Ihere are several general principles to cosmetic closure. All wounds heal with some scarring, the goal is to use techniques that make the scar as small and invisible as possible. Scars become visible when they cast a shadow, have a rough surface, are wide, or develop permanent secondary color change.
Scars most often cast a shadow when they become concave from wound contraction during healing. Wound-edge eversion during the initial repair will therefore gradually flatten with healing and have a final appearance that is cosmetically acceptable. Wounds that are not everted will contract into linear depressions that will become noticeable cosmetic defects because of the tendency to cast shadows under incident light.
In closing a laceration, it is important to match each layer of a wound edge to its counterpart. Ihe epithelium-to-epithelium interface should match perfectly to create a hairline smooth scar. Care must be taken to avoid having one wound edge rolled inward, so that the cut edge of the epithelium on one side is opposed against the dermis on the other side. Ihe skin edges may look matched up but actually are not. Ihe rolled-in edge occludes the capillaries, promoting wound infection. Ihe dermal side will not heal to the rolled epidermal side, causing wound dehiscence when the sutures are removed. Everting the edges helps prevent skin rolling. Likewise, overeverting the edges causes problems; the exposed dermal surfaces promote granulation tissue and a rough scar.
Ihe relationship between the wound tension and the distance between sutures is also important for a cosmetic repair. Ihe more tension on the wound, the closer the sutures need to be to each other to minimize the tension on the wound edge. Further spaced sutures have more tension that is distributed to each loop leading to cut-over marks, stitch marks, and stitch holes. Another technique to reduce tension on the wound is to close the wound in layers. However, deep stitches can cause an inflammatory response, leading to increased scarring as well as an increased risk of infection. Sutures placed through the epidermis can cause stitch-mark scars. Iherefore, the minimum number of sutures necessary to accomplish closure should be placed just far enough from each other that no gap appears between the wound edges. Ihe knots should be placed away from the wound edges to prevent an inflammatory response.
Io prevent the development of needle-puncture scars, percutaneous sutures must be removed as soon as possible and the wound edges reinforced with skin-closure tape to prevent wound dehiscence.
Iopical agents (antibiotics, vitamin E, and aloe vera) have been found to reduce the incidence of wound infection, accelerate healing, and increase wound tensile strength after suturing. Dressings are usually necessary for only the first 12 to 24 h, after which gentle periodic cleaning with mild soap and water can commence. Ihe area should be gently patted dry and re-dressed with a sterile dressing. Wounds closed with skin-closure tapes or tissue adhesives should not be covered with a dressing or washed. Pressure dressings are useful in minimizing intercellular fluid collection and limiting the dead space, both useful in achieving cosmetic closure. Abraded wound areas may develop an exudate that dries on the surface, forming a scab during the first 24 h. This dry scab resists epidermal cell migration and interferes with wound healing. If abraded areas are covered with a dressing to maintain moisture during the first 24 h, epidermal cell migration is encouraged and healing promoted. If sutures are placed in and around abraded areas, small amounts of water-soluble ointment may be beneficial in preventing scab formation. Gently cleaning the wound with half-strength hydrogen peroxide every 6 h until the wound edge is free of blood prevents scarring due to clot formation around the wound edge.
Exposure of abraded skin and healed lacerations to sunlight during the first 6 months after injury may cause permanent hyperpigmentation. Hyperpigmentation can be prevented by protecting the injured skin area from sunlight with a sun-blocking agent with sun protection factor of 15 to 30 for 6 to 12 months.
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