Skin Tension Research Articles

Post-reconstruction dermatitis of the breast

Approximately one-third of women diagnosed with breast cancer undergo mastectomy with subsequent implant-based or autogenous tissue-based reconstruction. Potential complications include infection, capsular contracture, and leak or rupture of implants with necessity for explantation. Skin rashes are infrequently described complications of patients who undergo mastectomy with or without reconstruction. A retrospective analysis of breast cancer patients referred to the Dermatology Service for diagnosis and management of a rash post-mastectomy and expander or implant placement or transverse rectus abdominis myocutaneous (TRAM) flap reconstruction was performed. Parameters studied included reconstruction types, time to onset, clinical presentation, associated symptoms, results of microbiologic studies, management, and outcome. We describe 21 patients who developed a rash on the skin overlying a breast reconstruction. Average time to onset was 25.7 months after expander placement or TRAM flap reconstruction. Clinical presentations included macules and papules or scaly, erythematous patches and plaques. Five patients had cultures of the rash, which were all negative. Skin biopsy was relatively contraindicated in areas of skin tension, and was reserved for non-responding eruptions. Treatments included topical corticosteroids and topical antibiotics, which resulted in complete or partial responses in all patients with documented follow-ups. Our findings suggest that tension and post-surgical factors play a causal role in this hitherto undescribed entity: "post-reconstruction dermatitis of the breast." This is a manageable condition that develops weeks to years following breast reconstruction. Topical corticosteroids and antibiotics result in restoration of skin barrier integrity and decreased secondary infection.

Application of skin tension evaluation in syndactyly release without skin graft

Objective To explore the indications of simple syndactyly release without skin graft by analyzing the tension of skin in each segment. Methods In 38 cases of syndactyly release without skin flap, the tension of the fused skin was assessed segmentally. The relationship between the skin tension and the postoperative complications was analyzed to deduct the indications of simple syndactyly release without skin graft. These indication criteria were then applied to 10 finger webs in congenital syndactyly to verify the feasibility of these indications. Results Retrospective analysis of 38 cases showed skin necrosis at the distal phalange in 2 cases that resulted in nail deformities, and sunken lateral nail fold in 1 case. The above 3 cases were proven to be unsuitable for syndactyly release without skin graft according to our skin tension criteria. The 10 prospective cases which were performed with or without skin grafting based on the skin tension criteria all had satisfactory function and appearance. Conclusion Preoperative evaluation of the tension of the fused skin segmentally could predict the indication of skin graft in syndactyly release and guide the surgical design. Key words: Hand deformities,congenital; Syndactyly; Skin tension assessment

Wetting and adhesion evaluation of cosmetic ingredients and products: correlation of in vitro-in vivo contact angle measurements.

The aim of this work was to use the contact angle measurement in order to predict the behaviour of ingredients and finished cosmetic products on skin to improve skin feel and product texture. Different classes of cosmetic ingredients and formulations were evaluated. The contact angle measurements were carried out by the sessile drop method using an apparatus, designed and set up in laboratory. Glass, Teflon and human skin were the reference substrates. In a preliminary phase, TEWL parameter, sebum content and hydration of human skin were measured to set up method. Data demonstrated that glass substrate may be used as replacement of the skin:critical surface tension of skin and glass were about of 27 and 31 dyne cm-1 , respectively. Non-ionic surfactant with increasing HLB was evaluated: a correlation between contact angle measured and HLB was not observed because of different and complex molecular structure. In detail, ethylhexyl hydroxystearate (θglass = 17.1°) showed lower contact angle value with respect to Polysorbate 20 (θglass = 28.1°). Sodium laureth sulphate and stearalkonium chloride were also evaluated: anionic molecule showed more affinity for glass with respect to Teflon (θglass = 21.7° and θTeflon = 52.3°). Lipids and silicones showed different affinity for substrate according to hydrophilic groups and hydrocarbon chain: contact angles of silicones remained unchanged independently from substrate. Finished cosmetic products (O/W, W/O emulsions, cleansing oil, dry skin oil) showed different profiles according to surfactant and its affinity for continuous phase of the formulation. Comparing the values of the contact angle on skin of non-ionic surfactants, as ethylhexyl hydroxystearate and Polysorbate 20, they showed values lower (near to zero) than ones of sodium laureth sulphate and Stearalkonium Chloride (21.7° and 66.8°, respectively). Finally, finished cosmetic products tested on human skin showed different profile: corresponded contact angle values were less than 20°. The product tended to be quickly adsorbed on human skin. Systematic study carried out by evaluating the wettability of single cosmetic ingredients on different substrates allowed to find correlations between the use of certain ingredients and the final performance of a cosmetic product.

