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Demographics: Participants were required to provide demographic data including age, sex, ethnicity, religion, marital status, highest educational qualification and number of siblings. They were also asked to state how religious they were using a seven-point scale (1 = not at all religious, 7 = very religious). Personal experience: Participants were asked whether they have ever undergone cosmetic surgery (1 = no, 2 = yes) and given the option to state the procedure. Due to only 11 of the 204 participants (5.4%) reporting having undergone cosmetic surgery, this item was not included in the analysis.Procedure Once ethical approval had been obtained, participants were approached in various places in the British public (eg, libraries, cafes, train stations, churches, universities) by various researchers experienced in this technique. Individuals were briefed about the nature of the study and then offered the opportunity to participate. They were assured that their data would remain completely anonymous. Once they had provided informed consent, they completed the five-page questionnaire, which took approximately 15 min to complete. Participants were debriefed after completing the questionnaire. Of those approached, approximately 70% agreed to participate; the majority of the remainder claimed insufficient time to spare. A factor analysis with VARIMAX rotation was performed on the 15-item attitude toward cosmetic surgery scale. The results of the factor analysis are shown in Table 1. Two factors emerged, labelled: 1) Likelihood of having cosmetic surgery; and 2) Benefits to having cosmetic surgery. The two rotated factors accounted for 66.1% of the variance, with the first factor accounting for 34.8% of this variance.**P<0.01. Scores were marked on a seven-point scale: Strongly disagree 1 2 3 4 5 6 7 Strongly agree. (R) indicates that the scoring for that item was reversed Slightly less than one-half showed significant differences, which were all in the same direction (women scored lower than men) and nearly all those items that loaded on the second factor. An ANOVA on the two factor scores showed no significant difference on factor 1 (F[1, 202]=0.81) but a highly significant sex difference on factor 2 (F[1, 202]=21.42, P<0.001). Women scored higher than men on the second factor.Correlations were very similar, with the two-factor scores indicating that those with low self-esteem, life satisfaction, self-rated attractiveness and religiousness but high media consumption were more positive toward cosmetic surgery. The table shows that all hypotheses were confirmed. Two regressions were performed with each factor score as the criterion variable and four sets of predictor variables: Demographic data (sex and age), were entered first, then religiousness, then self-assessment (self-esteem, life satisfaction, attractiveness) and, finally, media consumption. Table 3 shows the results of the final step in the regressions. The first factor was significant and accounted for nearly 20% of the variance. surgery and innovation in medicine.” Plastic Surgery, Vol 1: Principles, 3rd edition. Ed. Peter C. Neligan and Geoffrey C. Gurtner. Elsevier, 2012. 3. Wilhemi BJ, Blackwell SJ, Phillips LG. Langer’s lines: to use or not to use. Plast Reconstr Surg. 1999 Jul;104(1):208-14. 4. Borges AF. Relaxed skin tension lines (RSTL) versus other skin lines. Plast Reconstr Surg. 1984 Jan;73(1):144-50. 5. Hollenbeck ST, et al. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg. 2010 Mar;125(3):924- 34. 6. Spear SL, Davison SP. Aesthetic subunits of the breast. Plast Reconstr Surg. 2003 Aug;112(2):440-7. 7. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985 Aug;76(2):239-47. 8. Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg. 1994;93:1503-1504. 9. Janis JE, Kwon RK, Attinger CE. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg. 2011 Jan;127 Suppl:205S-212S. 22 CHAPTER 5 WOUNDS Tulsi Roy, MD and Michele Manahan, MD, FACS A wound can be defined as a disruption of the normal anatomical relationships of tissues as a result of injury. The injury may be intentional such as a surgical incision, or it may be accidental following trauma. I. STAGES OF WOUND HEALING Wound healing is a complex, highly-regulated, multiphase process involving inflammation, fibroblast proliferation, and remodeling in the setting of tissue injury. Wounds may progress or even regress through these stages based on local and systemic factors. A. Inflammatory phase (typically 1-4 days, if primarily closed) 1. Physiology of inflammation a. Cytokine release is initiated by affected tissue cells and blood clot, which promotes recruitment of platelets and macrophages to the site of injury b. Leukocyte margination and emigration through neighboring vessel walls c. Venule dilation and lymphatic blockade d. Neutrophil chemotaxis and phagocytosis 2. Presence of foreign material, bacterial load, and extent of devitalized tissue and bleeding modulate the body’s inflammatory response to tissue damage 3. As long as the wound remains open, wounds remain in this phase. Reestablishment of epithelium or wound closure is important in order to progress through the remaining phases of wound healing. B. Proliferative phase (days 4-42) 1. Platelet degranulation initiates the proliferative phase of wound healing by establishing a fibrin clot that can be used as a scaffold to support angiogenesis and extracellular matrix formation 2. Synthesis of collagen tissue from fibroblasts 3. Increased rate of collagen synthesis for 42-60 days 4. Rapid gain of tensile strength in the wound C. Remodeling phase (4 weeks-1 year) 1. Provisional tissue regenerated in the proliferative phase is revised through cellular apoptosis and expression of matrix metalloproteases. 2. The extracellular matrix and subsequent scar is reorganized largely in response to mechanical tension, inflammation, and genetic phenotype 3. Maturation by intermolecular cross-linking of collagen leads to flattening of scar 4. Requires approximately 9-12 months in an adult, longer in children. (Scar revisions may be delayed a year or longer after injury to ensure remodeling is complete.) 23 5. Tensile strength of a healed scar will peak at approximately 60 days post-injury and achieve up to 80% strength of unwounded skin II. FACTORS INFLUENCING WOUND HEALING A. Local factors 1. Fluid collection: hematoma or seroma 2. Early wound closure 3. Blood supply 4. Temperature 5. Infection 6. Technique (gentle handling of tissues, orienting incisions or closures along optimal vectors to disperse mechanical tension) and ideal suture materials B. Systemic factors – optimize nutrition, palliate or optimize chronic illness, deleterious effects of medications that interfere with wound healing (chemotherapy, steroids, etc.) III. WOUND CLOSURE Several general surgical principles are important to keep in mind to expedite wound healing and reduce the incidence of hypertrophic or pathologic scarring. Approaches to wounds should always include adequate debridement, removal of any nonviable tissue and foreign bodies, bacteriologic control, and optimization of systemic factors governing wound healing. A. Healing by primary intention - wound closure by direct approximation, pedicle flap or skin graft 1. Debride necrotic or nonviable tissue and irrigate copiously to expedite inflammatory phase 2. Dermis should be accurately approximated. Skin glue may be used if the wound is limited to partial thickness depth 3. Scar may be red, raised, pruritic at peak of collagen synthesis 4. Scar remodeling occurs over approximately 9-12 months in adults, as collagen maturation takes place (may take longer in children) 5. Final result of scar is dependent on length of time until definitive wound closure, location, and mechanical tension, and factors influencing amount of inflammation. B. Healing by secondary intention – wound is left open to heal 1. Myofibroblasts promote contraction of wound edges 2. Epithelialization proceeds from wound margins towards center at 1 mm/day under ideal circumstances 3. Secondary healing beneficial in heavily contaminated or “dirty” wounds (e.g. perineum), or wounds in areas that have excellent vascular supply (e.g. scalp) C. Healing by tertiary
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