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MORPHOLOGICAL JUSTIFICATIONS FOR THE USE OF INTRAOPERATIVE
BALLOONS TISSUE STRETCHING
Madazimov K.M.
Teshaboev M.G.
Andijan State Medical Institute
Abstract:
In this article, the author presents morphological changes in tissues during
intraoperative balloon stretching. To confirm the adequacy of the experimentally developed
method and scheme for performing intraoperative balloon stretching, the morphology of
intraoperatively stretched tissues taken from patients was additionally studied. The authors
revealed a rather specific reaction of the burn-affected skin of the cranial vault to its
intraoperative balloon dermotension. This reaction consists of a significant increase in the
number of hair shafts in the hair follicles, which is accompanied by thickening of the walls of the
hair follicles.
Keywords:
morphology, soft tissue, skin, hair shaft, cranial vault, scar, deformation.
Relevance of the problem. In world practice, the most relevant studies continue to be those on
reducing the consequences of impaired blood flow and tissue oxygen supply during balloon
dermotension [4] with optimization of hypoxic training modes, increasing tissue resistance to
acute and chronic oxygen starvation [7]. Of particular interest continue to be studies on
determining the technique and scheme of rapid balloon tissue stretching depending on the area of
reconstruction, taking into account the morpho-functional [2] features of the soft tissues of the
cranial vault, additional clinical, physiological and morphological studies [3], allowing for the
development and justification of a method and scheme of rapid intraoperative tissue stretching.
Of increasing interest are studies of complications of tissue stretching in post-burn alopecia [1, 5],
which include divergence of the edges of the postoperative wound, rigidity of the stretched
tissues, osteoporosis of the cortical plate of the cranial vault bones under the balloon, hair loss
along the suture line, excess tissue in the form of skin folds during rotation of stretched flaps
during subsequent plastic surgeries [6].
Materials and methods of the study. Morphological studies were conducted in the Department of
Pathomorphology of the State Institution "Russian Scientific Medical Center of Surgery named
after Academician V.V. Vakhidov" (Head of the Department - Professor I.M. Baibekov). Light,
scanning and transmission microscopy were used. For light microscopy, samples from various
areas of the cranial vault skin (a total of 22 samples) subjected to stretching, obtained during
surgery, were fixed in a 10-12% solution of neutral formalin. After appropriate processing, the
samples were embedded in paraffin and 5-7 μm thick sections were prepared. The general
morphological picture was studied on sections stained with hematoxylin and eosin. For scanning
electron microscopy (SEM), the preparations, after fixation in a 2.5% solution of glutaraldehyde
on a phosphate buffer, were dehydrated in alcohol-acetone, then dried by the critical point
method in an HCP-2 apparatus and sprayed with gold in an IB-2 apparatus. Photographs were
taken using a Canon digital camera from the monitor screen of a Hitachi S-405 microscope. For
transmission microscopy (TEM), skin biopsies from patients were immediately fixed in 2.5%
glutaraldehyde solution in 0.1 M phosphate buffer pH 7.4 for 2-12 hours after excision, washed
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in phosphate buffer, post-fixed with 1% osmium tetroxide solution and, after dehydration in
alcohol - acetone, embedded in a mixture of epon and araldite.
Ultrathin and semi-thin sections (1 μm) were prepared from the obtained blocks on an Ultracut
ultramicrotome (ReichertYong). Semi-thin sections were stained with 1% methylene blue and
fuchsin. Ultrathin sections were contrasted with uranyl acetate and lead citrate solutions
(UltrastainerLKB microprocessor). The study and photography of light-optical preparations were
carried out using the light microscope "AXIOSKOP-40" (CarlZeiss), Germany, with a digital
camera ProgRess, CapturePro 2.6, coupled with a PentiumIV computer. As a control, we used
skin biopsies of the cranial vault area obtained during plastic surgeries without preliminary skin
stretching. Results and their discussion. In burn lesions of the skin of the cranial vault, thinning
and, in places, damage to the epidermis, pronounced proliferation of connective tissue fibers of
the dermis, with atrophy of the sebaceous and sweat glands are noted (Fig. 1, 2).
Fig. 1. The skin of the cranial vault, burn, proliferation of connective tissue.
G-E 10x10
Along with thickening and coarsening of the dermal fibers, there are infiltrative accumulations of
connective tissue cells, the appearance of cell-free edema zones.
Stretching the skin with balloon dermotension leads to a pronounced unevenness in the thickness
of the epidermis, smoothing of the papillary layer of the dermis, it is characteristic that the
number of rows of cells in the spinous layer becomes the same throughout. Their number is
reduced to 3-4. In the early stages of dermotension, proliferation of connective tissue of the
dermis and the preservation of structureless edema zones persist.
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Fig. 2. The skin of the cranial vault, proliferation of connective tissue, damage to the epidermis.
G-E 10x10
In more remote periods of intraoperative balloon distension, significant thickening of the hair
follicle walls in the dermis is observed, with the appearance of a greater number of hair shafts in
them (Fig. 3). This is accompanied by the proliferation of connective tissue layers around the
walls of the hair follicles (Fig. 4).
Fig. 3. Hypertrophy of hair follicles. Increase in the number of hair shafts after balloon stretching.
G-E 10x40
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Fig. 4. Hair follicle hypertrophy after intraoperative balloon stretching. G-E 10x40
In more remote periods of intraoperative balloon dermotension, there is a significant thickening
of all layers of the epidermis. This is accompanied by an increase in the volume fraction of
microvessels in the dermis and normalization of its structure, which is expressed in the
reorganization of the fibrous components, which become thinner, and their location is less
chaotic. However, the papillary layer of the dermis remains smoothed.
Intraoperative stretching of the skin leads to the loss of the papillary layer of the dermis, which is
not restored even in remote periods of observation.
At the same time, no violation of the integrity of the epidermal part of the skin of the cranial
vault is noted (Fig. 5).
No phenomena of acantholysis of the spinous layer were detected. The integrity of the dermis is
not violated either. There are no tears in its fibers or violations of the integrity of the vessels. No
hemorrhages are detected in the dermis (Fig. 6).
Fig. 5. Hair follicle hypertrophy, increase in the number of hair shafts after intraoperative
balloon distension.
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G-E 10x40
H-
Fig. 6. Hair follicle hypertrophy, increase in the number of hair shafts after intraoperative
balloon distension.
G-E 10x40
Hemorrhage areas are found only in the hypodermis, among layers of fatty tissue cells. No
damage to the integrity of the blood vessel walls was observed (Fig. 7).
Fig. 7. Restoration of skin structure 30 minutes after intraoperative balloon distension. G-E
10x40
Results. Thus, the morphological studies showed that intraoperative skin distension according to
the scheme developed by us in the experiment does not cause violations of its general
architectonics. In the epidermis, no violations of integrity in the form of tears or cracks are
determined. A decrease in the number of rows of cells in the spinous layer is noted. At the same
time, the phenomena of acantholysis and cytolysis are not noted.
In the dermis, skin distension also does not cause structural changes indicating a damaging or
traumatic effect of this manipulation. Smoothing of the papillary layer of the dermis is noted. No
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damage to blood vessels or hemorrhages in the dermis were found. The reticular-felt structure of
the fibrous framework of the dermis is not damaged. The architectonics of the fibrous framework
of the dermis is also preserved.
Conclusion. Intraoperative balloon stretching of the scalp using the developed method and
scheme does not cause any disturbances to its general architecture, but leads to a significant
increase in the number of hair shafts in the hair follicles, which is accompanied by thickening of
the walls of the hair follicles.
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