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12 Wound Care andTreatment ofScars
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203
and epithelialization. Magnesium also
functions as a cofactor in enzymes required
for protein and collagen synthesis [4, 13].
Tip
Benets of supplementation of arginine and vitamin A have been demonstrated in wound healing.
Specically, vitamin A is used to reverse the detrimental effects of corticosteroids on wound
healing.
– Drugs: Many drugs can interfere in the wound
healing process. The most frequently associ-
ated are corticosteroids, antineoplastic agents,
and anti-inammatories. Steroids decrease
inammation, inhibit epithelialization, and
decrease collagen production. Antineoplastic
agents specially affect vascular endothelial
growth factor (VEGF) and increase the risk of
development of wound infection. Lastly, anti-
inammatories may decrease collagen synthe-
sis [9].
– Radiation therapy: Surgical incisions located
in radiated areas are more likely to develop a
wound complication. Chronic damage, bro-
sis, atrophy, and occlusion of small vessels
generate bad perfusion in radiated tissues[4,
14].
– Genetics: Recent research indicates that the
formation and growth of hypertrophic scars
and keloids are clearly associated with genet-
ics [15].
healing response is altered, the result may be an
undesirable scar. Abnormal scarring is usually
classied into hypertrophic, keloid, or atrophic
scars.
12.2.3.1 Hypertrophic Scars
andKeloids
Recent research suggests that hypertrophic scars
(Figs.12.2 and 12.3) and keloids (Fig.12.4) are
caused by the same broproliferative pathology
and that their different clinical and pathological
features largely reect the degree of inammation in the healing wound [16].
The diagnosis of hypertrophic scars and keloids
is usually clinical, based upon history, scar shape,
size, and growth pattern (Table 12.1). Firstly,
Fig. 12.2 Hypertrophic scar after cesarean section
12.2.3 Scarring
Human tissue is repaired either by scar formation
or by regeneration of the original tissue. Scar formation consists of the substitution of a different
cellular matrix as a patch to immediately reestablish a physical and physiological continuity
to the injured organ, whereas regeneration is a
recapitulation of the developmental processes
that initially created the injured organ. Ideally, all
defects made by wounds should be restored by
regeneration, but the skin is an organ that repairs
itself through scarring rather than regeneration.
Furthermore, wound repair and scar formation
are a dynamic process, and if the normal wound
Fig. 12.3 Hypertrophic scar in the leg, secondary to primary closure of a traumatic wound
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Fig. 12.4 Keloid in the back, secondary to surgical extirpation of a benign skin tumor
Table 12.1
scars and keloids
Hypertrophic scars Keloids
Usually remain restricted
to the original wound
Development in the rst
months (up to 6m)
Possible regression No regression
Clinical differences between hypertrophic
Extend beyond the
margins of the original
wound
Beginning of development
variable
hypertrophic scars usually respect borders of the
original scar, while keloids grow outside original
borders. Secondly, hypertrophic scars usually
present a rapid growth phase, followed by possible
regression over the following 12–18 months. On
the other hand, the beginning of development of
keloids is very variable (from months to years) and
they do not regress spontaneously (even they
enlarge progressively over time) [16, 17].
Hypertrophic scars and keloids also differ in
their histology characteristics. Hypertrophic
scars present dermal nodules only, and keloids
present hypocellular dermal nodules plus multiple thick eosinophilic collagen bundles called
keloidal collagen.
M. Estiragues et al.
The risk of formation of keloids and hypertrophic scars has been associated with genetic, epigenetic, and systemic and local risk factors
(particularly skin tension around scars, delayed
wound healing [17], and deep wounds). A genetic
predisposition is suggested by the fact that
keloids are more common in dark Africans,
Americans, and Asians, and patients often have a
family history of these scars. They also present
endocrine inuences, as their growth increases in
puberty and pregnancy.
Hypertrophic scars affect 5–15% of wounds.
They can be classied as linear or widespread.
Linear scars usually result from surgery or trauma
and widely spread from burn injuries or extensive
soft-tissue trauma or infections (for example necrotizing fasciitis).
