Scarring after stitches: How to minimize a scar
Scars – NHS
A scar is a mark left on the skin after a wound or injury has healed.
Scars are a natural part of the healing process. Most will fade although they never completely disappear.
Types of scars
A scar can be a fine line or a pitted hole on the skin, or an abnormal overgrowth of tissue.
Normal fine-line scars
A minor wound like a cut will usually heal to leave a raised line, which will gradually fade and flatten over time.
This process can take up to 2 years. The scar will not disappear completely and you’ll be left with a visible mark or line.
Fine-line scars are common following a wound or after surgery. They are not usually painful, but they may be itchy for a few months.
A keloid scar is an overgrowth of tissue that happens when too much collagen is produced at the site of a wound.
The scar keeps growing, even after the wound has healed.
Keloid scars are raised above the skin and can be pink, red, the same colour or darker than surrounding skin. They’re often itchy or painful, and can restrict movement if they’re tight and near a joint.
Like keloid scars, hypertrophic scars are the result of excess collagen being produced at the site of a wound.
Unlike keloid scars, hypertrophic scars do not extend beyond the boundary of the original wound. They may continue to thicken for up to 6 months before gradually improving over a few years.
Pitted or sunken scars
Some scars caused by skin conditions, such as acne and chickenpox, can have a sunken or pitted appearance.
Pitted scars, also known as atrophic or “ice-pick” scars, can also develop as a result of an injury that causes a loss of underlying fat.
Scar contractures are often caused by burns.
They happen when the skin “shrinks”, leading to tightness and a restriction in movement.
Complete scar removal is not possible, but most scars will gradually fade over time.
A number of treatments are available that may improve a scar’s appearance and help make it less visible.
If scarring is unsightly, uncomfortable or restrictive, treatment options may include:
- topical silicone gel or silicone gel sheets
- pressure dressings
- skin camouflage (make-up)
A combination of treatments can often be used.
Read more about treating scars
Emotional effects of scarring
Scarring can affect you both physically and psychologically.
A scar, particularly if it’s on your face, can be very distressing. The situation can be made worse if you feel you’re being stared at.
If you avoid meeting people because of your appearance, it’s easy to become socially isolated. This can lead to depression.
See a GP if you feel your scars are making you depressed, or if they’re affecting your daily activities.
Read more about living with facial disfigurement and improving self-esteem.
Help and support
A number of support groups and organisations provide help and advice for people living with scarring.
How scars normally form
Scarring is part of the body’s natural healing process after tissue is damaged.
When the skin is wounded, the tissues break, which causes a protein called collagen to be released. Collagen builds up where the tissue is damaged, helping to heal and strengthen the wound.
New collagen continues forming for several months and the blood supply increases, causing the scar to become raised and lumpy.
In time, some collagen breaks down at the site of the wound and the blood supply reduces. The scar gradually becomes smoother and softer.
Although scars are permanent, they can fade over a period of up to 2 years. It’s unlikely they’ll fade any more after this time.
Stretch marks are narrow streaks or lines that appear on the skin’s surface when the deeper layer of skin (dermis) tears.
They’re often caused by hormonal changes during pregnancy or puberty, or as a result of bodybuilding or hormone replacement therapy.
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Page last reviewed: 23 October 2020
Next review due: 23 October 2023
Am I going to have a scar?
Whether I am seeing a patient after a chain saw accident in the emergency department or in consultation for a tummy tuck one of the most common questions I am asked as a Plastic Surgeon is “ Am I going to have a scar?” The quick answer is YES. Whenever an injury goes through the second layer of the skin (the dermis) a scar is formed. OK, so now you know the answer no matter what injury, procedure or surgery you have it will leave a scar if the dermis is injured.
So the next question is how visible or “bad” will the scar be. This depends on a multitude of factors. First the nature of the injury will in part determine how the resultant scar will look. A sharp cut with a knife or scalpel will leave a much less noticeable scar than a crush injury that results from a fall or motor vehicle accident. Crush injuries that result in open wounds do so because the skin has been crushed or scraped to a point that is can no longer handle the force so it splits or tears. Unlike a cut from a blade or sharp object where the location of the skin cut is the only injured area, the area or injury from a crush extends for a good distance around the open wound, this often leads to poorer wound healing and a more visible scar. Contamination of the wound with dirt, gravel or other substances can lead to infection or traumatic tattooing and therefore a more visible scar. Age and overall health status also play significant factors in wound healing. Children heal very quickly which is good but can lead to prolonged redness of scars or hypertrophic scarring. Elderly people heal more slowly and with less inflammation therefore in general produce less visible scars. Factors such as smoking, diabetes, family history of keloid formation and certain medications can inhibit wound healing result in worse scarring. Also some patients just tend to produce more visible scars. Finally location of the injury on the body can also affect the final appearance. Injuries or wounds over joints or high tension areas of the skin can result in more visible scars due to spreading of the scar. This is one of the reasons why incisions over joints are typically oriented longitudinally and not transversely.
The logical next question patients ask is what can be done to improve scarring or make the resultant scar less visible. The good news is there are many things that can be done to improve the final appearance. The first and often most important step to improved scarring is appropriate closure of the wound. This often but not always means stitches (sutures is the medical term) . Does it need stitches? Well depends what you mean by the word need. Many wounds wound heal without stitches but would take much longer to completely heal, have a higher risk for infection, and leave a horrible looking scar. So if you want the best possible chance of having the least noticeable scar the answer is often yes it will need stitches. Placing stitches (sutures) re-approximates the edges of the wound which helps in two ways. If the wound is gaping then the stitches will bring the wound together so that your body does not have to fill in the area in between the wound edges and will therefore heal quicker. The second aspect is to stabilize and realign the appropriate tissues so they heal to each other. It’s not just the stitches though, it is how they are placed, what type of sutures are used (there are over 20 different types of suture material), and how many layers of stitches are placed. Other factors at the time of repair that have an effect on wound healing include cleansing of the wound removal of contaminants, preparation of the wound by trimming crushed skin edges as needed and many other factors.
After the repair of the wound or surgical incision healing has just begun and by providing the right environment for healing scarring can be minimized. Wounds for the most part heal better in a moist environment which can be obtained with a variety of dressings and bandages. Vaseline or petroleum jelly based antibiotic ointments are easy to obtain and apply, and can increase the speed of healing due to maintenance of a moist environment.
Scars mature over the course of 6 months and sometimes up to one year. So that means final appearance can be influenced for six months up to one year. Several treatments have been shown to improve the final appearance of scars in scientific studies when used within this time frame. One the best proven ways you can help is to protect the area from the sun. The injury or incision site will be sun sensitive for 6 months. Either covering the area or using a SPF 30 sunscreen daily and a SPF 50+ for intense sun exposure every day for six months will make a significant improvement in scarring. Unprotected exposure to the sun even if just with daily activities will lead to discoloration or redness of the scar.
Silicone has been shown in research studies when applied near continuously (24hrs a day except while showering) to an injury to significantly improve the final appearance of scars. Silicone scar strips are great for areas where they will adhere and stay in place, most often on the torso. They are now made with opaque backing which will block the sun if used in a sun exposed area. The downside is that as stated they need to be in place nearly 24 hrs every day which is difficult on the face or extremities. In these locations I prefer a silicone scar gel which is typically applied twice a day make sure the area being treated has silicone on it nearly 24hrs a day. Unfortunately not all silicone scar gels are created equally. Also if you do not use one that has a sunscreen in it. You will need to add a layer of sunscreen over the silicone gel as the gels do not block UV. I prefer Silagen scar gel with sunscreen. Silagen has been shown to adhere to the skin strongly giving 24hr coverage when applied twice daily and also contains a non chemical sunscreen safe for children and those with sensitive skin. I recommend to apply an additional coat of SPF 50+ sunscreen and to re-apply this as directed for intense sun exposure such as outdoor sports or beach activities even when using the Silagen with sunscreen.
Finally just massaging the area of injury with anything from cocoa butter to emu oil has been shown improve the final appearance of the scar. It is not really the product at all but the actual mechanical force of the massaging that improves the appearance. Massaging 2-3 times per day 10-15 min is usually what I recommend but the more often the better.
If you have done all of the above or none of the above and still are not pleased with the appearance of your scar, don’t worry there are options. While not all scars can be improved, most can even after they have matured. While it is preferable to do everything possible to achieve the best outcome during the maturation period of your scar. Lasers, dermabrasion, chemical peels and surgical scar revision can significantly improve the appearance of scars but can never erase them. Schedule a consultation with a Board Certified Plastic Surgeon if you wish to discuss options to improve or treat scarring. The best way to prevent scarring is to practice appropriate safety precautions when possible. Stay Safe .
Raymond Jean MD Board Certified Plastic Surgeon Main Line Plastic Surgery www.mainlineplasticsurgery.com 484-245-6206
Everyday Cuts and Scrapes: How to Prevent Scarring
Ouch! Gardening, food preparation, sports and leisure activities, and life in general can result in occasional minor skin injuries. But scarring doesn’t have to be part of the picture. You can take steps to avoid ending up with a permanent reminder of your mishap — if you know what to do.
Proper treatment of all skin injuries is essential to avoiding scars, says Scott Hultman, M.D., M.B.A., a plastic surgeon who is the director of Johns Hopkins’ Burn Center and part of the Scar Revision Clinic team.
Hultman says, “Scarring can come from cuts — these are the most common injuries. But scrapes and burns can leave scars as well. Scars are more likely in injuries where the skin is not just cut but also crushed or otherwise damaged. Clean cuts can heal very well if they’re washed out and treated to avoid infection.”
If there’s no loss or destruction of skin and tissue, Hultman notes, “Stitches can be a great idea, since health care professionals are good at lining up skin borders, which can minimize scarring “
How Scars Happen
To understand how scars form and how to avoid them, it’s helpful to
understand your skin’s healing process. When you get a cut, scrape or burn,
your body immediately responds with a series of steps to heal itself:
The first stage is hemostasis. The body prevents blood loss by
sending platelets to the site, which bind together and seal the wound,
forming a scab.
Next comes inflammation. White blood cells arrive at the area
to fight off bacteria. You may notice redness, swelling, heat and pain.
This is a natural part of the healing process and resolves on its own
unless infection takes over. More inflammation in the healing process can
mean a greater chance of scarring.
Proliferation is the next step. This is when the skin and
vessels create new cells. As proliferation continues, you’ll see the edges
of the scab shrink toward the middle, leaving new skin behind.
Finally, maturation occurs. The wound is healed, and
there may be a scar in its place.
Once as scar has formed, are you stuck with it? Not necessarily. Plastic and reconstructive surgeons can do a lot to minimize scars and help you feel better about your appearance. Bonus: Some of these treatments can also address itching and pain associated with severe scars.
Here are some of the therapies available. You may need multiple or repeated treatments to get the results you and your doctor want.
- Topical treatments: medicated gels and creams, sometimes used with compression bandages to help flatten scars
- Injections: to fill scars that appear as “dents” or hollowed-out areas in the skin
- Skin smoothing procedures such as dermabrasion and chemical peels
- Laser therapy, which can flatten and soften scars and address abnormal skin coloration
- Bleaching for discolored areas
- Surgical removal of the scar
For the best chance of getting the results you want, choose a plastic and reconstructive surgeon with experience in minimizing scars, and be clear about what you hope to accomplish from the treatment.
Learn More from Scott Hultman
If you have a scar — large or small — or even an old one, there are more possibilities than ever before for minimizing its appearance.
