Effect of Surgical Repair in Wound Healing - Essay Example

EFFECT OF SURGICAL REPAIR IN WOUND HEALING: A LITERATURE REVIEW Introduction Wounds are defined as a destruction of the integrity of the skin including the epidermis and the dermis(Moy, 1993). Acute wounds are recent wounds that as yet to proceed through the stage of sequential healing(Attinger et al., 2006). They are either traumatic or atraumatic. They are traumatic when they occur as a result of an accident or an injury, and atraumatic when a surgeon for the purpose of carrying out a repair creates them. On the other hand, a chronic wound is a wound that is arrested in one of the healing stages, especially the inflammatory stage, and cannot proceed further(Attinger et al., 2006). Reports are vague on how the prehistoric man treated wounds, but in the primitive tribes, wounds are covered with plant parts and other materials believed to have healing properties. Wounds were also filled with spider web in time past. Various crude methods of wound draining and wound closing are also reported among some tribes. An ingenious wound clamp was devised out of the jaws of insects by primitive tribes of India and South America who made the insects bite across the apposed edges of a wound.(Haeger, 1988) . Wound management has two main approaches: the surgical and non-surgical categories of intervention. In the non-surgical approach, classical methods such as administration of topical or systemic therapeutic agents, locally applied enzymes, and dressings designed to optimize the wound for later surgery, or to heal the wound by secondary intention (Knox et al., 2007). The surgical approach involves the implementation of preparatory surgical procedures which help to prepare the wound for accelerated recovery and augment the body healing process. Both of these approaches are different, yet aim at the same goal. This review is concerned with the surgical aspects and how they provide a facilitating environment for timely wound healing. Aims of Surgery For effective wound healing in modern day surgery, the aims are to ensure quick regeneration of damaged tissue, reduce infection, and maximize immune response, and central to achieving these aims are blood perfusion, oxygen supply, prevention of re-injury and good diet(Hunt and Hopf, June 1997a). Reduction of infection and quick tissue regeneration are directly related to wound blood perfusion and oxygenation. Perfusion therefore appears to be the most important factor in wound healing. Wounds in well perfused areas of the body tend to heal faster, even when they are massively infected. They also form less scar. The same goes for wounds that occur in areas of the body that are adequately supplied with oxygen(Hunt and Hopf, June 1997a). A surgeon has to consider four important factors when planning to make a surgical incision(Moore and Foster, 1998). (1) The incision should be adequate for the surgery (2) It should allow for effective healing of the wound without undue interference with postoperative functions of the affected part. (3) Through effective use of analgesic and judicious post- and perioperative planning, patients should not experience pain after surgery (Wall and Melzack, 1995) (4) Lastly, for aesthetic reasons, emphasis should be placed on making incisions that appear neat and with less scarring on healing. Wound Bed Preparation Wound bed preparation is defined as the management of a wound to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures(Falanaga, 2002). It is a systematic approach that aims to correct the underlying molecular environment of the wound in order to stimulate healing. The sequence of healing is acute injury followed by coagulation, inflammation, repair and modeling(Granick et al., 2006). Wound bed preparation involves an aggressive cleaning of the wound surface and edges to remove foreign bodies, dead-appearing tissue, and then primary closure. This process is referred to as debridement, and was introduced by an 18th century French military surgeon, Pierre Joseph Desault(Reichert, 1928). There are various debridement methods, e.g enzymatic, mechanical, and biological, but because of their limitations(Knox et al., 2007), the most widely accepted is the surgical method, and it is the only method that will be considered in this write-up. Surgical debridement is defined as the removal of necrotic tissue, foreign materials and bacteria which impede the body’s attempt to heal from an acute or a chronic wound(Granick et al., 2006). Debridement plays a part in removing desiccated tissue, foreign materials, necrotic and non viable tissue from a wound, controlling infection, and restoring a viable epithelial edge(Granick et al., 2006). The principles of surgical debridement are early, radical excision, rapid resuscitation, removal of all necrotic tissue, preservation of viable skin, planned incision to facilitate reconstruction, inspection of deep fascia and muscles, packing wound open, and re-operating wound if necessary(Granick et al., 2006). Bacteria produce wound inhibiting enzymes