Keloids are less frequent than hypertrophic
scars, and they occur predominantly on the upper
chest, shoulders, upper back, and head and neck
(especially on the ear). Pain and pruritus are frequently associated symptoms. Keloids can be
classied according to their size: minor or major
(with the latter being more than 0.5cm).
12.2.3.2 Atrophic Scars
Atrophic scars usually develop after an inammatory process and can be the result of collagen
loss and dermal atrophy. These tend to develop
after insults to the skin such as acne, varicella, or
trauma; therefore, they are not common consequences of cesarean section (C-section), episiotomy, or elective surgeries.
12.2.3.3 Other Scarring Disorders
• Widened scars: They look wide and depressed
from wound tension perpendicular to wound
and mobility during maturation phase. For
example, periareolar and medial horizontal
inframammary fold scars, associated to mas-
topexy, are proper to wide (Fig.12.5).
Important One of the principal reasons
c
for patient dissatisfaction after mastopexy,
associated or not with breast reduction
surgery, is unaesthetic scars.
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Fig. 12.5 Widened periareolar and vertical scars after
mastopexy
205
• Depressed scars: They are the consequence
of brosis and adherence to deep planes. As a
result, the scar function may be impaired, and
patients may suffer from scar stiffness and
limited range of motion. For example,
depressed and adherent scars can be observed
associated with C-section (Fig.12.6).
• Pigmented scars: Pigmented scars are not only
caused by sun exposure; they are usually caused
by post-inammatory hyperpigmentation and
neovascularization. In fact, post- inammatory
hyperpigmentation can appear on sun-exposed
skin or sun-protected skin, although it is proved
that ultraviolet (UV) exposure usually worsens
post-inammatory hyperpigmentation.
Fig. 12.6 Depressed scar after cesarean section. Frontal view (left) and lateral view (right)
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M. Estiragues et al.
12.3 Surgical Technique
12.3.1 Physiology andBiomechanics
ofSkin Flaps
A ap is a tissue with its own vascular supply,
unlike for skin grafts, which does not have its
own vascular supply.
This chapter focuses on skin aps that are
typically composed of skin and subcutaneous tis-
sue, because they are the ones involved in abdominoplasty and mastopexy. However, aps can also
be composed of other types of tissues, such as
fascia (fasciocutaneous aps), muscle (myocutaneous aps), or even bone (bone aps).
According to their vascularization (Figs.12.7
and 12.8), aps can be classied into random pattern aps (based on unnamed smaller vessels)
and axial pattern aps (based on an identied
pedicle) [18, 19]. Flaps in abdominoplasty and
Dermal plexus
Subdermal plexus
Subcutaneous plexus
Fascial plexus
Cutaneous perforator
Segmental artery
Fig. 12.7 The cutaneous vascularization. Reprinted from Thomaidis VK. Cutaneous Flaps in Head and Neck
Reconstruction: From Anatomy to Surgery. Berlin: Springer; 2014
s
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Direct cutaneou
artery
Fig. 12.8 Random pattern ap (left) and axial pattern ap (right). Reprinted from Thomaidis VK.Cutaneous Flaps in
Head and Neck Reconstruction: From Anatomy to Surgery. Berlin: Springer; 2014
207
mastopexy are random pattern aps, so their vascularization is based on the longitudinal dermalsubdermal plexus. For example, at mastopexy,
the thickness of the skin aps, preserving some
subcutaneous tissue and respecting the dermalsubdermal plexus, is essential to avoid ap
necrosis.
12.3.1.1 Flap Physiology
When a ap is raised, the normal vessels supplying that skin are cut and the ap depends on
decreased circulation from the collateral vessels.
At that moment, ap survival is dependent on
Fig. 12.9 Abdominoplasty closure done under excessive
tension, resulting in vascular stress on the tip of the ap,
necrosis, and dehiscence
various factors [20, 21]:
– Blood ow: Sufcient blood ow through the
base of the ap is essential in the rst 24–48h.
