From the Department of Plastic Surgery of the Mercedes University Hospital, Havana, Cuba

Transcription

1 SCAR PROGNOSIS OF WOUNDS By ALBERT F. BORGES, M.D. From the Department of Plastic Surgery of the Mercedes University Hospital, Havana, Cuba WHEN a wound heals a scar takes its place. Any injury to the skin that sections or destroys the papillary layer of the corium leaves a scar, which may be inconspicuous or in-some instances very disfiguring. It is the purpose of this paper to analyse the factors which govern the scar prognosis following the healing of a wound. The cicatricial prognosis of a wound is a subject of great concern to the plastic as well as to the general surgeon ; nevertheless, I have not been able to find it thoroughly discussed in any textbook of medicine and there are but few references in the literature relating to this problem. This may be due to the emphasis given to the pathology and to the surgical technique which has been treated with a relative disregard to the skin incision which should "be ample in order to expose the important deep structures." The resultant scar will not alter the mortality rate but it will alter the statistics on psychological morbidity, since the appearance of a person has been given increasing significance in recent years. The way a cicatrix is going to look is not determined so much by the technique with which a wound is sutured as by the way in which it is inflicted. In other words, if one follows a perfect surgical technique in the closure of a wound, one probably will get the best results, but this result in some instances may be very far from good or even fair (see Figs. 7 and IO). How depressing an ugly scar can be to a young surgeon who ponders on the reason for his failure to obtain an ~esthetic cicatrix. The different factors which will determine the prognosis of the physical aspect of the scar after healing of a wound is the subject of this presentation. Before progressing further we should briefly differentiate between a true keloid and a keloidal scar or pseudo-keloid. Both are very similar microscopically as they are hypertrophic scars. The keloid is seen almost exclusively in the coloured races m patients with a tendency to keloid formation, while a keloidal scar may appear in any race and may develop in any cicatrix which has been submitted to tension. As to prognosis, a scar may develop into a keloid if the wound is inflicted in a predisposed coloured patient, more so if that patient has keloids in other regions and if it lies over the sternum, shoulders, ears, or infraumbilical midline ; they are rare on the hands and feet (Figs. I to 5). So much so for the prognosis of a true keloid ; no other factor is of much importance in its appearance. At times the difference between a keloid and a keloidal scar is not so easily discernible. The microscopic and macroscopic difference between a keloidal scar and a wide flat scar is obvious but the main mtiological substratum of both is generally the same, i.e., tension on the scar. Most other factors which give rise to one also. give rise to the other (see Figs. 28, 29, and 30). These factors are the following : I. The Region.--The most important factor is the region where the wound lies. There are two regions which are notorious in the formation of bad scars: these are the sternalis region (Figs. 6 and 7) and the shoulder region (deltoid-acromial-scapular) (Figs. 8, 9, and io). In the brachial (Figs. I I and i2),, 47

2 4 8 BRITISH JOURNAL OF PLASTIC SURGERY antebrachial, gluteal, femoral, and crural regions scars tend to widen and at times hypertrophy. Going over the last 3o0 cases that were seen at the " Instituto del Radium del Hospital Mercedes " (anticancerous centre), I found that 35 per cent. complained of scar hypertrophy over the sternum, 15 per cent. in the infraumbilical midline surgical incision, IO per cent. in the shoulder, and the rest over other regions of the body. The reason for the frequency of hypertrophic scars in the infraumbilical region is the great number of laparotomies done through this midline incision. FIGS. I to 5 Figs. I and 2.--Case A. Bilateral huge keloids of the ear lobes which followed puncture for ear-rings in a coloured woman. In the coloured races punctures of the ear lobes are liable to this danger. Treatment would consist in excising most of it within the limits of the tumour followed by X-ray therapy... and hoping for the best! Figs. 3, 4, and 5.--Case C. Burnt coloured boy. Most areas are hypertrophic (arrows) but there are some regions where the patient has only flat scars~ e.g., in the forehead and part of the hand. This is hard to explain and just as difficult to treat. Following through on this, wounds in or close to the palpebral fissure, mouth, nares, or eyelashes should be treated with the utmost care since any deviation from a very good result will be most unsightly. Further, a wound that crosses from a surgical msthetic region to another will be more unsightly than if it did not, for example, one that goes from the dorsum of the nose to the cheek. Wounds on mucosas heal better than on the skin. The structures over which the scar lies also bear some importance. If the scar lies over a hard convex surface, for example the forehead, the cicatrix will be better than one over soft concave tissues like the axilla. 2. The Course.--The next factor which follows in importance is the direction of the scar. When a scar follows the "lines of skin tension," sometimes called Langer's lines, the scar is as inconspicuous as it can be (Figs. 13 to 20). If it falls perpendicular to them, it becomes wider and possibly hypertrophic (Figs. 21 to 30). These lines of tension follow the normal skin wrinkles, those that are formed when a muscle is contracted or those furrows which can be easily seen when the skin is pinched in the opposite direction. These lines do not correspond to Langer's lines in some regions such as the forehead, cheek, outer aspect of the eye, across the anterior aspect of neck, sternalis region, lower abdominal, penis, antecubital fossa, and fingers. These differences are due to the fact that Langer studied the lines of tension in cadavers which are different from the dynamic forces acting on the skin of a living person. The following surgical

