What if the Phantom of the Opera had never needed a mask to hide his disfigured face?
In adaptations of the 1909 French novel, the phantom uses his mask to cover, among other scarring features, a gash on the side of his head. At that time–and in fact, until relatively recently–if you got a scar, you had it for life. But today, advances in technology have yielded innovative ways to manage scars, such as ones resulting from surgery or acne, leaving a less noticeable blemish on the skin.
PAs in dermatology are performing these procedures, including laser treatments and intralesional cortisone injections. A number of dermatology PAs spoke with ADVANCE about courses of treatment for scar management, and a number of surgical PAs shared their insight about the best suturing techniques that result in the cleanest scar from the start.
Had "The Phantom of the Opera" been written in 2007, the techniques the PAs discuss here might have turned the phantom into a regular Joe—just a lover of music with a major crush.
The State of the Wound
First things first: Before planning for the best possible suture for each wound, make sure the wound is ready. For surgical wounds, this begins with the incision.
Put simply, "The best looking scar is made with the best planned incision," says Robert Sammartano, RPA-C, senior surgical PA in pediatric surgery and program director of the postgraduate residency for PAs in surgery at Montefiore Medical Center in Bronx, N.Y.
If the wound is not surgical, but instead is an open wound from a trauma, you might need to freshen the edges, according to William R. Drace, PA-C, faculty instructor at the surgical PA program at the University of Alabama at Birmingham and a former cardiothoracic surgery PA.
"Make sure that your skin edges are clean and sharp," he says. If necessary, use a knife to make the cleanest possible wound edges for suturing.
Suturing calls for a clean and sterile environment. Mechanically debride the wound with water and make sure there's no foreign matter left behind, Drace says.
Suturing Methods
When it comes to providing the best environment for healing, using staples appears to be the best option, according to PA experts. Staples may not leave the best-looking scar, Drace says, but they are the easiest and fastest to use. Staples, as well as some types of sutures that are above the skin, leave what are often referred to as "railroad tracks."
But the winner for "prettiest scar," according to Drace, is the subcuticular stitch with an absorbable suture. "This is the one the patients love the most, because they don't have to come back to the clinic or have any type of sutures removed, because the absorbable sutures just dissolve away. And we use a type that will stay long enough that the wound will heal," he says.
The subcuticular stitch is made by passing the suture needle right below the dermis, in the subcuticular layer, and advancing while weaving the suture back and forth, then pulling the suture tight. "It brings together the wound real nice," Drace says.
But keep in mind that the subcuticular stitch may not be the best option for your patients with circulation problems, since the stitch momentarily cuts off the blood supply to the edge of the wound every time you go underneath the skin and pull the suture tight, Drace says.
Another option for a cleanly healed scar is using a liquid adhesive, such as Dermabond, which is spread on top of the wound while the skin edges are held together. The adhesive then wears off the skin as the wound heals, and like the absorbable sutures, no removal is necessary.
When removal is indicated—for staples and nonabsorbable sutures—how long you leave them in depends on the type of scar. "If left in too long, the inflammatory response to the foreign materials can result in a less than optimal appearing scar," Sammartano says.
It is also important to consider that wounds heal from side to side. When you're preparing to suture, evert the wound edges, rather than invert them. "If you bring a layer of tissue, not skin, over the skin on the other side, the skin is not going to grow to that tissue," Drace says. When the sutures are removed, this area will open, creating a secondary type of wound healing that may result in a larger scar.
Time to Heal
No matter how you or your patient treats the wound after suturing, there will always be a scar.
"Any injury to the skin is going to produce a scar. The question is whether it's perceptible or not perceptible," says Robert Higham, MPAS, PA-C, a PA at Mid Valley Dermatology in Sherman Oaks, Calif., and president-elect of the Society of Dermatology Physician Assistants. "There's no way for us to surgically cut something out or do something to the skin to have absolutely no scar. There's some type of scar, it's just whether you can see it or not."
Treat the wound appropriately from the start to minimize scar development. For instance, keep the wound moist and use a nondeodorant mild soap to keep the wound clean.
Drace says that the wound is still in a healing and inflammatory stage until about three weeks after the wound is sutured. Then, the wound may be red until about nine months after the suturing. If all goes well, he says, "After a year, other than the line, you won't even know you have a scar there."
Once the wound has healed, products such as topical creams or gels and silicon gel sheeting may be of help to prevent some scarring or reduce redness. "But there's no magic eraser with these," Higham says. "If you've got a really thick scar, putting a scar Band-Aid on is not going to take care of it."
The way the wound heals also depends on age. The younger the patient, the nicer the wound will heal, Sammartano says. "An incision in a three-week-old without secondary infection tends to heal nearly without a scar," he says. "It's nice to have good, new tissue to work with."
If a Keloid Forms
Some people—especially African-Americans—are genetically predisposed to developing a keloid scar—an overgrowth of scar tissue that extends beyond the area of the original wound. The desire to remove or reduce a keloid is one of the top reasons patients visit a dermatology PA, the experts told ADVANCE.
The first step to reduce a keloid is to plan a schedule of intralesional cortisone injections, says Allison Wagner, PA-C, a PA at Chevy Chase Cosmetic Center in Chevy Chase, Md. The injections work well because they don't provide a lot of trauma to the skin, she adds.
