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[MakeMeTallAF]

There is a relatively old drug which is being trialed for scarless healing. It has had positive trials in mice, and I believe they're working on pigs currently (whose skin is similar to humans)

https://med.stanford.edu/news/all-news/2021/04/drug-enables-healing-without-scarring.html

This could be a relatively large development in limb lengthening. The obvious use for this is with scarless healing of the surgical incisions. But another angle is that this can be used to promote scarless healing of your soft tissues such as your muscles/tendons etc (especially if they're perfoming an IT band release). Scars in soft tissues are one reason for lowered athletic ability and function in limb lengtheners.

[ilovescience]

There is a relatively old drug which is being trialed for scarless healing. It has had positive trials in mice, and I believe they're working on pigs currently (whose skin is similar to humans)

https://med.stanford.edu/news/all-news/2021/04/drug-enables-healing-without-scarring.html

This could be a relatively large development in limb lengthening. The obvious use for this is with scarless healing of the surgical incisions. But another angle is that this can be used to promote scarless healing of your soft tissues such as your muscles/tendons etc (especially if they're perfoming an IT band release). Scars in soft tissues are one reason for lowered athletic ability and function in limb lengtheners.

If it works with LL then it should work with all the major cosmetic surgeries correct?

[MakeMeTallAF]

It should work with any surgery, and any injury that produces scars (but the drug has to be administered before the wound heals)

Theoretically though if a scar forms, I think you should be able to surgically remove the scar and then apply verteporfin and it will heal without scarring. Not sure how this would work in vivo but it's possible those who already have scars from LL can go and get this done retroactively.

[SirStretchAlot]

It is indeed a promising field of research, however it is unlikely to arrive to LL soon because...

1) Normal skin has fibroblast cells that lay collagen in a complex lattice form. During scarring, the same cells lay collagen in a simple parallel form. This is faster, and allows blood to clot quickly. As with any major operation, during LL, significant blood loss occurs, and scarring is essential for you to stop losing more blood and prevent infection. You're going to have to apply mechanical force and wait weeks for your incisions to close with Verteporfin, which is simply not feasible after a major blood-losing surgery. It may be possible to do this as a follow-up cosmetic procedure, but that really isn't a LL surgeon's job or specialty.

2) There is no scarring of your soft tissues during LL. Nerves and muscles are not touched. Only bones, skin, and ITB are damaged. Your bones and ITB will regenerate with identical tissues eventually, so no permanent scarring. Your muscles and tendons need to be stretched, which merely realigns existing fibers, so no scarring. Unless you injured yourself during LL, there should be no scarring except for the skin.

[MakeMeTallAF]

You make a good point, with major surgery like LL it may not be possible to use this drug as it blocks the cells from sensing mechanical stress. It may be a situation where a surgeon (probably plastic not orthopedic) would have to go back and reopen the scars and then apply verteporfin - that is if this is even possible in vivo. 

However I disagree that there is no scarring of the soft tissues. For example stretch marks form when your skin stretches too fast for it to grow, which is a form of scarring. And when the incisions are made to insert the rod and to break the bone, there will be inevitable scarring of any soft tissues they have to go through. If you do externals there will obviously be lots of scarring especially where the pins attach. You can't treat these during lengthening but with this as well it may be a retroactive procedure.

As for the ITB, when they release the ITB I imagine it doesn't heal without any degree of scarring. You cannot compare bone to tendons, as bones don't scar when healing whereas tendons/muscles/nerves all do.

[SirStretchAlot]

You make a good point, with major surgery like LL it may not be possible to use this drug as it blocks the cells from sensing mechanical stress. It may be a situation where a surgeon (probably plastic not orthopedic) would have to go back and reopen the scars and then apply verteporfin - that is if this is even possible in vivo. 

However I disagree that there is no scarring of the soft tissues. For example stretch marks form when your skin stretches too fast for it to grow, which is a form of scarring. And when the incisions are made to insert the rod and to break the bone, there will be inevitable scarring of any soft tissues they have to go through. If you do externals there will obviously be lots of scarring especially where the pins attach. You can't treat these during lengthening but with this as well it may be a retroactive procedure.

