Key Principles In Reducing Surgical Scars On The Foot

­­When an artist sits with a blank canvas, the first stroke of the brush sets the trajectory for the outcome of the piece. The same is true when deciding on surgical incision placement. From the start of the case and for the rest of the patient’s life, the incision shapes the path for the entire outcome. 

Although there are many benefits of minimally invasive surgery, I have found minimal indications for it in my practice. Maybe a digit procedure, an exostectomy and other minor procedures benefit from this concept as it provides less tissue damage and a less visible scar. It is also a surgical marketing tool. With minimally invasive surgery, patient satisfaction early in the post-op period may be better than it might be with a full exposure incision. At the first post-op visit, patients see a small scar and incision, and they are thrilled.

Contrary to this, I believe that over the long term, a small scar does not make a difference in patient satisfaction. Function does. In fact, I have yet to find a better outcome with minimally invasive surgery in comparison to making an incision large enough to accomplish your surgical reconstructive task. If you utilize good principles of plastic surgery, the scar will not be a concern.

Having a basic understanding of the six various skin types is the starting point.¹ Skin type I will redden and then hyperpigment with an incision. Skin type III will turn purple. Skin type V and VI can darken, cause uneven pigmentation, hypertrophy and keloids.

Next, a dermatological approach to your relaxed skin tension lines not only helps to expedite wound healing but hide the scar as well. When your skin is at rest and when you are in motion, the resting tension lines are in the direction of the least amount of skin strain. Making an incision along the resting skin tension lines provides fewer opposing forces of the dermal tissue with less interruption of the collagen crosslinking. Any motion, movement or friction of the skin during the healing period will inhibit your capillary healing network, which carries proteins and growth factors. Performing an incision within skin zones and in an area of good vascular supply will also expedite skin healing and minimize scarring. Finally, consider a lazy S incision instead of a linear incision, which provides greater visibility into the foot and produces a scar with less tension.

Tissue handling greatly affects scarring. The type of forceps you choose, how aggressively you handle the tissue and skin retraction are important factors in restoration. Easy, light, less aggressive techniques create less microdamage to the collagen makeup of tissue, making healing faster and easier with fewer inflammatory markers engulfing the surgical site.

Suture material, suture size and the type of the suture thrown are also considerations that affect the outcome of the scar. You wouldn't choose to use a 2-0 suture size in the forefoot nor a 5-0 suture on the heel. You must use the appropriate size suture for the thickness of the skin. Too many Vicryl (Ethicon) sutures will lead to difficulty in scar healing and can cause spitting sutures. I find an absorbable 4-0 or 5-0 Monocryl (Ethicon) works well for a subcuticular suture in the forefoot. Although mattress sutures evert skin edges, which aids in healing, horizontal mattress sutures leave the worst scar. Vertical mattress sutures are slightly better.

I have also found that postoperative edema will lead to poor scarring. The less edema in the foot, the better the scar. Fluid sitting stagnant in the foot will lead to extravascular edema, hyperpigmentation and possible dehiscence.

To assist with scar healing, early in the postoperative period is the best time to address it. Starting scar reduction with Laser Genesis (Cutera) for two weeks will help increase oxygenation and blood flow, and decrease inflammation to the scar. It will also help organize the collagen fibers in a well structured pattern as opposed to fibrotic scarring that has a disorganized cluster of cells on histologic appearance. Laser genesis uses heat energy to gradually warm the dermal layers of skin while gentle massage assists in the collagen organization.

Topical scar treatments, preferably silicone sheets or gel, can improve scar healing. Silicone works by increasing hydration of the stratum corneum and thus fibroblast regulation, increases growth factor mitigation and decreases the irritation and itching of scars. Some silicone sheets have synthetic byproducts that do not work as well so be cautious and research the products first.

If a patient does have a hypertrophic scar or a keloid, I have found that laser therapy coupled with steroid injection therapy works well. If you find a scar that is resistant to improvement, perform scar revision.

Dr. Jodi Schoenhaus is an award-winning foot and ankle specialist in Boca Raton, FL. She is a Fellow of the American College of Foot and Ankle Surgeons. She is board-certified in foot surgery and reconstructive rearfoot and ankle surgery by the American Board of Foot and Ankle Surgery.

Reference

1. Fitzpatrick TB. Soleil et peau [Sun and skin]. Journal de Médecine Esthétique (in French). 1975; 2:33–34.

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