On the anatomy and physiology of the skin: conclusions by Professor K. Langer

Characterization of the anisotropy of the natural human cheek skin tension in vivo

Natural skin tension plays an important role during surgical procedures and during the healing process especially for the face. The study of skin tension can be a means of assessing the aging effect, or the application of a medical or cosmetic product. In this work we propose a characterization of the natural human cheek skin tension in vivo and its variability with age using three characterization methods. These methods consist of facial photography to assess the ptosis of the lower face and the nasolabial fold, suction test to estimate mechanical parameters using the cutometer, and topographic analysis of the skin at rest and during folding test to study the skin relief. The study was carried out on 41 volunteers representing two age groups: 18 young volunteers [20-30] years-old and 23 elderly volunteers [50-65] years-old. The results show that the ptosis of the lower face and the nasolabial fold increase with age. The sagging of the skin observed on the facial photos is related to the loss of elasticity and the increase in the skin viscoelasticity with age. The analysis of the cheek skin relief shows that it has a very fine and flexible lines network. This analysis of the skin relief at rest and during the folding test allowed to determine the main directions of skin tension for the different age groups: [20°-40°] for the young group and [20°-60°] for the elderly group. The natural skin tension decreases with age, wrinkles appear and the skin becomes more anisotropic.

The assessment of natural human skin tension orientation and its variation according to age for two body areas: Forearm and thigh

Human skin has a complex multilayer structure consisting of non-homogeneous, non-linear, viscoelastic and anisotropic materials subjected to in vivo natural pre-tension. This natural tension stems from networks of collagen and elastin fibers. The 3D organization of the collagen and elastin fibers underpins the multidirectional natural tensions in the skin volume while the state of the networks formed influences the surface topography of the skin. This topography depends on the area of the body and on the age of the person. Experiments reported in the literature have been performed ex vivo or on cadavers. By contrast, this work proposes the characterization of the anisotropic natural tension of the human skin in vivo. Experimental tests were performed on the forearms and thighs of 42 female volunteers representing two age groups [20 - 30] and [45-55] years old. Non-contact impact tests and skin-folding tests were conducted using devices developed at the LTDS (Lyon, France). The impact test generated a Rayleigh wave that spread in the skin. The speed of this wave was measured in 7 directions to study the anisotropy of the skin tension. The image of the skin relief at rest and during the skin folding test was reconstructed by optical confocal microscopy and provided the density of the skin lines printed on the outer surface of the skin. Skin folding test enables the clinician's manual procedure to be instrumented to identify tension lines i.e., Langer lines, for better healing during a surgical procedure. The main directions of natural skin tension deduced from the measured wave speed and the densities of skin lines were [40°-60°] for the forearm and [0°-20°] for the thigh, considering that the longitudinal axis of the body is situated at 90° and the transversal axis at 0°. This method shows the remarkable effect of age and body area on the mechanical behavior of human skin in vivo. The elastic properties and natural tension of the skin decrease with age. This decrease is greater in the directions orthogonal to the skin's tension lines, leading to the accentuation of the anisotropic behavior of the cutaneous tissue. The main direction of skin tension is highly dependent on the area of the body and is directed towards a preferred direction which corresponds to the main direction of skin tension.

In vivo panoramic human skin shape and deformation measurement using mirror-assisted multi-view digital image correlation

Panoramic shape and deformation measurements of human skin in vivo may provide important information for biomechanical analysis, exercise guidance and medical diagnosis. This work proposes the application of an advanced mirror-assisted multi-view digital image correlation (DIC) method for dynamic measurements of 360-deg shape and deformation of human body parts in vivo. The main advantage of this method consists in its capabilities to perform full-panoramic non-contact measurements with a single pair of synchronized cameras and two planar mirrors thus representing a lean yet effective alternative to conventional multi-camera DIC systems in 'surrounding' configuration. We demonstrate the capabilities of this method by measuring the full-panoramic shape of a plastic human head, the deformation of a woman face and the principal strain distribution over the full-360-deg surface of a forearm during fist clenching. The applications of this method can be the most disparate but, given the possibility to determine the full-field strains and derived information (e.g. skin tension lines), we envisage a great potential for the study of skin biomechanics in vivo.

Epithelial mechanobiology, skin wound healing, and the stem cell niche

Skin wound healing is a vital process that is important for re-establishing the epithelial barrier following disease or injury. Aberrant or delayed skin wound healing increases the risk of infection, causes patient morbidity, and may lead to the formation of scar tissue. One of the most important events in wound healing is coverage of the wound with a new epithelial layer. This occurs when keratinocytes at the wound periphery divide and migrate to re-populate the wound bed. Many approaches are under investigation to promote and expedite this process, including the topical application of growth factors and the addition of autologous and allogeneic tissue or cell grafts. The mechanical environment of the wound site is also of fundamental importance for the rate and quality of wound healing. It is known that mechanical stress can influence wound healing by affecting the behaviour of cells within the dermis, but it remains unclear how mechanical forces affect the healing epidermis. Tensile forces are known to affect the behaviour of cells within epithelia, however, and the material properties of extracellular matrices, such as substrate stiffness, have been shown to affect the morphology, proliferation, differentiation and migration of many different cell types. In this review we will introduce the structure of the skin and the process of wound healing. We will then discuss the evidence for the effect of tissue mechanics in re-epithelialisation and, in particular, on stem cell behaviour in the wound microenvironment and in intact skin. We will discuss how the elasticity, mechanical heterogeneity and topography of the wound extracellular matrix impact the rate and quality of wound healing, and how we may exploit this knowledge to expedite wound healing and mitigate scarring.