3 SCAR PROGNOSIS OF WOUNDS FIGS. 6 to i2 Figs. 6 and 7.--Case D. Hypertrophic scar over sternum in coloured woman. In Fig. 7 can be seen the result after various attempts at surgical excision and X-ray therapy. Scars in this region have such a great tendency towards hypertrophy that I hesitate before operating on benign tumours in this region in either white or coloured patients and do not try to improve on hypertrophic scars already present. Figs. 8, 9, and I o. - - C a s e E. Hypertrophic scar in white boy. It was carefully excised with good immediate result (Fig. 9)~ but it later recurred although not as severely (Fig. Io). In spite of the fact that this scar followed the lines of skin tension it hypertrophied because this region has that tendency. This boy had scars on other regions which were not at all hypertrophic. Figs. 11 and i C a s e F. Scar in arm due to vaccination. Its excision and suture under tension left a linear wide scar almost as unsightly (Fig. I2). Vaccination scars in extremities are better left alone. ID 49

4 5 BRITISH JOURNAL OF PLASTIC SURGERY FIGS. I3 to 19 Figs. I3 and r4.--case G. Epithelioma treated elsewhere by electrofulguration. In spite of the fact that the raw area was not sutured but left to heal by secondary intention, a fair-looking scar developed because it followed the lines of skin tension, it is located in the lateral aspect of the neck~ and the patient is an old person. Figs. I5 and r6.--case H. Young white girl with traumatic nearly transverse wound in forehead. Prognosis is good and results excellent because of many favourable factors stated in text. Figs. 17, r8~ and r9.--case I. Hypertrophic scar due to burn. Excised and carefully sutured. Excellent result (Fig. I9), even without any make-up, planing, or X-ray therapy because the wound followed the lines of skin tension.

5 SCAR PROGNOSIS OF WOUNDS 51 incisions are frequently and erroneously done perpendicularly to the lines of skin tension : drainage of abscess in the axilla ; cannulation of a vein in the antecubital fossa ; excision of a ganglion at the wrist (see Fig. 27) ; excision or ligature of the FIGS. 2O to 22 Fig. 2o.--Case J. Carbuncle treated by three transverse incisions with a fair result. Vertical antitension line scar in the nape as the one present in cross-shaped incisions are most unsightly. Figs. 2i and 22.--Case K. Vertical scar as a result of surgical wound to drain abscess on forehead. This scar was excised and sutured with the utmost care but the post-operative scar (Fig. 22), although less conspicuous, has widened. A W-plasty would have given a better scar. FIGS. 23 and 24 Case L. Very difficult case which had an antitension line vertical forehead scar and transverse cheek scar plus a horseshoe-shaped right cheek scar. Z-plastics and planing gave the post-operative result seen in Fig. 24. internal saphenous vein at the groin or the external saphenous vein at the popliteal fossa ; drainage of a carbuncle in the nape (see Fig. 2o) ; tracheotomy ; excision of turnouts in the forehead (see Figs. 21 and 22) ; biopsy of the mammary gland ; laparotomies (see Figs. 28, 29, and 3o) ; herniorrhaphies ; etc. 3. The Pattern.--Straight linear wounds which follow the lines of tension give excellent scars (see Figs. 15 and 16), but if they run perpendicular to them the scar becomes wide and/or hypertrophic (see Figs. 22, 28, 29, and 30). L-shaped

