Gupta AS
Surgical wounds leave scars. The type of scar that forms depends on wound healing that in turn is affected by variable factors. Patient’s having co morbid conditions like obesity, diabetes, malignancy and vascular insufficiency affect the wound healing and thus the scar formation. Suture materials used, site of the surgery, infections modify the wound healing. Well healed hair line invisible scars are ideal and provide cosmetic satisfaction for the patients especially women. However, this is not a universal outcome. Surgical wounds that are mainly clean cut incisions heal by primary intention. When a wound is inflicted and sutured various suture materials are used. An inflammatory reaction is triggered, hyperemia at the surgical site brings in the fibroblasts that start laying down collagen for wound healing. However, if the inflammatory reaction is severe, or the suture materials are more reactive or micro organisms have been inoculated at the wound site then this acute inflammatory reaction is so severe that it can lead to hyper granulation tissue formation resulting in poor wound healing, wound breakdown or formation of abnormal scars. Production of excessive collagen can result in the formation of hypertrophic scars or keloids. Hypertrophic scars are formed due to the heaping up of excessive collagen. The scar is elevated above the skin level but it does not extend beyond the scar margins. It does not keep growing not does it result in pruritis. They may regress over time. Biopsy taken from these scars show fibroblasts arranged in a disordered pattern but the fibrous tissue is laid in whorls. Keloid scars are also thickened but they usually go beyond the wound margins and can grow in various directions giving the appearance of projections and claws. They continue to grow and are many a times tender and cause intense itching. Biopsy from these scars show plenty of collagen strands that are infiltrated with eosinophils.
Localized chronic inflammatory reactions mainly to foreign material like sutures, mesh and tape, or to infections result in focal collections and nodules that are known as granulomas. Suture granulomas usually heal well after the foreign body that is the cluster of usually non absorbable sutures are removed. The other rarer type of scar granulomas are due to scar endometriosis, scar sarcoidosis, scar botryomycosis and scar actinomycosis.
Scar endometriosis is commonly encountered in women who have undergone procedures like cesarean births, hysterectomies, myomectomies, hysterotomy or even tubal liagation. These are typical nodular, tender masses formed on skin scars, fascia or muscle. These enlarge and become tender cyclically during menstruation and this typical presentation pinpoints the diagnosis. Wide excisional biopsy treats and conforms the diagnosis. The tissues are seen to be infilterated with the endometrial glands and stroma. Non caseating granulomas that develop in old, even remote surgical, injection or tatoo scars or cause reactivation of the old scars should alert the clinicain to the presence of scar sarcoidosis. Scar actinomycosis is a rare, chronic, suppurative, inflammatory, granulomatous condition that occurs due to infection with microareophilic or anerobic bacteria. It can also cause sinuses, fistulae and abscesses. Scar Botrymycosis is another chronic non inflammatory reactions to the bacterial antigens.
Clinicians when faced with these unusual cases of wound healing and abnorm scars shod keep the above differentials r proper management.
This issue has an interesting article on scar botrymycosis and I hope our dedicated followers and readers enjoy reading all the articles.