Overview of Surgical Scar Prevention and Management
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: Skin Tension Line, Skin Wound Healing, Cicatrix, Hypertrophic, Keloid, Surgical Wound
Advanced understanding of stem cell lineages, biomolecular signaling cascades, cellular responses, and wound healing kinetics has shed much insight into the mechanism of wound healing. Significant findings in basic science research have been translated into clinical applications. Notable examples are biologic acellular matrices, negative pressure wound therapy, and bioabsorbable polymer products.
For most physicians and patients, however, clinical management of wounds continues to lag behind decades-old research. The plethora of ineffective commercial product (miracle scar creams, for instance) confuses and misleads patients, while the tsunami of basic science text amount to an indigestible intellectual burden for busy clinicians. The opinion of the authors is that a sixteen-page chapter out of general surgery textbook from the 1980s still contains 90% of the clinically relevant information found across multiple chapters in a contemporary multivolume plastic surgery textbook.
This article was prepared in an attempt to re-iterate the time-honored traditions of wound healing management and to clarify the most up-to-date rational for these traditions. We review the wound healing processes and discuss how these processes, especially the remodeling phase, relate to prevention and management of unsightly surgical scars.
The generic model of wound healing can be divided into three main processes: inflammation, proliferation, and remodeling. Inflammation commences with disruptions in capillary blood vessels and induction of hemostatic cascade. The leaked intravascular contents form fibrin clots, which are composed of fibrin mesh and platelets. This provisional extracellular matrix (ECM) in the wound paves the way for migration of various cells that participate in the wound healing process.
The second stage in wound healing is proliferation, which begins around day 4 or 5 with the migration of fibroblasts into the wound matrix. By 2 to 4 weeks, the fibroblasts are maximally up-regulated and replace the fibrin with a more robust matrix of collagen fibers. In the mature wound, the initial elastic fiber network is no longer observed and explains the firmness and absence of elasticity of scars (1). Another important aspect of the proliferative phase is the inward epithelialization of keratinocytes from the wound margin. Wound contraction begins around day 10 to 12, but this timing can vary with wound severity and general conditions of the patient (2).
The third and last stage in wound healing is the remodeling phase, which usually begins 3 weeks after tissue injury. Microscopic findings of this stage include decreases in fibroblast count, occlusion of blood vessels, and hardening of collagen fibers. Continuous collagen production and degradation has an effect of remodeling the mature wound matrix for approximately 6 months post injury. At this point, production and degradation balances each other, and no significant change in collagen amount is observed. The remodeling phase is the most responsible for intra- and interpersonal variations in scar qualities. A healing incisional wound can become an unsightly scar during this period.
Understanding these three main phases, wound healing can be optimized. Modifiable factors of incisional scar response include incision design, atraumatic handling of soft tissue, hemostasis, aseptic techniques, and tension reducing approaches in both the short and long-term postoperative setting (3).
Wound healing phases are not discrete. Proliferation phase begins even before the inflammation phase has completed and continues even as remodeling has begun. The remodeling phase itself continues long after the sutures have been removed and dressing abandoned. Because of this, the care of an incisional wound should be considered as a continual process, and minimizing scar formation should be a long-term goal. These are important aspects of wound management that must be emphasized to encourage patient participation (4, 5).
Skin tension and incision design
The external shape of human body is determined by the underlying bony skeletal framework, which the skin must cover. To conform to this complex shape, the skin must be both viscous and elastic to deform and return to its original shape. Mechanically, it needs to be both strong and flexible.
The tension vectors across the skin are specific to the volume and movement of the underlying structure, and high skin tension is most closely associated with scar formation. Unfortunately, quantitative measurement of skin tension is neither reliable nor practical in clinical settings. Instead, skin lines have been used as surrogate indicators of tension vectors. While a multitude of skin lines have been introduced over time (6), Langer’s line and relaxed skin tension line are the most widely known. A punch excision in the skin usually results in a circular defect that immediately deforms into an ellipse. When multiple punch excisions are performed and the major axes of these ellipses are connected, the resulting line is considered as a Langer’s line () (7). These lines run parallel to the main collagen bundles in the dermis but do not always follow the line of wrinkle.
Relaxed skin tension line (RSTL) is a furrow created when the skin is pinched and relaxed in the absence of local tension () (8, 9). Clinically, the skin is maximally extensible perpendicular to RSTL, and this implies that the tension is minimized when incisions are created along RSTLs. While Langer’s lines and RSTLs run in the same direction over many parts of the body, they are significantly different in mechanically complex areas such as the mouth corner, lateral canthal area, and temple.
Resting static tension lines on the face.
A proper understanding of skin tension vectors is crucial to incision design. In the opinion of the authors, improper incision designs are the number one reason for hypertrophic scar response observed in a remodeling wound. Great tension across an incision threatens to pull the skin edges apart. In response, the wound must try to hold itself together more tightly. Microscopically, this appears as increase collagen deposition. Macroscopically, the wound appears to become hypertrophic. The cruelty is in the timing. Because hypertrophic responses are observed months after an incision has been made, the surgeon cannot correct the errors of his/her ways – except perhaps to placate the patient.
In certain areas of extreme skin tension, hypertrophic response is unavoidable regardless of the direction of incision (i. e. shoulders). For this reason, traditional incisions almost always avoid the skin directly over extensor joints. The converse is also true; flexor creases welcome the scalpel with open arms.
Determinants of scar response other than skin tension
Blood supply is a significant factor in wound healing, and area of the skin with rich supply of vasculature is known to heal with finer scars. The face is a prime example.
From the major arteries, the blood flows through septocutaneous and musculocutaneous perforators, and supplies the fascial, subcutaneous, and dermal plexuses. Eventually, the blood exchanges nutrients and oxygen for carbon dioxide and other unwanted metabolites during the transit through dermal capillaries. The epidermis has no blood vessel, and nutrients are delivered from the dermis to epidermal cells by the process of diffusion.
A viable wound margin must receive its blood supply, and the blood supply has to come through one of two routes. Either it comes from a perforator vessel in the vicinity of wound bed, or it comes from a distant perforator vessel by the way of the dermal plexus. Often, the perforator vessels in the operative field cannot be preserved, especially if extensive undermining is required. In these circumstances, it is of utmost importance that the dermal plexus is respected. A skin flap created next to an old incision line is an island flap unless proven otherwise. If the few perforator vessels under the flap are divided during dissection, the surgeon has turned the flap into a full thickness composite tissue without any vascular supply. Many unfortunate abdominal incision wounds have died in this manner.
Aging tends to decrease skin tension and sebaceous gland activity, and as such, hypertrophic scars are observed with lesser frequency in the elderly. This is in contrast to incisional scars in children, among whom hypertrophic scars are common because of increased cellular activity, prolonged scar maturation, rapid physical growth, and increased skin elasticity.
Additionally, ethnic skin characteristics and their association to postoperative scar response have been well documented. People of European descent are more likely to form fine scars, while people of African descent appear genetically predisposed to hypertrophic scars and keloids.
Previous history of poor wound healing, hypertrophic scars, and keloids overrides all other patient factors. It is the patient with a keloid in the earlobe who is more likely to develop a keloid after a surgical incision.
While these demographic factors are just as important as respecting skin tension and blood supply, none of these is physiologically modifiable. Still, understanding these patient factors is important because the knowledge becomes a liability if not used as a part of informed consent. Untold, the liability has a tendency to grow with compound interest. Appropriate, patient-specific discussion during the preoperative visit can make the difference between a day in the courtroom and a thank you card after the postoperative follow up.
The operator experience and technique are known modifiable factors of outcomes relating to scar appearances, with increased experience associated improved aesthetic outcomes (10). The experience incorporates the time-honored incision designs used in various fields of surgery, as well as intraoperative techniques described as the 5 A’s – asepsis, absence of tension, accurate approximation, avoidance of raw surface, and atraumatic tissue handling.
Delicate instruments force operators to use as little traction and crushing force required to handle wound edges. In the same line, the smallest sutures that can adequately overcome wound tension is used in all layers of approximation. Non-absorbable sutures, such as nylon, should be removed as soon as the wound has gained the strength to hold itself together. With every skin closure, the surgeon must remember that the role of suture is to provide “approximation without tension”. It is the job of the fibroblasts and collagen fibers – not sutures – to hold the wound together.
Postoperative care in the first few days
Dressing materials are known to influence postoperative surgical wound healing and scar formation (11, 12). After closure, wound hydration is controlled with foam dressings, which is changed daily or every other day. The wound can be cleaned with saline or tap-water, but alcohol or iodide is cytotoxic to the cells trying to do the work of healing within the wound. These cleaning products from a by-gone era should not be used to clean a wound that is healing well without any signs of infection.
Postoperative care in the first week
Any non-absorbable sutures are removed, and skin tape is applied to reduce tension. At one week after the surgery, the tensile strength across an incision is only 3% of that of uninterrupted skin. This figure increases to 20% by the third week when remodeling begins and to 80% after three months. Therefore, skin tape should be applied across the incision for at least three months to reduce the tension the remodeling wound must bear (13). These load-bearing tapes are most appropriate on convex skin surfaces but are not mandatory over flexor crease incisions.
Postoperative care in the first three months
This is the time at which remodeling is at its peak during a normal wound healing process. While most properly designed and executed operative incisions will continue to heal without significant protest, those incisions destined for hypertrophic response will begin to reveal themselves during this period. Therefore, monthly clinic examination of the scar is reasonable. Patients should be encouraged to continue dressing the wound with skin tape. Additionally, each patient be counseled to return to clinic earlier than the appointed clinic visit if the wound is beginning to look “beefy” or “upset”. During this period, a scar can undergo hypertrophic response, which is discussed in the following subsection.
Keloids and hypertrophic scars
Keloids and hypertrophic scars are suboptimal consequences of skin wound healing, and are believed to be unique to human skin. These two clinical entities belong to a spectrum of fibroproliferative disorders, and are difficult to differentiate histologically in the absence of relevant clinical details (14).
Synthesis and degradation of collagen fibers define the remodeling phase. As a wound reaches maturity, extracellular cytokines change for cessation of further collagen synthesis and degradation. However, a number of genetic and environmental factors can interfere with this ‘stop’ signal, and the lack of negative feedback can lead to continual production of collagen fibers in the wound. Clinically, this response is observed as a hypertrophic scar.
A distinctive feature of hypertrophic scar is that, while its surface is elevated in relation to normal skin, the proliferation is contained within the margin of the wound. Under excessive tension, a scar can become wider and hypertrophic. However, the increase in collagen deposition does not continue beyond the wound margin.
Clinically, hypertrophic scars are often red and grow from 3 to 6 months (). Most hypertrophic scars begin to lose the redness and diminish in size around 6 months, and this process continues for 2 yr until the elevated surface flattens (15). Severe hypertrophic scars, however, can cause severe pain and pruritus. The latter often responds to antihistamine medication.
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.
Silicone gel sheets or silicone oil-based cream has been proved to be effective in limiting hypertrophic growth of scars (16), and are believed to decrease scar size by the increase in hydration and local skin temperature under the occlusive membrane (17, 18). In patients with predisposing factors for hypertrophic scar, silicone gel sheets should be applied as early as two weeks after an operation. The gel sheet is trimmed slightly larger than the scar, and is applied every two hours with 30-min rest intervals between. The interval is gradually increased to four hours with 30-min rest intervals. This is continued for up to six months after the operation. In locations where sheet attachment is difficult, scar cream can be used instead (19) upon complete epithelialization of the wound surface. The cream is topically applied 3 to 4 times a day and massaged for 5 to 10 min with each application.
While used more frequently for keloids, intralesional steroid injections are highly effective in the management of hypertrophic scars. As with keloids, the steroid (Kenalog 40 mg/mL) is injected directly within the fibrous portion of the scar (20, 21). The steroid inhibits expressions of genes related with collagen synthesis, which reduces collagen production and increases degradation.
