NO SMALL THING The size of the scar is sometimes just as important to patients as the surgical outcome.

For plastic surgeon Richard Vagley, MD, FACS, ensuring that patients are happy with scars is one of the key goals of surgery. "In my business, the scar is the surgical procedure," says Dr. Vagley, of the Pittsburgh Institute of Plastic Surgery. Whether you use suture, staples, glue or some other adhesive to close skin wounds, here are 4 ways to minimize scarring.

1. Find the right suture
Dr. Vagley says the correct suture material and the right technique play equally big parts in producing a good outcome. His personal choice is a nylon monofilament suture, which some studies have shown results in superior cosmetic results. It has several other benefits, he says, including its ability to hold its shape and its strength. "The workhorse for me is nylon," he says. "I like it because its strength is beyond what one would expect for its size, so I can use a relatively small caliber knowing that it is less bothersome to the skin."

The right suture depends on a number of factors, including the case, where the incision is located, the tension of the skin and surgeon preference. Some choices, though, are better than others to minimize scarring. Multifilament sutures may be easier to tie, but they result in a less-than-pretty outcome, says Dr. Vagley, since they more easily absorb surrounding fluid that could put pressure on tissue. Research also suggests that these braided sutures come with a higher infection risk, a key factor in scarring.

Another suture consideration is absorbable vs. nonabsorbable. While many previously thought that absorbable sutures offered inferior post-op cosmetic outcomes, several recent studies have suggested that the 2 produce similar results.

Suture technique also plays a role in how scars form. Dr. Vagley prefers using a "buried retention" suture, which uses an inner circle — placed just below the skin's surface — and an outer circle to bring the incision together and create a less noticeable scar. He'll also use a subcuticular suture that snakes back and forth just below the skin's surface. One to try to avoid? The mattress stitch, says Dr. Vagley. Despite being a strong suture, he says the mattress stitch tends to dig into skin and cause prominent stitch-mark scars.

2. Explore your adhesive options
Eliminating sutures and staples is one of the best ways to reduce scarring. "It goes without saying that the best suture is no suture at all," says Dr. Vagley. While deeper skin layers often require suturing, Dr. Vagley uses adhesive strips to close the skin's surface and eliminate the "railroad track" aftereffect of sutures. After closing deeper layers with traditional sutures, Dr. Vagley will apply skin closure strips along with a sticky spray — usually tincture of benzoin — to close the superficial layer. These strips also can work well in addition to sutures in the top layer, with research showing they reduce puncture marks and increase patient comfort during the first 48 hours post-op.

Another option is medical glue, a product that's been improved to be more convenient to use and work better with wet tissue. While some surgeons are skeptical, there's been more research lately showing that medical glues are comparable to sutures. Not only do they produce similar results, they also can come with additional benefits like increased efficiency. In a study published in the December 2014 issue of the Annals of Plastic Surgery (osmag.net/ozKRK9), researchers note that a new type of skin adhesive closed wounds as well as sutures did, but 14 minutes faster.

SINGLE APPROACH Because the umbilicus is already a scar, surgeons can go directly through it to perform common laparoscopic surgeries and improve cosmetic outcomes.

3. Try alternatives
Several new wound closure devices (see product roundup below) promise to improve the cosmetic appearance of the incision. Besides eliminating puncture marks, proponents say these devices are simple to use and are quicker than conventional wound closure methods.

You can also improve the look of your sutured and stapled wounds using additional therapeutic dressings on top of closed incisions. Sharona B. Ross, MD, FACS, places silver-impregnated strips over closed incisions. These strips have an antimicrobial property that improves wound healing. "I wasn't a believer at first, but then I started to use them, and now I love the results," says the director of minimally invasive surgery and surgical endoscopy at Florida Hospital Tampa's Southeastern Center for Digestive Disorders and Pancreatic Cancer, Advanced Minimally Invasive and Robotic Surgery. "The scar really heals nicely."

Other options include silicone sheets, used only after the incision has healed. These sheets can be obtained either by prescription or over the counter and have been clinically proven to be very effective at reducing hypertrophic scars thanks to their moisture-retaining properties. Another option for high-risk incisions are highly specialized dressings that use negative pressure therapy to improve blood flow and limit dehiscence of the wound.

4. Cut through the umbilicus
For abdominal surgery, one way to dramatically reduce or eliminate scarring is to cut through the umbilicus. "The existing defect is there," explains Dr. Ross. "We all have a scar in the umbilicus. We make the incision over the belly button, so when you heal, nothing shows." Dr. Ross was one of the first surgeons to pioneer a single-incision technique that's performed through a port using a 1.2 cm incision over the umbilicus.

Other options to reduce scarring include using a robot to convert open procedures — like pancreatectomies or total gastrectomies — to minimally invasive ones. "If you can't avoid making an incision, make as few as possible," says Alexander Rosemurgy, MD, FACS, director of the Surgical Digestive Disorders and GERD Center at Florida Hospital Tampa and Dr. Ross's colleague.

Of course, the best way to prevent scarring is to avoid incisions altogether, to practice what Drs. Ross and Rosemurgy call "minimally invasive, no-scar surgery." By reducing the number and size of incisions in the abdominal wall, any surgeon can enjoy better cosmetic outcomes. Then there's truly scarless surgery. Dr. Rosemurgy passes an endoscope through a natural orifice to correct certain conditions like gastroesophageal reflux disease. Performing surgery through natural orifices eliminates any scarring, and allows for faster recovery.

PRODUCT ROUNDUP
3 New Wound Closure Devices

Suture-Quality Closure at the Speed of Staples
Your physicians can shorten their OR closing times without sacrificing good cosmetic outcomes by using Zip Surgical Skin Closures from ZipLine Medical. The non-invasive, adhesive-tape-based device approximates and secures skin edges with adjustable tensioning straps. The company says you can apply it to dry skin in less time than it takes to complete subcuticular stitches. The closure devices are easy to peel off after 7 to 14 days of healing, eliminating time-consuming suture or staple removal and the patient discomfort that comes with it. Zip Surgical Skin Closures are available in 8 cm and 16 cm lengths.
ziplinemedical.com

Heal Incisions With Negative Pressure
This innovative device uses negative pressure therapy (but not batteries or electricity) to prevent infection and promote healing in high-risk incisions. The ciSNaP Closed Incision System by Spiracur combines negative pressure therapy with controlled tension relief to help reduce infection and dehiscence. It's a small, silent, single-use device. You apply ciSNaP (Smart Negative Pressure) over an incision following sutured or stapled closure. It can be left on for several days without the need for dressing changes. The system creates consistent levels of negative pressure on the wound through a device that uses a spring mechanism, which the company says results in increased blood flow.
spiracur.com

Stronger, More Flexible Tissue Adhesive
Histoacryl Flexible Tissue Adhesive from Aesculap is the newest generation of the company's Histoacryl glue. It's formulated to be more flexible and easier to apply than classic Histoacryl, and may help act as a barrier to microbial penetration. The glue can be used on incisions up to 25 cm and polymerizes immediately after contact with human tissue. Because of this, the company says that the glue won't dry out or clog like others can. Only a single layer of the adhesive is necessary to achieve the full-strength bond, saving you time and adhesive.
aesculapusa.com