Postoperative care in the practice of an aesthetic medicine specialist

Danne Montague-King, Doctor of Biochemistry and Pharmacology, founder of DMK (USA)

Healing of any wound is a natural process that starts a chain of reparative mechanisms in the skin after surgery. These mechanisms represent both biochemical and cellular processes. The final result is restoration of the skin surface and reconstruction of the dermis. In general, the whole process goes through five stages.

STAGES OF RESTORATION OF THE DERMIS

Stage 1. Inflammation (or exudative phase)

A number of changes occur in the blood vessels cut with a scalpel to stop bleeding. The vessels are coagulated (thrombosed). Fibrin stops bleeding. Other biochemicals are secreted to dilate the capillaries and bring new cells to the wound area. These chemicals are called chemotactic factors and growth factors.

When treated, certain ingredients, such as oleaginous oil and beta-glucans, enhance the action of growth factors - hence the standard cosmetic industry term EGF (epidermal growth factor). EGF is not some special substance, as representatives of cosmetic companies often say, but rather a natural wound healing process with the participation of platelets, which are responsible for blood clotting and substances that attract other new cells to wound sites. The above ingredients, however, are among the few that can be applied topically by an esthetician and will enhance the effects of EGF in normal healing in a short period of time.

Cells damaged by surgical manipulation will secrete histamines, causing swelling and erythema as surrounding vessels dilate. This process should not be interrupted by medical procedures during the first days after surgery, as it is necessary for wound healing. Cold compresses are the only treatment at this stage (after blepharoplasty, for example, it is necessary to apply very cold compresses several times during the day).

The presence of polymorphonuclear cells and macrophages is also vital in the first stage. They destroy bacteria, help in the resorption of blood clots and other fragments of destroyed cells. Macrophages also biologically activate secretions, which lead to further wound healing.

Stage 2. Proliferation (phase of granulation tissue formation)

After the wound has been cleansed by these cells, the process of structural restructuring begins: blood vessels and cells at the edges of the wound begin to grow. This process should begin immediately after surgery to avoid tissue necrosis and areas of baldness in the scalp. These cells can appear several hours after surgery and do not require increased cellular proliferation (maturation). If desmosomes (the regulators of how quickly cells proliferate and rise to the surface) are destroyed, scars will form faster and a keloid scar may form. A good surgeon will watch these cells become active, but even the closest attention may miss the massive destruction of desmosomes. This is why they say that surgery is an inexact science.

The basal cells, after the appearance of the mentioned cells at the edges of the wound, slowly weaken their attachment to other cells, contracting the tonofilaments, and then dissolving the desmosomes. At this stage, the basal cells develop pseudopodia (feet) that allow them to move around and over other cells. Once this migration occurs, normal proliferation to the surface begins and the rate of cell movement to the surface increases in accordance with the natural rhythm.

Fibronectin and collagen are also formed along with the formation of granulation tissue. It is important to note here that cell proliferation in our body and skin has a different regulated level of advancement to the surface in the internal organs or in the skin. Anything that increases this movement is inconsistent with its normal level of proliferation and will also increase the risk of certain types of scar tissue forming.

Stage 3. Regeneration phase

After about three days, as granulations appear, the cosmetologist can begin to work. The tissue consists of new vessels, new matrix (intercellular fluid), collagen, glycoproteins and glycosaminoglycans (GAGs). Glycosaminoglycans provide skin turgor and elasticity, are a deep natural moisturizer, but do this in a slightly different way than the acid mantle of the skin, consisting of the secretion of the sebaceous and sweat glands, which is a superficial skin moisturizer. The main cells in this process are fibroblasts, a kind of factories for the production of new collagen and elastin.

At this stage, the beautician prescribes topical serums with beta-glucans and vitamin C: these are applied before creams and are preferred due to their water base and penetrating abilities. Serum can be dripped directly onto the incision areas, even if there are still stitches. In particular, I mix 50% beta gel and 50% contractubex (medicine in gel form made in Germany) and apply it to the incision area, cleaned with peroxide.

After the stitches are removed or ten days later, I apply a vitamin C serum to the entire area. Vitamin C is a precursor of amino acids that form peptide chains that become new proteins and thus new collagen fibers. I also apply a special enzyme mask to the entire face and neck, extending up to three centimeters from the incision line or stitches (I never treat the stitches themselves!). This will ensure maximum improvement in blood circulation and at the same time gentle lymphatic drainage, and will also prevent the formation of a rough scar.

Stage 4. Wound contraction phase

The “star” of the wound contraction phase is the myofibroblast, a cell that produces tiny microfilaments in the cytoplasm that allow the cell to contract (move) and migrate to where its presence is needed.

As the filaments in myofibroblasts contract, they pull on the surrounding matrix. As a result, the wound contracts and closes completely (imagine dozens of tiny needles pulling threads through a small hole in a wool sweater and closing it). The skin is now ready for matrix and collagen remodeling, resulting in new, fresh skin.

