Management of lacerations and scars

The purpose of this paper is to review and update the subject of management of scars and lacerations. The surgion who accepts responsibility for management of soft tissue injuries must be aware of fundamental surgical principles as well as detailed technique. Knowledge of basic anatomy and wound physiology is utilized and applied. Emphasis is placed on management of the total pateint. The specialist must accept the role of team captain and establish an order of priority in management and in wound analysis. By having a basic knowledge of wound healing and the lines of favorable contracture, one is better able to prognosticate the eventual healing of the wound after proper management. By being able to predict wound contracture and scar maturation, the patient can be better informed as to what to expect during the period of healing. With lacerations immediate repair is carried out. With scars there is more time for planning and photographic analysis. The contracting forces will by this time have identified themselves and the degree of release of the contracture or camouflage can be determined. Specific wound management emphasized meticulous closure in layers and the use of skin hooks with the interrupted subcuticular suture. Skin sutures with both the continuous subcuticular suture and interrupted sutures of monofilament nylon using the spring-loop are described. Emphasis is placed on the preparation of the skin margins with slight beveling of the skin edges and undermining with precise even thickness of the skin especially at the wound margin. For scar revisions a minimum time of six months should elapse, and 12-18 months is better. Complications include infection, hematoma, wound separation, and rejection of suture materials. Keloids are discussed briefly, particularly regarding the use of intralesional injection steroids. Broken line camouflage techniques are discussed with the regard to breaking up contracture without lengthening. Lengthening either existing or anticipated contractures is accomplished with Z-plasty. The multiple Z-plasty, W-plasty, and Zig-Zag plasty are aimed towards creating a less conspicuous scar and creating some diffusion of the forces of contracture. A technique for a "practical Z-plasty" is described. Both free grafts and skin flaps sometimes must be utilized to fill tissue defects and break up line of contracture. The materials presented and conclusions drawn are based on 25 years of active emergency room coverage and long term follow-up of treated patients. It is the responsibility of the physician to act within the first few hours and to take the time necessary for accurate approximation and realignment of both soft tissue and bone injuries. Minimal scarring depends on accurate approximation of skin margins without tension. The need for early meticulous repair, so that unsightly scars and disfigurements may be prevented, cannot be overemphasized.