As for the ITB, when they release the ITB I imagine it doesn't heal without any degree of scarring. You cannot compare bone to tendons, as bones don't scar when healing whereas tendons/muscles/nerves all do.

So

1) Stretch marks are again skin scars, which face the same fibroblast problems previously discussed. The muscle and fat tissues underneath do not undergo scarring when the individual loses weight.

2) I can't speak for external fixiators, but during my internal Betzbone implant, no muscles or nerves were touched. Muscles are lateral fibers that can be pulled apart during screw insertion and released back to their original position afterwards. Nerves and tendons are not touched. I did not lose any function immediately after my procedure except for pain from the surface skin wounds, only general weakness expected from operational trauma. I definitely would have felt it, had I scarred anywhere else.

3) I had my ITB released 3 weeks ago. The ITB is not a tendon but a fascae and will of course first scar. However, during the remodelling process like bones, it will be replaced with identical fiborous tissues. The regenerated ITB will be indifferentiable from the original.

Most long-term impairment from LL patients I've talked to mainly derive from losses in flexibility in ITB and hip flexors, as hamstrings and quads are very responsive to stretching. The losses in flexibility are not due to scarring, but age, starting flexibility, and effort.

[MakeMeTallAF]

Based on this video by Rozbruch, I feel like there will be damage done to the soft tissues during the procedure itself because they literally drill through your leg for the osteotomy. That will of course produce scarring as those tissues heal.

In fact the reason so many patients experience permanent knee pain when doing internal tibias is because they drill through the patellar tendon to insert the nail I believe (which heals by scarring) and never recovers 100%. I believe for femoral lengthening when they drill into the femur they don't go through any tendons which is why there generally isn't long term hip pain.

As for the ITB, if it is regenerated without scarring, I'm not sure why there would be losses in flexibility. Is there even a process of natural scar reversal in humans?

[SirStretchAlot]

Based on this video by Rozbruch, I feel like there will be damage done to the soft tissues during the procedure itself because they literally drill through your leg for the osteotomy. That will of course produce scarring as those tissues heal.

In fact the reason so many patients experience permanent knee pain when doing internal tibias is because they drill through the patellar tendon to insert the nail I believe (which heals by scarring) and never recovers 100%. I believe for femoral lengthening when they drill into the femur they don't go through any tendons which is why there generally isn't long term hip pain.

As for the ITB, if it is regenerated without scarring, I'm not sure why there would be losses in flexibility. Is there even a process of natural scar reversal in humans?

Again, I cannot speak for tibias or externals since I did femur with internal nails.

As with a drill, my bones were sawed clean. After the skin incision, muscles and tendons in the femur were pulled apart like a curtain and released to their original position after the osteotomy is complete.

The ITB does scar, but the scar tissue is replaced with identical tissues to its surrounding afterwards. This is because fascae are simple fiborous tissues, not too much more complex than the scar tissues they are replacing. Your skin has pain nerves, sweat glands and blood vessels interwoven throughout. Scars do not have any of those functionalities, hence why skin scars are so much harder to recover.

Because your ITB is not a tendon or muscle, it is not very responsive to stretching or elongation. As you lengthen, your band will become short in contrast, limiting your mobility. It's the muscles nearby that will stretch, hence why the band is cut during lengthening for patients.

[MakeMeTallAF]

As with a drill, my bones were sawed clean. After the skin incision, muscles and tendons in the femur were pulled apart like a curtain and released to their original position after the osteotomy is complete.

Ah ok that is good to hear. In that case it should minimize the damage done during the osteotomy.

As for the ITB, Rozbruch in his interview with Cyborg said it grows along with the bone, that's why they perform the ITB release.

So I'm still confused as to why the ITB is causing a loss of flexibility.

[SirStretchAlot]

Ah ok that is good to hear. In that case it should minimize the damage done during the osteotomy.

As for the ITB, Rozbruch in his interview with Cyborg said it grows along with the bone, that's why they perform the ITB release.

So I'm still confused as to why the ITB is causing a loss of flexibility.

