DCH Auriga recently held their first Aesthetics and Suturing Workshop under the IMPACT continuing medical education series – a scientific platform that aims to cascade the latest updates on disease management and share best clinical practices among healthcare professionals in Singapore. Two experts on aesthetics and aesthetic surgery shared their insights on suturing techniques and current approaches for scar prevention and management.
Scarless Scars – Is There Such a Thing?
Scars, also called cicatrix, are dense masses of granulation tissue that form on injured skin as it heals. While scars can occur on any injured area, they typically form around an area where there is constant movement. Genetic predisposition may also contribute to the formation of scars.
Scars could either be hypertrophic, keloid, or atrophic. Hypertrophic scars are visible and elevated but remain within the boundaries of the original wound; they also tend to regress over time. Keloids, on the other hand, are firm, mostly raised, and sometimes hyperpigmented. They do not regress and may infiltrate surrounding tissue. Atrophic scars may be easily distinguished from the former two as these clinically appear as skin depressions.
Histologically, hypertrophic scars primarily contain type III collagen that are of parallel orientation to the epidermal surface, with abundant nodules and large extracellular filaments. Keloids are composed of abnormally thick, irregularly branched and septal disorganized type I and type III collagen bundles, without nodules.1
For atrophic scars, there is loss of collagen, elastin, and deep dermal fat, causing a downward pull on the epidermis.
Distinguishing hypertrophic scars from keloids could be difficult due to two factors: keloidal collagen is not always visible, while a-smooth muscle actin, which is considered a differentiating marker of hypertrophic scars, is variably expressed in both types of scars.
Hypertrophic scars and keloids represent a dysregulated response to cutaneous wounding, resulting in an excessive deposition of extracellular matrix especially collagen, possibly due to transforming growth factor-β (TGF-β).
To prevent the formation of hypertrophic scars and keloids, it is important to reduce mechanical tension during wound healing (ie, align surgical incisions along rather than across relaxed skin tension lines). The risk of wound dehiscence can also be minimized by using the appropriate strength, depth, and number of sutures. Inflammation may be reduced by adhering to sanitary protocols during surgery and observing appropriate wound care measures to prevent further infection. The use of inert suture materials and silicone sheeting and/or silicone gels is also recommended as a scar prevention strategy.2
Stratamed® for scar prevention
Stratamed® is a silicone gel-based wound dressing that decreases capillary activity, hyperaemia, and collagen deposition, thereby enhancing wound healing and reducing abnormal scar formation. Stratamed® is an inert, bacteriostatic gel that can be applied directly onto open wounds immediately aft er dermatological interventions such as laser treatment, dermabrasion, chemical peels, fractional carbon dioxide resurfacing, minor surgery for lumps and bumps, etc. It does not adhere to granulation tissue and is clinically proven to rapidly improve visible treatment outcomes (Figure 1).3 It is nearly invisible when dry and can be applied on exposed wounds. Once dry, it can be applied under sunscreen, cosmetics, or pressure garments. When applied on damaged skin or wounds requiring a secondary dressing, Stratamed® should be reapplied during dressing changes.
Evidence supports the use of silicone gel or sheeting, pressure dressings, and corticosteroid injections as first-line treatments for hypertrophic scars and keloids.2
Cryotherapy may also be useful for smaller lesions.2
Corticosteroid injections, eg, triamcinolone acetonide suspension 10–40 mg/mL reportedly flattens 50–100 percent of keloids; however, recurrence rate can be as high as 50 percent.2
As intralesional injections can be painful, lidocaine may be administered for pain relief.
Other scar management techniques for hypertrophic scars and keloids include laser therapies, dermal radiofrequency, radiation, and microplasma/ultrasound transepidermal delivery. For atrophic scars, laser therapy, microneedling, autologous fat transfer, chemical peels, injectable fillers, and subcision may be recommended.
Keloids and hypertrophic scars represent an abnormal tissue response during wound healing. Any trauma to the skin may potentially form scars. It is crucial for physicians to be aware of strategies for minimizing the risk of postoperative scarring, and to identify therapeutic approaches that may improve excessive scarring.
1. Seifert O, Mrowietz U. Arch Dermatol Res 2009;301:259-272
2. Juckett G, Hartman-Adams H. Am Fam Physician 2009;80:253-260
3. Monk EC, et al. Dermatologic Surgery 2014;40:76-79
Pearls in Suturing Techniques and Scar Management for Surgical Patients
In surgery, the quality of instruments and materials to be used – including the type of needle and sutures – is an important consideration to optimize wound healing.
Choosing surgical needles and suturing materials depends on the type of procedure to be performed, the surgical site, and the surgeon’s preference and experience. There are three types of suturing needles that can be used: round-body needles for stitching muscle or fascia; cutting needles for skin procedures; and reverse-cutting needles for subcuticular stitching.
Regarding suturing materials, two frequently used types are monofilament sutures and braided sutures. Monofilament sutures create less drag when passing through tissues and therefore cause minimal trauma. Braided sutures, on the other hand, comprise multiple filaments and provide more tensile strength and better knot security. The thickness and composition of the suture material may also vary. Absorbable sutures are primarily used under the skin and are particularly recommended in paediatric cases, as it is often difficult to remove stitches in children.
Mastering stitching techniques including needle driving and knot placement, as well as selecting the appropriate type of suture, is paramount to achieve optimal wound healing.
Post procedure care including the use of silicone-based scar gel is also of utmost importance to ensure the best cosmetic outcome.