Conference Coverage

Use time-appropriate scar improvement sequencing



Every dermatologic surgeon ought to have at hand a wide array of techniques for improving surgical scars, according to American Academy of Dermatology President-elect George J. Hruza, MD – and he’s got a raft of them.

Dr. George J. Hruza, Saint Louis University Bruce Jancin/MDedge News

Dr. George J. Hruza

“There are going to be situations where your scars aren’t going to be as wonderful as you’d like, or even if they’re pretty good, you might improve them further if you do some modifications,” he observed at the Hawaii Dermatology Seminar provided by the Global Academy for Medical Education/Skin Disease Education Foundation.

He became convinced of the importance of having a large toolbox for scar improvement in part as a result of an Australian prospective study of 576 patients surveyed 6-9 months following skin cancer surgery. Far and away the most important factor influencing patients’ overall perception of their experience wasn’t the cost, pain, quality of nursing care, complications, wait time prior to surgery, or gratitude that they’d successfully had a cancer removed. It was their perception of the scar (J Am Acad Dermatol. 2007 Sep;57[3]:445-53).

To be effective, interventions for scar improvement need to be timed in sync with the three phases of cellular activity involved in wound healing. For example, neurotoxin injections are effective during the first few days of the initial acute inflammation period, when cellular migration is active. Silicone and taping are of value when employed long term, starting at about 1 month and continuing for 3-6 months, throughout the neovascularization/granulation phase, then the time of fibroblast proliferation and matrix formation that follows, and even beyond. Pulsed dye and fractionated ablative lasers are best utilized to reshape matrix formation, starting at about 2 weeks. Intervention using dermabrasion or fillers has to wait for the scar to be a bit more mature, at about 2 months; utilized earlier these can cause dehiscence, explained Dr. Hruza of St. Louis University.

He shared what he called his “scar improvement hierarchy,” the sequence of interventions he turns to from the most to least often. But he began with prevention, noting that more than 2 decades ago, he and his coinvestigators demonstrated that running horizontal mattress sutures for primary closures of facial wounds provide better cosmetic results, with a final scar that’s smoother and flatter than the more commonly used simple running sutures (Dermatol Surg. 2005 Oct;31[10]:1313-6).

Scar improvement sequence

Massage. “I recommend this to almost every patient. I have them start at about 6 weeks and do it for several months. It’s really more like kneading dough, not rubbing. You want the skin pressing on the bone underneath,” according to Dr. Hruza. Various investigators have suggested that scar massage works by increasing hydration and capillary proliferation, while promoting desensitization, but the evidence is really anecdotal.

“I think it’s mainly tincture of time. Scars get better on their own,” he observed. Regardless, massage allows patients the satisfaction of actively participating in their own recovery.

Intralesional triamcinolone. Dr. Hruza calls this “our big friend.”


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