Overview of surgical scar prevention and management

Abstract

Management of incisional scar is intimately connected to stages of wound healing. The management of an elective surgery patient begins with a thorough informed consent process in which the patient is made aware of personal and clinical circumstances that cannot be modified, such as age, ethnicity, and previous history of hypertrophic scars. In scar prevention, the single most important modifiable factor is wound tension during the proliferative and remodeling phases, and this is determined by the choice of incision design. Traditional incisions most often follow relaxed skin tension lines, but no such lines exist in high surface tension areas. If such incisions are unavoidable, the patient must be informed of this ahead of time. The management of a surgical incision does not end when the sutures are removed. Surgical scar care should be continued for one year. Patient participation is paramount in obtaining the optimal outcome. Postoperative visits should screen for signs of scar hypertrophy and has a dual purpose of continued patient education and reinforcement of proper care. Early intervention is a key to control hyperplastic response. Hypertrophic scars that do not improve by 6 months are keloids and should be managed aggressively with intralesional steroid injections and alternate modalities.

Keywords: Cicatrix, Hypertrophic; Keloid; Skin Tension Line; Skin Wound Healing; Surgical Wound.

Fig. 1

Langer's lines.

Fig. 2

Resting static tension lines on the face.

Fig. 3

Serial photographs of a healing wound from abrasion over the ankle. (A) At full epithelialization, (B) 3 months, (C) 6 months, and (D) 12 months from abrasion.

Fig. 4

Steroid injection in keloid. (A) Keloids over the sternum in a 62-yr-old female patient after open heart operation. (B) The keloid responded well after three injections of intralesional steroid.

Fig. 5

Radiation therapy after keloid excision. (A, B) Photographic views of a 15-yr-old teenage girl with keloids from ear piercing. (C, D) One year after surgical excision and radiation therapy.