Many years (uh, decades) ago, about midway through my general surgery residency, one of my co-residents and I performed a below-knee amputation on an elderly, diabetic, hypertensive gentleman. In order to minimize operative time, each of us closed one half of the resulting stump. My co-resident used larger-caliber, vertical mattress suture to close his half of the stump, while I, aspiring to a career in plastic surgery, decided to use a "plastic closure" that I hoped would leave the patient with the best scar possible. I employed a layered closure technique using smaller- caliber, dissolvable simple suture in tiny, non-crushing bites designed to create a "kissing," not "scrunched," closure of the surgical wound edges.

Several days later my half of the stump appeared to be progressing well, but my co-resident's half looked necrotic and eventually became infected and dehisced. After multiple revisions, the shortened stump later proved difficult to fit with a prosthesis. Needless to say, we both learned that careful wound closure is beneficial to producing cosmetically desirable scars and, even more importantly, to providing good medical care.

Careful incision planning
Every surgeon recognizes that certain areas of the body are prone to unsatisfactory scars — regardless of efforts to minimize scarring — and that scars running contrary to skin grain and skin creases are more obvious than necessary and often problematic as well. For example, every cardiothoracic surgeon knows that a certain percentage of midsternal scars will prove unsatisfactory, even hypertrophic, no matter how carefully and delicately the midsternal incision is repaired.

Likewise, abdominal surgeons know that incisions positioned vertically along abdominal skin, even short incisions associated with laparoscopic procedures, can lead to unattractive scars and a deformed abdomen. Scars that cross natural creases, especially at joints, may contract, shorten and limit joint motion. Therefore, careful incision planning should be the first step toward ensuring the best possible scar formation. A surgeon should take into account the vagaries of wound healing and scar formation in each area of the body and consider the consequences of crossing skin tension lines.

For example, I was trained to perform carpal tunnel exploration and decompression via a distal forearm to proximal hand incision that crosses the transverse carpal crease. However, over the years I noticed that the resulting scar often contracted and became hypertrophic at the crease. I was able to eliminate this problem by redesigning my surgical approach in order to avoid the crease. As a result, I've found that patients experience less pain and downtime following surgery and are left with comfortable, almost hairline scars that usually don't interfere with wrist motion and mobility.

Respect for tissues
Surgery is, in essence, the intentional infliction of injury on tissues. So the less traumatic and destructive the surgical injury, the less compromised the tissues will be. As a result, tissues are more likely to recover fully from the injury and less likely to become deformed and distorted. Gentle, almost reverential, handling of tissues, meticulous attention to hemostasis and restoration of a tissue-friendly wound healing environment are crucial to healing and scar formation.

Many surgeons, certainly all plastic surgeons, know that handling tissues with thumb and fingers (still the best surgical instruments) is preferable to retractors. When plastic surgeons do use retractors, we usually use single or double hooks, which inflict minimal injury on tissues. Admittedly, given their limited retraction capabilities, hooks aren't practical for all surgical procedures.

Because of the surface nature of most plastic surgical procedures, I rarely use ties to control bleeding, since I can usually control bleeding with electrocautery. However, I'm careful to limit electrocautery to only the bleeding vessel and not the surrounding tissues. Avoiding ties lets me minimize the foreign material — and the risk of reaction to it — that I leave in the operative area.

Before closure, I flush the wound copiously with warm sterile saline to remove any debris such as microscopic fragments of a surgical sponge or loose electrocautery "charcoal." I'm not a big fan of depositing antibiotics or steroids in the wound before closure because they may evoke an undesirable reaction and disturb wound physiology. However, I recognize that some cases may benefit from antibiotics or steroids.

In procedures that create a skin flap, such as a facelift or abdominoplasty, I do coat the wound bed with 0.5 percent bupivacaine in order to minimize post-operative pain. I've found that when the patient suffers less pain there is less post-operative movement and disturbance to the operative area. The goal is to help the body bounce back from the surgical injury in a way that least taxes the body's responses and resources.

No secrets
Plastic surgeons aren't privy to any inside information when it comes to scarring. But we do have a good feeling for the variables that contribute to the outcome of a scar. For example, we know that scars of thicker skin, such as on the trunk, will never be as "invisible" as scars on the face, no matter how neatly they have been created. From the plastic surgeon's perspective, the best wound closure consists of:

• repairing only viable tissues and removing any non-viable tissues prior to closure;
• layered tissue-to-tissue repair and approximating like tissue such as fascia-to-fascia or dermis-to-dermis;
• using the smallest caliber suture possible to repair a tissue and using dissolvable or non- to minimally-reactive suture whenever possible to produce tension-free, non-strangulating closures; and
• dressing and managing the wound in ways that support wound healing.

While there's no perfect suture, monofilament nylon is second only to stainless steel — obviously limited in its applicability — for its tensile strength, easy removal and minimal reactivity, especially when compared with braided suture. Monofilament nylon is the workhorse in most of my surgical procedures as far as surface sutures are concerned. I use polydioxanone suture at the dermal and deeper levels when I want to position strong, non-eruptive sutures that dissolve over time and leave no foreign material behind. Still, I keep an open mind toward new suture materials as long as they allow me to follow the precepts of good wound closure. However, like many surgeons, I have learned that new is not always better.

The closest thing to the perfect suture is no suture at all. Whenever I can avoid surface sutures, I use adhesive skin closure strips, usually after pre-treating the skin with a liquid adhesive. I often use skin closure strips to dress the wound because they let me observe its progress, which would be hidden by an occlusive dressing. Adhesive skin closure strips are well suited to the evolution of the wound as it changes in size and shape as a result of post-operative swelling.

Scar manipulation and revision
If plastic surgeons enjoy more expertise than other surgeons, it is in redirecting a young scar toward a more favorable final result and revising an established but unsatisfactory scar.

I have learned in many years of practice that applying external pressure to a newly developing scar, early and often, is the best way to direct a scar toward a better-looking outcome. A better scar is as narrow as possible, flat and neither darker nor lighter than the surrounding skin.

How external pressure is applied depends on where the scar is located. For example, if it involves an upper extremity, a simple, possibly custom-made, elastic sleeve may be the most convenient way to apply external pressure.

However, not all scars lend themselves to this method. In difficult situations, adhesive-backed silicone sheeting is extremely effective. It can be cut to a desired shape, applied to almost any scar regardless of its location, and is well-tolerated and unobtrusive.

No one really knows why silicone sheeting is beneficial, though some have speculated that, like the elastic sleeve, it applies pressure to the newly developing scar. Other means of manipulating scars, such as steroid injections and external irradiation, can be equally or even more effective, but are associated with more fuss-and-muss than silicone sheeting.

Surgery's visible reminder
Plastic surgeons aren't magicians. Given our demanding clientele, we invest more time and attention to surgical wound repair. With a little forethought, any surgeon regardless of his specialty can use our tricks successfully. I hope that creating the best possible scar becomes part of your daily routine in the OR. It doesn't cost any more and takes only a little more time. And your patients will appreciate it for years to come.