Management of surgical wounds remains fairly straightforward, according to facial plastic and reconstructive surgeons. Excellent surgical technique and appropriate precautions to avoid infection and stress on the wound are the general rules to follow to minimize scarring, the experts agreed.
Planning the incision is the most important consideration in preoperative management of facial plastic surgery patients, said Jill Hessler, MD, Assistant Professor of Facial Plastic Surgery and Dermatology at Washington University in St. Louis.
The scar should be placed along relaxed skin tension lines or at the boundary of facial subunits where there will be the least amount of pull on the scar and the best scar camouflage. Identification of relaxed skin tension lines can be determined by looking at natural skin wrinkles or pinching the skin between two fingers to determine the natural folds. The lines run perpendicular to the underlying muscle actions. The shadows in those areas will hide the scar, she explained.
For example, the orientation of an incision on the forehead would be along the horizontal lines, whereas an incision along the lips should be oriented in a more vertical position, she said.
Preoperative recommendations include cessation of smoking for at least two weeks prior to surgery and continued avoidance of smoking for at least two to four weeks afterward. Smoking decreases arterial blood flow to tissues, which impairs wound healing, Dr. Hessler said. Smoking cessation prior to surgery is just as important as it is after the operation for optimal results, she added.
Dr. Hessler recommends adequate nutrition as part of the preoperative regimen for surgical candidates, including adequate hydration and a balanced diet that contains protein and other nutrients as well as a multivitamin. It’s important to limit alcohol, especially two to three days before surgery, because alcohol can lead to postoperative edema and fluid retention, she commented.
Patients planning to undergo facial/plastic surgery should refrain from taking ibuprofen, aspirin, or other nonsteroidal anti-inflammatory drugs (NSAIDs) for 10 days to two weeks before surgery to limit the risk of bleeding.
Another important consideration to discuss with your patients is herbal supplements. It is important that physicians specifically inquire about their usage. Many patients don’t realize the side effects of these poorly regulated substances so neglect to ask about them, Dr. Hessler advised. For example, ginkgo biloba, vitamin E, and garlic can predispose a patient to bleeding, whereas St. John’s wort can interfere with anesthetics used in the procedure.
Tanning prior to surgery can lead to postoperative hyperpigmentation, so patients should be instructed to stay out of sun before surgery. Patients should also be advised to use a sunscreen over scars for at least six months following the surgery. Scars are more susceptible to scarring, she said. A sunscreen of SPF 30 with both UVA and UVB coverage should be used daily.
After surgery, Dr. Hessler suggests using a simple regimen of cleaning the scar with mild soap and water and a cotton swab saturated with half-strength hydrogen peroxide along the length of the incision to remove any blood or crusting. The peroxide should be gently wiped away.
Keep the incision clean and moist for the first week. Apply topic polysporin or double antibiotic ointment to the incision for three days after surgery; after that use Vaseline, she advised. Triple antibiotic ointment is not recommended because it can occasionally lead to a contact dermatitis presenting as significant redness along the skin incision, she said.
Bed rest depends on the extent of the surgery and patients’ subjective assessment of how they feel. The head should be elevated during sleep to improve lymphatic draining and reduce any tension on the scar, she noted.
Part of preoperative planning includes inspection of any previous surgical scars to see how the patient has healed. For patients who are prone to keloids or hypertrophic scarring (i.e., darker-skinned individuals), Dr. Hessler recommends topical silicone gel sheeting applied to the scar with a bandage. This will reduce the incidence of keloids or hypertrophic scars by at least 50%.
Scars are noticeable because they are discolored, irregular, raised, or cross facial subunits. Each problem requires different treatment. Pulse-dye laser or intense pulse light laser (IPL) can be used to treat scars that are raised or erythematous. Use of these lasers will decrease blood flow and redness and flatten out the scar, Dr. Hessler said. If the scar is irregular or the edges are not well aligned, the best treatment is either scar revision surgery using a geometric broken line closure or dermabrasion to smooth out the skin.
If there is evidence of development of a thickened scar, steroid injection is used to decrease fibroblast proliferation; fibroblasts create the collagen needed for strength in the wound, she noted. When this proliferation continues uncontrollably, a hypertrophic or keloid scar forms. If the patient responds to the steroid, these injections can be repeated monthly for a total of three to four months. Response should be reassessed with each injection, and the scar should be massaged following each injection to break up cellular bonds in the matrix.
