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REFERENCES
1. Falanga V, Isseroff RR, Soulika AM , et al. Chronic wounds. Nat
Rev Dis Primers. 2022;8(1):50. doi:10.1038/S41572-022-00377-3
2. Rodrigues M, Kosaric N, Bonham CA, Gurtner GC. Wound
healing: a cellular perspective. Physiol Rev. 2019;99(1):665-706.
doi:10.1152/PHYSREV.00067.2017
3. Leavi T, Hu MS, Marshall CD, Barnes LA, Lorenz HP, Longaker
MT. Scarless wound healing: finding the right cells and signals.
Cell Tissue Res. 2016;365(3):483-493. doi:10.1007/s00441-016-2424-8
4. Singer AJ, Tassiopoulos A, Kirsner RS. Evaluation and
management of lower-extremity ulcers. N Engl J Med.
2017;377(16):1559-1567. doi:10.1056/NEJMRA1615243
5. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and
their recurrence. N Engl J Med. 376;2017:2367-2375.
doi:10.1056/NEJMra1615439
6. Gompelman M, Van Asten SAV, Peters EJG. Update on the role of
infection and biofilms in wound healing: pathophysiology and
treatment. Plast Reconstr Surg. 2016;138(3 suppl):61S-70S.
doi:10.1097/PRS.0000000000002679
7. Liu G, Li Y, Pan A , et al. Adherence to a healthy lifestyle in
association with microvascular complications among adults with
type 2 diabetes. JAMA Netw Open. 2023;6(1):E2252239.
doi:10.1001/JAMANETWORKOPEN.2022.52239
8. Bus SA, van Neen JJ. A shift in priority in diabetic foot care and
research: 75% of foot ulcers are preventable. Diabetes Metab Res
Rev. 2016;32:195-200. doi:10.1002/DMRR.2738
9. Bus SA, Lavery LA, Monteiro-Soares M , et al. Guidelines on the
prevention of foot ulcers in persons with diabetes (IWGDF 2019
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update). Diabetes Metab Res Rev. 2020;36(suppl 1):e3269.
doi:10.1002/DMRR.3269
chronic wound diagnostics. Adv Wound Care. 2020;9(5):245-263.
doi:10.1089/WOUND.2019.0967
on the management of chronic limb-threatening ischemia. J Vasc
Surg. 2019;69(6 suppl):3S-125S.e40. doi:10.1016/j.jvs.2019.02.016
the classification of foot ulcers in people with diabetes (IWGDF
2023 update). Diabetes Metab Res Rev. Published online May 14,
2023. doi:10.1002/DMRR.3648
MM, Rakhorst H. SCI-QOL and WOUND-Q have the best patientreported outcome measure design: a systematic literature review of
PROMs used in chronic wounds. Plast Reconstr Surg Glob Open.
2023;11(1):E4723. doi:10.1097/GOX.0000000000004723
Niezgoda J, Yu Z. Image-based artificial intelligence in wound
assessment: a systematic review. Adv Wound Care.
2022;11(12):687-709. doi:10.1089/WOUND.2021.0091
consensus. Wound Repair Regen. 2022;30(2):156-171.
doi:10.1111/WRR.12994
dressing for various wounds. Front Bioeng Biotechnol. 2020;8:182.
doi:10.3389/FBIOE.2020.00182
interventions to enhance healing of chronic foot ulcers in diabetes
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(IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36(suppl
1):e3283. doi:10.1002/DMRR.3283
Weibel S. Hyperbaric oxygen therapy for chronic wounds.
Cochrane Database Syst Rev. 2015;2015(6):CD004123.
doi:10.1002/14651858.CD004123.PUB4
therapy for treating foot wounds in people with diabetes mellitus.
Cochrane Database Syst Rev. 2018;10(10):CD010318.
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platelet-rich plasma for treating chronic wounds. Cochrane
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balance. Tissue Eng Part B Rev. 2022;28(5):1151-1167.
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meta-analysis of débridement methods for chronic diabetic foot
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doi:10.1016/J.JVS.2015.10.002
reconstruction of chronic/non-healing wounds. Surg Technol Int.
2020;38:65-71. doi:10.52198/21.STI.38.WH1371
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CHAPTER 3 Management of Scars
Anne Warren Peled and Ziv M. Peled
KEY POINTS
When clinical risk factors that increase the chance of
postoperative hypertrophic scarring or keloids are
present, postoperative interventions such as specialized
wound care protocols or intralesional steroid injections
can be considered to reduce the risk.
Surgical techniques including placing scars in natural
creases or lines of tension, reducing tension on the
dermal closure, and careful eversion of incisional closure
can help optimize postoperative scarring.
