Any tissue injury suffered by a human body initiates an elaborate cascade of events that are aimed at restoring tissue integrity.
In postnatal mammals, scarring and fibrosis are the results of this wound repair process. Insects, by comparison, possess no wound healing potential at all! Interestingly, foetal skin can heal without scarring and with regeneration of appendages like sweat glands and hair.
Adult wound healing involves inflammatory, proliferative and remodeling phases. These three phases overlap in highly coordinated relationships to heal skin defects. During the inflammatory phase, which peaks after 48-72 hours and lasts about 5-7 days, haemostasis (clotting with platelets) occurs first followed by an infiltrate of early inflammatory cells (mostly white blood cells). Fibrosis and contraction characterises the proliferative phase (with the deposition of collagen) and lasts for approximately 4 weeks. The final phase of remodeling involves scar maturation, which progresses over months to years (during which the redness subsides and the tissues soften).
In order to get the best possible scar after a surgical procedure it is important to understand what measures can be taken at every stage of the healing process.
The first steps that Plastic Surgeons take, begins with the intra-operative handling of the tissue. Meticulous handling of tissues, careful suturing in layers, minimisation of dead space and scrupulous haemostasis (control of bleeding), all help reduce the chances of an excessive inflammatory response to the injury.
Other measures to improve early healing include:
• Reduce the risk of infection by cleanliness, antibiotics and control of bleeding.
• Aim for excellent primary wound healing by using high quality suture materials and good techniques.
• Ensure moist wound healing conditions instead of a dry wound environment (scabs and crusts are undesirable).
• Porous taping over the early wound helps reduce tension, retains moisture and allows the application of antibiotic ointments.
• Occlusive or semi-occlusive dressings are helpful.
Once the fibrotic phase starts (during which collagen is laid down in the wound) and the early scar has epithelialised:
• Daily massage commences.
• Multiple scar treatment options (including herbal options) are available and can be individualised to any patient’s needs.
• On-going taping provides protection and moisture control.
• A healthy balanced diet rich in vitamins, especially A, C and E is advised.
• Avoidance of any irritation, such as ‘scratching’ will prevent excess scar tissue formation.
What is an unfavourable wound?
If any of the phases of healing are exaggerated or persist too long, an abnormal scar can occur. Terms such as hypertrophic or keloid may then be used to describe the red, thick and excessive scars that can result.
How to handle a troublesome scar? Additional therapies are then used, such as:
• Pressure care and customised garments.
• Cortisone treatments – topically and injected.
• Silicone gels or sheets applied to the wound.
• Time – is underestimated since in some cases it may take up to 12-18 months to obtain a result (burns are a good example of this phenomenon, since thermal wounds take many months to mature).
• Occasionally treatments such as laser or cryotherapy (freezing) may help.
What to do about a bad scar that persists after all efforts to improve it?
The last resort remains surgical scar revision. Most surgeons would advise to wait at least 6-12 months before embarking on revision surgery. In patients with keloids, low dose radiation therapy can be given to the wound bed very early in the healing process to reduce the risk of recurrence.
Points to remember about an early wound:
• Keep it clean and covered.
• Keep it moist.
• Don’t irritate a scar, it prolongs the healing process.
• Massage all scars for 10-15 minutes a day (as if ‘kneading dough’).
• Give it time (Scars take 6-12 months to mature).
• Avoid exposure to the sun (it causes irritation and pigmentary changes).
• Avoid cigarette smoking.