The ITB consists of fiborous, not elastic tissues as with muscles and tendons. It does not flex or contract, thus damage and repair is the only way to stimulate growth, like with bones. If your bone lengthens, and the band doesn't, the band will cause your legs to abduct to compensate for the length difference between your femur and ITB. This is known as wide legs.

An ITB release essentially severs the band near the knees where it's the thickest. This alleviates a lot of tension throughout the entire band, allowing stretching to become more effective and damage/repair/lengthen a greater cross-section of the band.

[MakeMeTallAF]

So you are saying even with an ITB release there will be a loss of flexibility, or is that only the case when ITB release is not performed?

[SirStretchAlot]

So you are saying even with an ITB release there will be a loss of flexibility, or is that only the case when ITB release is not performed?

The ITB is not "flexible." ITB release allows you to stretch effectively to regain mobility. Not performing ITB release will lead to loss of function for some people. The band will abduct your legs and make you walk like a duck or penguin.

[Worzezterlire]

The ITB is not "flexible." ITB release allows you to stretch effectively to regain mobility. Not performing ITB release will lead to loss of function for some people. The band will abduct your legs and make you walk like a duck or penguin.

This is correct.  Talking to many surgeons and physical therapists, any notion that the ITB can be “stretched” is pseudoscience.  You absolutely must release in cases of large lengthening, over 5cm for sure.  They’ve done examples with cadaver ITB bands where they hang hundreds of pounds of weights on the severed band and the band stretches only a small amount.  The ITB is not flexible, incredibly tough, and not releasing it will cause more problems than release will.

[MakeMeTallAF]

The ITB is not "flexible." ITB release allows you to stretch effectively to regain mobility. Not performing ITB release will lead to loss of function for some people. The band will abduct your legs and make you walk like a duck or penguin.

But my question is, even if the ITB band is released why is there a loss of flexibility in the leg? Does the growth of the ITB band not keep up with the bone, therefore leaving the ITB shorter than the rest of the tissues in that segment?

Is this permanent?

[SirStretchAlot]

But my question is, even if the ITB band is released why is there a loss of flexibility in the leg? Does the growth of the ITB band not keep up with the bone, therefore leaving the ITB shorter than the rest of the tissues in that segment?

Is this permanent?

1) You lose flexibility due to various muscle/tendon/fascae. Hip flexors and ITB are for everyone. Few also have trouble with quads and hamstrings. The ITB is just one of the tissues you need to lengthen to match your lengthened legs.

2) A release will relieve tension the ITB, allowing you to stretch other important muscle groups, instead of being stuck in an abucted position where you can't stretch at all.

3) The ITB does not "grow". The only way for it keep up with the length of your femur is if you cut it, so the gap regenerate with identical tissues. This will lead to an ITB with nearly the same length to your femur. Again, this is not from stretching, but from damage and regeneration.

4) While the band will not stretch there are muscles such as TFL and smaller muscles near the knees that will. However, these are small muscles thus their lengthening capacity is very limited. Therefore for any long lengthening (>5cm like HobbitMan said), it is strongly recommended to perform a release.

[MakeMeTallAF]

Ah ok gotcha. It was unclear because I thought you meant the ITB is causing the loss of flexibility so I assumed your ITB ends up shorter permanently.

If it's just muscles that cause the loss of flexibility I imagine that isn't permanent since with enough stretching eventually they will grow (due to distraction histeogenesis). Though, if any of the tissues scar during the process that could be a cause of permanent loss of flexibility.

Btw, can there ever be non-union of the ITB? How does that work?

[SirStretchAlot]

Ah ok gotcha. It was unclear because I thought you meant the ITB is causing the loss of flexibility so I assumed your ITB ends up shorter permanently.

If it's just muscles that cause the loss of flexibility I imagine that isn't permanent since with enough stretching eventually they will grow (due to distraction histeogenesis). Though, if any of the tissues scar during the process that could be a cause of permanent loss of flexibility.

Btw, can there ever be non-union of the ITB? How does that work?

1) Not releasing your ITB can cause loss in range of motion. There's no flexibility involved with the ITB as it's not a flexible tissue.

