Lacerations, Surgical Wounds& Unsightly Scars
what causes them?
Patients present with wounds from various causes:
- Sutured wounds from surgery, such as cosmetic surgery overseas in Korea, Japan or Thailand (increasingly common nowadays)
- Accidents such as cuts and falls
- Previous scars that did not heal nicely or were sutured in a suboptimal fashion for example: with mismatched edges, or not along relaxed skin tension lines
to treat lacerations, surgical wounds, ugly scars
safely and effectively
A special scalpel blade or instrument such a specialized suture cutting scissors is used to cut the suture enabling it to be removed by special forceps. Sutures used in cosmetic surgery can be very fine and located in inaccessible areas such as deep in the nostrils. In-depth knowledge of cosmetic surgical procedures is essential to understand the location and purposes of the sutures as well as assess how well the wound has healed and if the sutures are ready to be removed.
Toilet & Suturing
The laceration is anaesthetized and cleaned to assess if any cut structures such as nerves are affected. The direction and position of the laceration is assessed and may need to modified to blend inconspicuously into the surrounding facial contours and borders of the facial subunits to camouflage the scar. The wound is then closed with a tension free layered technique using absorbable and non-absorbable sutures according to plastic surgical principles to produce an aesthetically pleasing result.
Fractional Energy Devices
Fractional Infrared Lasers
Fractional laser resurfacing involves the deposition of a pixelated pattern of microscopic laser wounds surrounded by healthy tissue resulting in both greater efficacy and shorter downtime compared to non-fractionated treatments. It can be further subdivided into ablative and non-ablative. Ablative fractional lasers have longer wavelengths (e.g. CO2 10600nm) and lead to full thickness destruction of skin, whereas non-ablative fractional lasers have shorter wavelengths (e.g. Erbium Glass 1550nm) and leave an intact skin surface. CO2 has greater efficacy compared with Erbium Glass but longer recovery time and a higher risk of complications.
Fractional Infrared Lasers have a good body of research evidence demonstrating safety and efficacy.
Fractional Picosecond Laser – Discovery Pico Plus
Discovery Pico Plus is a second-generation triple wavelength picosecond laser that generates the highest peak power in the world. A special microlens array further focusses the energy into numerous micro-beams 2mm under the skin. The highly concentrated energy produces laser-induced optical breakdown (LIOB) stimulating collagen production with almost no downtime.
Fractional Bipolar Radiofrequency
Fractional Radiofrequency creates a pyramidal thermal injury zone (a relatively large coagulation zone deep in the skin with minimal surface damage) as opposed to the columnar shape of ablative lasers. Hence Fractional Radiofrequency has a favourable side-effect profile (such as downtime, post-inflammatory hyperpigmentation) in comparison to fractional lasers.
Fractional Microneedle Radiofrequency
Skin remodelling requires heat delivery to the deep part of the skin. However, in most machine-based treatments for scarring such as lasers, much of the energy is dissipated at the skin surface and little reaches the deep layers. Fractional microneedle radiofrequency overcomes this using insulated microneedles to spare the upper part of the skin and deliver radiofrequency energy precisely up to 4mm deep in the skin, resulting in faster recovery, higher efficacy and increased safety.
Vascular lasers / Intense Pulsed Light
Vascular lasers (such as pulsed dye lasers, yellow lasers, long pulsed diode or NdYAG) target haemoglobin in blood vessels destroying them. They are useful for hypertrophic / keloid scars and fresh stretch marks. Intense Pulsed Light used together with special vascular filters can be used for similar purposes as well but is generally less powerful
Intralesional steroid injections
Corticosteroid injections decrease over-active inflammation and collagen synthesis hence improving the appearance and symptoms of keloid or hypertrophic scars.
Subcision and Filler
In subdermal incision (subcision), surgical tools inserted under the skin via small needle punctures are used to release tethered skin scars stuck down to the deeper fascia by abnormal scar fibres. Filler is then interposed to prevent the two layers from sticking back together during the healing process.
Scar revision is used for scars that have not been sutured properly. The scar is excised and direction and position of the wound is assessed and may need to modified to blend inconspicuously into the surrounding facial contours and borders of the facial subunits to camouflage the scar. Various plastic surgical techniques such as V-Y plasty M-plasty, geometric closure, W-plasty, Z-plasty may be useful here. The wound is then closed with a tension-free layered technique using absorbable and non-absorbable sutures according to plastic surgical principles to produce an aesthetically pleasing result.
dr wan’s perspective
Suture removal and laceration repair may seem simple but they require a lot of background knowledge. In Dr Wan’s view, wound closure is much more complex than just putting in a few stitches so that the skin heals over. Dr Wan has personally seen many cases of poorly closed wounds, such as steristrips or tissue glue for deep facial wounds, overly tight sutures resulting in tram track marks or mismatched wound edges. Given that specialized knowledge is required to assess and plan the closure, even medical aesthetics doctors may not have adequate plastic surgical training to do a proper layered closure. Engaging a plastic surgeon may not always be the best idea, however, as they cost a pretty penny. Dr Wan’s experience in wound closure during his numerous plastic surgical rotations has equipped him with the knowledge and skills to remove sutures from cosmetic surgery, close wounds nicely and address wound healing complications.
Prophylactic fractional energy treatments and topical medications such as scar gels should be instituted early to improve the final result.
Wounds that have not healed nicely can be further treated:
- Textural issues treated with fractional energy devices
- Redness, hypertrophic or keloid scars treated with intralesional steroids, and vascular or fractional lasers
- Tethered scars treated with subcision and filler
- Scars that have slightly mismatched edges can be treated with ablative lasers or fractional energy devices
- Scars that have grossly mismatched edges or unfavourable directions may require scar revision