In the face, 2.5-20 mg/mL of the mixture is injected, and 20-40 mg/mL can be injected for lesions elsewhere in the body. The injections can be repeated every month for 4-5 months. The total amount of one-time injection should not exceed 120 mg in adults and 80 mg in children. Because injections into the scar tissue requires significant amount of pressure, syringes with fixed needle or dermojet are used to deliver the mixture. The authors prefer the use of 1 mL syringe with fixed needle.
Steroid injection into subcutaneous fat of surrounding skin can result in skin atrophy, depigmentation, and telangietasis. In such cases, injections should not be repeated, and these changes ameliorate over time.
Pressure therapy can prevent some scar elevation (22) and should be started soon after clinical wound healing. Local hypoxia by physical pressure induces regeneration of fibroblasts, suppresses collagen production, and activates collagenase, which expedites collagen dismantling. The pressure should exceed 24 mmHg for more than 30 min every day for 3-12 months. Pressure therapy is physically uncomfortable. Patient compliance is expectedly low. Thus, results are highly dependent on patient motivation. This treatment significantly limits daily activity and should be reserved for more severe cases of hypertrophic scars.
Additionally, various forms of lasers, including Nd:YAG 1064, fractional laser, pulsed dye laser, IPL, Q-switched laser, have been reported to improve scar appearance (23, 24).
Ultimately, hypertrophic scars unresponsive to treatments above can be revised through excision. If the orientation of the previous incision placed the scar in the line of tension, a Z-plasty or W-plasty can be used to transpose the tension vector across the newly created incision.
Keloids are frequently observed in wounds experiencing high tensile forces. Additionally, predisposition to keloids are known to be passed down as autosomal dominant traits and are more commonly found in Africans and Asians than in Caucasians (15). More specifically, populations of African descent experience keloid incidences as high as 4.5 to 16 percent (25).
The feature distinguishing keloids from hypertrophic scars is the continued scar hypertrophy during the later phase of remodeling process between 6 and 18 months. A keloid scar grows beyond the original wound margin, turns from red to brown, and behaves like a benign tumor of the skin ().
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.
From a molecular biology perspective, a keloid is product of uninhibited deposition of collagen. Within a normally healing wound, proliferation of fibroblasts phases out, with cells undergoing apoptosis in the peripheral margin. This down regulation of fibroblasts and collagen deposition is also observed within hypertrophic scars in the late phase of remodeling (26, 27). In keloids, however, fibroblasts continue to proliferate despite the fact that the dermal matrix is more than strong enough to offset the tensile forces across the wound. Even after decades of research, the exact etiology behind keloids remains unclear (28, 29, 30).
Postoperative management of keloid begins with frequent survey of the incision site for early keloid formation. Silicone gel sheeting and silicone oil-based cream are often applied to keloids, but the outcomes are not as encouraging when compared to hypertrophic scars. Instead, the mainstay of keloid treatment continues to be intralesional steroid injections, which often result in significant improvements after 3 to 4 administrations. The steroids also improve pain and itching frequently associated with keloids. Unlike hypertrophic scars, however, keloids can recur after cessation of steroid injections. Follow up interventions are often necessary.
Physical pressure treatments generally are not effective, but one exception is found in magnetic pressure earrings. The ring can be applied on small keloids of the earlobe, and large keloids can be debulked prior to the application of magnetic earrings.
Keloids have been removed using a variety of surgical methods, from simple core excision with primary closure to complete wide-margin excisions and closure with skin grafts. Despite the variations in surgical techniques and adjunctive treatment options, relapse rates range from 45 to 100%. Radiation therapy is effective as an adjunctive treatment to surgical excisions (). In a previously study, the authors have found that radiation therapy was associated with an average decrease of 55% at 30 months of follow up (31). Although adjunctive radiation therapy decreases recurrence rate, non-discriminate use of radiation is discouraged because of increased risk of cancer with all ionizing forms of radiation. Nonetheless, reports of cancer cases after irradiation on keloids are rare.
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.
The use of intralesional steroids and radiotherapy do decrease recurrence rates, but this does little to comfort the patients still experience from recurrence after having exhausted all available forms of treatments. Prior to any surgical intervention, patients with significant personal or family history of keloids should thoroughly be counseled regarding the high likelihood of recurrence and the need for continued management.
Alternative approaches have been described in keloid literature. Chemotherapy agents, 5-fluorouracil and bleomycin, have been used in keloid (32, 33). Presently, novel modalities such as molecular targets (34) and mesenchymal stem cells (35, 36, 37) lack adequate evidence for clinical application.
Wound Healing and Care (for Teens)
We’ve all had cuts and scrapes that we can take care of at home. But what about more serious wounds — the kind that involve stitches or a hospital stay?
Different Types of Wounds
Most of us think of wounds happening because of accidents. But even clean surgical incisions are wounds. So are places where tubes or catheters go into the body. Skin is the largest organ in our body and helps protect it from germs (bacteria, fungi, and viruses) that live on its surface. So, anything that breaks the skin is a wound because when the skin is broken, there’s a risk of germs getting into the body and causing an infection.
The deeper, larger, or dirtier a wound is, the more care it needs. That’s why a team of doctors and specially trained wound care nurses work together to monitor and treat serious wounds.
Doctors and nurses start by evaluating a wound based on the risk of infection:
- “Clean” wounds — those that aren’t contaminated with bacteria — have the lowest risk of infection, making them easier to care for. The incision a surgeon makes on a person’s knee during ACL repair is likely to be a clean wound because the area is cleaned with an antibacterial solution before surgery — and it’s in a place where there’s a low risk of infection.
- Dirty or infected wounds, like an abscess, a deep scrape or cut, or gunshot wound, are a different story. They need special treatment and monitoring to prevent infection.
Sometimes a wound is clean but there’s a risk of infection because of where it is on the body. If the wound is in an area that has more bacteria — like the urinary tract, gastrointestinal system, or respiratory system — fluids and other contaminants could get into the wound and cause infection. Dirt or a foreign object in the wound also can increase the risk of infection.
Closing Serious Wounds
If a wound is clean, a doctor will close it by stitching the edges together in two separate layers. The doctor will use dissolvable stitches to join the deeper layer of tissue under the skin. Then he or she will staple, tape, or stitch the skin over it.
Sometimes doctors use dissolvable stitches or tape to join the upper layer of skin as well as the lower layer. Otherwise, the doctor will remove any surface stitches or staples after about 7 to 10 days.
Doctors don’t always close a wound right away, though. If there’s a chance a wound is contaminated, they will leave it open to clean it out (for example, with an animal bite). Closing a contaminated wound can trap bacteria inside and lead to infection. When they’re sure there are no remaining bacteria or other contaminants, they will stitch or close the wound.
Sometimes, doctors decide it’s best not to sew up a wound at all. If someone has lost a lot of tissue (like after a serious accident), it’s often helpful to leave the wound open to heal through natural scar formation.
Your doctor will also ask about your tetanus vaccine status, to make sure you are up to date.
The Healing Process
Before healing begins, the body gears up to protect against infection. For the first few days, a wound may be swollen, red, and painful. This
inflammationis a sign of the body’s immune system kicking in to protect the wound from infection. Keep your wound clean and dry at all times to help the healing process.
As the body does its healing work on the inside, a dry, temporary crust — a scab — forms over the wound on the outside. The scab’s job is to protect the wound as the damaged skin heals underneath.
Under the scab’s protective surface, new tissue forms. The body repairs damaged blood vessels and the skin makes
collagen(a kind of tough, white protein fiber) to reconnect the broken tissue.
When the work of healing is done, the scab dries up and falls off, leaving behind the repaired skin and, often, a scar. At this point, the scar will be almost 80–90% the strength of normal skin. It’ll take a few months for the scar to be back to 100% strength of normal skin.
Why do scars look different from normal skin? Our skin is made up of two proteins: elastin, which gives skin its flexibility, and collagen, which gives it strength. But because the body cannot create new elastin, scars are made entirely of collagen. So they’re tougher and less flexible than the skin around them.
Caring for Serious Wounds at Home
Serious wounds don’t heal overnight. It can take weeks for the body to build new tissue. So after you leave the hospital or doctor’s office, good home care is important to prevent infection and minimize scarring.
Because wounds can be so different, your doctor will give you instructions on how to take care of yourself after you go home from the hospital. In most cases, doctors will ask patients to:
- Keep the wound covered with a clean dressing until there’s no more fluid draining from it. A doctor or nurse will give you instructions on how to change your dressing and how often.
- Wait about 2-4 days after surgery before showering. Because each case is different, ask your nurse or doctor what to do before you can shower again.
- Avoid soaking in the bathtub or swimming until your next doctor visit. Dirt in the water could seep into the wound and contaminate it. Also, there’s a risk that a wound might pull apart if it gets too wet.
- Try to keep pets away from the wound.
- Avoid picking or scratching scabs. A scab may itch as the skin underneath heals, but picking or scratching can rip the new skin underneath. The wound will take longer to heal and the scar it leaves may be worse.
Our bodies rely on vitamins and minerals to heal. Try to eat healthy foods — especially lots of vitamin-rich fruits and vegetables and lean proteins — while your wound heals. Drink plenty of water and eat high-fiber foods like whole grains to avoid constipation. (Constipation can be a side effect of pain medicine.)
Your wound might heal quickly, but scars can take longer. For thick scars, try massaging the area with lotion or petroleum jelly. Doing this helps the collagen mingle with the elastin in the surrounding skin, decreasing some of the scarring. But ask your doctor or a wound care nurse if massaging the wound is a good idea before you try it.
When Should I Call the Doctor?
If a deep or large wound gets infected, it can be a serious problem. Call your doctor or surgeon right away if any of these things happen:
- You develop a fever or swollen glands (or both).
- You have increased pain even though you are using pain medicine, or the pain radiates out beyond the wound area.
- The area around the wound is getting more swollen.
- There’s an expanding area of redness around the wound or red streaks on the skin around the wound.
- You see blood or pus draining from the wound.
- You have signs of dehydration, such as peeing less, dark pee, dry mouth, or sunken eyes.
There’s good news about wound healing when you’re a teen: Age is on your side because young bodies heal faster.
It may be frustrating having to hold back on activities like sports while a wound heals. But if you take good care of yourself and follow your doctor’s advice, it won’t be long before the wound is a distant memory.
Scars & Healing – Mark Henley
Anytime there is an incision or cut in the skin, there is going to be a scar. Mr Henley says, “There is no such thing as no scar – it cannot be completely eliminated.” However, the goal is to make any scar as small and discreet as possible. Plastic surgeons take great care with ‘sewing up’ the skin and are also good at hiding scars in places that you may not see. Be mindful though, however good the surgeon, scars are a natural part of the healing process.
How long will it take my scar to heal?
“We usually advise people that it takes about a year for them to judge the final results from any cosmetic surgery treatment”, says Mr Henley.
“Usually the scars will heal rather quickly – within the course of a few weeks to one or two months – but you may not see final results for up to a year. Individual factors also influence how quickly your body is able to recover from a wound.”
In older patients, or where the skin is more lax, scars settle more rapidly. In younger patients, or where the skin is more taught, it will take eighteen months to two years before the scar is mature.
What will my scars look like?
This will of course depend on the operation site and a number of personal factors come into play. However, there are three distinct stages to healing and your scar will have a different appearance during each stage.
The three phases to healing are the inflammatory stage, the proliferative stage and the remodelling stage. The inflammatory stage begins immediately and lasts a few days. During this time, the bleeding stops and white blood cells come to the site and fight any infection. The wound at this point will look red and swollen and pink.
