Wounds, Scars and Surgery for Moh's

Did you wound heal as you wanted, with a nice, thin, flat scar?

You can educate yourself on the best ways to heal wounds by reading below. We also talk about scars, including hypertrophic scars and their unhappy cousins, keloid scars. We give tips on Moh's reconstructions, and finally outline the Plastic Surgery "reconstructive ladder" to deal with complex wounds.

Give yourself the best chance for a great result by calling Pulsar Health in West Palm Beach, FL, to book an appointment.

How a wound is handled can make a huge difference in how it heals and scars long term. Many surface wounds will heal without difficulty if you are fairly healthy, but providing the right conditions can speed up that process, reduce the appearance of scars, and minimize the risks of infection or other complications.

In order for a wound to heal well, it must have a good blood supply, good alignment of the edges and layers, and, on the surface, a good balance between moisture and dryness. It is helpful to keep it clean and protected from irritants. Applying some antibiotic ointment, but not keeping it too moist can aid healing. If it is getting too moist, betadine "paint" can help dry it up, whilst being antimicrobial too (be careful if you have a shellfish allergy if using betadine, as it contains iodine). The amount and type of coverage of the wound will also affect the moisture level, so use more woven dressings and change more frequently if moisture is not being evaporated adequately. Occlusive dressings are important the first couple of days to reduce infection risk as it takes 1 to 3 days for the skin surface of a clean cut to close up, but after that pay attention to the skin moisture level and dress appropriately.

Plastic surgeons get involved in deeper and more complex wounds, where there may be loss of tissue or skin. If someone has an accident where a piece of skin is missing and you can find the piece easily, it may be possible to reattach it successfully. Just wrap it up in a moist clean gauze and place in a clean empty ziploc bag, with another bag of ice outside of that bag. Dr. Gill has successfully reattached pieces of lip and fingers from dog-bites and accidents, helping one grateful client continue to play his guitar!

It is not always appropriate to close a wound, such as if it grossly contaminated or looks like it is getting infected. During healing, there are times when the tissues are weak and need more support. Consult with your plastic surgeon to help guide you through the healing process.

Scars are the natural consequence of wound healing. Even when operating in utero, scars form on the skin. They are far less apparent in mucosal tissues, such as the inside of the mouth. Plastic surgeons try to disguise the scar as much as possible in elective cosmetic surgery. If you do have an injury, a plastic surgeon may be able to help improve the final appearance. Usually, we want to make sure there are no defects underneath the skin, and that muscle and, if necessary, bone is repaired in the correct position. The skin closure may involve stitches that have to be taken out, in order to use finer stronger stitches, or stitches that dissolve, where there is less tension. 

Where stitches are to be removed, you usually use a mild antibiotic ointment in the area until the stitches come out, and then a "steristrip" like a band aid to help to continue to support the skin as it heals. Silicone sheeting or ointments can help the scars heal in a calmer manner, and taping a fresh scar can be helpful in avoiding it becoming thickened. Again, we want to make sure the moisture balance is correct for healing - not too moist and not too dry.

Sometimes scars become "hypertrophic" or too thick, at which point interventions such as kenalog (a long-acting steroid injected into the scar) may be helpful. We also use lasers to treat scars.

The color of the scar is generally red for about three months due to the increased blood flow in the area for wound healing, and then it gradually fades. In darker skin tones, there is a higher likelihood of post-inflammatory hyperpigmentation, which is darkening of the skin in response to injury. This does fade by itself over time in many people, but may need extra help. See the website section on Pigmentation Problems to get more information on hyperpigmentation. Creams and lasers can help treat discoloration.

For true keloid scars (grows beyond the original injury), more aggressive treatments are needed. Radiation therapy can be very effective but also affects the skin color, so for more cosmetically sensitive areas, we generally go down the route of surgical re-excision and a series of steroid shots to gain control. 

For long-standing scars such as acne scars, or skin that is thinned and stretched out from scarring, microneedling with or without radiofrequency can be very helpful. It can break up the scar tissue, allowing growth of new skin into the area. It can also strengthen the skin. We may use stem cells or other products to further improve the results. Platelet rich plasma (PRP) and exosomes can also greatly assist in healing.

Sometimes wounds are intentionally created, such as surgical procedures, or when skin cancers are removed. Skin cancer is the most common type of cancer in the United States. Moh's surgery tries to minimize the amount of tissue taken when removing the cancer, by examining under a microscope if all the cancer has been taken. Whilst we do not do Moh's surgery at Pulsar Health (but can recommend a great dermatologist!), we do repair the wounds from Moh's surgeries. Dr. Gill is a craniofacial specialist and can assess what would be the most aesthetically acceptable way to close a wound from Moh's surgery. She will discuss options with you, if there is more than one good solution. 

Some tips to bear in mind when having repair of a Moh's defect from cancer excision are:

• Care has to be taken around the eyelids, as too much tension and/or inadequate skin there can lead to distortion of the eyelid, called an ectropion, which may result in tearing or too much exposure of the eyeball. Also, there can be issues with drainage of fluid near the lower eyelid, leading to a "festoon" or swelling there, sometimes related to blockage of small lymphatic channels. 
• Nose closures can also be challenging as millimeters matter in the nose, and can create significant three-dimensional distortions unless actively corrected in the reconstruction, as there isn't much "spare skin" on the tip of a nose. 
• If a portion of the lip is missing, we may need to use other portions of the lip to reconstruct it effectively. Not only do we need to consider the aesthetics, but functional considerations such as closure of the muscles around the lip (orbicularis oris) are important too. 

More complex reconstructions may be needed for larger cancers, or for other surgeries or wounds that did not heal, such as exposed hardware after Orthopedic procedures. The Plastic Surgery "reconstructive ladder" involves doing the most appropriate degree of intervention to get a healthy wound closure as simply as possible. This may involve:

• For wounds that are failing to heal, we may use special wound care to help, such as treatment using platelet rich plasma (PRP) or collagenase in conjunction with other treatments such as amniotic derived therapies, depending on what is covered by insurance. Pressure garments or improving the blood flow to the area may be necessary.
• Sometimes we need to take skin or cartilage from one area and place it in another. This can be seen in a "full thickness skin graft" or cartilage graft. 
• More complex repairs can involve rotating a flap, a thicker "wad" of tissue including skin and blood vessels from one area to another, such as a forehead flap or distal pedicled sural neurovascular flap. More than one surgery may be necessary to get the final result. 
• Large wounds, such as pressure ulcers, can involve movement of muscles as well as overlying tissue in order to repair the defect. These are repaired under general anesthesia and usually require inpatient recovery.
• Finally "free flaps" can be done to move tissue from one part of the body to a whole different area, to help heal complex issues such as exposed metal from fracture sites. This requires careful monitoring afterwards, so is usually only done at specialist centers.

Book a consultation with us if you have any further questions.