Keloid and Hypertrophic Scars Are the Result of Chronic Inflammation in the Reticular Dermis.

Keloids and hypertrophic scars are caused by cutaneous injury and irritation, including trauma, insect bite, burn, surgery, vaccination, skin piercing, acne, folliculitis, chicken pox, and herpes zoster infection. Notably, superficial injuries that do not reach the reticular dermis never cause keloidal and hypertrophic scarring. This suggests that these pathological scars are due to injury to this skin layer and the subsequent aberrant wound healing therein. The latter is characterized by continuous and histologically localized inflammation. As a result, the reticular layer of keloids and hypertrophic scars contains inflammatory cells, increased numbers of fibroblasts, newly formed blood vessels, and collagen deposits. Moreover, proinflammatory factors, such as interleukin (IL)-1α, IL-1β, IL-6, and tumor necrosis factor-α are upregulated in keloid tissues, which suggests that, in patients with keloids, proinflammatory genes in the skin are sensitive to trauma. This may promote chronic inflammation, which in turn may cause the invasive growth of keloids. In addition, the upregulation of proinflammatory factors in pathological scars suggests that, rather than being skin tumors, keloids and hypertrophic scars are inflammatory disorders of skin, specifically inflammatory disorders of the reticular dermis. Various external and internal post-wounding stimuli may promote reticular inflammation. The nature of these stimuli most likely shapes the characteristics, quantity, and course of keloids and hypertrophic scars. Specifically, it is likely that the intensity, frequency, and duration of these stimuli determine how quickly the scars appear, the direction and speed of growth, and the intensity of symptoms. These proinflammatory stimuli include a variety of local, systemic, and genetic factors. These observations together suggest that the clinical differences between keloids and hypertrophic scars merely reflect differences in the intensity, frequency, and duration of the inflammation of the reticular dermis. At present, physicians cannot (or at least find it very difficult to) control systemic and genetic risk factors of keloids and hypertrophic scars. However, they can use a number of treatment modalities that all, interestingly, act by reducing inflammation. They include corticosteroid injection/tape/ointment, radiotherapy, cryotherapy, compression therapy, stabilization therapy, 5-fluorouracil (5-FU) therapy, and surgical methods that reduce skin tension.

Biochemical, Biophysical and Mechanical Characterization of Decellularized Dermal Implants

Allografts have been used in a variety of applications to augment as well as replace tissues throughout the body. A number of steps are involved in selection, harvesting, processing and testing of dermal allografts. Grafts can be obtained that are: free of antibodies to viruses and low in viral titers. Cellular material can be eliminated from the tissue and the product becomes almost exclusively a collagen fiber network. The purpose of this paper is to examine the changes in collagen structure and properties that occur during processing of decellularized dermis. The results indicate that collagen fiber swelling occurs during processing although the product preserves the native collagen banding pattern at the fibrillar structural level. Fiber swelling and decreased collagen deformability of processed dermis, may lead to stress concentration at the implant-tissue interface and up-regulation of mechanotransduction. This may lead to premature mechanical failure due to creation of a chronic inflammatory condition at the implant-tissue interface. It is suggested that all dermal allografts be oriented such that Langer’s lines of the implant match those of the host tissue, and that wound closure by suturing be done under conditions that preserve the normal tension in skin in order to minimize implant-interfacial failure.

Biodynamic Excisional Skin Tension (BEST) Lines: Revisiting Langer’s Lines, Skin Biomechanics, Current Concepts in Cutaneous Surgery, and the (lack of) Science behind Skin Lines used for Surgical Excisions

Biodynamic Excisional Skin Tension (BEST) Lines: Revisiting Langer’s Lines, Skin Biomechanics, Current Concepts in Cutaneous Surgery, and the (lack of) Science behind Skin Lines used for Surgical Excisions

Keloids and Hypertrophic Scars: Pathophysiology, Classification, and Treatment.