Scar at one week
Scar at eight weeks
Scar at one year
After this, the proliferative stage takes place and continues for about three to four weeks. (To proliferate means to grow by rapid production). Fibroblasts (cells that are capable of forming skin and other tissue) gather at the site of injury. One of the most important duties of the fibroblasts is to produce collagen. Collagen is important because it increases the strength of the wound. The collagen continues to be produced for two to four weeks, pulling the edges of the wound together, and new capillaries (tiny blood vessels) are formed to aid the healing process. After this time, destruction of collagen matches its production and so its growth levels off. Abnormal scars can develop if this stage goes ‘faulty’.
The scar becomes thicker, red and contracts. It makes the scar more obvious and uncomfortable. The unpleasant appearance understandably causes some people concern at this point.
Finally, the remodelling stage begins and continues for a period from several weeks to a few years. Scar remodelling is what changes a thick, red, raised scar to a thin, flat, white scar and over the course of time, your scars will usually fade and become barely noticeable.
Personal factors that affect wound healing
How you heal will depend greatly on your genetics, for example, darker skin can produce darker and thicker scars.
- Certain illnesses such as diabetes, thyroid disease, high blood pressure and poor circulation can decrease the body’s ability to heal.
- Nutrition – Studies show that your body needs zinc, vitamin C, protein, iron, adequate calories, vitamins and minerals to heal effectively.
- Your age – Younger people generally heal more easily than older people, but older people’s scars fade more rapidly.
- Non-smokers, on average, heal more quickly than smokers.
- Skin quality and blood supply to an area. For example, skin that has already been thinned and stretched through the weight of heavy breasts is at increased risk for raised, wide or irregular scars.
Abnormal scars – Keloids and Hypertrophic Scars
Keloids are large, bulky, raised, reddish scars that develop at the site of an injury or operation site. They can be very unsightly indeed. Unlike other scars, they gradually grow bigger.
This will of course depend on the operation site and a number of personal factors come into play. However, there are three distinct stages to healing and your scar will have a different appearance during each stage.
The three phases to healing are the inflammatory stage, the proliferative stage and the remodelling stage. The inflammatory stage begins immediately and lasts a few days. During this time, the bleeding stops and white blood cells come to the site and fight any infection. The wound at this point will look red and swollen and pink.
Normal Scar following a face lift
With keloids, the fibroblasts that make the collagen continue to multiply even after the wound is filled in. Thus, keloids grow above the surface of the skin and form large mounds of scar tissue. “It is often described as the scar that doesn’t know when to stop”, says Mr Henley.
Keloids can occur anywhere on the body, but are most common on the ears, neck, shoulders, upper arms, chest, or back. Symptoms include pigmentation of the skin, itchiness, redness, unusual sensations and pain. Although anyone can form a keloid scar, some ethnic groups are more at risk. People of African or Asian descent are more likely to develop keloids than people with lighter skin. However, people with ginger hair and very fair skin are also at increased risk of hypertrophic or keloid scarring. Men and women are equally affected.
Says Mr Henley, “The upper arm was specifically chosen as the most appropriate site for a TB vaccination on the basis that poor scarring could occur in that area. This allowed teams of doctors to quickly and easily check if populations had been vaccinated without the need to look at any medical records or other paperwork. All that had to be done was to line people up and inspect their left upper arms.”
There is a genetic component to keloid scarring. If someone in your family has keloids then you are at increased risk.
A hypertrophic scar looks similar to a keloid. Hypertrophic scars are more common, but they don’t get as big as keloids and often subside by themselves (a process that can take up to one year or more). They occur in all racial groups.
A hypertrophic scar remains within the length of the original wound. If it grows beyond the original wound’s boundary, it becomes a keloid scar.
Treatments for scars
Different scars need different treatments. Do not be surprised if Mr Henley advises leaving the scar alone for a while to see if this problem resolves on its own, particularly if it is less than a year old. Mr Henley might recommend compression therapy, intense pulsed light or laser therapy, steroid injections, application of a special silicone sheet or scar revision surgery.
Do scar treatment creams work?
There are a variety of skin treatment and scar creams out on the market. For some of the thickened, raised or hypertrophic scars, there have been some studies that show that silicone gel sheeting or other treatments do work. However, “For a healing, straightforward scar, I would leave it alone”, says Mr Henley, “although it is, of course, important to watch for further scientific advances in this field.”
What treatments are there for new scars in plastic surgery?
There has been a lot of research recently into laser treatment for young scars. Young scars are those that are within a year or two old. They are either pink or red and they don’t have the mature, light quality of the older scars. Some of the lasers that are available now may be effective on newer scars, but some of the older scars probably won’t benefit from laser treatment.
What can I do to give my wounds the best chance of healing?
“Cover up!” Mr Henley cautions, “Sun-block is vitally important if the scar is on exposed skin. Scars do not contain the normal pigments that protect skin and so burn easily. The sun can also either lighten or darken the scar and that’s really what you want to avoid.” He advises to keep those scars or incision sites hidden from the sun. ”If you can’t wear clothing, the best thing is SPF 30 or higher. This should be generously applied making sure all scar areas are covered.” When exercising, you can also cover any scars with a plaster. The plaster works as a splint, preventing the scar from being stretched or pulled too much.
Don’t smoke or use nicotine substitutes! Nicotine in any form (cigarette, patch, gum) causes the blood vessels to constrict. This decreases the delivery of oxygen to your wound, preventing sufficient nutrients from being delivered to allow adequate healing to take place.
Although oxygen delivery is important in any wound, it is especially important when the skin has been separated from underlying structures, creating a flap.
A flap is formed in many cosmetic procedures, such as face-lifts, neck-lifts, breast-lifts and tummy tucks. If you smoke, you are greatly increasing your chances that the skin flap will die, leaving you with an even larger problem than you started with. This is because among other things, cigarette smoke contains carbon monoxide, which reduces the oxygen carrying capacity of the red blood cells. It causes the small blood vessels in the skin to go into spasm and also causes the platelets, which start the blood clotting process, to become much stickier. This combination can cause the oxygen supply to the tissues to fail, killing the flap.
The risk of complications is so high for some cosmetic procedures that Mr Henley will not operate on you if you smoke. So, if you are planning cosmetic surgery, stop now and make sure that you can comfortably stay stopped before you plan any surgery.
Stick to the post-operative instructions! Too much movement can cause fluid to collect (swelling) and interfere with the laying down of collagen which is necessary to hold the wound together. In more drastic cases, the force of movement can pull the incision apart. In general, the less tension on the wound, the less the scar will widen with time. After surgery, Mr Henley may limit your exercise regime, range of movements, lifting or driving for a while. He may also supply you with special post-op compression garments to promote healing by limiting bruising and pushing excess fluid out of the operated area.
Have a healthy diet! A balanced diet will ensure that you have the right nutrients to promote healing. The body particularly needs a good supply of vitamin C to make collagen.
Caring for Your Incision After Surgery
When you’re recovering from surgery, the last thing you want is a problem with your incision. An incision is the cut or wound from a surgery. It is sewn closed by your doctor. It may also be stapled, taped, or glued closed. With proper care, it turns into a scar. Taking care of your incision after surgery is important to your health. Proper care can reduce the risk of infection and help you return to normal sooner. Incisions vary by size and location.
Path to improved health
After surgery, your doctor will tell you how to care for your incision. His or her instructions might include:
- When to remove the bandage.In some cases, your bandage should be removed the day after surgery. This depends on the location of the surgery, the seriousness of the surgery, and incision. Most wounds don’t require a bandage after a few days. However, you may decide to wear a bandage to protect the incision.
- Keep your incision dry.This is especially true for the first 24 hours. Avoid showering or bathing the first day. Try taking a sponge bath instead. It’s usually okay to wash with soap and water by the second day. Take a shower instead of a bath if you have stitches or skin tape on your incision. Gently towel-dry the incision after washing.
- Removing the stitches.This is done by your doctor. You should not remove your own stitches. He or she will remove stitches that don’t disappear into your skin on their own. Those types of stitches are usually removed 3 days to 3 weeks after surgery. This will depend on where they are and how quickly you heal. Your doctor may apply skin tape after the stitches are removed. Skin tape provides additional wound support. The tape can be removed in 3 to 7 days. Sometimes, your incision will be closed with internal stitches (stitches under the surface of your skin). Those typically are absorbed by your body gradually and don’t need to be removed. Healing skin may need months to regain most of its strength.
- Limit movement around the stitches.Limiting movement of the area around your incision improves healing. Avoid activities that could cause your incision to pull apart. Your doctor may ask you to avoid lifting, straining, exercise, or sports for the first month or so after surgery. Call your doctor if the incision pulls apart.
- Always wash your hands before caring for your incision. Ask your doctor if you need to use a rubbing alcohol-based soap or wipes to clean the wound.
Things to consider
- If you incision breaks open, call your doctor. Your doctor may decide not to close it again with stitches. If that happens, your doctor will show you how to care for your incision a different way. This will likely involve the use of bandages to absorb the drainage that comes from the incision. The bandages will have to be changed frequently. The incision will heal in time, from inside out. People who have diabetes are at risk of wound care problems. This means wounds heal more slowly and require more care.
- If your incision is red, this may be a sign of infection. Some redness is normal. However, call your doctor if the redness is increasing or if it spreads more than half an inch from the wound. Call your doctor if you see pus in the incision or if the incision is more than mildly tender or painful. Your doctor may ask you to apply an antibiotic ointment to the incision. This does not require a prescription.
- If your incision bleeds, replace your bandage with a clean, dry bandage or gauze. Apply pressure directly to the incision for a few minutes to stop the bleeding. If it continues to bleed, call your doctor.
- If you’re outside in the sun, cover your scar with tape or sunscreen for the first 6 months after surgery. A healing scar will darken and become more noticeable if it gets sunburned.
Questions to ask your doctor
- Can a new incision become infected during my hospital stay?
- How can I prevent my clothing from irritating my incision?
- Does it hurt when the stitches are removed?
Centers for Disease Control and Prevention: Frequently Asked Questions About Surgical Site Infections
National Institutes of Health, MedlinePlus: Would care centers
Copyright © American Academy of Family Physicians
This information provides a general overview and may not apply to everyone. Talk to your family doctor to find out if this information applies to you and to get more information on this subject.
Correction of the postoperative scar of the anterior abdominal wall
Abdominoplasty is most often performed to tighten the skin of the abdomen: loose soft tissues look ugly. But this operation helps to remove other problems as well: to restore a normal muscle frame, to save a person from an umbilical or incisional hernia, to remove scars and scars after a cesarean section.
In Operating Room 1 in Aleksandrov, abdominal plastic surgery is performed by experienced doctors using various methods of aesthetic surgery.The way to eliminate defects and the type of anesthesia are selected individually for each patient after the tests, visual examination and conversation.
Types of abdominoplasty
The following types of abdominoplasty are performed in our center:
- Mini operation. During the procedure, defects in the lower part of the peritoneum are removed. The procedure helps to get rid of loose and sagging skin. The scar after the mini-intervention is small, not conspicuous.
- Traditional abdominoplasty.The doctor removes excess fat, sutures the muscles of the abdominal wall, removes excess skin in this area and transfers the navel. After such an operation, more visible scars are formed.
- Endoscopic deformity correction . The surgeon sutures the muscles through the incisions, almost without touching the skin. Scars after endoscopic abdominoplasty are minimal. However, the procedure is more suitable for young women with firm and elastic skin who want to have a beautiful flat stomach after giving birth.
In difficult cases and with an increased risk of recurrence / entrapment of a hernia, surgeons strengthen the abdominal wall with a polypropylene mesh. It helps to restore a person’s own connective tissue, strengthens the muscle frame.