Continuing the same procedures using beta glucans, vitamin C and enzymes in the 4th stage of the process is very important. Your daily cleanser should be mildly acidic and contain natural surfactants, such as yucca plant or white oak bark, and antibacterial ingredients, such as chloroxylenol.

Stage 5. Scar reorganization phase

At stage 5, approximately a month after surgery, remodeling processes increase significantly, although collagen and matrix are constantly being produced and remodeled in earlier stages.

As collagen synthesis increases, fibronectin is replaced, and water in the matrix is also gradually replaced in the scar tissue at the surgical site. Collagen binds and the wound becomes stronger, but this process can take months or even years to complete. Most wounds reach their maximum strength by three months, but they never regain the strength of normal skin, reaching only about 75–80% of their original strength.

VITAMIN AND PHYSIOTHERAPY IN WOUND HEALING

Vitamin A deficiency slows epithelialization and increases the risk of infection (at least 25,000 IU per day is recommended). Vitamin E should not be taken before surgery, but may be given a week later to maintain antioxidant levels.

Vitamin C, necessary for collagen biosynthesis, is taken orally (about 2,000 IU per day, 1,000 IU in the morning and evening). Its deficiency leads to slower wound healing. Many people believe that 2,000 IU of vitamin C per day is an excessive dose, but these "old wives' tales" about kidney stones and gallbladder dysfunction due to excess vitamin C intake have absolutely no scientific support. An overdose of vitamin C can only cause minor diarrhea, and if the patient, as the Germans say, has fuschtaf (any kind of constipation), this is only beneficial!

A lack of microelements such as zinc, copper, iron and magnesium will also lead to disruption of the immune response, protein synthesis and vital collagen. Essential fatty acids (EFAs) are essential for healing processes and to ensure a healthy, thick and resilient matrix. EFAs also help reduce excess scar tissue. I have personally seen distinctive wound healing processes with virtually no scarring after taking three or more EFA-containing capsules per day. This is especially preferable after laser surgery, and the best source of EFAs is evening primrose oil.

Once the scars have healed, continue using enzyme therapy to support microcirculation and oxygen delivery from within. Also use crushed vitamin E, which is applied directly to the scar tissue (regular vitamin E capsules from the pharmacy are not suitable as it does not have a crushed base). Crushing (fractional distillation) is a special process that breaks down the oil molecule. Oil molecules are much heavier than water molecules, and thus they can diffuse through the surface of the skin rather than penetrate inside. However, when the oil molecule is broken down into several smaller molecules, they can penetrate the skin, where their power will be available to new cells.

It has been proven that massage in the area of scar tissue after the skin has completely healed prevents the development of capsule formation around the implant in case of breast surgery and the formation of ligature granulomas (“bumps” on the skin from sutures). Many surgeons in the United States now take courses in massage and, in turn, teach patients the basics of self-massage to prevent the formation of rough scars and adhesions.

Deep facial cleansing, exfoliating creams containing mild retinoids, and desincrustation procedures to remove post-surgical comedones and milia can be used after four weeks after surgery or when the wounds have fully healed and remodeled. I do not recommend using creams containing tretinoin, as I believe that this member of the retinoid family is too powerful and unpredictable. I have always preferred the "softer" retinyl palmitate with beta-carotene and added resorcinol. Both ingredients have keratolytic (removes dead cells), vitamin A receptor-specific (retinyl) and anti-inflammatory (resorcinol) properties. Bruising and pigmentation disorders are not contraindications for facial procedures and should be combined with oral rutin immediately after surgery. One of the best post-surgical procedures is electromagnetic therapy using appropriate frequencies aimed at wound healing. This technique, combined with everything described earlier, makes the surgeon’s work 50% more efficient and allows the client to look like a movie star!

PREPARATION FOR OPERATION

Every surgeon's nightmare is that normal blood circulation in the skin, after the capillaries have been cut, is not restored within two hours after the operation. This can lead to the development of hematomas, which can be easily controlled with proper drainage, and to patches of baldness (the follicles around the incision on the scalp die and permanent patches of alopecia form). In this case, it is necessary to use dynamic enzymatic procedures that create a plasmatic effect that stimulates and strengthens the capillary walls, ensuring the restoration of good blood supply almost immediately after the operation. These procedures must be prescribed at least one and a half months before surgery and are carried out once a week.

Remember: plastic surgery does not give your client new skin, it only removes sagging tissue that cannot be eliminated by other conservative methods. She can change the shape of the nose, give a different oval to the face, improve the shape of the zygomatic arches, shape the contour of the hips, tighten and enlarge or reduce the mammary glands. But only the skin cells themselves can provide your patient with "new skin", and in cases of severe trauma - such as a scalpel separating tissue, separating skin and fascia from muscle and cutting capillaries - preparatory treatment can bring the skin to its peak healthy state, to survive such stress.

Post-surgical procedures can provide the best path for new cells to remodel and restore skin's firmness and texture after the surgeon has worked his magic.

First published: Les Nouvelles Esthetiques Ukraine, No. 5(93)/2015