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Wound healing

Understanding the wound healing process and what your skin needs and when it needs it can help reduce the tendency towards scarring. Read more...
 

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Photo: Wix

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What is a surgical scar?


Scars as a result of surgery are, in most cases, considered "clean" wounds. This is because the procedure was likely performed in a sterile, or close to it, environment such as an operating room, surgicenter, or outpatient facility. Prior to cutting the skin, the area cut had the opportunity to be cleaned, prepped, and draped to reduce the chances of bacterial contamination in the wound created. The skin was likely cut with a stainless steel scalpel blade. After reapproximating the skin, sutures or other wound closure methods were used to hold the skin until it heals.





How long does it take for sutures to dissolve?



The choice of sutures is a decision made by your surgeon based on several factors including the location of the wound, depth, length, tension, and risk of scarring amongst other factors that may be related to the procedure itself.


Dissolving stitches may be under the surface of wounds after the surface stitches are removed or dissolved. These may take 6 to 12 weeks to dissolve. Surface-dissolving stitches may dissolve within 1 to 2 weeks. Stitches under the surface of the skin take a little longer to dissolve with the intention of offering continued support for the wound.



What happens if my stitches do not dissolve?



It is common for patients to feel a thickness to a scar for a few months after the procedure as stitches dissolve. It is also possible that your stitches may not dissolve and start to “poke” through the skin. When this happens, a reaction occurs where swelling, redness, and an opening may develop in the wound making it appear as though it is becoming infected. In fact, what is occurring is an inflammatory reaction directed toward the suture attempting to “help” your body remove or “spit out” the stitch. This is referred to as a spitting suture. If the stitch is obvious, removing the stitch will calm the reaction. If it persists, it is time to see your doctor as it may struggle to “pop out” on its own and need to be removed. This will help accelerate healing.



What are the best wound care practices?



Understanding the wound healing process and what your skin needs and when it needs it can help reduce the tendency towards scarring. There are 4 stages to wound healing, regardless of the type of wound. These stages are:


  1. Hemostasis

  2. Inflammation

  3. Proliferation

  4. Remodeling



What is hemostasis?



Hemostasis is a term that refers to the control of bleeding. Your body slows blood flow to the wound from local blood vessels by vasoconstriction while fibrin is produced by local cells to form a temporary seal on the wound. This process can take up to 2 days. Fibrin forms a sticky lattice that develops over the wound creating a scaffolding for healing to continue. It can appear yellowish or white. This color is not from bacteria necessarily even though it has a yellowish hue. If necessary, pressure dressings, topical hemostatic agents, and/or cautery may help accelerate this process.



When does the Inflammatory stage of wound healing begin?



The second stage of wound healing, inflammation, overlaps with the first stage of hemostasis. Just as the bleeding is controlled and temporary sealant forms, your body can recruit inflammatory cells to the area of the wound to release mediators to assist in healing. The white blood cells and platelets recruited to the area are responsible for changing the environment of the area of the wound into one focused on providing the necessary elements for healing. This includes:

  • New skin cells are forming

  • New blood vessels are forming

  • Collagen is initially broken down to make way for new collagen that is laid down starting after days 5 to 7

  • Peripheral nerve repair starts to take place

  • White blood cells, such as neutrophils, stick to the sticky fibrin to protect the wound from bacteria and infectious agents


During this phase, the wound does start to pull together or contract to make it appear more sunken and firm to touch. The new collagen formation is responsible for some of this tightening of the skin.



Is the proliferation stage next? What happens to a wound during proliferation and when does this start?



The proliferative stage of wound healing is occurring from the beginning and is essentially a process occurring in the background allowing your skin to restore itself. Much of the remodeling process begins by day 5 to 7 of wound formation, however, studies have shown that reepithelialization can start within 24 hours of wound formation. Reepithelialization is the first layer of new skin formed on top of the wound. This process continues through the end of the remodeling phase.




When does remodeling occur?


Remodeling is the last phase of wound healing, starts around weeks 2 to 3, and can last upwards of 3 months. Yes, healing is still occurring well after the time you stop wearing a bandage. This is when the new skin really matures and the healing components such as increased blood vessel formation start to diminish leaving less redness associated with the wound over this time period. It is also when the initial collagen laid down, which was type III collagen, is replaced with Type I Collagen. The wound softens and starts to appear less bound down over this window of time. If there are absorbable stitches underneath the surface of the wound, these are gradually dissolving over this time as well.



What is the most important thing a wound needs to heal?



In a word, moisture. There is a landmark study that changed the way that wounds are managed back in 1962 by George Winter. Through his study, the formation of a scab on top of a wound was determined to actually hinder healing. Petroleum jelly, also known as white petrolatum, has been repeatedly shown to benefit this process dramatically by providing both the hydration and occlusive qualities to permit your skin the ability to heal without the environment negatively impacting the wound. Remember that only a single layer of new skin cells may have been laid down in that first week of healing. This skin will be thin and not able to retain hydration on its own and release its moisture to the air resulting in it drying and forming a scab. Our skin heals like a purse string- from the outside in and the bottom up. Giving your skin the opportunity to do so will result in less scar formation and a scar that is less tense or firm over time as the collagen has a chance to transition over time. Without moisture in the initial one to two weeks of wound healing, the skin will stay in a prolonged perpetual state of attempting to heal which will impact its overall appearance and texture over time.





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