Scarring Post Surgery
Scarring is an entirely normal physiological process evolved over billions of years to heal wounds and an inevitable consequence of injuries, whether they be deliberate and necessary (following an operation) or unintended (following an accident).
But, what actually is a scar? A scar is a healed wound that has healed in a way that is non-identical to the neighboring tissue – that is to say, it is identifiably different from the tissue it’s replacing and next to it, and it is that difference that makes it apparent. A scar can technically refer to any tissue that has healed “imperfectly” from heart muscle to tendons (and even on a metaphorical level to psychological wounds). In general, though, when we talk about scars (particularly in surgery) we mean skin scars.
This definition of a scar then itself raises two questions: why is the healed skin different from the neighboring tissue, and what is the practical result of those differences? To understand these, it is important to understand the actual components of the skin.
The skin is composed of two layers – the epidermis on the outside and the underlying dermis on which it sits. The epidermis is very thin and is primarily made of cells (epithelial cells) that multiply very rapidly. It forms a waterproof barrier with the outside world, protects from infection, and also from ultraviolet light (largely thanks to the melanin in it that comes from special cells called melanocytes and gives the skin its color). It is extremely thin and relatively flimsy, so much so that if one were to lift it off the dermis, it would be almost see-through. The dermis is much thicker and tougher (animal dermis is the main component of leather) and is mainly composed of a strong fibrous protein called collagen and an elastic one called elastin. It also contains hair follicles and nerve cells (so you can feel), sweat glands, a large blood supply (allowing body temperature to be regulated), and sebaceous glands (keeping the skin moist). When an injury occurs, the epidermis basically heals perfectly, but the dermis heals imperfectly – with different, weaker collagen and less elastin, making it more prone to stretching; changes in the nerve cells (which may make it less or more sensitive); initially more blood vessels (making it redder) and later fewer (making it paler); and no hair follicles, sweat glands, or sebaceous glands. It is these differences within the dermis that are primarily responsible for the “scar.”
Collagen forms the basis of scar tissue. At first, this is laid down in a disorganized way within a highly vascular environment. Over time, most of the collagen is reabsorbed and the remainder is remodeled. At the same time, the vascularity of the site reduces. Thus, all scars start the healing process with a red and raised appearance, but over the course of about 6-18 months, this changes to leave a pale, flat scar.
Every wound will heal with a scar, but it is the podiatrist’s aim to leave the patient with a mark that is as fine as possible. A podiatrist can do this in several ways – for example, by planning to place the scar in a less visible place, aligning it so there is less tension across it, using careful tissue handling, being mindful to reduce the risk of infection, offloading and instructing the patient to keep movement to a minimum for the first 14 days,and giving further advice as needed.
However, in some cases, the scar becomes a problem, and depending on its location, this can have psychological effects on the patient. Furthermore, there can also be functional problems with a scar, such as a contracture of a scar that crosses a joint across a toe or a natural crease, which can restrict the range of normal movement or distort appearance.
There are basically four groups of “poor scarring” that we think of:
Atrophic scars: These scars are very thin (sometimes so thin that they actually end up breaking down into a wound or “ulcerating” with slight trauma) and prone to stretching.
Stretch marks (striae distensae): These occur when the skin has been rapidly stretched and thinned, almost like a rubber band that has been stretched beyond its elastic limit.
Hypertrophic scars: These may occur following healing under significant tension or some post-injury/post-operative issue such as delayed wound healing or infection. The scar is raised and often red or light brown and can be itchy at times. While they may settle, they do not always do so. They are much more common in darker-skinned people.
Keloid scars: These scars share some similarities with hypertrophic scars but are usually much more lumpy, spread beyond the boundaries of the original scar, and can keep growing unchecked (in theory, they can be classified as “tumors,” though they are not cancers – they do not pose a danger to life or limb and do not spread). They are also much more common in darker-skinned people.
The final appearance of a scar is dependent on many factors. The surgical factors have already been mentioned, but some other factors, such as age, ethnicity, and hereditary disposition, location of scars, duration of scars are related to the patient and cannot be controlled by the podiatrist. Even so, a history of keloid or hypertrophic scar formation should be a signal that the patient will require close follow-up and possible early intervention should any complications occur.
The best time to influence the eventual appearance of a scar is at the time of initial wound repair. This is partly because once a scar has matured, the options for improving its appearance are limited. This is particularly true for hypertrophic and keloid scars, where excision may actually result in an even larger and more unattractive scar. The application of steroids, either through intralesional injection or applied as a topical cream, can improve itching and hyperpigmentation. Topical pressure, through the use of elasticated garments and silicone sheets such as Cira Care, speeds the maturation of collagen and flattens the scar. Recent advances in laser technology especially PICO laser may also offer new treatments for scar correction. However, for many scars, the best treatment is simply to wait: scars often improve so much spontaneously that after 12 to 18 months, there is no need for surgical revision.
While the public perception tends to be that podiatrists or any health professional can produce invisible scars, this is not actually the case. Every wound will heal with a scar (100% of the time); the aim is to make it as small as possible. While many factors that influence scar healing and formation are outside the control of the podiatrist, good planning and technique will help to minimize the chances of an adverse outcome. Furthermore, open communication with the patient should lead to realistic expectations of what can be achieved and what complications might occur.