In random pattern aps, the ow recovery is
12.3.1.2 Flap Biomechanics
Understanding the biomechanical properties of
the skin is essential when managing skin aps.
progressive for up to 4weeks, and it happens
from proximal to distal.
– Angiogenesis and vascularization: The ap
receives blood supply not only from its base,
but also from the wound bed.
– Edema: It affects ap blood supply.
– Wound healing tension: Suturing wounds
under excessive tension produces vascular
stress on the tip of the ap and risk of necrosis
and dehiscence (Fig.12.9).
– Postoperative complications (hematoma,
seroma, infection): Hematoma and seroma
increase tension and impair adhesion to the
wound bed; in addition, infection produces
important edema, vessel thrombosis, and
releasing of toxic free radicals, which can
Biomechanical properties [18]
– Stress: It is the force applied per cross-
sectional area.
– Strain: It is the change in length divided
by the original length of the tissue on
which a given force is applied.
– Creep: It is the increase in strain seen
when the skin is under constant stress.
– Stress relaxation: It is related to creep,
and it means that the amount of stress
required to maintain the tension
decreases with time when the skin is
held under constant tension.
facilitate ap necrosis.
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Although skin is considered an elastic struc-
ture, the stress-strain relationship of skin shows
that it is not totally true. If a small amount of
stress is applied, the skin length changes; however, it has a limit, and at certain point, even a
large amount of applied stress will not result in
further incremental skin length. This is caused by
the relationship between collagen and elastin. In
relaxed skin, collagen is randomly oriented and
elastin is loosely wrapped around, but when a
force is applied, the bers stretch and there is a
point when they cannot distend more.
If a constant force is applied for several min-
utes (approximately 5–10 min) to the skin, the
reorganization of collagen and elastic bers
enables to exceed the stretch limit (creep), and
some days later, the skin is able to relax (stress
relaxation).
Therefore, it is important to know that there is
a limit for skin elasticity and that it is necessary
to avoid excessive stress on the ap edges and
minimize tension on the wound closure. High
tension may lead to wound edge necrosis, wound
dehiscence, and unaesthetic scars.
M. Estiragues et al.
Fig. 12.10 Left: Cesarean section sutured with 3-0 silk
suture. Right: Cesarean section closed with staples. We do
not recommend these types of suture because of the risk of
skin marks
Important Aging and sun exposure decrease
c
the capacity of stretching of skin because of
collagen and elastic fiber damage.
12.3.2 Suture Techniques
Proper surgical technique has been found to
reduce scar width and hypertrophy, so surgeons
have to know how the surgical technique, the
suture techniques, and the suture material inuence scarring (Figs. 12.10 and 12.11).
Furthermore, the position and length of the incision line should be carefully considered, and if
possible, it should always be parallel to the
relaxed skin tension lines.
12.3.2.1 Wound Apposition
It is proved that contributing factors to pathological scarring are tension, melanin, and inammation. Some factors are not modiable, such as
melanin; in contrast, inammation and tension
are more controllable.
Fig. 12.11 A proper surgical technique can lead to
obtaining good aesthetic results after a cesarean section,
as we see in the picture
Inammation can be reduced by gentle tissue
handling, debridement of dead tissue, reducing
the risk of infection through rinsing and disinfection, decreasing thermal energy spread, and
proper suture selection.
Tension can be reduced by undermining (dissecting under the aps and its surrounding area to
allow tissue movement), but the possible
detrimental consequences must be estimated.
Undermining may compromise vascularization
and increase dead space, which can lead to surgical complications.
12.3.2.2 Suture Material
Sutures can present different physical characteristics (elasticity, memory, knot security, tissue
reactivity, visibility, etc.) that provide them different properties. Some of the most essential
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classications are according to the suture conguration, monolament, or multilament
(Table 12.2), and its absorption, absorbable or
nonabsorbable (Table12.3). In addition, the caliber of the suture is important, which is related to
the strength of the suture [13]
The surgeon should choose the suture according to the tension of the wound. The smallest
caliber suture that provides sufcient strength
should be chosen, and if an absorbable suture is
used, it has to lose strength comparable to the
timing of wound strength recovery.
