wound and scar care


the secret is in the detail...
The eventual outcome of a procedure does not only depend on the doctor, but also on you. A predisposition to good or not so good scar tissue formation can unfortunately not be changed. However, good preparation of the relevant part of the body and proper after-care of the wound is in your hands.


PREPARATION
A clean and healthy skin, with only normal quantities of harmless microbes, will heal best.

clean skin
Cleanse your skin in the usual manner (soap is only necessary on those parts of your body where you would ordinarily use soap). At the most, use a moisturiser, and only if your skin would otherwise dry out. Do not use any make-up. Even for minor procedures, no make-up is to be used on the face. Remove all jewellery from parts of the body to be treated. Do not forget earrings during procedures involving the face. During procedures on the upper arm, too, no rings may be worn on the hands.

hair
The hair of the head need not be cut away, neither prior to, nor during the procedure (except when treating very serious accidental injuries). Men shave their faces as usual; after all, the skin is used to this. Short downy hair (e.g. in a woman’s face) is completely harmless. All other parts of the body need to be depilated, and in the correct manner at that.
Shaving should take place at least two, preferably three days prior to the procedure. Stubble is harmless.
Depilatory cream can be used on the day of the procedure or the day before, but only if this method was used before (see box on depilation).
Warm wax depilation, epilation and such, are irritating to the skin. If so desired, this technique should be implemented one week prior to the procedure. This is only possible if you have used the technique before and are confident that your skin will quickly recover.
If you are having trouble depilating certain parts of your body, this can be done by a hospital nurse just prior to the procedure.

disinfectant soap
Only if your doctor considers it necessary should you cleanse your skin with disinfectant soap. This may be the case in poor health, infected skin or parts of the body which are hard to keep clean.

antibiotics
These compounds inhibit or kill microbes; they may, however, carry side effects. They are only prescribed in exceptional circumstances.


WOUND CARE
sutures:
The longer the sutures are left in place, the more the formation of scar tissue is stimulated. The shorter they are left in place, the higher the chance of the wound opening up again. The correct time to remove the sutures is based on a comparative assessment of the two issues; there is usually a margin of a few days. Sutures in the face are generally removed within a week; in the hand or wrist only after a minimum of two weeks. Many other, personal factors, may influence the ideal time span; so keep to the term indicated by the doctor (which he may also change according to progression!). Sometimes, degradable sutures may be used.

keep still
The less movement of the wound, the less chance of the wound edges being pulled apart. And the easier it is for your body to heal. However, not moving also causes swelling and joint stiffness. So take it easy, but keep the relevant part of the body moving as prescribed by the doctor. Make sure you do not exert yourself: this raises blood pressure and can cause subsequent bleeding.

good circulation without swelling
Unsupported limbs will swell and be painful after an operation. An arm should be supported by a sling for a few days (except after the most minor of procedures), a leg should be elevated as much as possible. Always rest your foot on a bench or chair at the same level as your seat. Ideally, a foot should be rested in an elevated position, walking around is not as good and standing still even worse.

do not smoke
Smokers heal slower and have a higher chance of the skin edges dying off. A blood vessel procedure can completely fail due to smoking. “Seriously cutting down” is insufficient; the first cigarette alone will cause the blood vessels to contract.

dry and clean
Sutures are like motorways for microbes: as long as there are sutures in a wound, the wound should remain absolutely dry and clean. There are waterproof plasters which still allow showering. Having a wound sweat for hours inside a glove or plastic sack is not a good idea! An exception is a hairy scalp: you may usually wash this as early as two days after the procedure using disinfectant shampoo, however, only after explicit approval from your doctor.

good check-ups, but not too many
An infected wound (e.g. as a result of an accident in an unclean environment, for instance after intestinal surgery) is riddled with germs and needs to be disinfected daily. It is best to also daily disinfect wounds on the soles of the feet or on the genitals. Most medical incisions, however, are performed on clean skin under extremely clean circumstances. Only normal microbes, which permanently live on the skin, will reappear on the skin afterward. Therefore, most procedures do not call for daily disinfecting. After all, disinfection does not only kill off germs, but also the frail, new skin cells needed to close the wound. Every act increases the risk of transferring other germs from your hands or instruments, into the wound. You should therefore have the doctor or nurse check the wound according to the guidelines, but do not feel called to rub it daily. A little fluid seeping through in the first few days or a coagulated blood clot are harmless.