and consume scarce resources like oxygen, nutrition and building blocks. (Attinger et al., 2006) Early debridement shortly after injury is important to prevent chronic infection, restoration of normal function and prevention of excessive scarring(Knox et al., 2007). Tools and Techniques of Surgical Debridement Before debriding, a wound should be assessed for etiology, age, origin, depth, and previous therapeutic measures. Tetanus immunization status of the patient should be assessed. The patient’s heath status should be assessed for possible underlying medical conditions that could interfere with wound healing, which if present should be medically addressed before surgery is carried out(Attinger et al., 2006). In surgical debridement, the border between healthy and dead/ dying tissue should be clearly defined. Atraumatic surgical technique using sharp dissection, skin hooks, etc ensures that viable tissue, which forms the basis for regeneration are preserved while dead necrotic tissues are dissected(Edgerton, 1988). If erythema beyond the delineated border of a wound is noticed after initial debridement, and before culture results are available, it is either the antibiotics are inadequate or the debridement is inadequate(Attinger et al., 2006). Bone and tendon involvements should be assessed either directly during debridement, or through radiography. In a gangrenous wound where blood flow is inadequate, debridement should be delayed till a later date when appreciable revascularization and infaction control has taken place(Attinger et al., 2006). Sometimes, wound is due to pressure ulcer as a result of prolonged loss of sensation. The inability to feel 10g of pressure applied by 5.107 Semmes- Weinatein filament is diagnostic of loss of proper sensation(Pham et al., 2000, Attinger et al., 2006). . An acute wound is debrided of all questionable viable- appearing tissue, while a chronic wound is debrided until it is converted to a fresh, acute wound, so that the arrested healing process could continue.(Attinger et al., 2006). Tissue culture and pathologic analysis will help to diagnose other pathologies(Attinger et al., 2006). Adequate consideration should be given to anesthetizing the sensate patient before debridement. The basic tools for surgical debridement are toothed pickups for grasping tissues, blades for dissection around bones and for cutting tissues, strong, sharp scissors for dissection of eschar and dead tissue, sharp-edged curette to remove accumulated coagulum, an rongeurs for removing deeply situated tissue and debriding of bone. Others like Cobb elevator and McElroy curettes are special tools commonly used in orthopaedic debridement(Attinger et al., 2006). After debridement, the wound is cleased of any remaining bacteria and debris by using the pulse lavage method, which is an irrigation of the wound with a solution of normal saline(Attinger et al., 2006). Hydrosurgery, e.g Versajet is an improvement over the use of rudimentary and traditional tools of debridement(Klein et al., 2005).(Attinger et al., 2006) It is a hydrosurgical water knife that has the advantage of precision; the depth and extent of debridement can be controlled such that more viable tissue is preserved. It works by forcing a stream of water through a narrow opening towards the wound at a considerable pressure. A vacuum is created around the pressure and it sucks dead tissues from the wound and pulverizes them. It is useful in debriding a large wound or when preparing a wound for grafting. A Versajet does not require a pulse lavage(Attinger et al., 2006). For the skin, immediate debridement is indicated if it is insensate, does not blanch, and has blisters. Cutaneous tissues should be excised until bleeding is observed(Attinger et al., 2006, Knox et al., 2007), while the appearance of shiny yellow fat should indicate proper debridement in the deeper subcutaneous tissues(Knox et al., 2007, Attinger et al., 2006) To reduce damage to surrounding tissue when debriding blood vessels in the subcutaneous space, small vessels should be coagulated using bipolar cautery, while larger vessels can be ligated by using metal clips which are less reactive. If a suture is used, silk should be avoided and tiny monofilaments that will not cause foreign body reaction and infection should be used(Attinger et al., 2006). The decision to cut or preserve nerves is with the surgeon and adequate measure needs to be taken to minimize pain(Attinger et al., 2006). Non viable fascia are debrided from the viable one (which must be kept moist), with care being taken not to damage the underlying neurovascular bundle(Attinger et al., 2006). Only muscles that are clearly dead are debrided. Dead muscles are usually dull, non bleeding and fall apart when pinched(Attinger et al., 2006). The covering of the tendon provides nourishment and should be preserved. If however it must be sacrificed as a result of infection and necrosis, then the tendon itself should be kept moist and covered with a viable tissue as soon as possible(Attinger et al., 2006). Bone