Keloid and hypertrophic scars represent an aberrant response to the wound healing process. These scars are characterized by dysregulated growth with excessive collagen formation, and can be cosmetically and functionally disruptive to patients. Objectives are to describe the pathophysiology of keloid and hypertrophic scar, and to compare differences with the normal wound healing process. The classification of keloids and hypertrophic scars are then discussed. Finally, various treatment options including prevention, conventional therapies, surgical therapies, and adjuvant therapies are described in detail. Literature review was performed identifying relevant publications pertaining to the pathophysiology, classification, and treatment of keloid and hypertrophic scars. Though the pathophysiology of keloid and hypertrophic scars is not completely known, various cytokines have been implicated, including interleukin (IL)-6, IL-8, and IL-10, as well as various growth factors including transforming growth factor-beta and platelet-derived growth factor. Numerous treatments have been studied for keloid and hypertrophic scars,which include conventional therapies such as occlusive dressings, compression therapy, and steroids; surgical therapies such as excision and cryosurgery; and adjuvant and emerging therapies including radiation therapy, interferon, 5-fluorouracil, imiquimod, tacrolimus, sirolimus, bleomycin, doxorubicin, transforming growth factor-beta, epidermal growth factor, verapamil, retinoic acid, tamoxifen, botulinum toxin A, onion extract, silicone-based camouflage, hydrogel scaffold, and skin tension offloading device. Keloid and hypertrophic scars remain a challenging condition, with potential cosmetic and functional consequences to patients. Several therapies exist which function through different mechanisms. Better understanding into the pathogenesis will allow for development of newer and more targeted therapies in the future.

Skin fragility in the wild-derived, inbred mouse strain Mus pahari/EiJ

Mus pahari is a wild-derived, inbred mouse strain. M. pahari colony managers observed fragility of this strain's skin resulting in separation of tail skin from the mouse if handled incorrectly. Tail skin tension testing of M. pahari resulted in significantly lowered force threshold for caudal skin rupture and loss in comparison to closely related inbred mouse species and subspecies and even more than a model for junctional epidermolysis bullosa. Histologically, the tail skin separated at the subdermal level with the dermis firmly attached to the epidermis, excluding the epidermolysis bullosa complex of diseases. The dermal collagen bundles were abnormally thickened and branched. Elastin fiber deposition was focally altered in the dermis adjacent to the hair follicle. Collagens present in the skin could not be differentiated between the species in protein gels following digestion with pepsin. Together these data suggest that M. pahari have altered extracellular matrix development resulting in separation of the skin below the level of the dermis with moderate force similar to the African spiny mouse (Acomys spp.).

The Efficacy of Local Application of Mitomycin C in Reducing Recurrence Rate of Keloid after Surgery

Introduction 
 Keloid is a hyperproliferative response of the fibroelastic connective tissue to dermal trauma, appearing predominantly in areas of high skin tension. Surgical excision produces immediate cosmetic correction, but recurrence rates after surgical treatment alone are high and post excision adjunct therapies should be considered. Topical application of Mitomycin C has shown to suppress cell division, fibroblast proliferation, protein and collagen synthesis and angiogenesis. In our study we applied it locally after surgical excision of keloid of auricle and compared the outcome with post-surgical perilesional Triamcinolone acetonide injection to reduce recurrence.
 Materials and Method
 Fifty cases with primary or recurrent keloid over auricle were studied from February 2015 to January 2016. They are divided into two groups; Group 1 received local Mitomycin C application after keloid excision while Group 2 had perilesional injection of Triamcinolone acetonide after surgical excision of keloid. The results were compared 6 months after the initial treatment.
 Result 
 There was no statistical difference in the baseline characteristics like age, sex, type of symptoms and previous history of recurrence between the two groups. Most of the patients in both the groups were aged between 14 and 30 years. The study population constituted predominantly of females. At the end of 6 months follow up, the recurrences noted were 5 and 6 respectively in Group 1 and 2 out of 25 patients in each group.
 Conclusion
 After surgical excision of keloid, topical application of Mitomycin C is as effective as intralesional Triamcinolone acetonide injection in terms of recurrence of the keloids affecting the auricle.