Indications for abdominoplasty
The procedure is desirable in such cases:
- after a cesarean section or other operation, when rough scars and stretch marks have formed on the abdomen;
- with an excess of belly fat, which cannot be removed with the help of sports, diet, hardware cosmetology;
- for sagging skin on the abdomen that has lost its elasticity.
Hernias of the abdominal wall must be removed by the surgeon in any case: they often lead to entrapment of the intestine and various complications. The same applies to diastasis (divergence of the muscles of the abdominal wall).
Contraindications to surgical treatment of abdominal scars
The procedure cannot be done in such cases:
- the patient has exacerbated chronic diseases or an infection;
- the patient has a weak heart or has heart failure;
- a person has impaired blood clotting or systemic diseases of the connective tissue.
90,011 people suffer from diabetes mellitus or thyroid diseases;
Preparation for operation
First, you make an appointment with a surgeon in Operating Room 1. He collects anamnesis, examines the problem area, assesses the muscle tone and elasticity of the skin, finds out the thickness of the subcutaneous fat layer.
After that, the patient undergoes tests and 2-3 weeks before the operation stops taking drugs that affect blood clotting, begins to use vaso-strengthening drugs.
You must not smoke or drink alcohol for 1 month before the operation.For 2 weeks it is necessary to remove sweet and starchy foods from the diet in order to slightly reduce body weight and prevent gas formation.
2-3 days before the procedure, it is necessary to give up physical activity and start taking light herbal sedatives.
They do not have breakfast or lunch before the operation. The doctor marks the problem area, and the anesthesiologist does anesthesia.
Rehabilitation after surgical correction of abdominal scars
For 1 month after the operation, you need to wear compression garments and be at rest.Sports should be postponed. Discomfort in the abdominal area is possible. In this case, you must take pain relievers prescribed by your doctor.
2 months after plastic surgery, patients wear stickers along the suture line, thanks to which the scar is small and invisible.
For 8-9 months, a cream is applied to the incision site to prevent new scars. Laser correction is possible if a small scar does form.
The healed cosmetic seam after abdominoplasty is almost invisible and is located below the bikini line.Women can wear two-piece swimwear and feel comfortable with their bodies.
The effect after the operation will be noticeable in 2 weeks, when the edema subsides, and will persist for 12-15 years after it is performed. Exercise and a balanced diet contribute to the prolongation of the effect. If the woman becomes pregnant, the abdominal muscles and skin may stretch again and the plastic will have to be repeated.
Advantages of abdominal scar correction in Operating room # 1
- The center employs experienced surgeons with extensive clinical practice, who know all the intricacies of abdominoplasty.
- Anesthesia is selected individually.
- Modern equipment is used for operations.
- The hospital has created the most comfortable conditions for recovery after plastic surgery.
You can make an appointment with a surgeon to correct postoperative abdominal scars any day by phone or online.
How are scars formed
What is it?
They remain for life, often creating noticeable cosmetic and functional defects.Disfiguring scars, scars that restrict even small movements, can cause serious difficulties for patients, both in business and in personal life. People who, by chance, faced with this problem, should know that the quality of most scars can be improved to one degree or another.
Mechanism of scar formation
Wound healing is a complex biological process that lasts about a year and ends with the formation of a mature scar. After a year, the scar tissue continues to change, but very slowly and imperceptibly.
From a physiological point of view, several links in scar formation can be distinguished: tissue damage -> damaged cells release biologically active substances -> biologically active substances trigger an inflammation reaction and attract cells that produce collagen (fibroblasts) to the injury site -> new collagen synthesis begins – > a “young” scar is formed (red, edematous, towering over the skin) -> 3 weeks after the injury, excess collagen dissolves, and a normal scar is formed (pale, flat).If you look at normal scar tissue under a microscope, you can see how the collagen fibers are arranged in an orderly manner – they are packed compactly and stretched parallel to the surface of the skin.
In some cases, the normal process of scarring is disrupted. There are many reasons for this: burns, wound suppuration, lack of adequate juxtaposition of gaping edges, strong tension of the skin surrounding the wound, features of the body’s immune system, hereditary predisposition, etc.
The disorder usually occurs at the stage of collagen synthesis and resorption of its excess.Instead of the usual flat scar, a sunken or protruding scar is formed, and in more rare cases, a keloid scar.
From a practical point of view, it is important to monitor the anatomical, visible changes in the healing tissue. For the doctor and the patient, two characteristics of the scar become relevant – strength and appearance. The developed clinical and morphological classification of the stages of healing makes it possible to track the stages of healing in a timely manner and select the appropriate types of scar correction.
Stages of healing
Stage I – inflammation and epithelialization (7-10 days after injury). Post-traumatic skin inflammation gradually decreases. The edges of the wound are connected to each other by fragile granulation tissue, there is no scar as such. This period is very important for the formation of a thin and elastic scar in the future – it is important to prevent suppuration and dehiscence of the wound edges. For these purposes, surgeons apply cosmetic fixing sutures with a special atraumatic suture material (very thin threads with a round cross section) and prescribe topical anti-inflammatory drugs for daily dressings.Restriction of physical activity is recommended, since frequent movements of muscles, tendons and ligaments under the wound can provoke the dehiscence of the wound edges.
Stage II – formation of a “young” scar (10-30 days after injury). Collagen and elastin fibers begin to form in the granulation tissue. There is an increased blood supply to the area of injury – a scar of bright pink color. Until the fibers have matured, the scar remains easily stretchable, therefore, in this period, repeated external trauma and excessive physical efforts should not be allowed.
Stage III – the formation of a “mature” scar (30-90 days after injury). The number of collagen and elastin fibers increases significantly, the fibers begin to line up in definitely directed bundles. The number of vessels decreases – the scar thickens and becomes pale. Physical activity is allowed in the usual amount. At this stage, unfavorable conditions (see above) lead to the formation of hypertrophic and keloid scars.
Stage IV – final scar transformation (4-12 months after injury).Scar tissue matures slowly – vessels disappear completely from them, collagen fibers line up along the lines of greatest tension. The scar becomes light and dense. Already at the beginning of this period, the surgeon can finally assess the condition of the skin scar and determine the type of surgical correction.
Types of scars
Normotrophic – occur as a result of the normal reaction of the connective tissue to injury. These are flat scars of light color with normal or reduced sensitivity and elasticity close to normal tissues.These scars are optimal.
Atrophic scars – occur as a result of reduced connective tissue response to injury. Not enough collagen is produced. Atrophic scars are located below the level of the surrounding skin (sink). With a small width, they practically do not differ from normotrophic ones.
Hypertrophic scars are the result of an excessive reaction of the connective tissue to trauma against the background of unfavorable healing conditions (inflammation, stretching of the scar).Fibroblasts with increased activity synthesize an excess amount of collagen, its excess is not fully absorbed. Externally, a hypertrophic scar is a slightly compacted cord (in the form of a rope) protruding above the surface of the skin, the width of which can vary. The size of the scar corresponds to the previous skin injury. Hypertrophic scars are able to smooth out 1-1.5 years after injury, but not always completely.
Keloid scars develop as a result of a perverse tissue response to injury.As a rule, keloids are formed against the background of decreased indicators of general and tissue immunity. Keloids have an elastic consistency, uneven, slightly wrinkled surface, significantly protrude above the skin surface. Sometimes they look like warts. Keloid scars are constantly growing – sometimes quickly, sometimes slowly, their growth can be accompanied by itching, burning and pain. As a result of continuous growth, the volume of the visible part of the scar can be several times greater than the volume of its intradermal part. Keloids are not capable of spontaneous regression.A typical example is keloid scars that form after piercing the earlobe to wear jewelry.
Source: Medical Center “ Paracelsus 2001″
- Zhang H., Zhang Y., Jiang YP., Zhang LK., Peng C., He K., Rahman K., Qin LP. Curative effects of oleanolic Acid on formed hypertrophic scars in the rabbit ear model. // Evid Based Complement Alternat Med – 2012 – Vol2012 – NNULL – p.837581; PMID: 23326292
90,000 Scars: marks with their history
Magazine “Cosmetologist” No. 4, 2005
To combine all existing methods of treating scars, the latest global trends in this area, a Scar Correction Center has been established in Ukraine at the Institute of Dermatology and Cosmetology of Doctor Bogomolets in Ukraine. It is logical that to cover this topic, we turned to the authoritative opinion of the specialists of this particular institution.“By treating and correcting the scar formed as a result of wound healing, the Center not only improves the patient’s appearance, but also helps to erase the tragic moment of his life from the memory of the victim,” says Olga Bogomolets, MD, coordinator of the European Association of Laser Dermatology in Eastern Europe, chief physician of the Institute of Dermatology and Cosmetology, Dr. Bogomolets.
CUTTING – ORGANISM REPAIR PROCESS
Scars always form at the site of injury.If they were not there, the defects would not heal. A scar is a ligament that connects tissue that does not function as a skin. There are no sweat and sebaceous glands, hair follicles in it. It is less elastic, but it fills the defect, so scar formation belongs to a whole group of repair processes that take place in the human body.
“Any scar should be under the supervision of a specialist,” says Igor Safonov, chief physician of the Scar Correction Center. – Usually, after three months, an untreated scar grows with blood vessels, and after nine months, the scar grows to the entire depth of the lesion with nerve tissue and already belongs to the body, that is, it is already a piece of human tissue.Such scars are difficult to correct. If a person comes after the operation, when they have just removed the stitches, this is the most favorable moment for the formation of a new, more aesthetic smooth scar.
After the operation, the scar gradually fades and becomes compact, this process is called physiological scarring . But sometimes the opposite process is suddenly discovered – the scar grows, becomes brighter, turns red or turns blue. In this case, pathological scarring develops, and urgent specialist intervention is needed to make a decision on the correction of the process.
Physiological scarring has three stages.
1) stage (fibroblastic) lasts up to 30 days, is characterized by the proliferation of young fibroblasts, an abundance of blood vessels, epithelialization by 18 days, the formation of a large amount of amorphous substance in the scar tissue and the production of reticular fibers.
2) stage (fibrous) is formed by the 33rd day from the moment of injury, is characterized by the presence of mature fibroblasts and the accumulation of fibrous structures in the scar tissue, primarily collagen fibers.
3) stage (hyaline) is formed by 42 days, characterized by hyalinosis of collagen fibers of scar tissue, a decrease in the number of cells and blood vessels.
Until 26 days, physiological (normotrophic) and pathological (keloidogenesis) scarring are similar.
What are the differences in the course of pathological scarring?
At stage 1 (fibroblastic) , against the background of an abundance of young fibroblasts, their perivascular clusters – “nodules” appear.The fibroblastic stage in keloid scars lasts up to a year; over time, maturation is observed only in the deep layers.
Stage 2 (fibrous) juvenile fibroblasts continue to dominate quantitatively and form large clusters.
At stage 3 (hyaline) , the number of young fibroblasts also does not change, but the synthesis of immature components of the intercellular substance is activated, and in the future the tissue has no tendency to maturation.
WHEN NOT BEFORE BEAUTY
The appearance of the scar always carries certain information and has its own history.In a situation when an ambulance is provided to a person, surgeons do not think about the beauty of the seam – it is about saving lives and minimizing blood loss. And only then there is a need to refine the scars, since after a hasty suturing, “pockets” (non-joining areas) may form in some areas of the skin. Sometimes the scars are colored – the so-called forced tattooing of a greenish-blue color, if brilliant green was used when treating the wound, or gray – if small particles of asphalt or gunpowder remained in the wound.Particles are gradually drawn in by the skin and go deeper, this must not be forgotten.