TEMPORARY DISCOMFORT
The body demonstrates a temporary overreaction upon formation of scar tissue: the scar becomes hard and pink (or even red or purple). The wound surface is often irregular or uneven. The surrounding skin also stiffens and becomes sensitive to pressure. A scar is only at its ugliest after four to six weeks. During this period the scar also contracts; occasionally you will feel a stab of pain. If healing properly, your skin will regain its softness; the surrounding skin will regain its elasticity, the discolouration will fade and any stabs of pain will become increasingly rare.


SCAR FORMATION PROBLEMS
mottled discolouration of irritated skin
Irritated skin is much more sensitive to ultraviolet rays (sun, solarium) than normal skin. As long as a scar remains coloured (purple, red or pink) the surrounding skin over an area of 1 cm is irritated. It is imperative not to tan that area. You would risk an ugly, mottled, excessive brown discolouration which will not go away. A markedly coloured scar can only be protected by a plaster also covering the surrounding skin over an area of 1 cm. Once a light pink colour remains, a suntan lotion with a very high protection factor (minimum 20) generally suffices

excessive scarring
The process of scars turning temporarily hard and red is normal. However, if this line becomes raised, too much scar tissue is probably being formed. Various treatments are provided, which are best started as early as possible. In other words, do not wait months to reconsult your doctor.

stretching
A properly healing scar will not grow wider than one to two millimetres. If you notice that it is growing wider, contact your doctor immediately. It often, though not always, helps to apply the plaster diagonally across the scar. Once stretched, however, the scar will never return to its more narrow state.


AFTER-CARE
The first three to four weeks you are to simply leave the scar alone: leave nature to promote proper healing. Once this has been achieved, you may do more. These treatments are required in case of excessive scar tissue formation. In case of normal scar tissue formation, they speed up the maturation of the scar, but the end result will be the same: so you can choose whether faster maturation is worth your while.

massage:
Firm scars may be massaged using the fingers two to three days a day (if need be, a professional massage by a physiotherapist). You can use a cream that enhances scar maturation as advised by your physician. You should definitely avoid rough handling: repeated wounding of the tissue will only aggravate scar tissue formation.

silicone gel
Silicone gel or a mineral oil gel may initially be applied for twelve hours a day. Once the skin is accustomed to the gel, it is applied 24 hours a day. Your doctor will first explain instructions for use. The treatment is only useful if kept up for a number of months.

laser treatments
The surface of a scar can be remodeled with a CO2 laser. Scar redness can be treated with an NdYag laser

scar injections
Excessive scar formation can be treated by your physician by local injection of medication.

compression garments
In case of problem scars (e.g. after burns) custom-made pressure garments may improve maturation. These are produced on prescription by a physician.


GENERAL PRACTITIONER
Always notify your general practitioner if you are about to undergo treatment, even if you made the appointment on your own initiative. He may point out certain medical information which needs to be passed on prior to treatment. It is useful to consult your general practitioner for wound care after treatment. If sudden problems should arise, you may not be able to reach your specialist straight away. Your general practitioner can assess the gravity of any healing problems, in particular if he has been informed beforehand of your treatment. He may either help you directly, or in case of bigger problems, ensure emergency after-care while avoiding panic.


HAIR AND HAIR REMOVAL
Hair growth creates problems with regard to proper disinfection of the wound and applying a comfortable bandage. However, shaving or depilating hair causes tiny cuts. After several hours, more microbes will be alive in these cuts than can be found in normal skin, a problem you can do without during surgery. For that reason it is best to shave the hairs off two to three days prior to treatment, to allow the skin time for full recovery. Do not do this the day before surgery. Shaving in hospital is done just before surgery, so that germs do not have time to multiply. Depilation using cream can be done at any given time: this does not cause cuts. However, you need to be sure that your skin on the relevant part of your body tolerates the depilatory cream well: irritated skin is not a good basis to start a procedure. These guidelines do not apply to the face and hair of the head (see above).


THE HAND HEALS SLOWLY
The skin of the hand consists of a living thin layer, and a non-living, thick horny layer. In the two weeks that the area is covered with a plaster, the horny layer no longer wears off. This results in two hard patches, together creating a hinging motion in the scar at every movement of the hand. After removing the sutures, the plates of horny skin separate, perhaps giving you the false impression that the wound is opening up. Moreover, some unsavoury fluid may be released, fluid which had built up between the living skin and the horny plates breaking off. The scar itself may turn into a wet cut. In this event, it is best to wash your hands with disinfectant soap several times a day. It is advised not to wear a plaster, or the horny layer of skin cannot wear off and a cut will remain in the wound. When in doubt, please always consult your doctor.