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About Face

Chapter Five Accidents Emergency Care Minimizing Scarring Scar Repair Excision Scar Transformation Dermabrasion

The needle used for a deep dermal stitch is shaped like part of a circle. These needles come in quarter circle, three-eighths circle and half-circle sizes. Their shape makes it easier to work in tiny spaces, but the ultimate skill lies with the surgeon: there should be as few sutures as possible, and they should not be drawn too tightly or the blood flow will be restricted and this will slow the healing process.

In most cases, we take a three-layer approach to closing up a wound. After the deep dermal stitch, the surface or second layer stitch is taken. This is a suture that makes the skin edges level with one another. It’s a loose stitch designed to make the meeting of the edges as flat as possible, rather than to hold the edges together. For this suture, we use a fast-absorbing gut that will dissolve out in five days, as long as it is covered. Unfortunately, some patients may end up in emergency rooms equipped with non-absorbing sutures and, unless they get these surface stitches removed with five days, they can suffer cross-hatch scars.

Cross-hatching comes about when the stitches stay in too long and the new skin begins to migrate down the sutures. This creates tiny holes. If there are other sutures laid across the wound, they’ll create scarring in another pattern that we call “railway tracking”. Over the years, I’ve had to help several patients with scarring created by sutures left in too long. Some surgeons avoid the whole problem of sutures by using Histoacryl glue to set the edges of the would evenly. I personally prefer the use of the deep dermal stitch to keep the wound edges as narrow as possible.

The “third layer” to close up a wound is actually anti-tension tape applied to the surface of the skin. The tape is sued to compress the wound so that, again, its tendency to widen is curtailed. Depending on the type of would and its severity, this taping might be applied for as long as two months after the operation to maintain a narrow edge.

In an abrasion type of skin injury, a scrape, there might be a lot of foreign particles imbedded in the dermal layer of skin - too many to be removed by the cleansing wash of peroxide. In this care, we might have to do a bit of dermabrading to remove all the foreign particles. Otherwise, the particles will result in a tattoo type of scarring when the wound heals.

Wounding to the ears, nostrils or lips demands special cosmetic consideration. If an ear has been partly torn away, for example, the chief concern is to sew the lobe and cartilage parts back into their natural position. If the outside edge of the ear, the helical rim, is not properly restored anatomically, a large “notching” deformity will become noticeable. Likewise, we try to match up the nostrils and avoid notching at the base of each nostril by lining up the rims in their natural positions.

The lips are a challenge because it’s important that the vermilion border (junction of dark and fleshtone lip) is restored to its original place. We also want to avoid the situation where a lip scar becomes very noticeable if a patient “animates” be smiling, or puckering up. This can happen if the muscle underneath the skin hasn’t been property sewn. The area surrounding the lips is one of the few places on the body where the skin is directly attached to the muscle, so we really can’t fix one without the other.

If, despite out best efforts, a facial wound becomes infected, symptoms such as inflammation, reddening and painful swelling will appear within seventy-two hours. If the infection is caught early, and it isn’t too deep, it usually can be brought under control with penicillin or other oral antibiotics. But if an abscess forms deep in the wound, then the wound must be opened up and drained. Either way, infection is something that every emergency officer, or doctor, tries to avoid because the resulting inflammation will contribute to more scarring.

Another possible outcome of facial scarring is the development of “hypertrophic” scars and “keloids”. Hypertrophic means thickened; these scars represent an abnormally thick and tough response to wounding. Keloids come about when the scar tissue begins to expand beyond the borders of the original wound. I’ve seen the tiny scar in a pierced earlobe grow to the size of a robin’s egg. Statistically, hypertrophic scarring and keloids are more likely to plague certain races: people of Asian, Negroid or South Mediterranean Caucasian extraction.

If keloids or hypertrophic scars begin to appear during the healing process, there are a few things we can do. The best method of treatment is to make injections of triamcinolone acetonide, known as Kenalog. Kenalog is the steroid noted earlier that works to dissolve scars. We can start the injections at the time of closing the wound or early in the healing process if keloids start to form. The injections are repeated at least once a month until the scar stops thickening. Hypertrophic scars respond a little more quickly to the injections than keloids, but it is important not to overdo the treatment. Too much Kenalog can result in a loss of pigment or “dermal atrophy”, meaning the skin in the area will be thinned and begin to look depressed.

Another method of treatment is to try cutting out the hypertrophic scars or keloids. Unfortunately, this isn’t always effective because, of course, the same racial factors apply to the new scar created by the excision. In fact, some doctors have reported that up to fifty-five percent of their patients simply redevelop the problem. However, the resultant scar after surgery is usually cosmetically more appealing to the eye.

Lastly, we can apply special pressure dressings that will, ultimately, make the scars more aesthetically acceptable. The catch is that such dressings must exert true pressure to be effective and they must be applied day and night for a minimum of six month to one year. The dressings cannot be removed for any period of time longer than thirty minutes. Obviously, this is a very restrictive form of treatment and impractical for use in the head and neck area.

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