β1 integrin signaling in asymmetric migration of keratinocytes under mechanical stretch in a co-cultured wound repair model.

BackgroundKeratinocyte (KC) migration in re-epithelization is crucial in repairing injured skin. But the mechanisms of how mechanical stimuli regulate the migration of keratinocytes have been poorly understood.MethodsHuman immortalized keratinocyte HaCaT cells were co-cultured with skin fibroblasts on PDMS membranes and transferred to the static stretch device developed in-house for additional 6 day culture under mechanical stretch to mimic surface tension in skin. To detect the expression of proteins on different position at different time points and the effect of β1 integrin mechanotransduction on HaCaT migration, Immunofluorescence, Reverse transcription-polymerase chain reaction, Flow cytometry, Western blotting assays were applied.ResultsMechanical receptor of β1 integrin that recognizes its ligand of collagen I was found to be strongly associated with migration of HaCaT cells since the knockdown of β1 integrin via RNA silence eliminated the key protein expression dynamically. Here the expression of vinculin was lower but that of Cdc42 was higher for the cells at outward edge than those at inward edge, respectively, supporting that the migration capability of keratinocytes is inversely correlated with the formation of focal adhesion complexes but positively related to the lamellipodia formation. This asymmetric expression feature was further confirmed by high or low expression of PI3K for outward- or inward-migrating cells. And ERK1/2 phosphorylation was up-regulated by mechanical stretch.ConclusionWe reported here, a novel mechanotransduction signaling pathways were β1 integrin-dependent pattern of keratinocytes migration under static stretch in an in vitro co-culture model. These results provided an insight into underlying molecular mechanisms of keratinocyte migration under mechanical stimuli.

Non-invasive evaluation of skin tension lines with elastic waves.

Since their discovery by Karl Langer in the 19th Century, Skin Tension Lines (STLs) have been used by surgeons to decide the location and orientation of an incision. Although these lines are patient-specific, most surgeons rely on generic maps to determine their orientation. Beyond the imprecise pinch test, there remains no accepted method for determining STLs in vivo. (i) The speed of an elastic motion travelling radially on the skin of canine cadavers was measured with a commercial device called the Reviscometer® . (ii) Similar to the original experiments conducted by Karl Langer, circular excisions were made on the skin and the geometric changes to the resulting wounds and excised samples were used to determine the orientation of STLs. A marked anisotropy in the speed of the elastic wave travelling radially was observed. The orientation of the fastest wave was found to correlate with the orientation of the elongated wound (P<0.001, R2 =74%). Similarly, the orientation of fastest wave was the same for both in vivo and excised isolated samples, indicating that the STLs have a structural basis. Resulting wounds expanded by an average area of 9% (+16% along STL and -10% across) while excised skin shrunk by an average area of 33% (23% along STL and 10% across). Elastic surface wave propagation has been validated experimentally as a robust method for determining the orientation of STLs non-destructively and non-invasively. This study has implications for the identification of STLs and for the prediction of skin tension levels, both important factors in both human and veterinary reconstructive surgery.

The Golden Spiral Flap: A New Flap Design that Allows for Closure of Larger Wounds under Reduced Tension – How Studying Nature’s Own Design Led to the Development of a New Surgical Technique?

This paper details the study of biodynamic excisional skin tension lines on the scalp and the development of a new flap technique for closure of scalp wounds. Recently, a study by this author, on pigskin, replicated whorls by placing tissue under rapid stretch using saline tissue expanders, by recreating rapid dermo-epidermal shear of skin – thereby concluding that the golden spiral pattern is nature’s own pattern for rapid expansion. Given the relationship between tissue expansion and stretch has been shown to cause deformation gradients that have both elastic and growth factors, the author set out to test the hypothesis that a golden spiral pattern therefore would be more efficient at closing wounds under less tension when compared with standard semicircular rotational flap patterns. The author conducted a series of experiments, both on pigskin (to first confirm the hypothesis, using a recently developed computerized tensiometer) and later a clinical study. This paper presents a new random pivotal flap technique for skin closures on the head and neck: the golden spiral flap. Biomechanics, planning, and advantages of this new flap are described in this paper.

High Double Eyelid Fold Correction Using Wide Dual-Plane Dissection.