debridement is indicated if it appears dead and non-bleeding. Dead bone characteristically appears soft, dull and discolored(Attinger et al., 2006). An osteomyelitic bone is removed without a second consideration and a reconstructive surgery can be done on the bone that is left to restore some protective framework(Attinger et al., 2006). A culture is obtained for the affected bone and the viable bone proximal to the affected part, and a one-week (or a longer) antibiotic course is instituted to clear infection(Attinger et al., 2006). To prevent extensive infection, proximal and distal portions of a wound should be explored for possible signs of infection, e.g. purulence, bogginess, etc, and appropriate measures should be taken if these signs are present. Debridement every 12 to 48 hours is indicated if an infection has spread far beyond the wound(Attinger et al., 2006). The decision to amputate a limb should be taken with great caution if debridement appears to have a prospect in salvaging the limb. Minimal amputation should be carried out where necessary and reconstruction after amputation should be of importance(Attinger et al., 2006). Application of growth factors topically to a wound has shown some beneficial effects, but this can only be an adjunct to aggressive debridement.(Attinger et al., 2006) Presence of coagulum on the surface of a wound inhibits the effect of growth factor. The only growth factor approved for use till date is the Recombinant Human Platelet-Derived Growth Factor(Attinger et al., 2006). Risk of Infection During Surgical Debridement The risk of infection of surgical wounds is assessed using an index that was constructed on 3% of surgical patients in the US between 1975-1976, and 1983. Patients are scored between 0 and 1 based on four patient factors. These factors are an abdominal operation, surgery lasting for 2 hours or more, wound infection, and patients that will have 3 or more diagnosis at discharge, apart from wound infection. A score of 0 is 1% risk, 1 is 3.6%, 2 is 9%, 3 is 17%, while a score of 4 is 27%. This predictive index was developed by the Centre for Disease Control in their study of the effect of nosocomial infection control (SENIC)(Haley et al., 1985 ) Wound oxygen tension may however be a better predictor of infection because the oxygen tension is always low in surgical wound infection irrespective if the SENIC score(Hunt and Hopf, June 1997b). The surgeon before operation should correct diagnosis of hypertension, diabetes, malnutrition and blood volume deficit at risk assessment. Antibiotic administration should also be given 30 minutes to 1 hour before operation, not earlier(Hunt and Hopf, June 1997b). Anti-inflammatory steroids administered during surgery are known to inhibit inflammatory stage of healing, thereby slowing the healing process, but this is corrected by the administration of vitamin A(Hunt et al., 1969) During operations, contamination occurs as new incisions are made. Antibiotic use should therefore be continued in long operations. Patients should also be treated for hypothermia that is likely to occur as a result of intraoperative dilatation secondary to anesthetic use. Maintenance of normal temperature during, and after surgery has been shown to reduce infection rate(Hunt and Hopf, June 1997b). Fluid lost into the third space and preoperative fluid deficit are replaced by giving fluid at the rate of 10-15ml/kg/hour, and four times the blood loss during major abdominal surgery.(Hunt and Hopf, June 1997b) The incision is made with due attention to blood supply, especially in old incisions. Dried wounds should be kept moist to ensure perfusion, and antibiotic irrigation is needed to keep the operating field decontaminated. Retractors should be released periodically to encourage blood supply. In wounds that cannot be closed for one reason or the other, polymeric materials are used to link the edges until closure can be effected.(Hunt and Hopf, June 1997b) Effect of Surgical Debridement on Wound Healing Normal wound healing involves formation of granulation tissue and neovascularisation. In an infected wound, this process is arrested and the bacteria count is very high. A radical debridement ensures lowering of the bacteria count. The wound is able to revascularise and it can proceed to heal by secondary intention. Usually, a topical application of antibiotic to such wound as an adjunct speeds up the healing process(Fox, 1968). Presence of offensive odour after initial debridement indicates that the infected wound was not properly debrided. This wound should therefore be redebrided until odour disappears(Attinger et al., 2006). Clinical studies have shown than frequent debridement is effective in wound healing probably because it removes wound healing inhibitors and allows proper functioning of growth factors(Nwomeh et al., 1999, Trentgrove et al., 1999). Scarring The epithelial tissue of the skin heals by scar formation. Sometimes, however, in the healing process, excessive (fibroproliferative) scar formation may result. Excessive scar formation