Model of the viscoelastic behaviour of skin in vivo and study of anisotropy

BACKGROUND

The single-axis extension test is relatively little used to study the mechanical properties of human skin in vivo. A campaign of tests was carried out with an original, modern machine developed in our laboratory. It can perform extension or compression tests using servo-controlled position or force in different directions. The load can either be of the extension or monotonous compression type, creep or relaxation. The results obtained were used to develop a viscoelastic model. The elastic modulus calculated helps us to determine the main directions of anisotropy on the forearm.

METHODS

We use a new in vivo single-axis extension machine (patent no. FR03/09220 application in progress). With it, we can carry out monotonous, creep and relaxation tests on the forearm. An associated finite elements model enables conversion to the intrinsic parameters of the skin under stress and strain from external stress applied in force and displacement. From the tests, we can propose a viscoelastic model and the identification of his parameters. We carried out tests in four directions with respect to the axis of the forearm of 63 people of different ages. The present report is limited to a brief presentation of the experimental set-up used, and a more complete presentation of the viscoelastic model and how it is defined and also the work on the anisotropy in the elastic domain.

RESULTS

The viscoelastic model proposed has only four intrinsic parameters: elasticity parameters E(e) and E(ve) and viscosity parameters epsilon(ve) and A. Skin being considered as orthotropic, we were able to determine the average main direction of 63 people, which is of 5.33+/-5.78 around the longitudinal axis of the arm. An average modulus E(1) (ave)=6.57E(5) (Pa) can be found in the direction close to the axis of the arm and E(2) (ave)=1.30E(5) (Pa) in the perpendicular direction and a G(12)=1.32E(5) (Pa) shear modulus.

CONCLUSIONS

The parameters obtained with the viscoelastic model are independent of the type of load, the same coefficients enable a correct representation in creep and relaxation tests. The main directions vary from one person to another, Young's modulus in these directions could be an indicator for dermatologists and cosmeticians.

Lacerations against Langer's lines: to glue or suture?

This study evaluated the effects of initial wound orientation on the cosmetic outcome of facial lacerations repaired with histoacryl blue (HAB), a tissue adhesive, vs. conventional suturing. This was a retrospective analysis of patients from a prospective randomized clinical trial on the use of HAB. Children in the initial cohort who had facial lacerations and were also evaluated for cosmetic appearance at a 2-month follow-up appointment were eligible. Orientation along Langer's Lines, which define the functional anatomy of the underlying structures to the skin, was determined by two investigators blinded to the initial method of repair. Photographs of the wounds were reviewed and the wounds were categorized as being: Langer (+) (<20 degrees deviated from Langer's Lines) or Langer (-) (> or =20 degrees deviated from Langer's Lines). Photographic appearance at follow-up was evaluated using a 100-mm visual analog scale (0=best, 100=worst) by two plastic surgeons blinded to the method of repair. Sixty-one patients were enrolled in the initial cohort, with 55 (90%) evaluated at the 2-month follow-up. Forty-eight of the 55 (87%) had facial lacerations, therefore meeting present study criteria: [HAB (n=26), Suturing (n=22), Langer (+) (n=27), Langer (-) (n=21)]. Langer (+) patients were comparable to Langer (-) for demographics, wound characteristics, and method of repair. There was no difference in overall cosmetic appearance of facial wounds closed with HAB vs. conventional suturing. Follow-up appearance was significantly worse for sutured Langer (-) vs. Langer (+) wounds. In contrast, cosmetic appearance of lacerations closed by HAB were comparable between Langer (-) and Langer (+) wounds. In conclusion, initial wound orientation had a greater impact on the cosmetic appearance for lacerations closed by suturing compared to HAB. HAB may be the preferred method of cutaneous closure for facial lacerations oriented against Langer's Lines.

On the orthogonal anisotropy of human skin as a function of anatomical region

Skin samples were obtained from 8 anatomical sites of 6 human deceased at ages ranging from 30 to 80 years 24 hours post mortem. As shown by biochemical analysis the collagen content varied between 71% and 78% depending on the anatomical location of the skin samples. The content of collagen type III was in the range of 19.2% to 22.2% of the total collagen concentration. As to the biomechanical analysis the axes of minimum and maximum shrinkage after excision were determined and correlated with Langer cleavage line drawn on the specimen with a marker after incision. Two-dimensional biomechanical tests were conducted with a multiaxial tensile testing device consisting of 12 loading axes. The in vivo configuration was a circle with 30 mm diameter. The in vivo stresses were determined by restoring the original shape of the specimen. According to the nonlinear stress-strain relationship incremental strains were applied to the sample with the in vivo configuration and states of uniform extension as reference. The corresponding stresses were recorded after stress relaxation was completed and the equilibrium stresses were regarded as the elastic contribution to the viscoelastic biomechanical behavior. The elastic parameters as a function of the initial strain level were calculated using a set of different incremental strains and stresses. The highest in vivo stresses were found in patella, and upper and lower back. The maximum deviation of the direction of maximum in vivo stress from the Langer cleavage line was found in upper back, the volar part of thigh, and sternum. In vivo orthogonal anisotropy was most pronounced in patella and hollow of the knee.