, and they must also know how to prevent scars and how to reduce them after surgery. In this sense, it should be borne in mind that, while there exist multiple treatment modalities, none of them guarantees a 100% success rate. Current guidelines suggest a multimodal approach to treating scars but there is no gold standard for their treatment. In this chapter, we will present two new ways to treat scars following plastic surgery. As explained in the following sections, these techniques were successfully implemented in a number of cases, and their comparative advantages regarding other methods were also evaluated. We hope that our contribution will help point in the direction toward an effective, uniform standard.
The first part of our research deals with cosmetic surgery scars, which generally receive different topical treatments that help maintain the moisture and the plasticity of the wound. Besides, these treatments prevent wound contamination or infection, which would delay healing. We have analyzed and compared the results of two of these treatment options and found that the best functional and esthetic results are obtained when using a cream with active ingredients. The second part of our research revolves around the combined use of two skin substitutes, cadaver skin and artificial skin, so as to obtain improved results in reconstructive surgery after trauma injuries with abnormal wound healing in response to skin trauma or inflammation. Employing dermal substitutes result in a better regeneration of the dermis and in dermal fibroblast optimization. In the next sections, we will present a detailed account of the two studies we have carried out, which will allow us to further discuss the aforementioned techniques to optimize surgical scars.
2. Topical treatment of cosmetic surgery scars
As we have already mentioned, the first study involved the comparison and evaluation of two topical treatments applied to scars resulting from cosmetic surgery. One was a cream containing 1 g of silver sulfadiazine, 248,000 IU of vitamin A and 0.666 g of lidocaine in each 100 g of product (Platsul-A®, Soubeiran Chobet Laboratory, Autonomous City of Buenos Aires, Argentina) (cream A), and the other was a moisturizing cream based on petrolatum, keto-stearyl alcohol, glycerin, and water without any active ingredient (cream B). About 32 patients participated in the study; 24 with bilateral breast implants and 8 with face and neck lifts, hence totaling 64 scars. The study included patients of both sexes: 31 women and 1 man, with ages ranging from 22 to 64 years (mean of 41 years). All patients received both topical treatments under study, each of their postsurgical scars (right and left) being applied one of the creams at random. We monitored patients for 1 month after the beginning of treatment, meeting them at an initial appointment and at subsequent appointments after 3, 6, 9, 16, 23, and 30 days from the intervention. Each patient’s progress was checked by the same medical examiner.
In these appointments, we measured the length and width of the scars to determine their total surface and assessed them in accordance with the Vancouver scar scale (VSS) and the patient and observer objective assessment scale (POSAS). We evaluated (1) the surface area of each scar by multiplying its length by its width, as measured with a ruler with graduation, (2) the quality of each scar as assessed by the VSS,  taking into account the parameters of pigmentation, vascularity, and thickness, and (3) the patient’s perception of each scar as appraised by the POSAS,  by having them rank a series of symptomatic and esthetic parameters. The results are reported as follows, discriminated on the basis of the type of surgery performed.
2.1. Surface area of each scar
In the group of patients with breast implants, the percentage of change did not differ significantly between the two treatments studied in the appointments of days 3, 6, 9, 16, and 23. On day 30, however, we detected a statistically significant difference (P = 0.017). The percentage of decrease was significantly higher in the scars treated with the cream with silver sulfadiazine, vitamin A, and lidocaine (cream A) than in those treated with the cream without active ingredients (cream B) (18.6 and 9.5%, respectively) (Table 1). In the group of patients with face and neck lift, there was no significant difference between the percentage of change achieved due to the two treatments on days 3, 6, 9, and 16. Nevertheless, on days 23 and 30, we encountered a statistically significant difference (P = 0.026 and P = 0.007, respectively). The percentage of decrease was significantly higher in the scars treated with cream A than in those that had been treated with cream B. On day 23, the surface area of the scars treated with cream A had decreased, on average, by 14.8%, while that of the scars treated with cream B had increased, on average, by 24.9%. On day 30, the surface area of the scars treated with cream A had decreased, on average, by 19.1%, whereas that of the scars treated with cream B had increased, on average, by 22.2% (Table 2). Figure 1 shows the changes in the surface area of each patient’s scars on days 23 and 30 with respect to the initial appointment and classifies the results according to the type of surgery undergone and the treatment received. As we can see, more favorable results were obtained with cream A than with cream B, except in the case of two patients with breast implants (patients No. 7 and 12).
|Days||Average percentage of change of the surface area as from treatment onset (breast implant)||P|
|Cream A (%)||Cream B (%)|
2.2. Vancouver scar scale
The VSS assigns values to the scar pigmentation, vascularity, and thickness, which are then added to obtain a total. Although the score may vary between 0 and 10, the average of the initial scores in our study was 2.7 and the maximum value observed throughout the study was 5. We conducted the analysis taking into account the absolute change in the VSS score with respect to the initiation of treatment (day 0). Results are expressed in absolute values. The analysis is carried out separately for each group of patients, depending on the type of surgery, on days 3, 6, 9, 16, 23, and 30.