is one of the long-term complications of surgery. These scars are of two histologically and pathophysiologically different types: hypertrophic and keloid scars. Both types are raised, erythematous and often itchy(Mancini and Quxife, 1962), but while hypertropic scar is limited to the area of injury, keloid scar extends beyond the area of injury(Mancini and Quxife, 1962). Hypertrophic scars form within 6 to 8 weeks of injury and may worsen for up to 6 months. They may regress without intervention and are often associated with contracture when located over joints or along extremities. Keloids on the other hand rarely regress, and even when they do, they often reoccur(Pollock and Goslen, 1982). They are not associated with contracture and often extend beyond the original area of injury(Pollock and Goslen, 1982). While hypertrophic scars often regress without any intervention, keloid scars are surgically excised, and intralesion steroid injection are used to reduce chances of reoccurrence(Rauscher and Kolmer, 1968). In surgical excision of fibroproliferative scars, the following precautions should be observed: wound closure should be free of tension; all inflammatory tissues that may cause reoccurrence should be removed; damage to the surrounding tissue should be avoided; all dead spaces should be completely obliterated; and corticosteroids should be used as adjuncts to surgery(Rahban and Garner, 2003). Hypertrophic scars usually occur with burns and wounds that cross lines of forces. Their occurrence correlates with the length of time before wound closure. Best treatment is surgery, but steroid injection may be helpful. Prolonged dressing with thick silicate sheets might also increase temperature thereby promoting collagen lysis. Keloids are common below the hairline and are usually seen in the trunk and the extremeties. It is believed in some other quarters that the definitive treatment is steroid injection, with surgery sometimes as adjuvant.(Hunt and Hopf, June 1997b) Contractures are as a result of shrinking scarring that limit movement. They are best prevented by putting in place prophylactic balancing measures, e.g. physiotherapy, pressure dressing, e.t.c that prevent the contracting force of the shrinking wound(Hunt and Hopf, June 1997b). Established contractures are best treated with surgery. Suture sinuses occur with unabsorbable sutures, and treatment is by suture removal(Hunt and Hopf, June 1997b). It is standard practice to use surgical intervention not as a standalone approach, but one in conjunction with adjunct therapies. These include intralesional steroid administration, pressure dressing, radiotherapy, or silicone gel sheeting (Rahban and Garner, 2003) . Some researchers have championed an alternative technique for hypertrophic scar removal which spares a rim of scar tissue. The rationale is the belief that intramarginal scar excision will sort of prevent recurrence. This technique has however not been validated by a prospective randomized clinical trial (Rahban and Garner, 2003). For some scars, measures such as local flaps, tissue expansion prior to operation, or successive excision will be required for complete scar elimination. Sutures in wound healing The choice of suture material should be made carefully because of its impact on the final outcome. Surgeons prefer silk for its handling properties, but polyfilament nylon is less inflammatory, and more permanent. Absorbable monofilament is used for skin suture as well as deep suture(Hunt and Hopf, June 1997b). The index of absorbability is the time to half loss of suture strength. For subcutaneous closure, polyactide sutures are preferred to catgut. Depending on choice, deep tissue as well as the chest and abdominal wall can be closed with interrupted or continuous sutures(Hunt and Hopf, June 1997b). Wound Closure On completing surgery, the surgeon on most occasions closes (sutures) the wound in layers and bring the skin together (healing by first or primary intention)(Dealy, 1994) Another table entirely containing a new set of instruments is used for this procedure in order to prevent recontamination of the wound. Gloves and gowns are changed by the surgeons.(Attinger et al., 2006) The skin and the deep tissues are brought together in a manner that obliterate, as much as possible spaces between the tissue layers and prevent tension. When fluids accumulate in some dead spaces, a drain is used so that deeper tissues can heal. A drain can also be used in surgery involving deeper structures to preempt the undesirable effect of possible breakdown of suture. In infected and contaminated wounds where suturing may not be safe, the wound is usually left to heal by itself. This is healing by secondary intention.