BackgroundThe ability to correct unnatural-appearing, high, and deep double eyelid folds has been limited by the lack of redundant upper eyelid skin and the presence of prior incision line scars in patients.MethodsFrom January 2000 to September 2011, 256 patients with high and deep double eyelid folds underwent our fold-lowering procedure. The first dissection was made at the superficial layer between the orbicularis oculi muscle and orbital septum/retroorbicularis oculi fat. The second dissection was at a deeper layer between the preaponeurotic fat and levator aponeurosis. The dissection proceeded 7 to 8 mm farther cephalad to the prior fold line to separate the upper flap and the floor from the prior fold line. The lower flap was undermined caudally to obtain normal skin tension, and the lower flap was secured to the septoaponeurosis junctional thickening or pretarsal tissue. Six months after surgery, the correction of the high fold scar and change in fold height (with eyes closed) was documented.ResultsUsing the authors' technique, unnatural-appearing, high, and deep double eyelid folds were converted to lower nondepressed folds. Although prior high fold incision scars could be seen postoperatively on close examination, they were not easily visible. Complications included fold height asymmetry in 10 cases, persistence of the prior fold in 5 cases, and redundant upper flap skin that needed further excision in 25 cases.ConclusionsUsing a wide double-layer dissection, high folds were lowered successfully even in situations where there was no redundant upper eyelid skin for excision.

Reconstruction after Anterior Chest Wall Keloid Resection Using Internal Mammary Artery Perforator Propeller Flaps.

Background:It is difficult to completely resect huge anterior chest wall keloids and then close the wound directly. We report here our retrospective analysis of our case series of patients with such keloids who underwent reconstruction with internal mammary artery perforator (IMAP) pedicled propeller flaps and then received postoperative high-dose-rate superficial brachytherapy.Methods:All consecutive patients with large/severe keloids on the anterior chest wall who underwent keloid resection followed by reconstruction with IMAP-pedicled propeller flaps and then high-dose-rate superficial brachytherapy in our academic hospital were identified. All cases were followed for >18 months. Donor site position, perforator pedicle, flap size, angle of flap rotation, complications, and recurrence were documented.Results:There were nine men and one woman. The average age was 37.9 years. The average follow-up duration was 28.7 months. The largest flap was 16 × 4 cm. The dominant perforators of the internal mammary artery were located in the sixth (n = 2), seventh (n = 5), eighth (n = 1), and ninth (n = 2) intercostal spaces. Twelve months after surgery, patients reported marked relief from keloid-associated pain and itching, except in two patients who underwent partial keloid resection; their remaining keloids were still troublesome but after conservative therapies, including steroid ointments/plasters, the keloids gradually ameliorated. Eighteen months after surgery, there was no keloid recurrence or new development of keloids on the donor site.Conclusions:IMAP-pedicled propeller flaps transfer skin tension from the anterior chest wall to the abdomen. Our series suggests that this approach combined with radiation therapy can control keloid recurrence.

Dermal Remodeling of Burn Scar by Fractional CO2 Laser.

Ablative CO2 fractional lasers have recently been introduced for burn scar treatment because of pronounced clinical outcomes with fewer treatment sessions than nonablative fractional laser. This study was conducted to observe clinical as well as histologic changes of burn scars after treatment with CO2 fractional laser. Eleven patients (one female and 10 males, aged 31-59years) with skin phototypes III to V with burn scars received 10 sessions of fractional CO2 laser treatments (UltraPulse(®) Encore; Lumenis, Santa Clara, CA, USA) over an average 5-week interval. Two passes were performed using the following parameters: deep FX mode, 12.5-30mJ, with a density setting of 5-10%. Clinical evaluations by three blinded dermatologists were obtained at baseline and at 6months after the final treatment via photographs using the Vancouver scar scale (VSS). Skin biopsies were done on four patients before and after treatment. All patients showed clinical improvement in their scars with significant decrease in VSS. Histologic findings showed the changes in the upper dermis with newly formed dermal papilla. This characteristic upper dermis change was presented as improvement in surface smoothness and skin tension clinically. Postinflammatory hyperpigmentation and itching sensation were the most common adverse effects. Burn scar treatment by fractional CO2 laser is effective by forming new collagen fibers mainly in the upper dermis. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Triangular lipodermal flaps in Wise pattern reduction mammoplasty (superomedial pedicle): A novel technique to reduce T-junction necrosis