In the breast implant patient group, the VSS score change did not differ significantly between treatments on days 3, 6, 9, and 16. On days 23 and 30, nonetheless, we noticed a statistically significant difference (P = 0.02 and P = 0.006, respectively). The decrease was significantly higher in the scars treated with cream A in comparison with those treated with cream B. On day 23, the score of the scars treated with cream A decreased by 1.13 points average, while that of the scars treated with cream B increased by 0.04 points average. On day 30, the average score decrease was of 1.88 points in those treated with cream A and of 0.42 points in those treated with cream B (Table 3).
In the group of patients with face and neck lift, the change in the VSS score did not differ significantly between treatments after 3 days. Yet, in all of the following appointments, a statistically significant difference (P ˂ 0.05) was observed. The reduction of the score was significantly higher in scars treated with cream A than in those treated with cream B. On day 23, scars treated with cream A had decreased by 0.86 points average, while those treated with cream B had increased by 1.75 points average. On day 30, the average score decrease of scars treated with cream A was 1.88 points, while the score of scars treated with cream B increased by 1.88 average points (Table 4). Figure 2 displays the changes in the VSS scores for each patient with breast implants on 23 and 30 days, compared to the initial control. In a majority of patients, we see a favorable effect with the cream A treatment compared to cream B, except for three cases (patients No. 16, 28, and 30). Figure 3 illustrates the changes in the VSS scores for each patient with face and neck lifts on days 6, 9, 16, 23, and 30 with respect to the initial appointment. In most cases, cream A shows a more favorable effect in comparison with cream B. Regardless of whether cream A or B had been used, in general, the changes observed in the VSS, either increase or decrease, were homogeneous in the three variables that make up this scale: pigmentation, vascularity, and thickness of the scar. Figures 4–6 illustrate the different results obtained when applying each cream.
2.3. Patient and observer objective assessment scale
This scale allowed us to evaluate numerically, based on the patient’s own answers, scar characteristics related to pain, itching, color, stiffness, and thickness. The treating physician recorded the data reported for each variable and for each scar during the corresponding appointments. Although the score may vary between 0 and 60, the average of the initial scores was 16 and the maximum value observed throughout the study was 25. We carried out the analysis taking into account the percentage change in the score of the scale with respect to that of the beginning of the treatment (day 0). We evaluated the results separately for each group of patients, depending on the type of surgery performed, and we considered the results obtained on days 3, 6, 9, 16, 23, and 30 of the postoperative period.
In the group of patients with breast implants, the percentage change of the score of the POSAS did not differ significantly between the treatments on days 3 and 6, but in the remaining appointments, we found a statistically significant difference (P < 0.05) in favor of cream A. The percentage decrease in the score was significantly higher in those scars treated with cream A than in those treated with cream B. On day 23, the score of scars treated with cream A decreased by 21.8 points average, while that of the scars treated with cream B did so by 1.3 points average. On day 30, the average score decrease was of 37.7 points in scars treated with cream A while, in those treated with cream B, the decrease was 7.3 points average (Table 5).
In the group of patients with face and neck lifts, the percentage change in the POSAS score did not differ significantly between the treatments on days 3, 6, 9, 16, and 23. On day 30, however, we detected a statistically significant difference (P = 0.021) in favor of cream A. The percentage decrease was significantly higher in cases treated with cream A versus those treated with cream B. On day 30, the score of scars treated with cream A decreased, on average, by 14.4%, while that of the scars treated with cream B increased, on average, by 26.6% (Table 6). Figure 7 presents the percentage changes of the POSAS scores for each patient with breast implants on days 9, 16, 23, and 30 with respect to the initial appointment, differentiated according to the treatment applied. In most patients, we see that the treatment with cream A resulted in a more favorable effect than that obtained with cream B, except for two cases (patient No. 15, days 9 and 16; and patient No. 13, day 16). Figure 8 shows the percentage changes of the POSAS scores for each patient with face and neck lift between the onset of the treatment and day 30 and organizes the results based on the cream employed. In most cases, a better outcome was reached with cream A than with cream B. Irrespective of the cream applied, in general, the changes observed, either increase or decrease, reflected homogeneous changes in the variables that constitute this scale.