(Moore and Foster, 1997, Marks et al., 1985) Intraoperative complications like uncontrollable hemorrhage are another reason why a wound may be left open, with a view to close the wound later when condition has subsided. This is delayed primary closure(Moore and Foster, 1998) Some surgical procedures are carried out in stages. An example is reconstructive surgery secondary to mastectomy. After due consideration, it is the prerogative of the surgeon in this case to consider what type of closure best suits the surgery being performed at a particular stage. Closure should be lax enough to allow for the swelling that follows surgery, and sutures that are prone to failure should be made at a considerable distance away from the edge of the incision, at regular intervals. Suction drains are used to close subcutaneous dead space(Hunt and Hopf, June 1997b). The best closure that guarantees non-infection is with skin tapes. Staples are good too but they require expert handling lest they cause compression of microvasculature(Hunt and Hopf, June 1997b). Wound dressing and surgical healing Dressing method for primarily closed wound is skin tape covered by a gauze, because the risk of contamination is minimal(Hunt and Hopf, June 1997b). If the underlying tissue is not infected, a biological dressing or negative pressure therapy can be applied as a temporary measure(Attinger et al., 2006). If on the other hand it is infected but viable, a topical antibiotic should be applied on the wound(Attinger et al., 2006). In large incisive wound, dressing is with nonadherent material covered by occlusive, moisture -retaining material that is changed daily, or left until the fourth day if delayed primary closure is intended.(Hunt and Hopf, June 1997b). The negative-pressure wound therapy is a special type of dressing which involves placing an open cell sponge on the wound surface and covering with an occlusive material. The pump lowers the ambient pressure such that the sponge content moves towards the pump(Attinger et al., 2006). This decreases the bacteria count of the wound and stimulates formation of granulation tissue(Argenta and Morykwas, 1997). Surrounding edema is reduced and blood flow is enhanced. Two important contraindications to the application of this dressing are gross wound infection and necrosis. Wound should therefore be extensively debrided before application.Pain, especially when dressing is changed, is a limiting factor(Attinger et al., 2006). Postoperative Management In the postoperative period, the surgical patient is managed as follows: Vasoconstriction should be corrected within the first 24 to 48 hours of surgery. Vasoconstrictive drugs and smoking should be avoided. Adequate wound perfusion should be ensured by giving liberal fluid, far beyond the routine order of 100-150 ml per hour. This should be irrespective of adequate urine output, as urine output measurement may not be a correct indication of tissue perfusion. Patient should be physically examined for dehydration and vasoconstriction, and if any of them is present should be corrected appropriately. If edema is present, diuretic measures should be instituted to ensure blood flow through transcapillary refill. Pain control favours pulmonary functions and vascular tone, and should therefore be achieved through the administration of opioid analgesic or patient-controlled analgesia(Hunt and Hopf, June 1997b) Surgical intervention in chronic wounds Chronic wounds are largely ischaemic, making vessel regeneration a big challenge. Complete excision of wound, rather than debridement may therefore be eventually inevitable. Before this, however, if trancutaneous oxymetry indicates adequate arterial blood supply, and infection is adequately curtailed, a skin graft may be done with a faint hope of non failure of the graft(Hunt and Hopf, June 1997b). In chronic ulcers due to arterial insufficiency usually seen in diabetes, surgical revascularization is often helpful. Warming of the exteremity has also been shown to increase oxygen perfusion(Hunt and Hopf, June 1997b). Surgically, bypass grafting or angioplasty in ulcers due to arterial insufficiency may cure the condition or it may enable the viability of skin graft.(Boyce and Shokrollahi, 2006) Venous insufficiency is the commonest cause of chronic leg ulcer, and tissue hypoxia as a result of venous congestion is the cause of ulcer. Compression dressing of the affected limb prevents congestion and edema. Limb should be investigated for valveless penetrating veins if ulcer fails to heal(Hunt and Hopf, June 1997b) In neuropathic ulcers, the limbs are insensitive and occurrence of repeated injury is a common feature. It is common in diabetics and the paraplegics. Adequate preventive measures and nursing care are the recommended treatment modalities(Hunt and Hopf, June 1997b). Surgically, they should be well debrided after which skin graft is considered. If there is no improvement, the limb is amputated(Boyce and Shokrollahi, 2006). Pressure sores occur in crippled or unconscious patients who had been bed-ridden for a long time. They occur over bone protuberances and heal very slowly. Prevention is the best treatment but when they occur, they can be excised with the bone protuberance and covered by skin graft. A myocutaneous or a fibrocutaneous flap could be used to close the defect(Boyce and Shokrollahi, 2006). Success rate of surgery is very low(Hunt and Hopf, June 1997b). In pilonidal sinus and abcess, and hidradenitis suppurativa, the wound is first excised, and the opening left to close by secondary intention. Further surgery like skin graft may follow, depending on the healing pace and the prerogative of the surgeon(Boyce and Shokrollahi, 2006). In chronic ulcers, dressing should be with wet dressing to keep wounds moist. This is important to healing. Bactericidal agents should be used sparingly as constant washing is enough to reduce bacterial load.