Higham also uses the injections for his patients with keloids. "(The injections) break up the scar tissue that's within the scar, oftentimes promoting a flattening of the scar," he says. "They can reduce its elevation, and they can typically flatten the skin, but they don't change a shiny, pink scar to normal skin."
In addition, Higham has had success injecting the patient's keloids with the anti-metabolite 5-fluorouracil in conjunction with intralesional cortisone to reduce the keloids and reduce the possibility of steroid atrophy.
Many topicals are not effective at reducing keloids, since they can't penetrate the scar, but some PAs have found that imiquimod (Aldara) may be helpful in keloid reduction. Wagner also uses topicals or a steroid tape as maintenance between intralesional cortisone injections for her patients. "That can just relieve the itching and some discomfort," she says.
In extreme cases, surgery may be indicated for keloid removal. However, Wagner says, "The thing about cutting a keloid out is that you're traumatizing the skin again, so there's a very good chance that the keloid will come back."
Patients who've had a very large keloid removed at Chevy Chase Cosmetic Center typically are sent to a radiation oncologist after excision, which may help prevent the keloid from returning.
Procedures on keloids typically are the only scar-management procedures that are reimbursed routinely by insurance companies, according to the PA experts, because the keloids usually are symptomatic, causing pain and irritation for the patient.
Individualizing Treatment
With the variety of scars dermatology PAs see and treat, it is important to know that there is not one perfect course of treatment for all types of scar.
"I look at each patient individually and see what I think would work best for them," Wagner says. "Sometimes it's a combination of a few different things." For example, Wagner says she may treat a keloid with an intralesional cortisone injection to flatten the scar and a bleaching cream for possible hyperpigmentation.
Higham agrees that it's important to evaluate possible courses of action for each individual patient. "You need to plan out a thoughtful course," he says. "You can't just go in there with both guns flaring. You need to have some plan of action as opposed to just cutting it out and doing nothing and then having the scar redevelop in the same place."
Scarring from Acne
Dermatology PAs also commonly see patients who want to have their acne scars removed. A few different options are available.
A new and effective laser treatment for acne scars is fractional resurfacing, using a laser such as the Fraxel. "It's a nonablative treatment with little downtime, as compared to CO2 laser resurfacing treatments," says Carla Crespo, MS, PA-C, a PA at Marina Plastic Surgery Associates in Marina Del Rey, Calif. "It's not going to erase (acne scars) — but it does minimize their appearance, and because it's a fractionalized erbium laser, with four to five treatments, you can really see the difference, and patients are usually very satisfied with it."
Crespo says that even three to six months after the fractional resurfacing treatments are complete, patients still see improvement because of the resulting increase in collagen production.
Wagner also uses fractional resurfacing for her patients with acne scars. "The great thing about this treatment as opposed to other treatments in the past is that it's nonablative, so you don't have the downtime and the redness," she says. "So in that respect, it works great for patient's busy lifestyles."
Some PAs report that fractional resurfacing is becoming the new gold standard for treatment of acne scars. Maria Capaldo, PA-C, in association with Marlene Mash, MD, in Plymouth Meeting, Pa., does use these nonablative lasers for acne scars, but also continues treatment with CO2 lasers, which she says are more effective for uneven or slightly raised scars.
Capaldo says a positive feature of the CO2 lasers is that the patient may only need one or two treatments compared with multiple treatments needed with fractional resurfacing. However, there is more downtime for patients treated with CO2 lasers, and these lasers are also not indicated for darker skin types because of the risk of permanent hyperpigmentation.
PAs also use intense pulsed light to treat red marks from acne rather than indentations.
One quick-fix treatment for indented acne scars is injectable fillers such as Restylane and Radiesse, Crespo says. She uses the fillers to temporarily "plump up the indentations" and make the scars less noticeable.
Getting to the Root of Acne
Taking care of skin and treating acne before it leads to scarring is the best route, if possible. "You almost have to treat the actual medical condition that's causing the (acne) scars, because if you can get that under control, then you don't have to worry about the scars," Wagner says.
Microdermabrasion and chemical peels alone or in combination are one answer.
"Microdermabrasion in combination with chemical peels is effective for almost all types of scars and skin types. They help improve the surface of the skin by removing any dead skins cells, which helps minimize mild acne type scars and evens out the skin tone," Capaldo says.
Although these treatments may be helpful for generalized redness and some mild indentations, remember that you must be careful with your patients with darker skin, since hyperpigmentation can occur. In fact, Capaldo usually pretreats these patients for at least six weeks with topical hydroquinone, tretinoin therapy or a combination of both.
Permanent tattooing may be an option for some people with smaller scars. For example, Higham had a patient with a very thin, very white scar by her eyebrow. She visited Higham for treatment; he told her the scar actually held up quite well, and there was nothing else that could be done from a surgical standpoint.
But he noticed that the patient had had her eyebrows permanently tattooed, so he suggested she visit her permanent tattoo artist to have the color in that area repaired.
Patients must be careful with permanent tattooing, though.
"Oftentimes, there's trouble matching skin pigments," Higham says. "Skin pigment colors change sometimes with age, or whether somebody's tan or not tan, so you have to give it a really thoughtful approach whether or not it's going to be a benefit."
Higham also suggests his patients first try nonpermanent camouflaging that can be matched to skin color, such as Dermablend.
"That might give somebody an idea of what it's going to look like without being permanent."
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