Background Although Wise pattern reduction mammoplasty is one of the most prevalent procedures providing satisfactory cutaneous reduction, it is at the expense of inevitable lengthier scars and wound complications, especially at the inverted T junction. Objective To describe a novel technique providing tension-free closure at the T junction through performing triangular lipodermal flaps. The aim is to alleviate skin tension, thus reducing skin necrosis, dehiscence and excessive scarring at the T junction. Methods One hundred seventy-three consecutive procedures were performed on 137 patients between 2009 and 2013. Data collected included demographics, perioperative morbidity and resected breast tissue weight. The follow-up period ranged from three to 30 months; early and late postoperative complications and patient satisfaction were recorded. Results Superficial epidermolysis without T-junction dehiscence was experienced in eight (4.6%) procedures while five (2.9%) procedures developed full-thickness wound dehiscence. Ninety-four percent of patients were highly satisfied with the outcome. Conclusions The technique is safe, versatile and easy to execute, providing a tension-free zone and acting as internal dermal sling, thus providing better wound healing with more favourable aesthetic outcome and maintaining breast projection.

A New Skin Tensiometer Device: Computational Analyses To Understand Biodynamic Excisional Skin Tension Lines.

One of the problems in planning cutaneous surgery is that human skin is anisotropic, or directionally dependent. Indeed, skin tension varies between individuals and at different body sites. Many a surgeon has tried to design different devices to measure skin tension to help plan excisional surgery, or to understand wound healing. However, many of the devices have been beset with problems due to many confounding variables - differences in technical ability, material (sutures) used and variability between different users. We describe the development of a new skin tensiometer that overcomes many historical technical issues. A new skin tension measuring device is presented here. It was designed to be less user-dependent, more reliable and usable on different bodily sites. The design and computational optimizations are discussed. Our skin tensiometer has helped understand the differences between incisional and excisional skin lines. Langer, who pioneered the concept of skin tension lines, created incisional lines that differ from lines caused by forces that need to be overcome when large wounds are closed surgically (excisional tension). The use of this innovative device has led to understanding of skin biomechanics and best excisional skin tension (BEST) lines.

Cutaneous Respirometry as Novel Technique to Monitor Mitochondrial Function: A Feasibility Study in Healthy Volunteers.

BackgroundThe protoporphyrin IX-triplet state lifetime technique (PpIX-TSLT) is proposed as a potential clinical non-invasive tool to monitor mitochondrial function. This technique has been evaluated in several animal studies. Mitochondrial respirometry allows measurement in vivo of mitochondrial oxygen tension (mitoPO2) and mitochondrial oxygen consumption (mitoVO2) in skin. This study describes the first use of a clinical prototype in skin of humans.MethodsThe clinical prototype was tested in 30 healthy volunteers. A self-adhesive patch containing 2 mg 5-aminolevulinic acid (ALA) was applied on the skin of the anterior chest wall (sternal) for induction of mitochondrial protoporphyrin IX and was protected from light for 5 h. MitoPO2 was measured by means of oxygen-dependent delayed fluorescence of protoporphyrin IX. MitoVO2 was determined by dynamic mitoPO2 measurements on the primed skin, while locally blocking oxygen supply by applying local pressure with the measurement probe. MitoPO2 was recorded before and during a 60-s period of compression of the microcirculation, at an interval of 1 Hz. Oxygen consumption (i.e. the local oxygen disappearance rate) was calculated from the decay of the mitoPO2 slope.ResultsOxygen-dependent delayed fluorescence measurements were successfully performed in the skin of 27 volunteers. The average value (± SD) of mitoPO2 was 44 ± 17 mmHg and mean mitoVO2 values were 5.8 ± 2.3 and 6.1 ± 1.6 mmHg s-1 at a skin temperature of 34°C and 40°C, respectively. No major discomfort during measurement and no long-term dermatological abnormalities were reported in a survey performed 1 month after measurements.ConclusionThese results show that the clinical prototype allows measurement of mitochondrial oxygenation and oxygen consumption in humans. The development of this clinically applicable device offers opportunities for further evaluation of the technique in humans and the start of first clinical studies.