(Hunt and Hopf, June 1997b). The focus of this writeup is the effect of surgical intervention in wound healing, but the chronic wound is covered superficially by a colony of bacteria and a deep tissue culture and biopsy may reveal an underlying pathology, e.g. vasculitis, diabetes, sickle cell disease, clotting abnormalities, e.t.c. that needs attention more urgently than the wound itself(Attinger et al., 2006).In this instance, serial debridement to convert the wound to an acute one is only a follow-up to initial medical treatment of underlying pathology(Attinger et al., 2006). In some cases of chronic wounds like diabetic foot ulcer, and in wounds too large for skin apposition, skin substitutes may be beneficial in wound closure. Xenograft (pigskin) and allograft (preserved cadaver skin) are examples of processed skin grafts that can be used. Their being taken depends on vascularisation and extensive debridement of the wound surface. It also depends on patient’s immune status and can therefore be used to assess a patient’s suitability or otherwise for autologous skin graft(Attinger et al., 2006). Split skin graft consists of the epidermis and a portion of the dermis usually harvested from the thigh, and the donor site is expected to heal within 2 weeks from the surrounding dermis.(Boyce and Shokrollahi, 2006). The size of skin available for grafting is limited, but this can be addressed by using an expander to expand the size of available skin over a period of time, after which skin can then be harvested(Boyce and Shokrollahi, 2006). In necrotizing infections, the hallmark of treatment is rapid debridement because a large surface is affected in a short time. This is then followed by an extensive split skin graft(Boyce and Shokrollahi, 2006). In fracture site, exposed bone and tendon, a higher reconstruction method such as flap reconstruction is desirable(Boyce and Shokrollahi, 2006). The flap is harvested with a blood vessel which forms its source of survival, and it could be a muscle, a skin, a fascia, a bone, e.t.c(Boyce and Shokrollahi, 2006). Engineered skin substitutes function like biological skin grafts, with the exception that it does not stimulate rejection(Attinger et al., 2006). Conclusion Surgical intervention in wound management is as old as man. The modern day approach to the treatment of chronic and acute wounds is focused on quick regeneration of damaged tissue with minimal risk of infection, restoration of function, and minimal scar formation. Important to achieving these set objectives is an adequate wound bed preparation, which has as its central theme effective surgical debridement. The principles of surgical debridement are early, radical excision, rapid resuscitation, removal of all necrotic tissue, preservation of viable skin, planned incision to facilitate reconstruction, inspection of deep fascia and muscles, packing wound open, and re-operating wound if necessary, with the use of an atraumatic surgical technique. Results have shown dramatic positive results in the healing process following debridement. Adequate assessment of the patient for the presence of underlying pathology, as well as comprehensive wound examination is important to the outcome of debridement. Minimizing the risk of infection by adequate antibiotic use is also vital. Other measures such as choice of suture material, wound closure method, wound dressing, and postoperative management of the patient have considerable effects on healing of the surgical wound. In chronic wounds, the healing process is arrested in the inflammatory stage, and the immediate aim is to convert the wound to a healing, acute wound. Again debridement is the important process here, after which each wound is assessed on its merit to determine further surgical and medical measures to be adopted. Application of skin substitutes has been found to be helpful in chronic, large wounds that may not heal by primary intention, or by delayed primary intention, but great caution is required to apply them because of the risk of graft rejection. References ARGENTA, L. C. & MORYKWAS, M. J. (1997) Vacuum-assisted closure: a new method for wound control and treatment: Clinical experience. Ann. Plast. Surg, 38, 563. ATTINGER, C. E., JANIS, J. E., STEINBERG, J., SCHWARTZ, J., AL-ATTAR, A. & COUCH, K. (2006) Clinical approach to wounds: debridement and wound bed preparation including the use of dressings and wound-healing adjuvants. Plastic & Reconstructive Surgery, 117, 72S-109S. 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