Scars & Surgery of the Skin
A scar is
an area of Fibrous tissue that replaces normal skin after an injury. Scars
result from the biological process of wound repair in the skin as well as in
other organs and tissues of the body. Thus scarring is a natural part of the healing
process. With the exception of minor lesions, every wound (after accident
disease or surgery) results in some degree of scarring. Under normal
conditions, scars usually fade but never disappear completely. Kindly note that
it can take from 1 to 2 years for a scar to mature completely and demonstrate
its final appearance.
However,
some wounds can lead to abnormal scar formation:
Contracted scars | Hypertrophic scars & Keloid scars
Contracted scars are known to cause dysfunction, deformity and even psychological trauma.
Hypertrophic scars are raised and discoloured and itchy but confined to the
original site of the injury.
Keloid
scars are also raised and discoloured and itchy but frequently extend well
beyond the original wound and often look like molten plastic.
Scar tissue is composed of the same protein (collagen) as the tissue that it replaces but the fibre composition of the protein is different. Instead of a random basket weave formation of the collagen fibres found in normal tissue, in scarring, collagen cross links and forms a pronounced alignment in a single direction. This collagen scar tissue alignment is usually of inferior functional quality to the normal alignment. For example, scars in the skin are less resistant to U.V. light, and sweat glands and hair follicles do not grow back within scar tissue. During the third or proliferative stage of wound healing, there is Fibro blast activation. Fibro blasts are a type of cell found in connective tissue that produces collagen which gives the skin strength, firmness and durability. Another type of cell involved in this phase are Myofibroblasts which play an essential role in the formation of scar contracture.
A
Myofibroblast can be thought of as a mix between a Fibroblast and a muscle
cell. Their function is to contract the wound and promote the formation of new
collagen to seal the wound. As the newly laid down collagen matures, it is part
of the normal process that the collagen fibres contract. This can lead to scar
contracture. A classic example of this is the round scar around the nipple in
breast surgery which joins onto a vertical scar on the lower pole of the
breast. As the vertical scar matures it can pull the circular scar around the
nipple areola complex downwards creating a tear drop shaped deformity of the
scar and nipple areola complex. !t must be noted that this kind of occurrence
is part of the natural healing process and a bona fida complication of any
surgery.
General Questions
The treatment of all types of abnormal scarring includes both non-invasive and invasive modalities as follows: Pressure Treatment Topical Silicone | Laser treatment | Chemical peels | Cortico Steroid injections | Vitamins Invasive treatment i.e. surgery
The
treatment choice or combination of choices will depend entirely on the
individual circumstance of each scar.
In patients
who have previously had keloid scars, we believe it is important to start
preventative treatment at the time of surgery rather than wait and see. This
usually involves injections of a Cortico steroid and/or specialised surgical
techniques. Hypertrophic scars on the other hand tend to settle down
spontaneously within three to six months. Non-invasive pressure therapy and
Topical silicone usually helps the process.
RISKS AND
COMPLICATIONS OF SKIN SURGERY
Kindly note
that even small surgical procedures to remove skin lesions can result in
unforeseen complications. Complications may be divided into immediate and
delayed.
IMMEDIATE
COMPLICATIONS
These can arise spontaneously during or shortly after surgery and include:
- Bleeding
- Damage to underlying structures 3: Adverse reactions to medication
- Difficulty in closing the wound
It is very
important to be aware of the blood thinning capabilities of many medications
even over the counter ones including high dose Omega 3 preparations, ginseng,
vitamin E etc. Certain areas i.e. head and neck often bruise more than other
areas. It is perfectly normal to expect a small to moderate amount of bleeding
post operatively. The plan is to control this bleeding with the dressing. This
bleeding will usually stop after 24 to 36 hours and the dressings are usually
changed at 48 to 72 hours by which time it is very unlikely for further
bleeding to occur. It is important to realise that tiny sensory nerves may be
cut during the radical excision of cancers which will result in a cure for the
cancer but leave behind a permanent area of numbness adjacent to the surgical
site. Other underlying structures can in theory be damaged and this is
something that all surgeons try their best to avoid.
Kindly note
that local anaesthetics and pain killers as well as non-steroidal
anti-inflammatory drugs and Opioids can all cause complications ranging from
nausea and vomiting through gastro intestinal upset including constipation etc.
DELAYED
COMPLICATIONS OF SKIN SURGERY
- Wound infection
- Wound breakdown
- Suture reactions
- Delayed healing
- Persistent swelling
- Contraction of the scar or the formation of Hypertrophic or Keloid scar
Wound
infection can occur and usually becomes apparent two to three days after a
procedure with signs of increasing redness swelling and pain around the wound
with a discharge. Certain anatomical areas are more likely to become infected
and sun damaged skin is also more likely.
The
following factors increase the risk of infection:
- Ulcerated or crusted skin lesion
- Increased skin tension at the wound site.
- Poor blood supply to the area
- Smoking
- Immune deficiency
- Poorly controlled diabetes
- T Malnutrition
- Certain drugs i.e. Cortico steroids and Chemo therapy agents
- Lower leg or skin fold surgery
- Old age
- Very long duration of surgery
- Soaking the wound soon after surgery (it is recommended to keep the wound dry for at least 48 hours)
Although
post-surgical infection is usually treated successfully with the appropriate
antibiotic, it may sometimes be necessary to re-operate.
Wound breakdown after skin surgery usually occurs in the following conditions:
- Excessive tension at the site
- Wound infection
As can be
expected the scarring resulted from a wound breakdown after surgery tends to be
larger than Without.
SUTURE
REACTIONS:
- Wounds are usually closed with
- Sutures made of synthetic material and some will be absorbable and others will need to be removed.
- Suture material may cause redness and swelling at the wound site without infection.
- Absorbable subcutaneous sutures may also occasionally extrude through the skin as they dissolve. This can occur weeks or months after the procedure. True allergy to suture materials is rare but has been occasionally reported.
DELAYED
HEALING AFTER SURGERY:
Factors that delay healing after surgery include:
- Wound infection
- Poor blood supply
- Open wounds
- Diabetes
- Chronic diseases i.e. heart failure, renal failure or malignancy
- Smoking
- Old age
- Malnutrition
- Marked swelling of the wound site
- Radio therapy
Wounds on
the lower legs that are left to heal by secondary intention after breakdown are
particularly at risk of delayed healing due to poor blood supply.
PERSISTENT
SWELLING:
Surgery may
damage the lymphatic channels under the skin which may cause swelling which
takes anything from weeks to months to resolve. This is an especially common on
the lower eyelid and on the lower legs.
Late
complications after skin surgery usually cause an unsightly cosmetic result. |
This can usually be improved with revision surgery and should be viewed as a
bona fida complication of surgery. Colour changes with a difference in colour
between the scar tissue and the surrounding skin occurs fairly frequently and
depends on the skin type.
Kindly note
that the contents of this advise section remain the intellectual property of Dr L.
van Oudenhove