Improving skin scarring begins before surgery (trauma by appointment)!

Skin scarring, like death and taxes, is an unfortunate but inevitable predicament that will get us all at some point or other in our lifespan!

Below, you will see a panel of potential scar types; following skin trauma by appointment (surgery) or accidentally, at best you will end up with a fine line scar that is flat and mostly asymptomatic but always present as a permanent mark and a reminder of the injury to your skin! Nevertheless, the chances are that you could also end up with either a depressed, a stretched or a raised hypertrophic scar. Indeed, in the spectrum of skin scarring, unarguably, the worst scar type to end up with is the keloid scar, where this lesion grows far beyond the boundary of the original injury, is progressive, recurrent and non-responsive to conventional therapy.

Pre-emptive priming of the zone of surgical incision is a novel concept that will no doubt create a transformative paradigm shift in today’s scar management.  It would lead to a significant improvement in the appearance and quality of surgically induced skin scars which should impact across the whole surgical spectrum.

Current management of skin scarring, is an afterthought focusing on application of topicals post scar formation. Pre-injury priming of skin (applying an anti-scarring topical to the planned zone of injury at least three days or preferably a week before) in anticipation of trauma by appointment (surgery), as shown in our previously published work (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8068279/) would lead to a significant improvement in the appearance and quality of surgically induced skin scars which should impact across the whole surgical spectrum. 

With an estimated 100 million patients being left with permanent scars after elective surgery in the developed world alone per annum, scarless or scar free cutaneous wound healing has long been something of a holy grail for surgeons and wound healing scientists alike. Although the skin in the fetus in the first trimester is privileged to regenerate without scarring in mammals, unfortunately any time after that period, a deep enough injury in any adult mammalian skin will also end up in permanent irreversible scarring.

From an evolutionary perspective, nature has never been interested in making you and I look pretty after a traumatic skin injury. Meaning that, regenerating scarless healing like an amphibian was never an option on the menu for homo sapiens. It was deemed by the almighty natural selection that an ugly scar that healed fast, was for all intents and purposes, a superior choice than healing slowly and beautifully. Scar free would have looked nice and as good as new but would have posed a serious risk of downtime and rendering us vulnerable as potential prey to a predator.

Certainly, our predecessors, didn’t have sutures, antibiotics and sterile surgical kits to hand. Therefore, the notion of taking your time while healing slowly was not seen as an evolutionary benefit. However, speedy repair leading to survival and procreation was an obvious advantage. Achieving scar free wound healing by disabling the impact of cellular orchestrators implementing the forces of natural selection is albeit a necessary evil.

One of these key cellular orchestrators with no function of any major significance to the healing process is the mast cell. It carries a cargo loaded with inflammatory mediators whose role and function is not essential and its loss is of no consequence to the healing wound although its persistent presence is to detriment of ongoing inflammation.

There are indeed other cellular mediators such as neutrophils and, macrophages that play a far more important  role in wound healing and disturbing their delicate balance can have an undesirable consequence on this precisely orchestrated healing process. It goes without saying that aim here is not create scarless healing but to modulate this process and enable the best outcome possible. 

The above proposition is based on several basic science research and clinical studies leading to major publications carried out over the course of the past few years that have culminated in the development of this novel scar management theme. Several in vitro and ex vivo experiments (https://www.nature.com/articles/labinvest201382.pdf) using whole human skin organ culture models followed by two double blind randomized clinical trials in human volunteers (https://www.jidonline.org/action/showPdf?pii=S0022-202X%2819%2930134-4) and (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8068279/).