MY PERSONAL PERSPECTIVE

Foot and ankle surgeons commonly perform elective surgery.  Patients tend to measure the success of their procedure by the reduction of the deformity and the cosmetic appearance of their scar.

Trauma patients are initially more focused on repair and return to normal function rather than cosmetics.  They eventually will also grade your work based on the appearance of the scar.

Scar control begins with incision planning.  See Brian Novack's lecture on Skin Incision Planning

Tissue handling is also quite important.  Learn to use those forceps gently and avoid forceful retraction.  Of course, your suture technique and choice of suture material is vital to achieving a cosmetically acceptable scar.  Dr. Brian Doerr's "Suturing 101" lecture is currently in development and will be available shortly.

There are also many things that you can do in the post operative period to lessen the likelihood of an unattractive scar:

• Avoid occlusive dressings that tend to macerate the incision site

• Keep the bandage clean, dry, and intact

• Remove sutures once the wound appears well coapted 7 - 12 days depending on the site

• Use Steri Strips while the sutures are in place and for at least a week after they are removed.  This helps to avoid tension on the scar.

I instruct all of my patients to perform daily scar massage for at least 3 weeks after the Steri Strips are removed.  In the past, I've recommended vitamin E or aloe type products.  I now exclusively recommend Mederma Gel.

Mederma is a topical gel formulated with Cepalin (a proprietary botanical extract from onions).  Mederma has shown effectiveness in reducing the size of scars, fading red scars and making various types of scars appear softer and smoother.

- Cosmetic Dermatology
      Clark and Baker.  March 1999

- Skin and Allergy News
      Millikan and Patrignelli.  Vol 30 # 3

Mederma works by reducing the foundation of a ground substance that makes up part of the scar matrix.  Typically, patients will massage the gel into the scar 2-3 x daily.  Each of my surgical patients are instructed to use Mederma post operatively to enhance the appearance of their scars.

Physically massaging the scar is important for scar control.  It also prevents formation of adhesions to the underlying tissue.  My patients are discouraged from exposing the scar to the sun.  If necessary, sun block should be used.

In the event the patient develops a hypertrophic scar, I will initially use gel sheeting.  This is now available OTC (Neosporin).  Direct compression using garments is also helpful.  Remember that scars must go through a maturation period.  Often scars that initially appear to be unsightly, go through a period of revision and will lighten and flatten considerably.

When a patient demonstrates obvious hypertrophic scarring, I will attempt to use 10% Kenalog injected intralesionally.  If unsuccessful, I may choose to revise the scar or make the appropriate referral to dermatology or plastic surgery.