How many times have you done an elliptical excision, and the postoperative scar result is widened at the center, despite your excellent technique? We accept this as the status quo. Of course, the scar result was wide at the center. That was the point of highest tension at the time of the closure. Let’s take a step back though. While this may be an “acceptable result”, can’t we do better?
It is well known that high tension areas create wide or excessive (hypertrophic or keloidal) scars. High-risk areas for scarring including the anterior chest, shoulder, scapula. These areas are high risk due to the dynamic tension applied to the healing scar due to range of motion of the upper limbs. Other high-risk closures for wide or excessive include larger excisional wounds on the trunk and extremities or smaller wounds on tight skinned areas like the scalp and pre-tibial region. In these latter cases, the healing scar has static high tension but is not subject to dynamic tension due to relative immobility of those anatomic regions. In all the above cases there is dynamic and/or static high tension imparted to the healing scar. We try to de-risk scarring in these closures by the use of technique/modalities including z-plasty, silicone gel sheeting, intralesional steroid injection in immature excessive scars, splintage to reduce mechanical stress, etc. But are we doing all we can perioperatively to create a lower tension environment for healing?
Let’s say we are dealing with a bad scar outcome from a prior procedure/injury. When we do a scar revision, are we doing everything possible to ensure the best scar outcome? What are we doing to change the intrinsic forces at play when we excise the old scar and reclose the wound with our excellent layered closure? This, alone, may yield a better result if the initial repair, for example, was a single layer closure with sutures removed at 5-7 days that had partial dehiscence postop. But how about a scar revision where the wound was previously closed effectively in layers by a competent surgeon (maybe you yourself)? Do you really believe your next layered closure is so much better than the last one? Let us try to do much better and make plan B much different than plan A as follows:
In the new paradigm for low tension healing, there are multiple perioperative tension lowering maneuvers to create the best scar outcome.
Preoperative: In the preoperative assessment, the anatomic location is critical. Inspect planned circular excisions to see if/how they become ellipsoid upon excision as this informs the surgeon of the static skin tensions at play. Preoperatively and intraoperatively range the affected limb or turn the head or have the patient animate their face and look at how the marked circular incision or excised wound moves and becomes ellipsoid. This informs the surgeon of the dynamic skin tensions at play. Prudent orientation of the closure along the lines of least tension is a good start.
If you are revising a scarred prior closure that was properly oriented, consider z-plasty to break the linear scar as this can affect the tension triggers that provoke heavy scarring.
One must not ignore the whole patients’ healing metabolism, and optimize conditions like diabetes, nutrition (to include supplemental vitamin C, adequate protein in the diet, etc.), and consider healing impairments such as corticosteroids that can be overcome by supplemental Vitamin A (25,000 IU/day).
Intraoperative: Once you have established the correct orientation of the repair, the skin can be stretched quickly and safely to reduce tension on the closure. Strong force (5-30 Newtons) will begin mechanical skin creep, that is collagen parallelization and fiber lengthening. More force does this more rapidly. Cyclical stretch (4 min stretch, 1 min rest) will allow progressive lengthening of the skin. This can be easily and quickly done with a device such as the SUTUREGARD® Intraoperative Skin Relaxation (ISR) device. Once the dermis is stretched, it remains in this configuration for months during which the healing is occurring in a lower tension environment than in non-stretched skin.
This is applicable to primary repairs and to linear or flap-based closures, intraoperative stretch will lower the tension of the highest tension points. This is especially applicable to scar revisions, where the new result will truly be healing in a lower tension environment. We can tell our primary repair patients that we have de-risked their closure by lowering tension at the points of greatest risk. We can tell our scar revision patients that we are truly making plan B different from plan A!
The closure technique is obviously important such that good dermal opposition occurs. An everted initial closure caused by dermal suturing is optimal. We explain to the patient that a raised initial closure will flatten over time, but that a flat initial closure will widen over time. Patients understand this and accept the temporarily raised ridge at the closure site. Medical therapy (ie Kenalog – a long acting corticosteroid) can be used topically in refractory keloids, applied to the wound prior to closure.
Postoperative: Secondary reinforcement of the closure with Steri-Strips, and then an additional tension bearing dressing such as transparent film can protect the incision in the early postoperative days from ambient dynamic tension. There are postoperative products such as EMBRACE where a tensioned silicone gel pad is applied, compressing the skin edges together once the wound is sealed at one week postoperatively. This or other equivalent modalities such as a compressive garment and/or silicone gel pad can accomplish similar results. Postop splintage to reduce movement at or around a joint will reduce dynamic tension on the closure and may be used for several weeks, intermittently removing the splint for brief range of motion exercises to prevent joint contracture. After 6 weeks, topical massage with vitamin E oil or equivalent may begin. Sun protection will reduce scar inflammation. Early keloid hypertrophic scar recurrence should receive monthly intralesional Kenalog. Multiply recurrent keloids may be treated by radiation or other modalities postop. It will take 6-12 months to see the result.
It is our hope that we surgeons can step back from the hum of daily work to reassess our “status quo” methods and consider this comprehensive approach to low tension healing. In this way we incrementally advance the practice of medicine and continue to strive to improve our patients’ outcomes.
Dan Ladizinsky, MD, CEO, SUTUREGARD Medical, Inc.
Prior Board Certification in General Surgery, Plastic Surgery, with Certificate of Added Qualifications in Surgery of the Hand, Former Fellow of the American College of Surgeons.