Minimizing scar formation resulting from traumatic wounds includes adherence to basic principles of wound care still practiced today: control of hemorrhage, removal of foreign bodies and cleansing, careful approximation of the wound edges, drainage (if needed), and appropriate dressings. Before the introduction of aseptic technique and
anesthesia, routine elective scar interventions, while documented, were infrequent. Because scars are not clearly distinguished from other forms of skin pathology, a coherent chronology of treatment recommendations is difficult. Therefore, surgical and nonsurgical interventions will be limited to those recommended from the times of Alibert’s recognition of “cheloids.” Alibert in his 1816 paper13 recommended topical treatments including sulfur, lead acetate, camphor, and opium, among others.
Linares, in a review on the history of keloids,34 attributes the first surgical recommendations to Robert Druit (1814 to 1883). For surgery on scars caused by burns, Druit35 discusses the need to shave the scar and keep it open using cautery, but also offers Jacques M Delpech’s (1777 to 1832) view that the entire lesion be removed. No other specific operation is discussed, but removal of larger burn scars and flap closure with normal skin is mentioned. Druit’s book (available online) is interesting to read and provides a comprehensive encyclopedia of standard surgical practices of the time. Though Linares suggests that Druit is referring specifically to keloids, this author’s own reading of the text did not find such specificity. This reference to Druit appears regularly in later review articles without page identification.
John Da Costa (1863 to 1933) in his 1894 text A Manual of Modern Surgery,36 states unequivocally that a “keloid should not be operated upon: it will only return, and will also recur in the stitch-holes. Trust to time for involution, or use pressure with flexible collodion,” by which method Professor Da Costa treated a case following smallpox. Ninety years later, a paper offering a comprehensive review of the treatment of keloids and hypertrophic scars recommends, “Surgery for the treatment of keloid scar has been relegated mainly to second-line therapy for lesions unresponsive to steroids or pressure and large lesions, requiring de-bulking. Combining surgery with other therapy is usually indicated.”37
Attention to hypertrophic scars as distinguished from keloids generally focuses on their better responses to treatment. In a 1969 review of all scars excised at Columbia Presbyterian Hospital between 1932 and 1958, 340 were clinically identified in the medical record as keloids. Cosman et al. noted a successful response to surgical excision in 83% of those lesions not histologically identified as keloids, as opposed to 53% of those confirmed as keloids.38 This paper provides an excellent review of the various factors considered relevant to the formation of keloids as opposed to other kinds of scars, but concludes that most of the previous literature blaming hormone status, the presence of foreign bodies, heredity, race, etc., are not correct. They also review the treatment of these lesions, noting that often the diagnosis of keloid is incorrectly applied to other skin conditions. The large number of remedies recommended, and the associated poor design of clinical trials make definitive treatment protocols impossible. This continues to be a problem. Some authors suggest that keloids are not distinct entities, but represent a continuum of disordered scars.39 The clinical distinction between keloid and hypertrophic scar is still largely based on clinical behavior. A keloid is characterized by the presence of scar tissue extending beyond the border of the original wound, while hypertrophic scars, though red, raised, and occasionally painful, remain within the borders of the original injury and often begin to resolve after
approximately 2 years.
One of the most consistently recommended primary or adjuvant therapies for keloids and hypertrophic scars is the application of pressure. In 1898, an Australian named Herman Lawrence recommended scarification of the keloid followed by several months of pressure.40 This single case report does not indicate how the pressure was applied or for how long. The use of pressure in wound healing appears in the Smith Papyrus (circa 1600 BCE), and regularly in subsequent wound care instructions. In 1924 Vilray Blair
studied the benefits of mechanical pressure on wound healing.41 James Barrett Brown and Frank McDowell, in their comprehensive 1944 paper on the healing of burn wounds of the skin, comment that without pressure dressings, skin grafts and donor sites will not heal properly. They note further that applying pressure to burn wounds may be aseptic.42 The first clinical documentation of the utility of pressure for burn scars came from Paul Silverstein at Brooke Army Hospital in San Antonio, Texas. He noted better healing in a grafted leg being treated with compression stockings for varicose vein disease than on the opposite extremity not using the stocking. Duane Larson at the Shriner’s Burn Institute in Galveston noted a similar response when using pressure splints, leading Larson to collaborate with the Jobst Institute to produce garments for postburn scar management. Their results, reported in 1971, made compression garments part of the standard of care for the prevention and treatment of scars.43 Recent clinical studies have not found a correlation between the pressure used and efficacy,44 and it seems that the evidence for the benefits of pressure garments is inconclusive at best; high associated cost and low compliance remain significant issues (see Chapter 19).45
The use of silicone topical gels and sheeting over keloids and hypertrophic scars has also been advocated for many years. In 1935, Robinson recommended topical silicone for use in nonhealing ulcers. Interest in the substance for skin lotions extended its use to dematoses and other hyperkeratotic conditions by 1954.46 Because of its inert nature, silicone also became used in soft tissue augmentation, or in solid form as a substitute for nasal or ear cartilage. The injection of various materials to correct deformity, including depressed scars, became quite popular in the early 20th century. These materials are summarized in a review article47 on the uses of dimethylsiloxanes, comparing them to other available synthetic materials. The list of now-unacceptable materials used in the past details celluloid, paraffin, various metals, heterograft, leather, pith wood, latex, vulcanized rubber, and gutta percha. It seems early clinicians used whatever was at hand. The clinical applications of synthetic polymers, dimethysiloxanes (silicone), halogenated carbons (Teflon), and polyvinyl alcohol compared by Brown and Ohlwiler found preferential advantages to silicone when used as a liquid, resin, or solid.47 It replaced, in contemporary use, all the previous materials until the introduction of bovine collagen in 1981, and the array of tissue fillers now available.
Frank J. Gerow (1929 to 1993), remembered best for his role in developing and popularizing silicone breast implants, coauthored a paper in 1967 on the use of silicone in burn care. The paper recommends liquid silicone in the treatment of acute hand burns. Silicone-impregnated dressings, splints, etc., were combined with bags of liquid medical-grade silicone in which the hands were immersed during and after healing of
partial thickness and deep burns. In a series of 50 hands in 29 patients, they reported supple, soft, satisfactory scars in all cases.48
The use of silicone gel and silicone sheets applied to scars became a recommended strategy in the 1980s, with multiple papers appearing subsequently.49,50 Negative results are seldom reported, but a 1973 study of silicone (silastic) sheets reported that while using the sheets on fresh skin graft donor areas provided excellent pain relief, nearly all became infected with Pseudomonas within a few days of application.51 This led to the recommendation for the use of silicone sheeting on healed wounds only.
The use of topical sheets or gels for prevention and treatment of scar remains commonly recommended, and there are hundreds of commercial products on the market today promoting this technique. In 1995, Reiffel noted that occluding the healing incision site with paper tape also yielded a satisfactory scar, at lower cost. He demonstrated the effectiveness of this in a series of patients, including those undergoing scar revisions.52 This has been confirmed in subsequent clinical trials.53 The question of whether it is pressure, occlusion, moisture, revascularization, or the related metabolic changes induced by pressure that influence scar formation and maturation remains unresolved.