Keep the incision clean to promote healing. Infection leads to prolonged healing, and longer healing times lead to an unfavorable scar, she stated.
Exquisite surgical technique is the most important consideration to avoid scars, regardless of the type of surgery, said Neal Futran, MD, DMD, Professor of Otolaryngology-Head and Neck Surgery, Plastic and Reconstructive Surgery, and Neurological Surgery and Director of Head and Neck Surgery at the University of Washington School of Medicine in Seattle.
Mark Wax, MD, Professor and Program Director for Otolaryngology and Head and Neck Surgery at Oregon Health Sciences University in Portland, agreed with Dr. Futran that surgical technique is the most important factor in minimizing scarring. Be sure to put the skin together with the least amount of tension on the incision, Dr. Wax said.
Patients should be advised on proper nutrition and adequate hydration before surgery, continuing on this regimen after surgery. When head and neck reconstruction is performed as part of cancer management, nutritional status is especially important, Dr. Wax said.
Always ask patients about supplements and herbal products they are taking, because some of these products may increase bleeding, Dr. Wax said. In addition, patients with comorbidities may be on medications that alter blood parameters. For example, patients with arthritis who are taking aspirin or NSAIDs need to stop these drugs prior to surgery. Patients with diabetes and hypertension should have blood sugar and blood pressure, respectively, well controlled prior to surgery, and these patients should remain on their drug regimens. Electrolytes should be checked prior to surgery to make sure they are normal, Dr. Wax said.
Despite the availability of several new types of gels and materials, Dr. Futran typically uses postoperative oral antibiotics for five days, along with topical antibiotic ointment for the first 48 hours, to avoid infection. He prefers a broad-spectrum oral antibiotic such as augmentin or clindamycin, and he uses double antibiotic ointment. The wound dressing should not be occlusive, so as not to create a friendly environment for infectious organisms.
After 48 hours, nature [usually] does a great job, Dr. Futran said.
The wound should not be exposed to water for the first 24 hours after surgery; after that, it can gently get wet, but Dr. Futran said patients should be careful of the incision when washing their hair.
For incisions in the neck (but not on the face), double antibiotic ointment alone is sufficient. For a face wound, Dr. Futran uses Mastisol adhesive on either side of the wound and Steri-Strips to hold the wound together.
Dr. Wax uses Steri-Strips or petroleum-based antibiotic ointments to protect the scar. Sometimes ointments are enough, he said. However, Steri-Strips are useful for wounds that will be exposed to the cold or to potential trauma, he added.
Either a silicone-based gel, such as Mederma, or silicone sheets can promote wound healing, Dr. Wax said, although the mechanism for this is not well understood. He also suggests vitamin E cream, cocoa butter, and aloe vera for expediting wound healing.
In patients with a predilection for keloids, I inject the edges of the wound at the time of closure with Kenalog to minimize widening of the scar, Dr. Futran said.
The night before surgery, Dr. Futran instructs patients to shower and wash their hair and tells male patients to shave. Patients use an antibiotic cleanser such as Hibiclens the night before and the morning of surgery.
Post-surgery, patients should be instructed to keep the wound dry for 24 hours; after that, gentle cleansing is allowed. Patients should avoid direct trauma, irritation, or stress/tension to the wound for five to seven days. Exercise and heavy lifting should be avoided until the wound heals.
Size or length of incision does not change the management for wound healing. It is straightforward, relying on local care, Dr. Futran said.
Biomaterials, such as artificial skin, are useful for wounds that cover large surface areas of the body, such as burns, but they do not play a big role in typical facial cosmetic/reconstructive surgery, agreed all experts interviewed for this article. Dr. Futran said that the newer biomaterials would probably be useful for problematic wounds (i.e., those that don’t heal or break down and get infected), but in general, if wound healing is uneventful, there is no role for biomaterials or bio-dressings.
Dr. Wax said that artificial skin such as Integra or Alloderm is useful when there is a gap in the wound, but he rarely uses these products. Most cosmetic or reconstructive surgery doesn’t require these biomaterials. Cosmetic/reconstructive surgeons try to use adjacent skin or skin grafts to close the wound, he said.
In the future, cytokines such as vascular-derived endothelial growth factor (VEGF) and platelet-derived endothelial growth factor (PDGF) may be used to promote would healing, according to Dr. Wax. Ongoing research will determine the role for these cytokines in facial and reconstructive surgery. Dr. Wax thinks that we are still five or 10 years away from having them approved for clinical use.
©2008 The Triological Society