Steps Towards Preventing and Reducing Hypertrophic Scars: One Surgeon’s Experience

Hypertrophic scarring secondary to wound dehiscence remains an ongoing challenge for foot and ankle surgeons, despite advancements in surgical techniques and products development. Unattractive or thick scars on any patient exasperate me, but they are especially tough to endure when the patient is a child. A significant portion of my practice focuses on pediatric patients. A thick, wide, noticeable scar on this patient cohort can discourage the parents, the patient, and the doctor alike.

Here is a scenario that I have dealt with more often than I care to admit. A well-executed Baumann, Evans, and Cotton procedure that heals as planned except for wound dehiscence and subsequent hypertrophic scarring at the Baumann and Cotton sites. Deformities fully corrected, check.

Osteotomy sites healed, check.

Improved function post-operatively, check.

Thin, unnoticeable scars, not so much.

Surgical technique, tissue handling, and wound closure matter for scar outcomes without question. Yet, some incisions are more problematic than others, in my experience. Numerous factors contribute to these problematic incisions unique to the procedure or anatomical location. For example, dorsal medial midfoot incisions for a Cotton or Lapidus and medial calf incisions for the Baumann procedure tend to give me trouble. Of course, there are others, but these two are everyday annoyances.

I switched my incision closure techniques after researching options, speaking with plastic surgeons, and seeing what our residents learned on their plastic surgery, dermatology, and orthopedic oncology rotations. The first step I adopted was switching to a looped, running, unidirectional 4-0 poligecaprone 25 (Monocryl^®, Johnson & Johnson) barbed-suture closure.

One benefit of barbed skin closure is no knots. Knots Introduce the potential of human error and interuser variability, have the highest density of foreign body material in any given suture line, reduce the tensile strength of all sutures by thinning and stretching the material, and are the weakest portion of any suture line.¹ Barbed suture has no knots. Unidirectional barbed suture uses a loop at one end of the incision line to lock the suture. Changing direction at the other end of the incision by taking the suture 90-degrees to the incision locks the barbs.

Wang and colleagues, in a recent study, demonstrated, "Usage of the symmetric anchor designed barbed suture is safe, efficacious, and demonstrates a decrease in surgical incision closure time in patients undergoing TKA [total knee arthroplasty] compared to interrupted closure using conventional sutures."² Shah reported similar findings for TKA wound closure with barbed suture compared to standard suture.³ Zaruby and colleagues showed advantages with barbed suture as well, stating, "Knotless, absorbable barbed suture devices are a safe and efficacious alternative for cosmetic skin closures and yield wound strength and tissue reaction scores that are comparable to those from closures performed with absorbable monofilament sutures and secured with knots." ⁴ Matarasso and Hammond in a review article titled, "Barbed Sutures in Plastic Surgery: A Personal Experience," noted "improved appearance in cutaneous scars." ⁵

The other change I made to my incision closures was incorporating the HEMIGARD® adhesive suture retention device (ASRD). HEMIGARD^® disperses tension away from the incision. Incisional tension results in decreased blood flow and possible skin tearing. Therefore, reducing the tension on the incision line with ASRD is profoundly beneficial. Roybal and team described the use of ASRD on the closure of fragile skin under tension, noting "significantly improved wound closure and cosmetic outcomes without any significant wound complications."⁶ The use of devices such as ASRDs applied at the center of the incision employing the "rule of halves" for skin closure reduces tension to a negligible amount.⁷ Minimizing tension improves perfusion to the skin margins, as demonstrated by Stoecker and colleagues.⁸ The authors concluded, "The reduction in local stress and enhanced perfusion around the suture site reveals the potential benefit of using an ASRD to enable more efficient healing by avoiding complications associated with both low perfusion and skin tearing, such as dehiscence, infection, and cheese wiring.”⁸

My experience following these two changes in my incision closure corresponds to the findings of Koide and colleagues; “closure of long wounds is faster and produces a better long-term aesthetic.”⁹ Patient-reported outcome measurements are multifaceted. Optimizing patient satisfaction includes attention to detail for all aspects of the surgical procedure. Scar aesthetics is one of those essential details. Modernizing incisional closure techniques with barbed sutures augmented with an ASRD provides ideal conditions for disappearing scars.

Disclosure: Dr. DeHeer discloses that he is a consultant for and stock owner in SUTUREGARD Medical Inc., the manufacturer of HEMIGARD^®.

Dr. DeHeer is the Residency Director of the St. Vincent Hospital Podiatry Program in Indianapolis. He is a Fellow of the American College of Foot and Ankle Surgeons, a Fellow of the American Society of Podiatric Surgeons, a Fellow of the American College of Foot and Ankle Pediatrics, a Fellow of the Royal College of Physicians and Surgeons of Glasgow, and a Diplomate of the American Board of Podiatric Surgery. Dr. DeHeer is a Partner with Upperline Health and the Medical Director of Upperline Health Indiana.

References

1. Greenberg JA, Goldman RH. Barbed suture: a review of the technology and clinical uses in obstetrics and gynecology. Rev Obstet Gynecol. 2013;6(3-4):107.

2. Wang W, Yan S, Liu F, et al. A symmetric anchor designed barbed suture versus conventional interrupted sutures in total knee arthroplasty: A multicenter, randomized controlled trial. J Orthop Surg (Hong Kong) 2020;28(3):2309499020965681.

3. Sah AP. Is there an advantage to knotless barbed suture in TKA wound closure? A randomized trial in simultaneous bilateral TKAs. Clin Orthop Rel Res. 2015;473(6):2019-2027.

4. Zaruby J, Gingras K, Taylor J, Maul D. An in vivo comparison of barbed suture devices and conventional monofilament sutures for cosmetic skin closure biomechanical wound strength and histology. Aesthet Surg J. 2011;31(2):232-240.

5. Matarasso A, Hammond DC. Barbed sutures in plastic surgery: a personal experience. Aesthet Surg J. 2013;33(Suppl 3):32S-39S.

6. Roybal LL, Howerter S, Markus B, Young J, Lear W. A novel adhesive suture retention device for the closure of fragile skin under tension. JAAD Case Reports 2020;6(2):109.

7. Lear W, Roybal LL, Kruzic JJ. Forces on sutures when closing excisional wounds using the rule of halves. Clin Biomech. 2020;72:161-163.

8. Stoecker A, Lear W, Johnson K, Bahm J, Kruzic JJ. Enhanced perfusion of elliptical wound closures using a novel adhesive suture retention device. Health Sci Rep. 2021;4(3): e364.

9. Koide S, Smoll NR, Liew J, et al. A randomized ‘N-of-1’single blinded clinical trial of barbed dermal sutures vs. smooth sutures in elective plastic surgery shows differences in scar appearance two-years post-operatively. J Plastic Reconstruct Aesthet Surg. 2015;68(7): 1003-1009.