Aesthetic wound closure is based on knowledge of healing mechanisms and skin anatomy, as well as an appreciation of suture material and closure technique. Choosing the correct materials and wound closure technique ensures optimal healing. Surgical wound closure directly apposes the tissue layers, which serves to minimise new tissue formation within the wound. Appropriate surgical wound closure eliminates dead space by approximating the subcutaneous tissues, minimises scar formation by careful epidermal alignment, and avoids depressed scars by precise eversion of skin edges. If dead space is limited with opposed wound edges, then new tissue has limited room for growth. Correspondingly, atraumatic handling of tissues combined with avoidance of tight closures and undue tension on wound margins by carefully undermining and loosening the surrounding tissue contribute to a better result (Figure 3).

Figure 3 Reduction of tension on wound margins by undermining and loosening the surrounding tissue (A–F)

Figure 3 Reduction of tension on wound margins by undermining and loosening the surrounding tissue (A–F)

Subcutaneous sutures with PDS II (polydioxanone) monofilament synthetic absorbable sutures (left, middle) can be combined with absorbable sutures or Steri-Strip™ (right)  for optimal epidermal wound closure

Subcutaneous sutures with PDS II (polydioxanone) monofilament synthetic absorbable sutures (left, middle) can be combined with absorbable sutures or Steri-Strip™ (right) for optimal epidermal wound closure

Figure 3c Resulting in inconspicuous scars (2 months post-surgery;)

Figure 3c Resulting in inconspicuous scars (2 months post-surgery;)

The authors prefer subcutaneous sutures with PDS II (polydioxanone) monofilament synthetic absorbable sutures, which provide extended wound support (for up to 6 months) and may be combined with absorbable sutures or Steri-Strip (3M) for optimal epidermal wound closure (Figure 3). Specifically, the authors use 2-0 PDS II or 3-0 PDS II sutures for subcutaneous/fascial sutures, and 4-0 or 5-0 PDS II for dermal sutures. It is also vital to adequately debride contaminated wounds, obtain good but not too intense (avoiding an access of tissue damage) haemostasis, and limit foreign bodies (Table 2).

Conventional and emerging scar prevention strategies

In addition to surgical approaches to minimise the risk of unpleasant scarring from the outset, as well as pressure therapy, a multitude of different cream or gel-based strategies are proposed to further improve the aesthetic appearance of fresh and older scars. However, convincing objective data is missing for most of the products available on the market. Based on the international and German Guidelines for the treatment (and prevention) of excessive scarring, the below-mentioned approaches may be recommended based on well-designed studies18, 23.

Pressure therapy

Since the 1970s, pressure therapy has been the preferred conservative management for prophylaxis and treatment of both, hypertrophic and keloid scars. To date, pressure garments are mostly used for the prevention of burn scars, but the mechanism of action of pressure therapy remains poorly understood. Decreased collagen synthesis by limiting the supply of blood, oxygen and nutrients to the scar tissue24-26 and increasing apoptosis27 are being discussed.

Recommendations for the amount of pressure and the duration of the therapy are merely based on empirical observations and support the continuous pressure of 15-40 mmHg for at least 23 hours per day for more than 6 months while the scar is still active25,28. In a recent study, the use of 20–25 mmHg was significantly superior to treatment of hypertrophic scars with 10–15 mmHg29. Nevertheless, no definite positive effect of compression garments was found in a meta-analysis30. The success of pressure therapy may also be limited by the ability to adequately fit the garment to the wounded area and by reduced compliance owing to significant patient discomfort (e.g. skin maceration, eczema, odour emanating from the garment). Compared with other treatment approaches, however, pressure garments may represent a promising alternative in preventing or treating unpleasant scarring in children; particularly because pressure garments bare the significant side-effects frequently observed with other means in younger patients (lipatrophy with corticosteroids, blistering and pain with cryotherapy) and demonstrate convincing results in children (Figure 4).