The Significance of Early Reposition in Patients with Visible Malposition of the Upper Ankle Joint

Background: Protracted dislocation of the upper ankle joint can lead to substantial damage to the surrounding soft tissue, possibly followed by local complications and longer hospitalisation. Although reposition is usually easy to conduct, it is commonly recommended that this should only be performed by an experienced specialist, as long as there is no neurovascular restriction. There are however no exact data or studies on this problem. The aim of the present study is to examine whether early reposition is of benefit for subsequent treatment. Methods: Retrospective study of all patients in a supra-regional trauma centre during the period from January 2009 to July 2015, with either prehospital reposition of the ankle joint because of visible malposition or documented visible malposition on arrival at hospital. Patients with relevant concomitant injuries elsewhere were excluded. Data on the duration of dislocation were matched with diagnostic findings at the time of hospital admission, the kind of primary care, local complications and the time of hospitalisation, using linear regression analysis and ANOVA calculations. Results: Of a total of 391 patients with a dislocation or a fracture dislocation of the ankle joint within this period, 132 fulfilled the inclusion criteria. These patients were divided into 5 groups on the basis of the time of dislocation. Time to reposition was less than one hour for 39 patients, between one and two hours for 29 patients, between two and six hours for 41 patients, between six and 24 hours for 13 patients and more than 24 hours for 10 patients, all with a visible dislocation. The results on admission showed a significant increase in skin bruises and tension bullae with increasing time of dislocation. A longer time of dislocation was associated with more two stage surgical procedures with external fixators and a decreasing number of single stage procedures. While there was immediate definitive treatment of 79.5 % of the patients in the first group, this figure decreased continuously to 10.0 % in the last group. The number of local complications increased significantly in every group with the duration of dislocation. In particular, the incidence of severe swelling, wound healing disorders, skin necrosis and the need for revision surgery and plastic reconstruction exhibit a significant linear increase within the groups (p < 0.05). The incidence of severe swelling rose from 10.3 % in the first group, to 31.0 % in the second group, to 100 % in the last group. The incidence of wound healing disorders rose from 7.7 to 13.8 to 80 % and the incidence of skin necrosis from 2.6 to 3.5 to 30.0 %. The duration of hospitalisation also exhibited a significant linear increase with group affiliation (p < 0.001), from 8.3 days in the first group to 12.5 days in the second group and 30.5 days in the last group. Conclusion: This study shows the importance of conducting reposition of the ankle joint as soon as possible if there is visible malposition, in order to avoid local complications and longer hospitalisation. If there is visible malposition of the ankle joint, the best procedure is immediate - ideally prehospital - reposition and in-axis splinting, in order to preserve soft tissue.

Reducing Wound Tension with Undermining or Imbrication—Do They Work?

Background:For the noncolonized wound, achieving tension-free, primary wound closure is ideal. Some surgeons advocate imbrication of deeper tissues rather than undermining, posing that imbrication preserves more dermal perfusion while still reducing tension at the wound edge. We sought to determine which technique most reliably reduced wound tension while preserving dermal wound perfusion.Methods:A total of 5 standardized, symmetrical pairs of full thickness wounds were created on Duroc swine. Wound tension was measured with a Tyrolean tensiometer before and after either method of closure, whereas a speckle contrast imager was used to assess dermal edge perfusion. Skin tension and dermal perfusion were evaluated for statistical significance via paired t tests and a multivariate analysis of variance.Results:There was a significant reduction in wound tension with undermining and imbrication relative to the raw wound tension (5 and 5.9 vs 7.1 N; P < 0.05) yet no significant difference between methods of closure (P > 0.05). There was a significant reduction in dermal perfusion between unwounded skin and the imbricated wound (222 perfusion units [PU] vs 48 PU; P < 0.05) and between the unwounded skin and the undermined wound (205 vs 63 PU; P < 0.05).Conclusions:We found no significant difference in wound tension between wound undermining or imbrication and a significant decrease in dermal perfusion after imbrication and undermining although the relative decrease in perfusion was greater with imbrication. Wound undermining reduces skin tension with greater relative dermal perfusion to the skin and should be selected over wound imbrication in standard primary wound closure.