Q: Dear Dr. Eppley, I had a browlift several months using a hairline approach. While the surgery was uneventful, I have had a persistent scab along one side of the scalp incision that only recently I was able to get off. The scab was stuck to what appears to be the dissolveable sutures that were used. It now looks like an area of infection with some sort of red tissue between the scalp and foreheads of a few millimeters wide. Why is this and what do I do now? I have attached a picture of the area so you can see what it looks like.
A: It is now clear as to why you have had this scab this long and why it looks the way it does now. The scalp has a tremendous blood supply and this is why infection and necrosis of skin and scalp tissues is very uncommon. Neither of these have been what has happened to you. It appears that you have had separation of the wound edges in the early weeks after surgery, undoubtably due to the combination of tension on the scalp closure (which is normal) and the dissolveable sutures used. It appears that in your case those dissolveable sutures were just not sturdy enough to hold the skin edges together as they were healing. I used these all the time and have never seen this problem before.
Whenskin edges come apart, the body then creates its own bandage (i.e., scab) to cover the open wound it as it heals underneath it. This explains why the scab was stuck on so well for so long. That is a natural reaction of the body to an open wound. Once the gap in the skin edges fills in with granulation tissue (beefy red tissue that you see in your wound), the scab will get loose and be capable of being removed. This now leaves the gap filled in with granulation tissue that is now level with the surrounding skin. This is a good and healthy sign of a healing wound despite how it may look. This granulation tissue looks very red and angry but this is just due to the many blood vessels that it contains.
What will now happen is that the surrounding skin can now grow over it to make it a completely healed wound. This should take just a few more weeks to happen. The combination of granulation tissue, with a very high level of cells that contract, and the new skin will make the width of the wound and final scar once it heals much smaller. In the interim, of course, you have to persist with this unsightly wound in an area that is impossible to hide.
This leaves you with two approaches at this point and each has its own advantages and disadvantages. The first approach is to let the wound heal and contract and manage the residual scar at a later date. This is the most ideal approach from a long-term scar standpoint. This will leave a much more narrow scar area to excise and the tissues will be of better quality to manipulate so there is not a recurrent problem. The disadvantage is that you have to exist with this unsightly area in the interim. The other approach is to intervene earlier before it heals and excise and re-close the wound now. This has the advantage that it deals with the cosmetic appearance of it earlier but the tissue quality is not as good and how well the wound edges will hold together is a bit unpredictable.
Dr. Barry Eppley