Hypertrophic scars and keloids.

By modifying the wound healing process, it is possible to deal effectively with most abnormal forms of scarring, through perhaps 15 per cent of these lesions cannot be managed to the satisfaction of surgeon and patient. A laboratory test to determine which patients will overrespond to the stimulus of wounding and a better understanding of why these patients have an inordinately high anabolic rate of collagen metabolism will help in the salvage of those patients who are yet unmanageable. The great majority of patients can be helped and with them the lesions are best managed prophylactically if possible and if not the established lesion is dealt with. In preventing such lesions at the time of surgery, in addition to the strict adherence to basic surgical principles, every effort should be taken to relieve the wound of tension; that is, the natural tension produced by the underlying skeleton and tension in the early period of wound healing when the wound is weak and vulnerable to spreading. The inflammatory phase of wound healing can be modified pharmacologically with anti-inflammatory agents, fibroblast reproduction can be suppressed with radiotherapy, and collagen bundles can be reoriented with pressure. One or all of these modalities are applicable to appropriate lesions. In the established hypertrophic scar or keloid, lesions of resonable size on the trunk can be treated with intralesional injections of triamcinolone only; lesions larger than 75 sq cm or facial lesions can be excised and closed or shaved and grafted, again with one or all of the above mentioned modalities being the control factor that modifies healing and prevents recurrence.