Finally, the alternative to sutures is stainless
steel staples (Fig.12.12). Although it is a timesaver closure method and there are some locations where they are recommended (for example
hair-bearing scalp), we do not recommend it in
C-section, episiotomy, or post-pregnancy surgeries. However, staples can be useful to position a
skin closure temporarily before suturing. Some
of the disadvantages of this skin closure tech-
Table 12.2 Differences between monolament and multilament sutures
Denition Characteristics
Monolament Single strand
Multilament Made of several
strands that can
be braided or
twisted
Table 12.3 Differences between absorbable and nonabsorbable sutures
Denition Characteristics
Absorbable Degradation by
proteolysis
(natural
materials) or
hydrolysis
(synthetic
sutures)
Nonabsorbable No degradation Sutures induce a
– Less friction →
less trauma
– Less risk of
harboring infective
organisms
– More friction
– More tensile
strength
– Handle easily
Lose tensile
strength
cell-mediated
reaction until the
suture becomes
encapsulated
nique are that they are inelastic, produce imprecise epidermal approximation, and pose the risk
of skin marks if they are not removed early.
Important When using staples, wound edges
c
must be everted with forceps to prevent
inverted skin edges.
12.3.2.3 Common Suture Techniques
The choice of closure technique should be based
on wound and patient characteristics, but it
should always be directed to the minimization of
tension on the closure and meticulous closure
with wound edge eversion.
Wound eversion is more likely to achieve a
ne and at scar than planar repair, which tends
to result in a depressed scar. It is best achieved
using deep dermal sutures.
Key Point
Deep dermal sutures relieve tension off the epidermis and produce skin edge eversion, whereas
subcuticular sutures do not support much tension
and their main function is approximating
epidermis.
Suture techniques most used in C-section, episiotomy (Fig.12.13), and post-maternity surgeries are the following:
– Simple interrupted suture (Fig.12.14): It is the
most commonly employed suture. The suture
must be placed at the same depth on each side
of the incision; otherwise, the edges will over-
lap. Their main advantages are that it provides
wound eversion and allows high-low correc-
tion and individual sutures may be removed
without disturbing others. The disadvantages
are the risk of skin marks, and it may increase
closure time (in comparison with continuous
sutures).
– Simple continuous suture (Fig. 12.15): It is a
time-saver closure technique, but it is not early
as precise as interrupted sutures, there is a risk
of leaving skin marks if they are not removed
early, and integrity depends only on knots on
either end.
– Deep dermal suture (Fig. 12.16): They are
essential to decrease wound tension. Sutures
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Fig. 12.12 Staples
M. Estiragues et al.
Fig. 12.13 Episiotomy sutured with simple interrupted
stitches. An absorbable multilament suture was used
must also be placed at the same depth on each
side of the incision.
– Vertical mattress suture (Fig.12.17): They are
indicated in high-tension areas, and it helps in
eversion of the skin edges. However, there is a
risk of leaving skin marks if they are not
removed early.
– Horizontal mattress suture (Fig.12.18): It has
the same indications as vertical mattress
suture, and it is used in tight situations when
vertical mattress suture is not possible. In
addition, although it may help in hemostasis,
it increases tissue ischemia.
– Subcuticular continuous suture (Fig.12.19):
This suture is used to approximate epidermis,
but it is not able to support wound tension. Its
principal benet is that there is no risk of
skin marks. It is usually the chosen technique
for epidermis layer closure in elective
surgeries.
– Three-point-U suture (Fig.12.20): This suture
is especially important in “T” area at masto-
pexy (the point when vertical and horizontal
scars join), but could also be necessary if the
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Fig. 12.14 Simple
interrupted suture
Fig. 12.15 Simple
continuous suture
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Fig. 12.16 Deep dermal suture
horizontal suprapubic scar of abdominoplasty
has to be prolonged with a small vertical scar
at midline. It approximates and relieves ten-
sion from the different aps.
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Fig. 12.17 Horizontal
mattress suture
Fig. 12.18 Vertical
mattress suture
M. Estiragues et al.
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