We have developed a quantitative microscopic method to determine changes in the orientation of collagen fibers in the dermis resulting from mechanical stress. The method is based on the use of picrosirius red-stained cryostat sections of piglet skin in which collagen fibers reflect light strongly when epipolarization microscopy is used. Digital images of sections were converted into binary images that were analyzed quantitatively on the basis of the length of the collagen fibers in the plane of the section as a measure for the orientation of the fibers. The length of the fibers was expressed in pixels and the mean length of the 10 longest fibers in the image was taken as the parameter for the orientation of the fibers. To test the procedure in an experimental setting, we used skin after 0 and 30 min of skin stretching. The orientation of the fibers in sections of control skin differed significantly from the orientation of fibers in sections of skin that was stretched mechanically for 30 min [76 +/- 15 (n=5) vs 132 +/- 36 (n=5)]. The method described here is a relatively simple way to determine (changes in) the orientation of individual collagen fibers in connective tissue and can also be applied for analysis of the orientation of any other structural element in tissues so long as a representative binary image can be created.

A controlled, quantitative histochemical study was performed in five piglets to establish changes in undermined and not undermined stretched skin. The skin was stretched with a stretching device for 30 minutes to close a large skin defect. On each flank of the piglet, at a standard position, 9 x 9-cm wounds were created under general anesthesia. On one flank, the surrounding skin was undermined cranially and caudally over a 10-centimeter area. Sections of skin biopsies obtained during stretching were stained with picrosirius red and studied with routine light microscopy and polarized light microscopy in combination with image analysis. The length of collagen fibers was analyzed as a parameter of changes in the dermis resulting from skin stretching. This newly developed quantitative method appeared to be valid, specific, and reproducible, allowing for objective determination of changes in the length of the fibers in the plain of the sections. Changes in the orientation of collagen fibers in the dermis as a result of skin stretching were thereby determined. Epidermal thickness did not change significantly under the influence of stretching forces in both undermined and not undermined skin. However, the orientation of the collagen fibers changed significantly as a result of skin stretching. In undermined wounds, parallel alignment and elongation of the fibers in the plane of the sections was already observed after 15 minutes of stretching. The fibers became aligned in the direction of the stretching force, perpendicular to the wound margin. After 30 minutes of stretching, the mean major axes of the collagen fibers were longest in the plane of the sections (p < 0.001). This meant that elongation and parallel alignment of the collagen fibers had occurred. Stretching of not undermined skin for 15 minutes resulted in significantly stronger parallel alignment in the plane of the sections as compared with undermined skin. This was less well defined after 30 minutes of stretching in not undermined skin. It is concluded that skin stretching with a skin-stretching device for 30 minutes results in significant histomorphological changes of collagen fibers in the dermis of both undermined and not undermined skin. The fibers realign rapidly as a result of stretching forces and become aligned in the direction of the stretching force, perpendicular to the wound margin. These dynamic changes in collagen fibers explain the significantly decreased wound closing tension resulting from skin stretching and explain how skin stretches beyond its inherent extensibility.

In a controlled study using 15 piglets, the efficacy of skin stretching using a skin stretching device was tested by quantifying the tension decrease during skin stretching in undermined and not undermined wounds. The viability of the skin margins was examined in both situations. Thirty standardized wounds was created: around 15 wounds on one flank, the surrounding skin was undermined; whereas around the 15 wounds on the opposite flank, the surrounding skin was not undermined. The force required to close the 9 x 9 cm defect was measured at the beginning, after undermining, and after 30 minutes of skin stretching. Also examined was the wound healing after 1 day and 1 week. A tension decrease of 3.02 N (13.6 percent reduction of the total force that is required to close the wound at the beginning) was seen due to undermining the surrounding skin. Skin stretching for 30 minutes without undermining the skin showed a tension decrease of 6.10 N (26.5 percent). Therefore, the tension decrease due to skin stretching was twice as high in comparison with undermining the skin margins alone. This has been statistically proven to be significant (-d (difference) = 3.08, 95 percent confidence interval = 2.16; 4.00, p < 0.001). When the undermined skin of the wound was stretched for 30 minutes, we measured a total tension decrease of 7.60 N (34.1 percent). There was a statistically significant but small difference in total tension decrease as a result of undermining combined with skin stretching in comparison with skin stretching without undermining (-d = 1.51, 95 percent confidence interval = 0.77; 2.23, p< 0.001). Undermining the surrounding skin involved cutting musculocutaneous perforating vessels. Looking at the viability of the skin, seven wounds, all found in the undermined group, showed skin necrosis after 1 week. Excessive seroma formation was seen in all wounds around which the skin was undermined. In the not undermined wounds, there were no problems in wound healing. In conclusion, skin stretching for only 30 minutes using a skin stretching device significantly reduces wound closing tension. The additional advantage of skin stretching over that of undermining alone is clearly shown. Undermining the wound margins before skin stretching gives a small additional tension decrease but has well-known complications, such as skin-edge necrosis and seroma formation.