2) There is always a theoretical maximum tissues can stretch before they are injured. Unless you surpass that maximum by lengthening too much, there will be no "scarring." The only way scarring can occur as you described is if you stretched irresponsibly and damaged your muscle. Stretching itself does not cause scarring, it simply realigns the muscle fibers. I think you're confusing stretching with resistance training, where muscles hypertrophy occurs through damage/recovery cycles.

3) I am not aware of any non-union cases with the ITB.

[MakeMeTallAF]

Well resistance training doesn't cause muscle scarring either

I don't think you understand though, the muscles aren't simply stretching they are growing too: "When gradual distraction forces are applied across the osteotomy, not only the callus elongates but also the soft tissues grow in response to mechanical stress (mechanostat hypothesis). The soft tissue grows pari passu (hyperplasia occurs) and is not just merely stretched. Hence, the term is “distraction histiogenesis.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4922221/

My concern was if the rate of lengthening is too fast for the soft tissues, will it scar rather than multiply? I don't really see any papers which address this.

Also do you know if there have been cases of pre consolidation of the ITB? Would they have to re-release the ITB in this case?

[Body Builder]

Well resistance training doesn't cause muscle scarring either

I don't think you understand though, the muscles aren't simply stretching they are growing too: "When gradual distraction forces are applied across the osteotomy, not only the callus elongates but also the soft tissues grow in response to mechanical stress (mechanostat hypothesis). The soft tissue grows pari passu (hyperplasia occurs) and is not just merely stretched. Hence, the term is “distraction histiogenesis.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4922221/

My concern was if the rate of lengthening is too fast for the soft tissues, will it scar rather than multiply? I don't really see any papers which address this.

Also do you know if there have been cases of pre consolidation of the ITB? Would they have to re-release the ITB in this case?

Muscles and soft tissues don't scar with LL. Some doctors say they are regenerate and expand, some others that they are stretched, there is no clear answer to that. The only thing clear is that they are not scarring.
They only scar in the pin sites when they cut through muscles with external lengthening methods. In tibias the muscles are minimal where the pins are so the problem is negligible but in femurs, pins of monorails cut through massive muscles. Thats the main reason why externals on tibias is a disaster.

[SirStretchAlot]

Well resistance training doesn't cause muscle scarring either

I don't think you understand though, the muscles aren't simply stretching they are growing too: "When gradual distraction forces are applied across the osteotomy, not only the callus elongates but also the soft tissues grow in response to mechanical stress (mechanostat hypothesis). The soft tissue grows pari passu (hyperplasia occurs) and is not just merely stretched. Hence, the term is “distraction histiogenesis.”
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4922221/

My concern was if the rate of lengthening is too fast for the soft tissues, will it scar rather than multiply? I don't really see any papers which address this.

Also do you know if there have been cases of pre consolidation of the ITB? Would they have to re-release the ITB in this case?

1) This is what happens when you read excerpts with minimal context. He is assuming some level of normal activity when undergoing bone distraction. If you are simply stretching and not exercising, your muscles don't grow or undergo any hyperplasia. This is why limb lengthening patients experience significant muscle weakness. The muscles are elongated without hyperplasia, leading to fewer muscle cells at each cross-section. You will only recover the same level of muscle density if you undergo resistance training along with stretching.

2) I inquired about early recovery of ITB specifically with Dr Giotikas. He stated that it is very unlikely the ITB would completely heal before distraction completes.

In conclusion, if you wish to do LL with internal nails on the femur, there is very limited damage to your soft tissues long-term, except for scars on the skin. ITB release is also performed by most surgeons except for older doctors like Betz.

[MakeMeTallAF]

That's good to know about the ITB.

On the first point, we are talking past each other. You are talking about muscle hypertrophy, which is the growth of the cells itself. That is accomplished through resistance training. Hyperplasia otoh occurs during distraction histeogenesis due to the muscle being stretched apart which triggers cell multiplication.

Also the study I posted is of an oral and maxillofacial surgery procedure (jaw elongation I believe) where there isn't really a resistance training regimen.