Wound healing – beginning of scar formation. What it will be – largely depends on the leading doctor. It is believed that crusting is a good sign. In fact, the crust (dead cells of the epidermis, leukocytes and erythrocytes, as well as particles of foreign bodies trapped in the wound), pulling together the tissues, does not allow the normal formation of new, young connective tissue. If you do not use special ointments that soften the crust as much as possible, a rough scar will form under it, which in the future will require secondary treatment – more complex than the initial formation.Therefore, at the stage of wound healing, from the very moment of suturing, it is important to prevent secondary infection, as a result of which deforming or disfiguring hypertrophic scars (rising above the skin surface) may occur.
KELOID SCARS REQUIRE CAUTION
There are “flammable” spots on the skin (décolleté, shoulder and back of the neck under the hair), where any slight violation of the integrity of the skin can lead to the formation of a rough scar.By the way, it is in these places that for some reason they really like to get tattoos. With unskilled removal of a neoplasm in beauty salons or hospitals in these areas of the skin, there is a high probability of the formation of a keloid scar, which has a conditionally tumor nature. The area of the scar can be ten times the area of the removed mole. Keloid scars rise above the skin and differ from hypertrophic or atrophic (below the skin level) in appearance, in their unpredictability and painful sensations during growth.They, unlike other scars, can increase in size, react to temperature changes after a shower or sun exposure. Therefore, people with keloid scars should avoid the sun. Such scars can be the result of any minor scratch, pimple, acne or piercing and appear in the place where there was even an imperceptible damage or abrasion of the skin.
There is still a lot of unexplained in the study of keloid scars. For example, the cause of their appearance has not been completely studied. But it has definitely been established that this disease is familial – if one of the parents had such a scar, children need to be careful.In addition, a connection with blood group A was found. Keloid scars are the lot of young people (from 10 to 30 years old), in whom the function of the skin is strong enough, the body grows, there is an increased synthesis of collagen. If the keloids are not touched, they can decrease by old age, because the breakdown of collagen begins to prevail in the body over its synthesis. It has been noticed that dark-skinned races are more likely to suffer from this disease, and their scars themselves are much larger.
What is a keloid in essence? Keloids (from the Greek kele – claw and oides – similar) belong to the group of pseudotumor fibromatosis and are the result of dysregeneration of the connective tissue of the dermis. Healing with a keloid is one of the variants of the pathological cicatricial process, which is realized under the condition of a combination of predisposing and initiating general and local factors and is characterized by a violation of the staging of the dermis repair.
Keloid scars are epithelialized dense tumor-like formations that rise above the skin surface with a smooth shiny, sometimes bumpy surface. The edges of the scar are clearly contoured with normal skin or gently sink into the surrounding tissue in the form of a “cancer claw”.There is always invasive growth beyond the original lesion. Subjective sensations – itching, pain, burning.
The development of keloids is due to a complex complex of etiological factors of endo- and exogenous nature. Among endogenous factors, both general and local factors should be considered. General factors (hereditary predisposition, including fermentopathies, manifested at the tissue level, hormonal imbalance, the state of the central nervous system) create the background for the formation of keloids.The provoking factor of keloidogenesis should be considered trauma, the vastness, topic and nature of which are important for subsequent regeneration. Local factors that are important for the development of keloid are tissue hypoxia and intercellular interactions.
Most often, keloid-type healing occurs in the areas of the sternum handle, upper back, shoulder, earlobes. These are areas of the skin that are constantly under tension or directly cover the bony protrusions, and also have other anatomical features that predispose to the development of keloids.
Areas in which keloids rarely develop include the lower back, abdomen, lower extremities, distal upper extremities, central face and genitals, and areas of the body where skin tension frequently changes, such as skin folds. The mechanical factor is also important in the development of the keloid: the appearance of keloids during wound healing by primary intention is associated with the intersection of the Langer lines by the operating wound.
Let’s talk separately about Dumbbel’s keloids.It is a spherical keloid that develops on the earlobes. The increased content of estrogens in the keloid on the auricle suggests that their development is provoked by a local endocrine imbalance.
How does keloid scars develop?
At the stage of epithelialization , the injured area is covered with a thin film of squamous epithelium, after 7-10 days it begins to coarse and slightly thicken, its color from pink becomes paler.In this state, the scar is 2-2.5 weeks.
The stage of swelling is characterized by scar hyperemia, tenderness on palpation and an increase in volume, so that the scar rises above the level of the skin. After 3-4 weeks, the soreness decreases, and the redness increases, acquiring a cyanotic hue.
At the stage of compaction , the scar is compacted throughout, focally covered with dense plaques, becomes bumpy and looks like a keloid.
In the softening stage , the scar turns pale, becomes soft, mobile, painless.The process can go into the stage of softening, and the scar will retain its keloid character.
Keloids can also be subdivided into young and old. The treatment tactics for these two forms are fundamentally different. Young keloids are keloids with a life span of 3 months to 5 years. They are characterized by active growth, have a smooth shiny surface and a color from red to cyanotic. The zones of the scar (subepidermal, growth zone and deep zone) are defined morphologically, and the growth zone is 5-10 times wider than the subepidermal zone.Old keloids are keloids with a life span of 5 to 10 years. They are characterized by an uneven wrinkled surface, sometimes by a depression of the central part, a paler color compared to young keloids. Morphologically determined: less clear division of the scar into characteristic zones, as well as partial reduction of the growth zone. Why does surgical removal of a young keloid or its resurfacing lead to a relapse? The answer is the following fact: the presence of an active keloid creates pathological local immunity, increases tissue sensitization – their readiness to breakdown in the delicate relationship between prostaglandins of tissue basophils and peptides.
Why is it possible to cure a certain number of patients with keloid and pathological scars with the help of conservative therapy? Conservative measures contribute to breaking the pathological chain and creating conditions for the adequate activation of the autoregulation mechanism. The key to regulating adequate skin repair is the relationship between tissue basophil prostaglandins, peptides and fibroblast cyclic nucleotides.
TREATMENT – COMPLETE
There is no universal method that would cure any scar and make it completely invisible, although scientists are looking and experimenting.For example, abroad have already learned to grow a suspension of keratinocytes from a small piece of the victim’s skin under special conditions. They are trying to take root in a new place after grinding the scar surface. So far, a positive effect has been obtained in 30-40% of cases. This technology has a great future, and the Scar Correction Center plans to introduce it in the very near future.
In the meantime, they are using proven and effective methods. Three, four or five methods can be applied to the same patient.It is better to start long-term step-by-step treatment when the scar is just forming, that is, in the process of wound healing. All types of scars, except keloid, can be made less noticeable – for this there is a large arsenal of different methods. If a person has found signs of a keloid scar, he should not try to get rid of it on his own with folk remedies or in a beauty salon. First of all, you need to confirm the diagnosis, and this can only be done in a specialized clinic. Competent specialists will never offer to operate or grind a keloid scar urgently, except in rare cases when, for example, it grows into the joint and begins to pull the ligament, contracture develops (there is no other way out: undercutting is a way to prevent limb deformation).
It should be remembered: surgical intervention activates the keloid tissue, the scar can increase several times in size, become coarser, appear on another part of the body. Active keloid scars can be dealt with only by conservative methods, which the doctor selects individually for each patient and each scar.
Laser resurfacing, dermabrasion or microdermabrasion are commonly used in the treatment of acne or atrophic acne scars. With their help, you can smooth the edges of a sunken scar, which makes it visually less noticeable.However, side effects are also possible: wound suppuration, pigmentation or depigmentation, an increase in scar in size. Injection of collagen, autologous fat or synthetic fillers is used for small sunken scars (for example, after chickenpox, acne, excision of atheroma). The result is noticeable immediately after the procedure, but short-lived – after a few months, the procedure must be repeated. Side effects may include persistent redness of the skin surface, allergic reactions.
The latest development in this area is a special laser that affects the connective tissue of the deep layer of the skin. After the procedure, the activated collagen begins to grow new fibers, lifting and straightening the sunken areas. The indisputable advantage of this method is non-trauma – no damage to the scar surface. Disadvantage – the effect appears gradually, usually at least five procedures are required with an interval of a month. This method can be supplemented with peels. According to this principle, treatment is carried out in the Scar Correction Center – a combined complex effect that provides a good cosmetic effect.It is also possible to use silicone plates, gels – when using them, the effect of constant squeezing of the scar and the blood vessels feeding it is created. The scar stops growing and flattens. This is a non-traumatic, painless, but rather long-term (many months) method of treatment. Cryodestruction using a special apparatus – the protruding part of the scar is “frozen” with liquid nitrogen, a crust forms on the surface. After its rejection, the scar looks flatter, creating a “polishing” effect.Laser resurfacing or dermabrasion leads to the same result.
Keloid scars are perhaps the most difficult task for a doctor. Due to the property of the scar to respond with even greater growth to any traumatic effect (surgical excision, freezing, resurfacing), the decision on the method of treatment should only be entrusted to an experienced doctor who, after several courses of treatment, will continue to monitor the patient.
In the treatment of such scars, various combinations of techniques are usually used, among them – injections of medicinal substances into the scar tissue that stop its growth.They are performed 1-2 times a month and can be both the main method of treatment and supplement cryodestruction or surgical excision. The vascular dye laser, which the doctors at the Scar Correction Center work with, allows the vessels in the scar to glue together, reducing blood flow in it. It is used both in the combined treatment of keloids and in the prevention of their re-growth after treatment.
The younger the scar, the less time it may take to heal. From the start of therapy to the end result, for example, in the treatment of a hypertrophic scar, it may take from 2 to 12 months, and the restoration of an atrophic scar can be achieved after one procedure.
The red color of the scar indicates the presence of an excessive number of blood vessels in it. In this case, it can be discolored by treating with a special vascular dye laser. In this case, the vessels stick together, the scar gradually turns pale.
If the color change is due to pigmentation, then dermabrasion, peels, whitening creams are applied.
Methods for the prevention of scarring include the following: planning of surgical interventions taking into account individual local and general characteristics of the body, strict adherence to the rules of asepsis, antiseptics, minimal trauma and matching the edges of the wound, taking into account the lines of maximum skin resistance, minimizing the inflammatory process and the timing of wound healing, predicting and drug or laser prophylaxis of keloid formation at an early stage.All this will help make scar correction and treatment more effective.
WHAT ARE THE SCARS?
A scar is an area of connective tissue that replaces a defect in the skin, mucous membrane, organ or tissue resulting from their injury or pathological process. The type of scar depends on the volume, depth, linearity of wound damage, the characteristics of the body, methods of treatment, the level of protein and vitamin supply of the body (since proteins and vitamins, in addition to their general action, contribute to an increase in the functional activity of cells that provide wound cleansing, the development of granulations and collagenogenesis) …Scars are physiological, pathological and mixed.
Physiological (normotrophic) scars result from wound healing. After 3-6 months, they become thin, whitish in color, do not cause physical discomfort to a person. These scars usually do not need correction. The exceptions are cases of aesthetic improvement in the appearance of the scar, smoothing of the surface or accelerating the rate of color normalization.
Pathological scars are divided into hypertrophic, keloid, atrophic.
Hypertrophic scars, like keloid scars, rise above the surrounding skin, but, unlike the latter, occupy an area corresponding to the previous injury. As a rule, they arise after surgical interventions and injuries as a result of inadequate inflammation, the addition of a secondary infection, a decrease in local immune responses, endocrine dysfunctions, etc.