|Days||Average change in the POSAS score as from treatment onset (breast implant)||P|
|Cream A||Cream B|
The results showed an improvement of all the evaluated variables when we used the cream with silver sulfadiazine, vitamin A, and lidocaine as treatment . In all the scars treated in this way, we observed a greater percentage decrease of the surface area as compared with those treated with the cream without active principles. In addition, the scars treated with silver sulfadiazine, vitamin A, and lidocaine obtained a lower POSAS score, associated with a better scar quality. Such decrease in the POSAS score throughout the treatment is indicative not only of a more positive perception by the patient of the healing process but also of improvement of all the parameters evaluated: pain, itching, color, stiffness, thickness, and irregular scarring . Therefore, our results indicate that performing a topical treatment with a cream containing silver sulfadiazine, vitamin A, and lidocaine from the beginning of treatment decreases wound size faster, improves the quality of the scar and the overall perception of the patients. In other words, such a treatment of postcosmetic surgery scars yields better esthetic and functional outcomes .
3. Combining skin substitutes for dermal reconstruction
The other treatment we are concerned with involves using different dermal substitutes in reconstructive surgery. Soft tissue impairment after an accident requires fast radical treatment and often multiple surgical procedures related to necrotic and poorly perfused tissue. Traditionally, dermal reconstruction meant harvesting grafts and flaps, which left major sequelae in donor sites. However, modern understanding of the composition of the skin has enabled researchers to develop numerous cutaneous substitutes which allow for the reconstruction of the dermis by providing a scaffold that promotes new tissue growth, thus compensating for the functional and physiological impairments caused by damaged tissue. Moreover, they offer the attractive possibility of employing grafts to treat large burns.
Skin substitutes are biomatrices that may be used to replace the damaged epidermis or dermis (or both) partially or totally, transitory or definitively. Although they can be classified in different ways , they fall broadly into two groups, either decellularized dermis derived from human or animal sources or artificially constructed scaffolds comprised of highly purified biomaterials or synthetic polymers. Many of these substitutes act by guiding the patient’s own cells to form a neodermis, both reducing pain and improving healing by avoiding excessive scarring . They allow practitioners to create a controlled environment appropriate for physiology and cellular function, as well as to identify and properly manipulate the cells so that parenchyma, stroma, and vascular components are generated, and to produce materials malleable by the cells.
One such cutaneous substitute is Integra®, which consists of a matrix of purified collagen from bovine tendon cross-linked with glycosaminoglycan obtained from shark cartilage and a silicone layer that functions as a temporary epidermis. It is a bilayer membrane system, consisting of an inner dermal substitute layer and a temporary outer epidermal substance layer. The inner layer is composed of a three-dimensional matrix of cross-linked bovine tendon collagen plus a glycosaminoglycan, and the outer layer is made of silicone. Integra® was introduced by Burke and Yannas in the early 1980s. The aim of their research was to find a substitute for the skin of patients with massive burns . Nowadays, Integra® is a fundamental part of the “reconstructive ladder” and is utilized for treating skin loss resulting from burns, trauma and oncologic and pressure sore surgery . After application of Integra®, the patient’s native fibroblasts, macrophages, and lymphocytes infiltrate and new capillary growth occurs into the matrix of the inner layer. The inner layer becomes degraded and an endogenous collagen matrix is deposited by the patient’s own fibroblasts, forming a neodermis. Once engraftment is complete, 2–3 weeks after application, the outer silicone layer needs to be removed and an epidermal autograft must be placed over the neodermis. One of the advantages of this process is that successful neodermis formation requires only a thin skin graft which provides epidermal coverage which also prevents infections. Furthermore, as no donor site is created, it eliminates the risk of donor site wound complications.