If hypertrophic scarring or keloid formation does occur,
conservative therapies can often successfully treat the
areas; if surgical excision is required, postoperative
radiation therapy can reduce the risk of recurrence
following keloid excision.
Although the goal of “scarless wound healing” has been and
continues to be sought after by researchers, currently only the early
gestation fetus can heal skin wounds without scar formation.1 Normal
wound healing is overall a healthy and beneficial process for
allowing for long-term wound stability. However, if mechanisms for
halting the repair process once the wound is fully healed are
disrupted, excessive scar formation can occur. The clinical
presentation of excess scarring is along a spectrum from
hypertrophic scarring, where excess scarring is confined to the
boundaries of the scar, to keloids, where the scarring extends
beyond the original wound, in some cases essentially behaving like a
benign skin tumor.2 Postsurgical hypertrophic scarring has been
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estimated to happen at rates as high as 40% to 70%,3 with even
higher rates described following burn wounds.4 Both hypertrophic
scars and keloids can potentially lead to functional and esthetic
issues depending on the degree of pathologic scarring as well as the
extent and location (Figure 3.1). For both excessive scars and
normal scars, certain clinical, surgical, and postoperative factors can
influence scar outcomes, some of which can be impacted by patients
and surgeons.
FIGURE 3.1. A. Keloid scarring of the ear after ear
piercing. B. Massive keloid scarring of the ear. (Photos
courtesy of Matthew Hiro, MD.)
OPTIMIZING POSTSURGICAL SCARRING
Clinical Factors
There are a variety of patient factors that can impact the likelihood of
poor scarring, including genetic factors, race, age, body mass index,
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and location of the surgical wound.5 Ongoing research is being done
to better understand the genetic component to poor scarring,
including performing genotyping of patients postoperatively to look
for correlations with scar outcomes.6 Additional systemic factors
increasing the risk of hypertrophic scarring that may potentially be
able to be modified include hypertension, inflammation, trauma,
burns, bacterial colonization, and infection. Prior to any planned
surgery, assessment of risk factors should be performed and
addressed as comprehensively as possible.
Surgical Technique
Adhering to basic plastic surgery principles for wound closure is
essential to optimizing scar outcomes. This includes thoughtful scar
placement, including placing scars in natural creases and at sites of
transitions such as the edge of the areola or at the border of hairbearing skin. Placing scars within relaxed skin tension lines is also
helpful, both to better camouflage scars and also to reduce tension
on the healing incisions and hopefully lead to thinner scars.
7
Additionally, careful reapproximation of the deeper aspects of
surgical wounds such as the subcutaneous and fascial layers can
help to minimize the tension on the dermis and allow for better skin
closure. Consideration for prophylactic Z-plasty in patients at higher
risk with incisions in high-tension areas such as across joints may
also be warranted in some clinical scenarios.
Postoperative Management
Active strategies for optimizing scarring are primarily related to
postoperative dressings and scar management, with the mainstays
of therapy typically described as scar massage, silicone gel, and
compression/pressure dressings.
Massage
Scar massage has been described in a variety of ways, with the
basic concept being that applying mechanical forces to the skin may
increase blood flow, release tissue directly, and induce
mechanotransduction that can help with scar remodeling.8 The
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clinical results include reduced tethering of scars and better scar
mobility/less tightness, improvement in pigmentation, and thinner
scars. Protocols and outcome measures evaluating scar massage in
the literature are heterogeneous,9 making data-driven practice
implementation challenging. Despite concern for bias and
heterogeneity in studies, physical scar massage has been shown
consistently to lead to significantly improved outcomes compared to
controls across scar parameters, including pain, pigmentation,
pliability, thickness, surface area, and pruritus.
10
Silicone Gel
Silicone gel has been described as a strategy for preventing poor
scarring in patients prone to hypertrophic scarring and keloids and to
provide overall improvement in scar appearance. The primary
mechanisms of action for silicone in improving scarring have been
reported as reduction in collagen production and regulation of wound
healing growth factors through the occlusion of the scar site and
hydration of the stratum corneum.11-14 Silicone gel is typically used
either in gel form or in sheets, with the gel thought to be more
versatile with regard to more widespread application throughout the
body, though there may be an additional mechanical benefit of the
sheeting, particularly if tension can be offloaded during healing.
15
Studies have demonstrated a significant reduction in the incidence
of hypertrophic scarring in people at higher risk for hypertrophic
scars with the use of silicone gel sheeting.
16,17
Randomized
controlled trial data have also shown improved pigmentation, scar
height, and pliability with routine use of silicone products in all
patients following various surgical procedures,18-20 with similar
improvements seen for silicone gel or sheets.