Keloid scars are formed at the site of burns, injuries, after inflammatory processes and operations. Keloids can be active (growing) and inactive (stabilized), regardless of the age of the scar.An active scar grows and causes pain, itching, a feeling of numbness, emotional distress, looks like a tense red scar, often with cyanotic edema. Inactive keloid – does not grow, subjectively does not bother the patient, the color of the scar is pink, close to the color of normal skin.
Atrophic scars are often the result of trauma or acne. The skin above the scar is flabby, has a cross striation (with linear scars), often such scars are devoid of pigment, therefore they look white.The characteristic appearance of these scars is due to a defect in the connective tissue under the scar, a deficiency of collagen and elastin, the main proteins that form the skin frame.
A type of pathological scar is a hypervascularized scar. Its characteristic feature is red or bluish color. In the scar, persistently dilated single or multiple blood vessels can be determined. Hypervascular scars can be either hypertrophic or atrophic.
A mixed scar is a scar in which areas of physiological and pathological organization are determined.
WHAT HAPPENS IF THE SCARE IS NOT TREATED?
In the absence of qualified treatment or its delayed initiation, uncontrolled scar growth or a connective tissue defect may develop. If the scar is in the area of the joint, contracture with limited range of motion may occur.
WHAT IS THE DIFFERENT TREATMENT OF A SCAR FROM CORRECTION?
At the stage of scar development, it is treated. This allows you to reduce edema, normalize blood circulation and collagen synthesis, and prevent secondary infection.And if the scar has already formed, it is corrected. The scar is smoothed in height, its color and skin texture are normalized.
ABOUT METHODS OF TREATMENT AND CORRECTION OF PATHOLOGICAL SCARS
For the treatment and correction of scars, antibacterial, anti-inflammatory, occlusive, compression, injection therapy, ion-phonophoresis, mesotherapy, sclerotherapy laser therapy, buccal therapy, X-ray therapy, microdermabrasion, dermabrasion, laser resurfacing, surgical excision, tissue transplantation.The variety of methods only confirms the need for individual selection for a particular patient.
Hypervascularized hypertrophic scar before and after treatment
Normotrophic scar before and after correction
Result of combined treatment of atrophic scar
Scar Removal – DoctorPlastic Clinic
The main priority of a plastic surgeon is aesthetic and natural result, so our surgeons master new techniques, use minimal incisions or punctures for plastic surgeries.
We analyzed the world experience of the best specialists and created our own suture technique based on it. Our clinic has the best rehabilitation program in Moscow, an important part of it is the treatment of scars, the prevention of pathologies in the development of connective tissue (the fight against keloid scars and fibrosis). We do our best so that the suture we have applied is completely invisible afterwards.
How should a suture be sutured to obtain a thin, inconspicuous scar?
The main condition for the correct healing of the suture is the absence of its stretching.Our clinic uses a special suture technique. Its essence is as follows: fabrics are sewn together in layers, so that all tensile stress falls on the lower layers. The skin, on the other hand, is sutured as freely as possible, without tension. If the suture is correctly applied, the top layer of tissue does not stretch during healing, so the scar on the skin turns out to be very thin. Over time, it brightens and becomes almost invisible.
Scars after trauma. Who to contact?
If your suture was not placed in our clinic and not even by a plastic surgeon, but urgently at the first trauma point that came across, we strongly recommend contacting our specialist – O. Tsyganova.A. “It is possible to alter the seam in the first 48 hours after the injury, if the time is missed and more than 2 days have passed since the injury (or operation), you need to consult not a surgeon for advice, but rehabilitation doctors – Ivanova Irina Nikolaevna or Tsyganova Olga Anatolyevna.
Do you need advice?
Scar treatment from the first days
In many clinics, scar treatment begins in a few months – after it has fully “matured”. Of course, if the suture is applied correctly and you do not have a tendency to keloid scars, you can follow this advice, but even in this case, you need to properly care for the scar: use special silicone gels, exclude any mechanical injury and irritation of the skin around the scar, do not sunbathe and carefully monitor the healing process.But it is still better to contact specialists who will carry out the necessary procedures and make sure that there are no complications that can lead to the formation of a rough scar.
In the first days, the following procedures can be prescribed:
- Preventive procedures – intravenous drip infusion of ozonated saline solution to saturate the blood with oxygen reduces the risk of pathological proliferation of connective tissue (keloid) ten or more times,
- Rehabilitation procedures.Decongestant procedures and measures to restore blood and lymph microcirculation: magnetotherapy, phonophoresis, microcurrent therapy, endermology, d’arsonval and cryotherapy.
For softening and resorption of rough connective tissue, injections of collost, longidase, diprospan are used. This effectively contributes to the formation of the thinnest and most elastic scar.
Attention! Dangerous period!
Week 3-4 is characterized by an increased risk of overgrowth of fibrous tissue.It is often itchy and looks like a sudden proliferation of keloid cells. The scar quickly swells, thickens and turns red. At this time, it is necessary to take urgent measures to stop the avalanche-like proliferation of fibrous tissue and prevent the formation of a keloid scar.
To stop this undesirable process and reverse it, injections of special preparations and local irradiation of the scar with Bucca rays help.
Treatment of chronic scars
After 6-12 months, the scar acquires its final appearance.This does not mean at all that he will remain with you forever and it will no longer be possible to fix him. At this stage, two main approaches are used to treat scars – surgical and conservative.
Surgical treatment of scars
For “hopelessly bad” scars, it is preferable to use surgery – excision of the scar followed by the imposition of a special cosmetic suture according to the method described above.
Conservative scar treatment
For conservative scar treatment, one or a combination of the following is usually used:
- Laser scar treatment (laser scar resurfacing),
- Injections of collosta, longidase, diprospan, etc.
- Collagen or hyaluronic acid injections.
Result of scar treatment
After treatment, the scar will be much smoother and thinner, and after a few months, you may have difficulty finding it! But don’t think that the scar can disappear without a trace. Modern medicine is not yet capable of this.
What needs to be done to make the scar invisible?
- Have the suture done by a qualified plastic surgeon.Contact him within the first 48 hours after injury or first aid.
- Consult a rehabilitation specialist 3-5 days after suture placement and start conservative treatment.
- In case a keloid scar has nevertheless begun to form, immediately contact a specialist for emergency treatment (injections, Bucca rays).
Correction of scars and scars – “Scandinavia” Kazan
Surgical removal does not completely remove the scar, but makes it much less visible.
Rough, thick and large scars after cuts, burns, acne, dramatic weight loss, wound healing and careless operations are corrected.
Stretch marks, retracted stripes, and other scars due to tearing of the connective tissue under the skin.
They do not protrude above the level of the skin, differ little in color from the rest of the skin, painless.
Dark scars protrude above the skin due to excess collagen, which does not have time to dissolve.
Crimson and purple growths protrude above the skin, extend beyond the wound, itch and ache.
Hypertrophic and keloid scars are more likely to be removed.
How is the removal of scars in “Scandinavia” (Ava-Kazan)
At the consultation, the plastic surgeon examines and measures the scar, assesses the condition of the skin, talks about the course of the operation and the peculiarities of the rehabilitation period.
The operation consists of excising the skin where the scar runs. Then the edges are sewn back together.After the procedure, a barely noticeable and thin scar remains. With a large lesion, for example, after burns, skin grafting is possible.
Correction of scars and scars after childbirth
After a caesarean section, transverse or longitudinal scars remain on the abdomen. They are usually thick and rough because gynecologists apply the stitches in one layer rather than in layers. In this case, the scars are depressed.
In this case, the plastic surgeon excises the skin of the scar and applies new stitches that will look more aesthetically pleasing.If the scar is thin, lipofilling can improve its appearance. Through special needles with a blunt end, fat cells are collected from other parts of the body, they are cleaned of impurities and injected into the desired zones. This procedure is effective for correcting atrophic scars and takes about an hour.
The duration of the correction depends on the scale of the scar and ranges from 30 minutes to two hours. It does not require a hospital stay – you can leave the clinic a couple of hours after the procedure.
The operation takes place under general anesthesia or local anesthesia. In “Scandinavia” (Ava-Kazan), Sevoran gas anesthesia is used, thanks to which patients after surgery do not feel the unpleasant consequences of anesthesia, such as distraction, headache and visual impairment. But consultation with an anesthesiologist is mandatory – this is a standard that allows you to avoid undesirable consequences.
Swelling and bruising after surgery will disappear in a few days. For a month, you should give up physical activity and trips to the sauna.
Contraindications for scar removal
Surgical correction of scars and scars is not performed on patients under 18 years of age, pregnant and lactating women.
The operation is prohibited for blood clotting disorders, diabetes mellitus, mental disorders, oncology, infections and endocrine diseases.
|Name of service||Prices (RUB)|
|Elimination of cicatricial deformity||16000|
|Elimination of cicatricial deformity with replacement of the defect with local tissues||21000|
|Elimination of cicatricial deformity with replacement of the defect with a free skin-fat flap||37000|
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90,000 Skin suture from the point of view of a general surgeon
It’s not a secret for anyone that quite often our patients evaluate the quality of the surgeon’s work, even after the most complex abdominal interventions, by the appearance of the skin scar. Yes, we are not engaged in aesthetic surgery – “surgery of pleasure”, we return people to health and, often, life. However, the common phrase that “having lost their head through their hair does not cry” for today’s overly demanding patients is often not enough to explain the appearance of a rough deformed scar on the abdominal wall.And such cases, as we know, are not uncommon. Of course, some of the wounds heal by secondary intention. But this is no more than 10% of all laparotomies. What’s the matter? It may be that at the end of the operation we pay much less attention to the skin suture than it deserves. Or, in general, we entrust its imposition to novice surgeons: where else can they learn to work with tissue and a needle? The most interesting thing is that according to colleagues – plastic surgeons, the skin is a very “grateful” tissue, whose healing is disturbed only with very gross errors of surgical technique.
Violation of reparative processes in the skin is understood not so much as its divergence after removal of sutures (this is an easily removable problem), as the occurrence of hypertrophic scars.
Hypertrophic scars consist of dense fibrous tissue in the area of damaged skin. They are formed by excess collagen synthesis. Scars are usually rough, tight, rise above the surface of the skin, have a reddish tint, are characterized by increased sensitivity and soreness, and often cause itching.Hypertrophic scars fall into two main categories.
1. The usual hypertrophic scar corresponds to the boundaries of the previous wound and never extends beyond the injury zone. The following factors play a leading role in the development of hypertrophic scars: the large size of the healing wound defect, ischemia of the skin in the suture zone, long-term healing and permanent scar trauma. After 6–12 months, the scar usually stabilizes, acquires clear outlines, delimiting the atrophic part of the scar and intact skin, somewhat decreases and softens.
2. Keloid – a scar that penetrates into the surrounding normal tissues, which were not previously involved in the wound process. Unlike hypertrophic scars, keloids are often formed in functionally inactive areas. Its growth usually begins 1–3 months after wound epithelialization. The scar continues to grow even after 6 months and usually does not shrink or soften. Typically, there is no parallelism between the severity of the injury and the severity of keloid scars; they can occur even after minor injuries (injection, insect bite) and often after IIIA degree burns.Stabilization of the state of the keloid scar usually occurs 2 years after its appearance. It is characteristic that keloid scars almost never ulcerate.
The pathogenesis of keloids is unknown. Some authors regard them as benign tumors. Apparently, the most correct idea is that the formation of keloids is due to a violation of the development of connective tissue. Autoaggression is possible due to the excess content of biologically active substances in the tissues. The role of endocrine disorders, individual predisposition to the development of keloids, the predominance of young and middle-aged patients with such scars is not excluded.
Hypertrophic scars are difficult to treat. Excision of the scar can lead to its re-development. Injection of steroids into the area of the scar (and / or injections following its excision), as well as close-focus radiation therapy, can prevent the re-development of the scar.