Another skin substitute is cadaver skin or homograft, which was included in protocols for the first time in the year 1981 in Philadelphia, United States. By virtue of the processing of cadaver skin through a skin bank, a suitable substitute is obtained and distributed to potential receptors . Depending on the way in which they are processed, these “acellular dermal homografts” (as Takami describes them ) can be used transiently or permanently. To reduce the probability of graft rejection, cadaveric grafts undergo a cell-removal process and the resulting acellular tissue is irradiated with gamma rays, which destroy the immunogenic potential of the tissue. Employing cadaver skin to treat severe trauma of lower limbs with skin impairment has a number of advantages. To begin with, this treatment produces a biological closure after escharectomy. Furthermore, it helps reduce the loss of fluids, proteins, and electrolytes, as well as the pain experienced by the patient. Apart from this, it prevents the desiccation of the wound bed, since it functions as a biological cover for complex wounds, ultimately improving the preparation of the wound bed before definite reconstruction . Finally, the addition of artificial skin over the vascularized homologous dermis creates a dermal structure of greater thickness and elasticity.
Another recent development which is of great importance for reconstructive surgery is vacuum therapy (VAC), which improves wound healing by means of two main mechanisms. In the first place, it acts on the interstitial level eliminating edema, inflammatory mediators, and bacteria. It thus combats the vicious cycle of increased interstitial edema and pressure, cell death, and necrosis which is begotten by the inflammatory response triggered after a lesion. In addition, this treatment promotes mitogenesis and granulation tissue formation . VAC is relevant to our research since, as Morykwas explains, it can be used to help incorporate Integra® and skin grafts as permanent replacements. Using a vacuum system after the escharectomy and the homograft placement and 1 week after positioning the artificial skin and the ultrathin autograft favors the arrest of these two substitutes. Moreover, negative pressure wound therapy can help augment the healing process and prepare the wound for definitive closure. A review published in Cochrane in 2007  reported that, after 6 months of treatment, a 71% success rate had been observed in wounds treated with both artificial skin and negative pressure through a vacuum system, whereas the success rate of wounds treated solely with negative pressure had been, at 37%, significantly lower. In terms of wound healing, even better results were obtained when Integra® was used as a dermal substitute .
As a consequence of the benefits we have mentioned, dermal substitutes have now been extended to treat other pathologies. Furthermore, the use of cutaneous substitutes added to the vacuum therapy has been incorporated into the “Modified Ladder of Reconstruction” . However, the usefulness of treating large wounds with deep skin impairment with both cadaver skin and artificial skins has not been, to date, exhaustively studied. Therefore, we wish to contribute to this line of research by reporting the successful esthetic and functional results we have obtained when treating extensive skin lesions with both substitutes. Our study involved the follow-up of the wound healing of four patients (N:4) who had suffered high impact trauma in their lower limbs (Figure 9) and who were treated at Hospital Alemán in the city of Buenos Aires. All of them were females with ages ranging from 19 to 73 years (median: 32 years). All of their lesions belonged to Group 4 of Benaim’s severity classification and ranked as full-thickness burns in Benaim’s depth classification . The affected body surface was calculated based on the rule of nines described by Pulaski and Tennison in 1949  (Figure 10) with the following results: 8% in the 19-year-old patient, 24% in the 22-year-old, 28% in the 43-year-old, and 8% in the 73-year-old (Table 4).
In all cases, escharectomy was performed on fascia within the first 48 h of the accident. Immediately afterward, the wounds were covered with cadaver skin from the tissue bank. Over the next 5–9 days, epidermolysis was observed (i.e., spontaneous removal of the epidermis), as well as vascularization and arrest of the homologous dermis on the receptor bed. In the second stage, the artificial skin was placed on the built-in vascularized homologous dermis. Once the artificial skin had been placed, we waited for 21 days before removing the silicone layer and completing the third and last surgical stage with the placement of a 1/4-thick autograft, obtained with an electric dermatome, over the heterologous vascularized neodermis. Figure 11 illustrates the procedure we followed and the results we obtained.
We used a grid of manual design to evaluate the arrest of the cadaver and artificial skin (expressed in percentages). The arrest of the cadaver skin was of 95% and the placement of the heterologous matrix with an ultrathin autograft was of 94%. The average hospital time was 46 days. No major complications were present, but only minimal difficulties belonging to grades 3b, 4, and 5 of the Dindo and Clavien table  (Table 7). After a year of follow-up, we observed that favorable functional results had been obtained in highly complex articular areas such as ankles or knees due to the contribution of homologous and heterologous matrixes that provided adequate scaffolding. With respect to the esthetic results, no depression of the covered surfaces was observed with respect to the adjacent normal dermal tissue. Furthermore, there was no evidence of pathological scarring (such as keloids or hypertrophic scars).