6 5 2 BRITISH JOURNAL OF PLASTIC SURGERY scars are superior to the latter because probably one of the two arms will follow the tines of tension, because light will reflect only over one of the arms at a time, and because the L-shaped scar has some elasticity if it is placed under tension from its two most distal points. The curved, horseshoe, or U-shaped cicatrix is FIGS. 25 and 26 Case M. Antkension hne scar in cheek. Treated by W-plastic procedure with excehent resuk as seen in Fig. 26. FIG. 27 Case N. Hypertrophic keloidal scar in wrist of white patient due to wrong direction of surgical incision in the treatment of ganglion. Simple excision of scar and suture of wound would not improve the cicatrix, but Z-plasty would. quite unsightly (see Fig. 23). The cicatrix itself when it contracts will become depressed and the skin it circumscribes will tend to bulge out. 4. Bevel-edge Wounds.--These wounds give rise to unmsthetic heating. The visible scar itself might be thin but the contraction of the dermal scar will bulge out the skin over it. 5. Surgical Technique.--This plays, of course, an important role in obtaining the best results. It includes approximation of subcutaneous tissues, use of fine external sutures~ early removal of skin sutures, atraumatic technique, etc. Nevertheless we agree with Straatsma (I947), who says that "surgical perfection per se is not the complete answer to obtaining fine scars." With the same technique in Figs. I9 and 24 an excellent result can be seen, in Fig. 22 a fair one, in Fig. xo a poor result, and in Fig. 7 a disaster.

7 SCAR PROGNOSIS OF WOUNDS Tension.mlf for any reason a wound is sutured under tension the scar will probably widen in spite of numerous subcuticular stitches and post-operative adhesive "butterflies " (see Figs. I I and i2). Could the excessive tension of the skin in the sternalis and deltoid regions be the responsible factor in obtaining these umesthetic scars? 7. Skin Thickness.--A scar in areas where the skin is thin (eyelids, neck) will give excellent results if it follows the lines of tension like that obtained with the transverse neck post-thyroidectomy incision; but will give very poor results if FIGS. 28 to 3 Case O. Two keloidal (or keloid?) scars over medial infraumbilical laparotomy wound. Note how they are separated by a non-keloidal wide flat scar although no X-ray therapy has been given. Why it is wide and hypertrophic above and below and only wide in the middle, I do not know, but I believe that it is tension on the scar produced by its direction (perpendicular to the lines of skin tension) that has widened it. In Fig. 3 can be seen the improvement obtained after excision and X-ray therapy. it crosses them, as happens in the vertical midline tracheotomy incision. In thick skins the difference is not so pronounced in regard to direction but it is still evident. Wounds with edges of unequal skin thickness, such as observed after avulsion of tissues, will not give very good scars. 8. Accidental contused wounds will not heal so well as clean surgical ones because in the former there is microscopic death of cells in the wound edges which will increase the amount of scar formation. Further, accidental wounds at times have embedded foreign bodies which is also detrimental. 9. Healing by second intention or infected wounds will give rise to visible scars for obvious reasons. IO. Race.mColoured people are more liable to hypertrophy than whites, and of these the blondes give better scars than brunettes. People with dark skins, such as Latins, may develop hyperpigmentation following dermal abrasion therapy. This pigmentation is transitory and will generally disappear even without treatment. I I. Psychoneuroses.--Psychopaths might be seriously affected over a scar that a normal mentally balanced person might disregard. Following through on this, sex does not play an important role in scar formation except that females to be satisfied demand better results than males, as a fair scar on a man might be considered a horrible scar on a woman. On the other hand, a wide scar in the beard region is more visible in the shaved adult male than a similar scar on an adult female.

8 54 BRITISH JOURNAL OF PLASTIC SURGERY I2. Age.--Older persons tend to have less visible scars than young adults or children. This, I think, is due to the fact that the skin in older persons is much more flaccid than in the young, therefore there is less tension on scars. Besides, in children, a sutured wound might receive further injury during the process of healing because of the difficulty in keeping them quiet. 13. Burn Scars.--Scars resulting from deep burns are notorious in their tendency to hypertrophy. This is not only due to the slow healing but also to the increased tension in all directions on the burnt region. This can be demonstrated by incising the hypertrophic scar perpendicular to the line of pull, skin grafting the raw area formed, thus relieving the scar from tension, after which it will frequently be found that in a few months the thickened scar will by itself become thinner. 14. Individual or Personal Factor.--Similar wounds in different patients most probably will give similar ~sthetic scars, but all patients upon application of the same stimulus tend to react slightly differently, except those with a true keloid tendency. SUMMARY The various factors which govern the prognosis of the physical aspect of the scar which follows the healing of surgical or accidental wounds are stated. Emphasis is laid on the factor "region" and on the course or direction a wound follows. Cases are presented to illustrate these factors. REFERENCES BORGES, A. (I959). Brit. ft. plast. Surg., x2, 29. STRAATSMA, C. (r947). Plast. reconstr. Surg., 2, 2I.