We in no way call for overly emphasizing the aesthetic aspects of the skin suture on a laparotomic wound – the main field of activity and the manifestation of the skill of abdominal surgeons is hidden from prying eyes.However, in addition to the “substrate of the cosmetic effect,” the skin is also a part of the surgical wound of the anterior abdominal wall, which requires no less care in the formation of skin sutures than when suturing the aponeurosis. Moreover, the skin suture does not require some incredibly complex technical and time expenditures (as it is often said in specialized institutions …).
When forming a skin suture, follow:
– Adhere to a precision technique with precise alignment of the epidermal and dermal layers;
– strive to evert the edges of the skin; inversion (screwing the edges of the skin into the wound) is unacceptable;
– use minimally traumatic suture material (monofilament or multifilament sutures with sizes 3 / 0-0 on an atraumatic cutting or reverse cutting needle in ½ circle);
– use atraumatic tweezers or single-tooth hooks for traction of the skin;
– avoid stretching the skin with a thread (only apposition and immobilization);
– eliminate cavities and pockets in the subcutaneous fat layer;
– shape the suture so that each thread passes through the skin only once, minimizing cross-infection along the entire suture line;
– use removable or absorbent threads;
– do not interfere with the natural drainage of the wound in the first two to three days of the postoperative period;
– Leave the minimum possible amount of suture in the wound.
It should be noted that the presence of some kind of special “cosmetic seam” is just a common misconception. Any skin suture that meets the above requirements can be fully considered cosmetic. Currently, several types of sutures are most common for suturing skin wounds.
Simple interrupted suture – a single suture applied in a vertical plane, the most common for apposition and immobilization of the edges of the skin wound, due to the ease of application, hemostatic effect, the possibility of good adaptation of the edges of the wound.
The nuances of the formation of a simple nodular suture of the skin include the following mandatory technical points:
– injection and injection are made strictly perpendicular to the surface of the skin;
– the injection and the injection must be strictly on the same line perpendicular to the length of the wound;
– the distance from the edge of the wound to the injection site should be 0.5-1 cm, which depends on the depth of the wound and the severity of the cellular layer;
– the thread is carried out with the capture of the edges, walls and, necessarily, the bottom of the wound to prevent the formation of cavities in the wound;
– with a significant depth of the wound and the impossibility of imposing a separate suture on the subcutaneous tissue, multi-stitch sutures should be used (for example, Struchkov’s suture);
– the distance between the seams on the skin of the anterior abdominal wall should be 1-1.5 cm; more frequent stitches lead to a violation of microcirculation, more rare – to the appearance of diastasis of the edges of the wound;
– in order to avoid microcirculatory disorders and unsatisfactory cosmetic effect (transverse lines on the scar), the tightening of the suture should not be excessive, with the formation of a pronounced “roll” over the skin, the thread should provide only a tight juxtaposition of the skin layers;
– the formed knot should be on the side of the line of the sutured wound, but not on it.
McMillen-Donati suture (McMillen-Donati) is a single vertical U-shaped interrupted suture with a massive grasp of the underlying tissues and targeted adaptation of the wound edges. Effectively used for suturing deep wounds with large diastasis of the edges. It is applied using a large cutting needle. The injection is made at a distance of 2 cm or more from the edge of the wound, then it is injected so as to capture as much as possible and is carried out to the bottom of the wound, where the needle is turned towards the midline of the wound and punctured at its deepest point.Then, on the side of the puncture, along the screed, a few mm from the edge of the wound, the needle is again injected and withdrawn into the thickness of the dermis on the opposite side, the needle is passed in the same way in the opposite direction. As the knot is tightened, homogeneous tissues are matched. The disadvantages of the seam include an unsatisfactory cosmetic result due to the formation of rough transverse stripes.
A slightly modified version of the Mac Millen-Donati suture is the Allgower suture, characterized in that the suture is not passed through the skin surface from the contralateral side.Single interrupted skin sutures have both advantages and disadvantages. The advantages of single interrupted sutures include their relative simplicity and low time consumption for their imposition, the presence of natural drainage of the cavity of the sutured wound in the first days of the postoperative period through the intervals between the sutures, the possibility of limited opening of the wound when removing one or several sutures. The disadvantages of single seams include insufficient cosmetic effect when using them, even if they are technically correct.The fact is that single sutures are removable, and for the correct formation of the scar, immobilization of the edges of the skin wound is necessary for as long as possible. In addition, during the formation of individual sutures, the appearance of transverse stripes or scars at the puncture-puncture points of the needle is inevitable. Based on the requirements for the cosmetic effect, J. Chassaignac and W. Halstedt proposed the formation of a continuous intradermal suture along the entire length of the wound.
Chassaignac-Halsted seam – continuous internal adapting.The suture thread runs through the dermis, in a plane parallel to the skin surface. The needle is inserted into one side of the incision, passing only intradermally. After that, they move to the other side of the incision. On both sides, the same amount of dermis is captured into the seam (0.5 – 1 cm). In fact, this seam is a continuous horizontal U-shaped. At the end of the seam, the needle is punctured on the skin, stepping back from the angle of the wound 1 cm. The thread is fixed either with knots directly above the wound, or with special anchor devices.
The formation of the Halstead suture ensures a complete adaptation of the epidermal and dermal layers of the skin and, accordingly, the best cosmetic effect.When forming this suture, especially careful hemostasis is required, preliminary elimination of the residual cavity by suturing the subcutaneous tissue and the absence of skin tension. In the case of a long wound (over 8 cm), theoretically, difficulties may arise when removing a long non-absorbable suture, therefore, when applying such a suture, it is recommended to puncture the skin surface every 8 cm in order to be able to subsequently remove the threads in parts.
As already noted, a prerequisite for the use of a continuous intradermal suture is a careful comparison of the dermal fatty tissue.In addition to the hemostatic effect and the prevention of residual cavities, suturing of tissue helps to bring the edges of the skin wound together and provides the possibility of applying a skin suture without tension. In this regard, J. Zoltan proposed an improved version of the intradermal suture.
Seam Halsted-Zoltan (Halsted – Zoltan) – two-row continuous. The first row is applied approximately in the middle of the subcutaneous base, the second – intradermally. The first injection of the needle is made near the end of the wound, at a distance of 2 cm from one of the edges.Then the needle is injected and punctured alternately in one and the other wall of the wound, passing it only in the middle of the thickness of the subcutaneous tissue in the horizontal plane (continuous U-shaped seam). After completing the formation of a deep row of seams, the thread is brought out to the surface of the skin. Both ends of the thread are pulled, thus bringing the edges of the wound closer. To form the second row, the tip of the needle is brought out into the dermis. Continue sewing in such a way that the puncture and puncture points are located symmetrically relative to the cut line, as with a regular Halstead stitch.Until the superficial suture is completed, the threads are held taut, then a knot is formed, tying the ends of the threads on the skin.
An indispensable condition for the formation of a continuous intradermal suture is the use of only monofilament suture of size 3/0 – 2/0 on the cutting or, better, the reverse cutting needle. The question of the preference for using an absorbable (non-removable) or non-absorbable (removable) monofilament suture for a continuous intradermal suture remains open today: some surgeons remain convinced supporters of Prolene, while the other part invariably uses Monocryl.
To achieve the best cosmetic effect, in many respects associated with trauma to the skin when carrying out the thread, combined methods of closing a skin wound are used. Recently, a method that includes, as one of the components, the use of an adhesive application to immobilize the skin after flattening and protecting the wound from the external environment, has become more and more popular. At the same time, Dermabond is used as a means of immobilization and protection – a medical glue based on 2-hydroxyanocrylate and a violet dye for contrasting with the skin.After application to the skin, Dermabond, due to contact with air, within 30-60 seconds passes from the liquid phase to the phase of an elastic-elastic gel with exceptionally strong adhesion to the skin. At the same time, a strong film is formed on the skin, preventing diastasis of the wound edges and protecting the edges and walls of the wound from contamination with microorganisms (the use of glue eliminates the need for aseptic dressings on the postoperative wound). Dermabond provides immobilization of the edges of the skin wound for up to 7-8 days and after this time it is independently fragmented and removed from the skin.Prerequisites for the use of Dermabond glue are thorough hemostasis and tight adhesion of the wound edges with a suture of the subcutaneous tissue: it is possible to use a continuous suture or separate sutures with absorbable material. That is why this method of closing a skin wound is combined – suture and adhesive. It can be assumed that the introduction into clinical practice of joining the edges of a skin wound using an adhesive application in itself indicates the direction of the evolution of methods of tissue joining in surgery: from thread to polymer adhesive materials.
Added on March 28, 2016
Surgical cosmetology: healing of postoperative stitches
Today, in the field of wound healing, attention is paid to the creation of 90,016 wet dressings. These coatings create conditions to allow wound healing without the formation of keloid scars.
Collagen-containing wipes and gels produced by NPF “LitaA-Tsvet”, which contain the patented active ingredient “Exolin” ®, have shown efficiency in the healing of postoperative sutures.
The drug “Exolin” ® is a scientific development of the company “Lita-Tsvet”, has no analogues in Russia and abroad, is an extract of young connective tissue. The drug is a peptide bioregulator, which accelerates the healing process of damaged skin without the formation of rough scars.
“Exolin” ® is a preparation with a high content of microelements. Thanks to the new production technology, “Exolin” ® is enriched with ions of calcium, sodium, potassium, phosphorus, iron and other minerals necessary for normal cell activity, which enhance the healing properties.
The production of “Exolin” ® is based on raw materials, which feature genetically programmed ability to grow and develop. This information is retained even after the processing of raw materials and is manifested in such properties of “Exolin” as acceleration of wound healing with a cosmetic effect and hypoallergenicity.
The composition of wound healing agents “Lita-Tsvet” includes gentamicin, a second generation aminoglycoside antibiotic with a wide spectrum of antimicrobial action, inhibits the growth of most gram-negative and gram-positive microorganisms, exhibits 99% activity against staphylococci and is effective against Pseudomonas aeruginosa – the main causative agent of wound infection.
Gentamicin acts bactericidal on a microbial cell: it does not stop growth, but kills. Resistance of microorganisms to gentamicin develops slowly, mainly in patients with chronic inflammatory processes. Gentamicin enhances the action of other antibiotics and is combined with them.
The principle of action of “Lita-Tsvet” preparations is based on the ability of “Exolin” ® to turn into a hydrogel. The hydrogel creates optimal conditions for wound healing.The antibiotic gentamicin, dissolving in the hydrogel, soaks the wound and dressing, provides reliable antimicrobial protection.
Clinical trials of the cosmetology clinic of the Institute of Beauty have shown that Exolin ® does not have an allergenic effect, is not toxic, and is well tolerated by the body.
Postoperative stitches are a particular focus of attention for both the patient and the doctor.
During a surgical operation, regardless of the method of carrying out, traumatic damage to nearby tissues occurs.Therefore, first of all, attention is directed to preventing the development of infection and accelerating the regeneration processes. The healing of postoperative sutures depends on the general resistance of the body and on the skin itself.
The rate of healing of postoperative sutures is limited by the genetic ability of the tissue to regenerate , normal metabolism. Bone tissue after a fracture is fused within 1 month. The epithelium is able to recover within 1-3 days.It takes 3 to 8 weeks for the skin to form a postoperative suture or scar. With age, the rate of recovery processes slows down.
In 90,016 some cases, the stitches after the operation begin to fester strongly, become inflamed and do not heal for a long time. And then it is really impossible to do without this or that remedy: healing ointments, gels, creams. Such means for the healing of postoperative sutures are prescribed only by a doctor. Self-treatment leads to negative consequences.