Nobody leaves this world without a scar, without a scar on the skin.
Scar Formation
A skin scar forms after a wound on the skin is caused by trauma or created by the surgeon. Skin scar is a form of wound healing.
There are three outcomes of wound healing:
- Normal scar formation – a scar that is flat and pale in color or almost blending with the surrounding skin.
- Hypertrophic scar – a scar raised above the skin level that stays within the confines of the original wound.
- Keloid – a scar raised above skin level that proliferates beyond the confines of the original wound.
What factors affect the outcome of wound healing, whether there will be a normal scar formation, hypertrophic scar, or keloid?
- Genetic
- Status of the wound at the time of wounding such as whether it was a dirty wound, linear, ruggedly lacerated, or big gaping wound, etc.
- How the wound was treated by the physician or surgeon
The physician or surgeon can only do so much in promoting a normal scar formation such as:
- Close wound by primary intention if possible
- Close wound without tension
- Close wound with proper apposition of skin edges
- Use of proper sutures
- etc.
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To use or not to use topical scar reduction medication:
First of all, there are no hard evidence yet of whether they are effective. All are anecdotal reports.
Use of topical medications to promote good scar formation:
In the market, Contractubex, Dermatix Ultra, Hiruscar, Hirudoid
Not well established as to effectiveness
High risk for keloids – past history of keloids, wound in areas where keloid is frequent, family history of keloids
Try topical medications
- Hiruscar
- Hirudoid
- Contractubex
- Dermatix Ultra
Try Silicone Gel Sheet
First sign of hypertrophic scar – try topical medications
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Hypertropic scars develop approximately 39% to 68% of patients after surgery and 33% to 91% of patients after burns.
- Niessen FB, Spauwen PH, Schalkwijk J, Kon M: On the nature of hypertrophic scars and keloids: a review. Plast Reconstr Surg 104: 1435 – 1458, 1999.
- Ward RS: Pressure therapy for the control of hypertrophic scar formation after burn injury: A history and review. J Burn Care Rehabil 12:257-262, 1991
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Wound healing processes (with overlaps):
- Inflammation phase
- Granulation tissue formation phase
- Matrix formation or remodelling phase
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There are a variety of treatments that have been tried for hypertrophic scars and keloids. No optimal treatment has been established yet.
- Intralesional steroids
- Cryosurgery
- Radiotherapy
- Pressure therapy
- Silicone gel sheeting
- Laser therapy
- Excisional surgery
- Topical silicone gel (Dermatix)
- Silicone gel sheeting
- Onion extract (Contractubex)
Contractubex
Dermatix (more expensive) – seems to be better than Contractubex
Comparison of efficacy of silicone gel, silicone get sheeting, and topical onion extract including heparin and allantoin for the treatment of postburn hypertrophic scars
Turkey
Huseyin Karagoz, Fuat Yuksel, Ersin Ulkur, Rahmi Evinc
Elsevier 2009
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Scars are accepted phenomenon.
Patients were told that little could be done about them and that they have to accept the appearance of their scars.
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Surgical approaches for the prevention and treatment of hypertrophic scars and keloids should be based on five main principles.
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General prophylactic approaches to minimize the risk of postoperative excessive scarring:
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Delayed epithelialization beyond 10–14 days is known to increase the incidence of hypertrophic scarring dramatically
10 thus achievement of rapid epithelialization is mandatory for avoiding excessive scar formation.
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Wounds subjected to tension due to motion, body location, or loss of tissue are at increased risk of scar hypertrophy and spreading, and patients should be informed of this important matter prior to any surgery
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Aesthetic wound closure is based on knowledge of healing mechanisms and skin anatomy, as well as an appreciation of suture material and closure technique. Choosing the proper materials and wound closure technique ensures optimal healing. Surgical wound closure directly opposes the tissue layers, which serves to minimize new tissue formation within the wound. Appropriate surgical wound closure eliminates dead space by approximating the subcutaneous tissues, minimizes scar formation by careful epidermal alignment, and avoids depressed scars by precise eversion of skin edges. If dead space is limited with opposed wound edges, then new tissue has limited room for growth. Correspondingly, traumatic handling of tissues combined with avoidance of tight closures and undue tension on wound margins by carefully undermining and loosening the surrounding tissue contribute to a better result. We do prefer subcutaneous sutures with, for example, PDS II (polydioxanone) monoflament synthetic absorbable sutures, which provide extended wound support (for up to 6 months) and may be combined with absorbable sutures or Steri-Strip™ (3M, St Paul, MN, USA) for optimal epidermal wound closure. The group of Ogawa and colleagues employs subcutaneous fascial tensile reduction sutures in their predisposed patient population, where the tension is placed on the layer of deep fascia and superficial fascia. The group prefers 2-0 PDS II or 3-0 PDS II sutures for subcutaneous/fascial sutures, and 4-0 or 5-0 PDS II for dermal sutures.
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In the case of hypertrophic scarring, timing of surgical treatment is an important consideration in the treatment protocol of scar revision strategy. Hypertrophic scars may mature over at least a 1-year period and can show significant flattening and softening without any physical manipulation.
13Surgical excision might thus not be needed, even though post-excisional recurrence rates of the original hypertrophic scar are usually low.
14,
15 However, if scar (joint) contractures are present, surgical approaches that release contractures should be performed earlier.
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Increased tension on wound margins represents a central aspect in the development of hypertrophic scars. Thus, successful and persisting removal of excessive scar tissue may be achieved by employing Z- or W-plasty, grafts or local skin flaps to interrupt the vicious circle between scar tension and consecutive further thickening of the scar due to permanently stimulated ECM production.
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Hypertrophic scars and keloids that have developed on the basis of delayed wound healing (eg, after deep dermal burn or wound infection) are transformed by surgery (excision with suture or graft) into a wound with appropriate healing time, thus minimizing the risk of a new excessive scar formation.
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By surgical removal of excessive scar tissue, a situation corresponding to a fresh wound is achieved, in which renewed excessive scarring can be reduced by adjuvant conservative therapy from the very beginning.
16 However, excision of keloids without any adjuvant therapy (eg, post-excisional corticosteroid injections, 5-fluorouracil (5-FU), intraoperative cryotherapy, pressure, or radiations) should be strictly avoided due to great recurrence rates (45%–100%). Excisions of the keloid may result in a longer scar than the original one, and recurrence in this new area of trauma may lead to an even larger keloid.
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18 Interestingly, surgical repair (core excision with low-tension wound closure, or shave excision) of earlobe keloids with post-surgery corticosteroid injections, postoperative pressure (pressure earrings), application of imiquimod 5% cream, or cryotherapy on the incision site has been shown to provide overall good cosmetic results.
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Problem-based Learning in Surgery 