Improved Scar Quality Following Primary and Secondary Healing of Cutaneous Wounds Bishara S. Atiyeh, M.D., F.A.C.S., Christian A. Amm, M.D., and Kusai A. El Musa, M.D Beirut, Lebanon Abstract. Poor wound healing remains a critical problem in our daily practice of surgery, exerting a heavy toll on our patients as well as on the health care system. In susceptible individuals, scars can become raised, reddish, and rigid, may cause itching and pain, and might even lead to serious cosmetic and functional problems. Hypertrophic scars do not occur spontaneously in animals, which explains the lack of experimental models for the study of pathologic scar modulation. We present the results of three clinical com- parative prospective studies that we have conducted. In the first study, secondary healing and cosmetic appearance following healing of partial thickness skin graft donor sites under dry (semi-open Sofra-Tulle dressing) and moist (moist exposed burn ointment, MEBO) was assessed. In the second study, healing of the donor sites was evaluated following treatment with Tegaderm or MEBO, two differ- ent types of moisture-retentive dressings. In the third study, 3 comparable groups of primarily healed wounds were evaluated. One group was treated by topical antibiotic ointment, the second group was treated by Moist Exposed Burn Ointment (MEBO), and the third group did not re- ceive any topical treatment. In the second study, secondary healing of partial thickness skin graft donor sites was evaluated following treatment with Tegaderm or MEBO, two different types of moisture-retentive dressings. In the second and third studies, healed wounds were evaluated with the quantitative scale for scar assessment described by Beausang et al. [1] Statistical analysis revealed that for both types of wound healing, scar quality was significantly su- perior in those wounds treated with MEBO. Scar formation is an inevitable outcome of wound healing, ranging clinically from fine asymptomatic to problematic hypertrophic and keloid scars that may give rise to both functional and cosmetic defects and may even restrict further growth [1]. Wound healing involves three processes: epithelialization, connective tissue deposition, and contraction; however, it does not culminate in tissue regeneration but rather in tissue restoration [2]. The contribution of each process varies according to the type of wound [3]. Epithelialization results in wound resurfacing and restoration of the stratified squamous epithelium that protects the body from fluid loss, bacterial invasion, electromagnetic radiation, and general trauma [4], whereas connective tissue deposition replaces the underlying damaged dermis. On the other hand, wound contraction is one of the most powerful me- chanical forces in the body [4]. It brings the margins of open wounds together and is an active process produced by fibroblasts and myofibroblasts [3,5,6]. Its consequences in certain anatomical locations may not be beneficial, ranging from gross scaring to loss of joint motion or major body deformations [3]. Usually with time, most scars become flat and flexible. In susceptible individuals, however, scars can become raised, reddish, and rigid, and cause itching and pain [7]. Due to the lack of an experimental an- imal model of this uniquely human disorder [7–9] theories about the causative mechanisms for excessive scar formation abound in the literature. Scars may be caused and influenced by traction forces as well as by the site of the initial wound. Infection, hematoma, the presence of foreign body, or hypoxia owing to microvascular occlusion contribute as well to the development of pathologic scarring. There is evidence as well that hormonal, immunologic and genetic factors, plus growth factors play an important role in the development of abnormal scar tissue [7]. It is obvious also that tissue mishandling and the use of Correspondence to Bishara S. Atiyeh, M.D., F.A.C.S., Division of Plastic and Reconstructive Surgery American University of Beirut, Beirut, Lebanon; email: aata@torra. net.lb Aesth. Plast. Surg. 27:411–417, 2003 DOI: 10.1007/s00266-003-3049-3