WCD: Bad scar? Remember the four Ts

VANCOUVER, B.C. – A simple mnemonic – Talk, Time, Training, and Tools – can help dermatologists optimize outcomes when facing “bad” scars after skin surgery, Dr. Evans Bailey said at the World Congress of Dermatology.

Cosmetically challenging wounds can occur because the patient is on anticoagulants or for other reasons that the clinician cannot control, noted Dr. Bailey, a dermatologist with the Surgical Dermatology Group in Birmingham, Ala. Managing these situations begins during the informed consent process, when dermatologists should educate patients about the procedure and set reasonable expectations for cosmetic outcomes, he said.

“When it comes to scars, the battle is won or lost before you do surgery,” he said. “If you tell patients beforehand, it’s an explanation. If you tell them afterward, it’s an excuse.”

When obtaining informed consent, Dr. Bailey uses a digital tablet to take presurgical photos and draw options for surgical repair, he said. “I let them hold the tablet and show them the possibilities, because sometimes the smallest spots turn out to be the biggest tumors.”

When a patient returns after surgery with a “bad” scar, “never show surprise!” Dr. Bailey emphasized. “Don’t give up. Don’t show surprise, but be compassionate and pull hard for your patient.” Continuing to talk with patients at this point is key, he said. He shows patients the preoperative photographs and explains why he chose the surgical approach. Then he verbally commits to sticking with the patient during the entire process of wound healing and repair. “Say, ‘don’t worry; this is all under control; this will take longer than we thought. But I will make sure everything heals well.’ ”

Besides talking extensively with patients, dermatologists it is important to allow time for the scar to fully mature and involute before they intervene, said Dr. Bailey. “Allow scars to repair themselves,” he said. “Do not jump in too quickly. The body is really quite dynamic and capable – often more capable than we are.”

It’s equally important to stick to the fundamental principles of skin surgery, no matter how formidable the wound, Dr. Bailey noted. “Remember your training,” he said. “Protect the free margin and redefine the cosmetic subunits.” Tacking or suspension sutures can be used to redefine the cosmetic subunit and eliminate or minimize tension across the tissue flap, leading to better cosmetic outcomes.

For scars that still need improvement, tools such as wire brush dermabrasion can be used for raised scars, and TCA CROSS (trichloroacetic acid chemical reconstruction of skin scars) for depressed scars, Dr. Bailey noted. Both techniques can dramatically improve the final appearance of the scar, he noted.

“But the enemy of good is better,” he said. “So at some point I say, ‘you’re done.’ ”

Dr. Bailey reported having no relevant conflicts of interest.

VANCOUVER, B.C. – A simple mnemonic – Talk, Time, Training, and Tools – can help dermatologists optimize outcomes when facing “bad” scars after skin surgery, Dr. Evans Bailey said at the World Congress of Dermatology.

Cosmetically challenging wounds can occur because the patient is on anticoagulants or for other reasons that the clinician cannot control, noted Dr. Bailey, a dermatologist with the Surgical Dermatology Group in Birmingham, Ala. Managing these situations begins during the informed consent process, when dermatologists should educate patients about the procedure and set reasonable expectations for cosmetic outcomes, he said.

“When it comes to scars, the battle is won or lost before you do surgery,” he said. “If you tell patients beforehand, it’s an explanation. If you tell them afterward, it’s an excuse.”

When obtaining informed consent, Dr. Bailey uses a digital tablet to take presurgical photos and draw options for surgical repair, he said. “I let them hold the tablet and show them the possibilities, because sometimes the smallest spots turn out to be the biggest tumors.”

When a patient returns after surgery with a “bad” scar, “never show surprise!” Dr. Bailey emphasized. “Don’t give up. Don’t show surprise, but be compassionate and pull hard for your patient.” Continuing to talk with patients at this point is key, he said. He shows patients the preoperative photographs and explains why he chose the surgical approach. Then he verbally commits to sticking with the patient during the entire process of wound healing and repair. “Say, ‘don’t worry; this is all under control; this will take longer than we thought. But I will make sure everything heals well.’ ”

Besides talking extensively with patients, dermatologists it is important to allow time for the scar to fully mature and involute before they intervene, said Dr. Bailey. “Allow scars to repair themselves,” he said. “Do not jump in too quickly. The body is really quite dynamic and capable – often more capable than we are.”

It’s equally important to stick to the fundamental principles of skin surgery, no matter how formidable the wound, Dr. Bailey noted. “Remember your training,” he said. “Protect the free margin and redefine the cosmetic subunits.” Tacking or suspension sutures can be used to redefine the cosmetic subunit and eliminate or minimize tension across the tissue flap, leading to better cosmetic outcomes.

For scars that still need improvement, tools such as wire brush dermabrasion can be used for raised scars, and TCA CROSS (trichloroacetic acid chemical reconstruction of skin scars) for depressed scars, Dr. Bailey noted. Both techniques can dramatically improve the final appearance of the scar, he noted.

“But the enemy of good is better,” he said. “So at some point I say, ‘you’re done.’ ”

Dr. Bailey reported having no relevant conflicts of interest.

VANCOUVER, B.C. – A simple mnemonic – Talk, Time, Training, and Tools – can help dermatologists optimize outcomes when facing “bad” scars after skin surgery, Dr. Evans Bailey said at the World Congress of Dermatology.

Cosmetically challenging wounds can occur because the patient is on anticoagulants or for other reasons that the clinician cannot control, noted Dr. Bailey, a dermatologist with the Surgical Dermatology Group in Birmingham, Ala. Managing these situations begins during the informed consent process, when dermatologists should educate patients about the procedure and set reasonable expectations for cosmetic outcomes, he said.

“When it comes to scars, the battle is won or lost before you do surgery,” he said. “If you tell patients beforehand, it’s an explanation. If you tell them afterward, it’s an excuse.”

When obtaining informed consent, Dr. Bailey uses a digital tablet to take presurgical photos and draw options for surgical repair, he said. “I let them hold the tablet and show them the possibilities, because sometimes the smallest spots turn out to be the biggest tumors.”

When a patient returns after surgery with a “bad” scar, “never show surprise!” Dr. Bailey emphasized. “Don’t give up. Don’t show surprise, but be compassionate and pull hard for your patient.” Continuing to talk with patients at this point is key, he said. He shows patients the preoperative photographs and explains why he chose the surgical approach. Then he verbally commits to sticking with the patient during the entire process of wound healing and repair. “Say, ‘don’t worry; this is all under control; this will take longer than we thought. But I will make sure everything heals well.’ ”

Besides talking extensively with patients, dermatologists it is important to allow time for the scar to fully mature and involute before they intervene, said Dr. Bailey. “Allow scars to repair themselves,” he said. “Do not jump in too quickly. The body is really quite dynamic and capable – often more capable than we are.”

It’s equally important to stick to the fundamental principles of skin surgery, no matter how formidable the wound, Dr. Bailey noted. “Remember your training,” he said. “Protect the free margin and redefine the cosmetic subunits.” Tacking or suspension sutures can be used to redefine the cosmetic subunit and eliminate or minimize tension across the tissue flap, leading to better cosmetic outcomes.

For scars that still need improvement, tools such as wire brush dermabrasion can be used for raised scars, and TCA CROSS (trichloroacetic acid chemical reconstruction of skin scars) for depressed scars, Dr. Bailey noted. Both techniques can dramatically improve the final appearance of the scar, he noted.

“But the enemy of good is better,” he said. “So at some point I say, ‘you’re done.’ ”

Dr. Bailey reported having no relevant conflicts of interest.