Soft Tissue Principles to Minimize Scarring




This article is a broad overview of measures and techniques that can be used to minimize soft tissue scarring.


Key points








  • Patient factors include skin type, medical conditions, ethnicity, medications, and soft tissue healing. Patient perception plays a role in the scar result.



  • Preoperative planning, intraoperative tissue handling, and suture techniques are vitally important to optimize wound healing and minimize scarring.



  • Postoperative use of ointments, taping, silicone, and sun protective products as well as adjunctive procedures (dermabrasion, scar revision, and laser therapy) can assist in the final overall scar appearance.






Introduction


Scarring is an inevitable consequence of surgery. Facial scars, due to their public visibility, can be very disconcerting to patients. They can have significant morbidity, ranging from functional problems to psychological sequela. Important principles and management techniques can be used that can minimize scarring to improve both patient functional outcome and satisfaction. The purpose of this article is to give a broad and practical overview of clinical measures to reduce facial scarring.




Introduction


Scarring is an inevitable consequence of surgery. Facial scars, due to their public visibility, can be very disconcerting to patients. They can have significant morbidity, ranging from functional problems to psychological sequela. Important principles and management techniques can be used that can minimize scarring to improve both patient functional outcome and satisfaction. The purpose of this article is to give a broad and practical overview of clinical measures to reduce facial scarring.




Scarring in relation to wound healing


Scars form when the deep reticular layer of the dermis is violated. As a part of the healing process, the body forms new collagen fibers resulting in a scar. Four phases of wound healing occur following a surgical incision. They are coagulation and hemostasis, inflammation, proliferation, and remodeling. A scar is formed primarily during the latter 2 phases. During proliferation, fibroblasts migrate into the wound to begin the process of making new collagen, which will eventually become a scar. New collagen is primarily type III collagen and is replaced with type I over time. As the scar gets stronger with time, wound strength approaches 70% of its original strength at 6 weeks but will never surpass 80% of its original skin strength. Remodeling is the last stage of wound healing in conjunction with contraction, which may last as long as 1 to 2 years.


Within the extracellular matrix, the fibrin-rich matrix during the inflammatory phase transforms to a collagen-rich extracellular matrix during the proliferative phase. During the remodeling phase, collagen deposition and cross-linking occur, forming an organized collagen fiber network, which later undergoes wound contraction as fibroblasts transform into myofibroblast. The collagen breakdown is controlled by matrix metalloproteinases. In addition, dermal extracellular matrix transformation occurs with fibronectin followed by hyaluronan (4–6 days) and then with proteoglycans deposition (7–10 days).


Any factors that delay wound healing will increase risk for scarring. Thus, measures to optimize dermal wound healing will result in reduced scar formation. Factors to ensure proper wound healing include (1) adequate nutrition, (2) sufficient blood supply, (3) proper wound management, (4) wound pressure relief, and (5) minimizing bacterial contamination.




Relevant anatomy


Skin Structure and Skin Condition


The skin consists of several layers: epidermis, papillary dermis reticular dermis, and hypodermis ( Fig. 1 ). The adnexal structures in the dermis (ie, hair follicles, apocrine and ermine glands) serve as progenitor cell sources for epithelialization. When injury occurs in the deep reticular layer of the dermis that is allowed to heal by secondary intention, more scarring usually occurs. Incisions through thicker skin tend to scar more than thin skin. Especially in thick sebaceous skin, incisions tend to scar easier.




Fig. 1


Skin anatomy. Diagram ( A ) and histological section ( B ) showing the layers of human skin.

( From Hebda PA. Skin wound healing. In: Hom DB, Hebda PA, Gosain AK, et al, editors. Essential tissue healing of the face and neck. Shelton, CT: People’s Medical Publishing House; 2009; with permission.)




Facial areas prone to scarring


Convex surfaces of the face, such as the chin, cheek, forehead, and nasal tip, are more prone to hypertrophic, widened scars compared with other regions of the face.


Also, areas in close proximity to mobile regions of the face have an increased risk to have widened scars due to the continuous pull on the incision. In this instance, taping the incision for several months after suture is removed may help reduce pulling on the incision as it matures, resulting in a less widened scar.




Patient factors


Medical Conditions


Several medical conditions and medications can predispose a surgical patient to scarring ( Box 1 ). Patients with hyperplastic joints have increased elastin in the dermis and are more prone to scarring. Surgeons should consider checking for signs of hyperelasticity by asking the patient to bend his thumb to his forearm or to touch his tongue to his nose ( Fig. 2 ). An additional patient factor that can contribute to scarring is age. In younger patients, the remodeling phase of the scar is more prolonged, resulting in increased erythema and hypertrophy. Remodeling becomes more adultlike after puberty. Any condition that increases the propensity for a prolonged inflammatory reaction during wound healing, such as an infection or a foreign body reaction, increases the probability of more scarring. Other medical problems, such as diabetes, collagen vascular disease, hypothyroidism, immunocompromised states, and diseases with delayed healing, have an increased risk for scarring.