21
Compression/Pressure Dressings
Pressure therapy has been used to optimize scar outcomes and
prevent hypertrophic scarring for many years and is thought to be
highly effective, particularly in the management of patients with burn
injuries.22 Pressure is applied continuously once the wound is healed
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sufficiently to tolerate compression and shear forces and can be
achieved through custom-fitted pressure garments or other types of
compression bandages. Although the mechanism of action is not
completely known, some hypotheses include realignment of collagen
fibers and reduction of collagen nodules, diminished fibrotic activity,
and reduced edema, all of which can improve scar thickness and
pigmentation as well as scar-related symptoms such as pain or
pruritus.
23
MANAGEMENT OF POOR SCARRING
(HYPERTROPHIC SCARS AND KELOIDS)
Conservative Management
Hypertrophic scars and keloids can frequently be managed with
conservative treatment alone, particularly with scars that do not
cause significant functional impairment like scar contracture.
Silicone Gel Sheeting/Compression
Compression of hypertrophic scars and keloids, either with a
compression dressing alone or with silicone gel sheeting, which has
the benefit of silicone gel in addition to the compression, has been
described as an effective treatment option for decades,24 particularly
for early hypertrophic scars. Some studies looking specifically at
silicone gel sheeting as treatment for hypertrophic scars and keloids
have shown improvement in scar thickness and color following
treatment.16 Overall literature on the use of silicone sheeting as the
primary treatment for hypertrophic scars is somewhat limited by the
heterogeneous data reporting and outcomes evaluated, minimal
randomized controlled trial data, and concerns around bias.
25
Laser Therapy
Different types of lasers including pulsed dye, nonablative fractional,
and ablative fractional (including carbon dioxide and Er:YAG) have
been evaluated in the treatment of hypertrophic scars and keloids.
Overall some studies have demonstrated an improvement in scar
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parameters using lasers,
26,27
though the studies are relatively small
and limited from a statistical standpoint.
28,29
One of the clinical areas
where laser treatment has been consistently effective is in the
treatment of hypertrophic burn scars. Multiple studies have shown
improvement in scar appearance as well as pain and other
symptoms using lasers,30 particularly with a targeted combination of
lasers to address different components of the hypertrophic scar.
31,32
Corticosteroid Injections
Corticosteroids can be used to treat hypertrophic scarring and
keloids by decreasing fibroblast proliferation, reducing collagen
synthesis, and suppressing inflammatory markers.33 Triamcinolone
acetonide is the typical steroid used for injections at concentrations
of 10 to 40 mg/mL, with injections usually occurring every 4 to
6 weeks and repeated serially as needed over the course of up to
6 months.34 Response to treatment has been reported in 50% to
100% of patients at 1 year, with recurrence in 33% to 50% of
patients after 5 years.35 There are some potentially significant side
effects from intralesional steroid injections including pigment
changes, soft-tissue atrophy, necrosis, and telangiectasias that
should be discussed comprehensively with patients prior to initiating
injections.
Radiation Therapy
Radiation therapy is thought to be effective in treating keloids by
targeting rapidly growing fibroblasts, mesenchymal cells, and
inflammatory cells, thus reducing excessive wound healing.36 While
radiation therapy has been used to treat keloids without prior surgical
excision, the more immature wound healing state following surgical
excision is a better target from a radiosensitivity perspective,37 which
is why radiation therapy is typically recommended in the adjuvant
setting following surgical excision rather than as a primary treatment
modality.
Surgical Management
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For management of hypertrophic scars, the degree of functional
impact including contracture or pain can help guide treatment. For
hypertrophic scarring over joints leading to joint contractures, release
through Z-plasty with or without flap or skin graft reconstruction can
be helpful. Hypertrophic scars that do not cross joints but cause
severe scar contracture can also be managed with Z-plasty and
reconstruction depending on the size and extent of the scar, or
potentially complete excision and closure in the cases of smaller and
narrow scars.
38
For keloids, complete surgical excision is frequently described as
primary treatment for keloids unresponsive to nonsurgical
management. However, surgical excision alone is often ineffective
(Figure 3.2), as it results in a larger wound and can lead to an even
larger keloid, with high rates of recurrence.39 Superficial radiation
therapy immediately following resection significantly reduces the rate
of recurrence down to rates as low as 12% in some series.
40
Radiation therapy is typically given in this setting as a 3-day course
and is well-tolerated with minimal reported adverse events.
41
FIGURE 3.2. Chest keloid due to acne scarring (A).
Recurrence of keloid after excision alone (B).
CONCLUSIONS
While postoperative surgical scarring is inevitable, there are some
clinical, technical, and postoperative factors that can be controlled to
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