Scarring from surgical wounds
Recommendations
| Identify and Treat the Cause | ||
|---|---|---|
| 1 | Take a careful history about previous scarring. | Level of Evidence Not Assessed |
| 2 | Conduct a skin inspection. | Level of Evidence Not Assessed |
| Address Patient-Centered Concerns | ||
|---|---|---|
| 3 | Discuss treatment options and expectations with the patient to allow informed decision-making. | Level of Evidence 5 |
| Provide Local Wound Care | ||
|---|---|---|
| 4 | Perform an accurate scar assessment to diagnose the scar and develop a management strategy. | Level of Evidence Not Assessed |
| 5 | Monitor most scars for at least one year to allow maturation before determining a course of treatment. | Level of Evidence Not Assessed |
| Provide Organizational Support | ||
|---|---|---|
| 6 | Establish and empower an interprofessional team to provide post-operative skin care. | Level of Evidence 5 |
Background
Skin scarring is the normal endpoint of tissue repair, and scars generally develop after dermal injury. Individuals vary considerably in their potential for scarring. Scars may be normal fine lines or abnormal scars, which may be categorized as widespread (stretched), atrophic, hypertrophic, and keloid. Scar contracture may also occur. (Bayat, BMJ, 2003;326:88–92) Abnormal scarring can produce functional (even disabling), cosmetic, psychologic and social problems that may carry a high emotional and financial cost. Scar revision considerations include balancing potential benefits against the risk of poor response and iatrogenic complications.• Stretched: Tension on a scar in one direction produces a stretched scar, usually in the first 3 weeks after surgery. Stretched scars are flat, pale, soft and symptomless, and they are often seen after knee or shoulder surgery.
• Atrophic: These scars are small, flat, depressed below the level of the surrounding skin, and often indented or inverted. Atrophic scars are often seen after chickenpox or acne.
• Scar contractures: Contracture often occurs in scars crossing a joint or skin crease at right angles, especially scars due to burns. Contracture begins before the scar matures and may be disabling or dysfunctional. Contractures are typically hypertrophic.
• Hypertrophic: These scars are raised but remain within the boundary of the original lesion. Tension on a scar from many directions produces a hypertrophic scar. Hypertrophic scars are often red, inflamed, itchy and possibly painful and often occur after burn injury. They tend to regress spontaneously.
• Keloid: These are raised scars that have spread beyond the margins of the original lesion. The pattern of keloid development tends to be site specific. Ear lobe keloids often grow into large lobules, deltoid keloids grow vertically, and central sternal keloids often assume a butterfly shape. This scar type may be inflamed, itchy and painful. Keloids do not regress, but continue to grow over time, and they almost always recur after simple excision.
Accurate assessment is required to diagnose a scar and develop an appropriate management strategy. Discussion of the options with the patient is crucial. Scar severity can be assessed visually or using a scar scale. Assessment considerations include:
• Cause and course (improvement or worsening)
• Anatomic location
• Symptoms
• Scar severity
• Severity of functional impairment
• Stigma or psychological impact.
Management approaches include:
• Leave alone: It is appropriate to monitor scars for at least a year to allow maturation before determining an appropriate course of action. Some scars are best left alone in the long term.
• Non-invasive: Compression therapy, masks and clips, splinting or casting, topical therapy, antihistamines, silicone sheeting, psychologic counselling, and massage therapy are non-invasive options.
• Invasive: Surgical revision, intralesional corticosteroid injection, laser therapy, injection of fluorouracil, bleomycin or interferon gamma, radiotherapy and cryosurgery are invasive options for scar management.
In general,
• Stretched scars are usually managed by revision to reduce the width, possibly with splinting.
• Atrophic scars can be improved with chemical peels, laser resurfacing, dermabrasion, punch excision and fillers.
• Keloid scars: Surgery plus radiotherapy or an intralesional corticosteroid is the most common treatment for keloid scars.
• Scar contracture: Surgical release with splinting, casting and compression may be required. Skin grafts may also be required.
Silicone gel sheeting and intralesional corticosteroids are the only therapies for which sufficient evidence exists to make evidence-based recommendations. These treatments are useful in a wide variety of abnormal scars, such as hypertrophic scars and keloids.
References
| Essential Publications |
|---|
| 1 | Fluid and pharmacological agents |
Quality Indicator
|
Type: Systematic review |
| Metwally M, Watson A, Lilford R, Vandekerckhove P. Fluid and pharmacological agents for adhesion prevention after gynaecological surgery. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD001298. DOI: 10.1002/14651858.CD001298.pub3. | |||
| In this review, the effect of fluid and pharmacological agents on preventing adhesion in pelvic surgery is examined. It demonstrates how the use of some pharmacological agents can cause complications and that many only show limited benefits. More research that takes outcomes such as pregnancy rate into consideration is needed. | |||
| 2 | Sutures – Absorbable vs. nonabsorbable |
Quality Indicator
|
Type: Systematic review |
| Al-Abdullah T, Plint AC, Fergusson D. Absorbable versus nonabsorbable sutures in the management of traumatic lacerations and surgical wounds: A meta-analysis. Pediatric Emergency Care 2007;23(5):339-44. | |||
| This review was well written and of high methodological quality. It compares the cosmetic outcomes that result from the use of absorbable and nonabsorbable sutures. No significant difference was found between the two types of sutures, but very few studies have been done on this topic. | |||