Box 1





  • Intrinsic Factors



  • Age




    • Fetus



    • Child



    • Adult




  • Hypertrophic scarring and keloids



  • Immune status



  • Hereditary healing disease




    • Ehlers-Danlos syndrome



    • Epidermolysis bullosa



    • Marfan syndrome



    • Osteogenesis imperfect



    • Werner syndrome




  • Disease states




    • Chronic pulmonary disease



    • Chronic cardiac disease



    • Chronic liver disease (cirrhosis)



    • Uremia



    • Alcoholism



    • Diabetes



    • Peripheral vascular diseases




  • Psychophysiologic stress




    • Stress



    • Pain



    • Noise




  • Metabolic states




    • Hypoxemia



    • Hypoxia



    • Anemia



    • Hypovolemia





  • Extrinsic Factors



  • Malnutrition




    • Protein, calorie



    • Vitamins



    • Minerals




  • Infection



  • Insufficient oxygenation or perfusion



  • Smoking



  • Cancer



  • Chemotherapy



  • Medications




    • Steroids



    • Anticoagulants



    • Penicillamine



    • Cyclosporine



    • Antiplatelet agents




Medical conditions that effect wound healing which have an impact on scarring



Fig. 2


Hyperelasticity. A patient who can bend his thumb to his forearm as shown in the photo has joint hyperelasticity, which gives an increased propensity for scarring.


Patients with poor nutritional status who have decreased wound healing are more prone to scar. Specific nutritional deficiencies known to delay healing are vitamin C deficiency, which is necessary for the hydroxylation of lysine and proline for collagen cross-linking. Zinc and copper are also required for collagen cross-linking, and vitamin K is necessary for clotting and prothrombin production. As a result, deficiencies in these vitamins impede healing.


Patients with a history of previous radiation have poor wound healing and scarring. Radiation affects wound healing by causing obliterative endarteritis, excessive fibrosis, and an aberration of normal cellular replication. A total radiation dose greater than 50 Gy is consistently associated with poor wound healing. Patients who smoke are also more likely to heal poorly and have a higher risk for scarring due to the vasoconstrictive effects of nicotine. Medications, such as corticosteroids and chemotherapy agents, also slow down healing and increase risk for scarring.


Type of Skin Injury


Planned, sterile surgical wounds will have less scarring compared with traumatic wounds. Traumatic wounds heal with more scarring due to a heightened inflammatory response from foreign bodies and bacteria inoculation. Infected wounds (>10 5 microorganisms per gram of tissue) induce a longer inflammatory phase of wound healing, and therefore, heal with more scarring. In addition, burn-inflicted trauma is more likely to result in scar hypertrophy.


Topographically, scars can be classified into several types, as seen in Fig. 3 . Linear wounds that are perpendicular to the relaxed skin tension line (RSTL) make scars more apparent.




Fig. 3


Scar types. ( A ) Keloid or hypertrophic scar lacking adnexal structures with thin epidermis. ( B ) Oblique scar in dermal depth with slanted contraction. ( C ) Uneven sloping scar with various dermal depths. ( D ) Iatrogenic step off scar from inaccurate apposition of skin edges. ( E ) Trap Coro or pin cushioning scar from circumferential contraction.

( Adapted from Rosie T, Harahap M. Scar Analysis and treatment selection: the “geo-topographic approach.” In: Harahap M, editor. Surgical techniques for cutaneous scar revision. New York: Marcel Dekker; 2000. p. 81.)


Ethnicity


Ethnicity plays a role in scar formation. Patients with Fitzpatrick skin types IVtoVI are at increased risk for scar hypertrophy, hyperpigmentation, and hypopigmentation. Specifically, Asians have an increased propensity for hyperpigmentation and widened scars. In addition, African American patients and those of other races with darker complexion (ie, Hispanic, Asian Indian) are more likely to have hypertrophic scar formation.




Age


Children can be more vulnerable to dermal scarring because the remodeling phase of healing is more prolonged than adults, resulting in increased scar erythema and scar hypertrophy. Thus, some think that elective cosmetic scar revision in children should be delayed until puberty unless a functional deficit is occurring.




Pretreatment of tissue before surgery


Very little is described in the literature about pretreating tissue before a surgical procedure. Optimizing the preoperative wound healing state is essential ( Box 2 ). These important common factors include maximizing the nutritional status, controlling diabetes, and reducing smoking. In fact, any component that delays healing increases the risk for scarring. If a patient has been taking isotretinoin (Accutane), elective skin ablative procedures requiring re-epithelialization (such as laser ablative resurfacing, dermabrasion, chemical peel) should be avoided for at least 1 year. This recommendation is because isotretinoins cause sebaceous gland atrophy, which diminishes an important epithelial cell source. When a partial thickness wound does not re-epithelialize within 3 weeks, scarring significantly increases if one is suspicious for a higher risk of scarring before a skin ablative procedure. A test dose can be delivered behind the ear to determine the pigmentary and scar skin response.



Box 2





  • Debride necrotic tissue to decrease infection risk.



  • Maintain fresh wound edges along the incision to encourage epithelialization.



  • Irrigate copiously to clean the wound and remove foreign bodies. Irrigation can be performed with normal saline or commercial wound cleanser. Irrigation is the single most effective technique to accomplish wound cleaning.



  • Obtain hemostasis and place drains to prevent any excess fluid collection (ie, hematoma, seroma) and to avoid infection.



  • Absorb excess wound exudate to prevent maceration of surrounding skin.



  • Divert any salivary drainage away from the wound to minimize bacterial contamination.



  • Maintain a moist wound environment with topical ointments or hydrogels to encourage epithelialization.



  • Protect the wound from trauma.



  • In wounds with potential for infection, institute appropriate oral and topical antibiotics for 7 to 10 days. Abrasions and wounds can be covered with hydrogel sheeting for exudative wounds or clear transparent dressing (ie, Tegaderm, Opposite) for nonexudative wounds.



  • To avoid cellular damage, do not repetitively apply skin cleansers (ie, hydrogen peroxide, Betadine, Hibiclens) in a wound.


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Aug 26, 2017 | Posted by in General Surgery | Comments Off on Soft Tissue Principles to Minimize Scarring
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