One would consider his/her skin to be flawless when it is smooth without any unsightly scar. A scar not only impairs the aesthetic appearance of the skin, but also has the potential to hinder functional movement. The formation of a scar, be it a fine inconspicuous scar or an abnormal scar, depends on the process of wound healing.
Wound healing is one the most complex processes of human physiology. A wound is generally defined as a raw surface on the body surface due to loss of skin. When a disruption happens on the epidermis (outer) layer of the skin, adjacent cells will migrate and proliferate, and the wound will heal naturally without the need of any special treatment. This results in a relatively inconspicuous scar. The more superficial the wound, the more inconspicuous the resulting scar.
A wound that goes deeper to the dermis (inner) layer, on the other hand, will need more effort and time to heal, depending on the depth and extent of injury. Epithelialization comes from the skin appendages i.e. hair follicles, sweat glands, and sebaceous glands.
Wound healing happens in 3 phases, all of which are overlapping rather than separate to each other:
- Inflammatory phase, which aims to stop any bleeding, remove dead tissue, and prevent infection. This phase starts immediately at the onset of injury and lasts until 4-6 days.
- Proliferative phase, where the formation of new vascular and skin tissue starts. This phase occurs during the second-third week. Most people consider a wound is “healed” when the open skin is closed by new epidermis. This is not true. What you see covering the previously “naked” wound is actually an immature wound. It is generally accompanied by several symptoms, such as redness, itch, pain, and rigid skin.
- A wound is considered healed after it has gone through the maturation phase, which is the final and longest phase. It can last for as long as 6 months-2 years from the onset of injury. A mature scar is characterized by pale color, lack of pain and itch, soft, and flexible. In this final phase, balancing between collagen deposition and degradation takes place. A deficient collagen deposition or synthesis will result in a scar which lacks tensile strength or an atrophic scar, while an impaired collagen degradation may result in an abnormal or pathological scar in the form of hypertrophic scar or keloid.
The process of wound healing depends on several local and systemic factors. The risk of abnormal scar formation can be minimized by creating an ideal local condition for a healing wound. The first is that all tissue involved must be viable. Dead tissue must be removed extensively and thoroughly during debridement (the effort to remove dead/damaged/infected tissue). Foreign bodies cause the wound to be unable to contract, grow new blood vessels, and epithelialize completely. Therefore they must be removed during wound cleansing. Contamination/infection also impairs wound healing, so it must be prevented, or managed adequately if it has already occured. Systemic factors that may affect wound healing are diabetes, smoking, hypothyroidism, aging, nutrition, medication (including chemotherapy), specific organ failure, and radiation.
The final appearance of a scar depends on numerous factors: the adequacy of wound care, sufficiency of skin moisture, wound site, age of the patient, the surgeon’s skill (should the patient need a surgeon’s expertise), the duration of wound healing, and genetic factor. In the case where an abnormal scar occurs, a variety of treatment options can be undertaken, such as surgery, silicone gel sheeting or covering, corticosteroid injection, radiation, compression garments, or a combination among them.
As the proverb says, to prevent is better than to treat. To prevent the formation of an abnormal scar, it is suggested that a wound is taken care of by a doctor – preferably a plastic surgeon – earlier since the onset of the wound so that it can be evaluated and managed adequately. For example, after the usual 1 week follow-up to your obstetrician following a caesarian section, ideally you should visit a plastic surgeon for follow-up, in order to achieve the optimal appearance of your scar. This way, the wound can be observed and managed adequately and an appropriate care can be undertaken should an abnormal scar appears. The timing of follow-up is usually at 2-3 weeks, 1 month, 3 months, 6 months, and 1 year post surgery.
- Prasetyono TOH. General concept of wound healing, revisited. Med J Indones 2009; 18: 206-14
- Anna LK. Agar luka tak meninggalkan bekas. Kompas 2012 Sept 21 [cited 2013 Jan 24]. Available from http://health.kompas.com/read/2012/09/21/18052051/Agar.Luka.Tak.Meninggalkan.Bekas
- Prasetyono TOH. Take care of your scar.