Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2019 Apr 8;39(Suppl_3):S103-S111.
doi: 10.1093/asj/sjz022.

Preoperative Skin Conditioning: Extracellular Matrix Clearance and Skin Bed Preparation, A New Paradigm

Alan D Widgerow  1 , Steven R Cohen  2 , Steven Fagien  3
Affiliations

Preoperative Skin Conditioning: Extracellular Matrix Clearance and Skin Bed Preparation, A New Paradigm

Alan D Widgerow et al. Aesthet Surg J. .

Abstract

This paper introduces the concept of "skin bed preparation" prior to surgical procedures. Following the theory of chronic wound bed preparation and adapting the skin model to one of chronic wound changes related to extrinsic and intrinsic factors, a topical formulation aimed at recycling the extracellular matrix (ECM) from accumulated waste products is evaluated and discussed. The clearance of these products and stimulation of new replacements has the potential to change the regenerative milieu of the skin so that when procedures are carried out, cellular signaling and cross-talk at the dermal level are improved and healing is optimized. By introducing a combination of peptides and other synergistic active agents, a sequence of clearance, regeneration, and remodeling is initiated. This is confirmed and validated by a series of biopsies and clinical studies that demonstrate changes in the ECM as early as 2 to 3 weeks after application. Clinical studies related to resurfacing procedures show accelerated healing and improved symptomatic relief compared with standard of care by preconditioning the skin 2 weeks prior to the procedure. A similar approach is suggested as a potential advantage for invasive surgical procedures based on similar scientific principles elucidated on in the text.

PubMed Disclaimer

Figures

Figure 1.
Figure 1.
Chronic sun damage and aging results in fragmented collagen, elastin, and senescent rounded fibroblasts in the ECM and thinned epidermal layer. ECM, extracellular matrix.
Figure 2.
Figure 2.
“Recycled” matrix where fragmented collagen and elastin have been replaced by new long-strand structural proteins, spindle-shaped active fibroblasts, a healthy basal stem cell layer, and a thickened epidermis.
Figure 3.
Figure 3.
H&E staining (100×) showing ECM and epidermal changes following a 3-week topical application of product containing TriHex Technology peptides and botanicals to the forearm (65-year-old female patient). (A) Baseline H&E-stained sections from nontreated forearm skin shows thicker, mature collagen bundles, and thinner epidermis with flattened basal cells. (B) Post-treatment (right), the epidermis shows less atrophy, with increased number of layers, more cuboidal basal cells, and recovery of normal epidermal maturation. The ECM shows finer collagen bundles, likely representing neocollagenesis. This is a low-powered representation that clearly shows a good distribution of newer fresh collagen well spread over the entire frame of the ECM as opposed to the mature older collagen apparent in the baseline ECM of the slide in panel A. ECM, extracellular matrix; H&E, hematoxylin and eosin.
Figure 4.
Figure 4.
H&E-stained sections (200×) from biopsies taken at baseline (left) and following a 3-week (right) topical application of TriHex Technology peptide gel to the preauricular region (62-year-old male patient). (A) Baseline H&E-stained sections from nontreated preauricular skin shows limited collagen in the upper dermis and basophilic solar elastotic changes in the dermal ECM. (B) Post topical treatment, there is less epidermal atrophy, with recovery of normal epidermal maturation. In the dermis, newly formed (pink) collagen is present, replacing some of the severe solar elastosis. An increased number of fibroblasts is easily identified among the newly formed ECM in the papillary dermis. Multiple views of these slides demonstrated 5% content of superficial collagen in baseline (A) vs 30% content of superficial collagen after 3 weeks (6-fold increase). ECM, extracellular matrix; H&E, hematoxylin and eosin.
Figure 5.
Figure 5.
Elastin immunohistochemical staining of sections from biopsies taken at baseline and following a 3-week topical application of the TriHex Technology product to the forearm (63-year-old male patient) (100×) [Abcam anti-elastin mouse monoclonal antibody (BA-4), 1:100 dilution]. (A) Baseline shows minimal elastin staining in the dermis. (B) Post topical treatment, there is a striking increase in the amount of dermal elastin staining. This is a low-powered magnification which gives a good overall view; assessment of the complete slide confirmed 10% elastic fiber in superficial layers vs 90% elastin content in superficial dermis (extending to deep dermis) after treatment.
Figure 6.
Figure 6.
Baseline prior to treatment. (A) A 53-year-old female received TriHex Technology pretreatment and follow-up treatment. (B) Day 1 following moderately deep ablative resurfacing. (C) Day 4 following treatment showing good epithelialization and advanced healing. (D) Day 7 following treatment showing complete healing; able to apply cosmetics.
Figure 7.
Figure 7.
Baseline prior to treatment. (A) A 54-year-old female received (Vaniply, Pharmaceutical Specialties, Inc., Rochester, MN, USA) pretreatment and follow-up treatment. (B) Day 1 following moderately deep ablative resurfacing. (C) Day 4 following treatment showing minimal epithelialization and healing compared with the experimental group; day 4 is the day where the most obvious difference between groups was evident. (D) Day 7 following treatment showing some unresolved healing and more redness than comparator.
Figure 8.
Figure 8.
Elastin VVG staining 200× (58-year-old female patient). (A) Left side the of the face received no pretreatment; elastin staining evident. (B) Right side following 2 weeks of pretreatment demonstrating increased elastic fiber in the dermis with more prominent and deeper elastin staining. Overall multiview assessment demonstrated 10% elastin content in the superficial dermis and deep dermis on the untreated side vs 20% and 25%, respectively, on the treated side (at least a 2-fold increase plus changes in the nature of the fibers—fragmented smaller fibers untreated, more solid longer fibers after treatment). VVG, Verhoeff-Van Gieson.
Figure 9.
Figure 9.
Eyelid specimens post upper blepharoplasty (47-year-old female patient, H&E staining, 100×). (A) Left eyelid specimen; no treatment prior to procedure showing extensive solar elastosis and minimal collagen in the dermis. (B) Right eyelid specimen following a 4-week pretreatment showing improved solar elastosis and increased collagen production. There are well-demonstrated changes in this slide; quantitative reassessment showed a superficial collagen content of 40% on the nontreated side (A) vs a 90% content of superficial collagen on the treated side as well as significantly improved solar elastosis. H&E, hematoxylin and eosin.
See this image and copyright information in PMC

Similar articles

See all similar articles

Cited by

See all "Cited by" articles

References

    1. Sibbald RG, Woo KY, Ayello E. Wound bed preparation: DIM before DIME. Wound Healing Southern Africa. 2008;1(1):29-34.
    1. Fisher GJ, Quan T, Purohit T, et al. . Collagen fragmentation promotes oxidative stress and elevates matrix metalloproteinase-1 in fibroblasts in aged human skin. Am J Pathol. 2009;174(1):101-114. - PMC - PubMed
    1. Fisher GJ, Varani J, Voorhees JJ. Looking older: fibroblast collapse and therapeutic implications. Arch Dermatol. 2008;144(5):666-672. - PMC - PubMed
    1. Sherratt MJ. Tissue elasticity and the ageing elastic fibre. Age (Dordr). 2009;31(4):305-325. - PMC - PubMed
    1. Lohwasser C, Neureiter D, Weigle B, Kirchner T, Schuppan D. The receptor for advanced glycation end products is highly expressed in the skin and upregulated by advanced glycation end products and tumor necrosis factor-alpha. J Invest Dermatol. 2006;126(2):291-299. - PubMed

Publication types