|Grade 1||Any deviation from the normal postoperative course without the need for pharmacological treatment or surgical, endoscopic, and radiological interventions
Allowed therapeutic regiments are: drugs and antiemetics, antipyretics, analgetics, diuretics, electrolytes, and physiotherapy. This grade also includes wound infections opened at the bedside
|Grade 2||Requiring pharmacological treatment with drugs other than such allowed for grade 1 complications. Blood transfusions and total parenteral nutrition are also included|
|Grade 3||Requiring surgical, endoscopic, or radiological intervention|
|Grade 3a||Intervention not under general anesthesia|
|Grade 3b||Intervention under general anesthesia|
|Grade 4||Life-threatening complications including brain hemorrhage, ischemic stroke, subarachnoid bleeding, and central nervous system complications (but excluding transient ischemic attacks) requiring intermediate care or intensive care unit management|
|Grade 4a||Single organ dysfunction (including dialysis)|
|Grade 4b||Multiorgan dysfunction|
|Grade 5||Death of a patient|
|Suffix “d”||If the patient suffers from a complication at the time of discharge, the suffix “d” (for “disability”) is added to the respective grade of complication. This label indicates the need for a follow-up to fully evaluate the complication|
The goal of any healing process is not only that the scar does not bring about functional disruptions, but also that it is as inconspicuous as possible. Patients of both cosmetic and reconstructive surgery expect scars that do not stand out from the normal surrounding skin, yet there is no consensus among medical practitioners as to which healing methods can achieve both functional and esthetic goals most effectively. In this chapter, we have accounted for two studies carried out at Hospital Alemán in the city of Buenos Aires, the promising results of which may help practitioners arrive at a standard for treating scars resulting from cosmetic and reconstructive surgery.
Regarding postcosmetic surgery scars, we have tested the progress of the scars of 32 patients, each having two postsurgical scars that were treated with two different creams. The results of our research show that performing a topical treatment with a cream that contains silver sulfadiazine, vitamin A, and lidocaine from the onset of the treatment decreases the size of the wound more quickly, improves the quality of the scar and the patient’s perception of it. These findings contrast with the less positive outcome of the scars treated with a moisturizing cream without active ingredients . Thus, we conclude that using creams with active ingredients should be promoted as a common practice.
In turn, in our study related to reconstructive surgery, we followed the progress of four patients whose massive skin loss was treated with a combination of artificial and cadaveric dermal substitutes. Using modern biotechnology to reconstruct damaged structures and to provide a new extracellular matrix constitutes the greatest breakthrough in reconstructive surgery of recent times. The development of homografts and artificial skin has allowed professionals to accelerate healing by covering wounds transitorily or permanently. At the same time, they work as a barrier against infections, help maintain the hydroelectrolytic balance , and improve esthetic and functional results. As we explained in the previous section, the quality of the scar and the properties of the neodermis depend on the use of an appropriate extracellular matrix .
As part of our research, we assessed the progress of the four patients’ scars, focusing on such characteristics as color, thickness, volume, and pain, as well as on the restoration of function at affected sites. We noted positive outcomes in all evaluated parameters, which points at the advantages entailed in implementing this technique. Moreover, the number of hypertrophic scars was lower than the average. Our method fulfilled the ultimate goal of tissue engineering, namely, to restore damaged or lost tissue in traumatic wounds that result in a functional barrier, providing, at the same time, for rapid closure to prevent dehydration and bacterial infection. As attested by our results, the advantages of combining both dermal substitutes include better functional and esthetic outcomes, pain relief, and enhancement of the overall quality of the scar.
All in all, the results of both studies are indicative of the direction that modern scar treatment can take in order to achieve the desired goals in both cosmetic and reconstructive surgery. In the case of the former, achieving an esthetically pleasing scar has long been recognized as a fundamental requirement of a successful intervention. Here, the most optimal results can be achieved if wound treatment and care are initiated early. However, the esthetic factor should not be limited to this type of procedures. Our work on reconstructive surgery centers around the concept that such surgery should not only merely aim at “rebuilding” but also at obtaining the best functional and esthetic outcome with the least possible number of interventions. Recent advances in biotechnology offer us effective skin substitutes, which can be combined so as to achieve a better evolution of the wounds.  Such improved esthetic and functional results in posttraumatic reconstructive surgery ensure an ad integrum recovery of the affected areas, which, ultimately, enhances the quality of patients’ lives.