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Scar Management

Scars are the normal and unavoidable outcomes of tissue healing where the fibrous tissue replaces normal tissue as a part of the remodeling phase of wound healing. The collagen synthesized initially is random and constituting bulky fibers, which eventually remodels along the lines of tension. As this normal process occurs there is a risk of adhesions in the adjacent tissues. Eventually, these collagen fibers are replaced with stronger and more organized collagen, representing a smoother and flat scar which is paler in appearance.

A scar that stays within the boundaries of the original wound is a firm scar.

Scars that progressively encroach on the surrounding area of skin tissue resulting in a cosmetic and emotional distress. They frequently develop in areas rich in blood supply like the ear lobe or the presternal area.

Hypertrophic scars
Prolonged inflammation causes excessive collagen deposition with an increased adhesiveness and contractility of the scar. The resulting scare is red, vascular, immobile and raised. This can adversely affect range of motion and cause functional limitations when present around a joint.

Color: This is a measure of vascularity as well as pigmentation (measure of the melanocytes, bile ad carotene pigments).

Pliability: This refers to the extensibility or elasticity of skin

Range of motion assessmentIt however is an indirect assessment of function and not merely a measure of the scar
Vertical pressure tools
Cicatronometer: hand held tonometer that’s held vertically on the skin, depressed is an indicator rod. The firmer the skin the higher the rod will move

Mdodified Shiotz tonometer: this device even gives a reading of the power required for a given deformation.

Properties good against the ultrasound, however not used frequently
Horizontal Stretch tools: These are the extensometer and elastometerThe reliability of these tools is yet to be tested.
NK Derma Durometer: This is a computerised device that uses the pressure required to deform skin through the electric resistance of skin.Non invasive, esy to use, objective but expensive
Cutometer: Measures vertical deformation using a suction deviceHighly sensitive.

Scar prevention
Prevention of a scar of of priority and can be done by 3 preventive measures:

Tension relief
Pressure garments.
The greatest tension of a wound is at its edges i.e. perpendicular to the langer lines, additional those in the sternal and deltoid regions are at a higher risk for developing excessive scarring. Stress shielding devices wen applied to the scar interface reduces the mechanical stresses and prevents excessive scar formation.

Botulinum toxin A (botox) reduces tensile forces on post surgical scar. Moisturizing and humectant creams reduce the scaring in itchy scar. Silicon products hydrate the scar across the stratum corneum and hence prevent excessive scaring. Altering the levels of inflammatory cytokines like TGF-β3, as it is necessary towards the end of wound healing. Avoiding exposure to sunlight an the continued use of sun screens until the scar has matured.

Scar Management
Aim: Altering the physical an mechanical properties of the scar by influencing the scar maturation process. Also promoting tissue strength and gliding by preventing adhesions.

Scar massage: During the proliferative stage massage has a beneficial role in collagen synthesis, as it prevents adhesions and helps in collagen synthesis. Also this mechanical stress when applied to the intermolecular bonds, helps in realigning collagen.

Splinting: Splinting can be used at all stages of wound healing, to immobilize at the earlier stages and with the aid of passive or active stretches to modify collagen alignment. Static and dynamic splinting can alter the viscoelastic properties of tissues thus it can elongate and stretch tissues over time.

Silicon gel: Silicone gel through sheeting and elastomers are said to have a hydrating effect on the scar. It helps to soften and elongate a scar by increasing the pressure, temperature and in turn blood flow to the scar.

Ultrasound therapy: The known effect of ultrasound is to promote healing in the inflammatory and proliferative stages. It stimulated the synthesis of growth factor that in turn increase the strength and elasticity of the collagen fibers formed,

Laser: Laser inhibits collagen and improves keloid and hypertrophic scarring. It improves pruritus but ha no effect on he cosmoses of the scar.

Pressure Therapy: When used for edema management and cosmoses in case of keloid and hypertrophic scars. These garments inhibit collagen synthesis in a remodeling scare through a mechanism that is unknown. Pressure therapy can reduce the scar height and erythema when applied for 23 hours per day for 12 hours. This should be applied at 20 to 30 mmHg and replaced every 2 to 3 months. This reduce abnormal pigmentation and accelerates scar maturation

Pressure garments: This is sued in case of more widespread scarring as in case of burns patients.

Steroids: An intraleisonal injection of a steroid improves the scarring. This is painful and is suggested with other routine treatments


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