Brief Answer:
I suggest topical tretinoin 0.05% cream and silicone gel twice daily

Detailed Answer:
Hello. Thank you for writing to us

I have gone through your query and I have understood your concern.

It must have been a split thickness skin graft (STSG).
STSGs are thin and are devoid of appendages like sweat glands, sebaceous glans, hair and thus appear 'dry and dark' therefore creating a color mismatch with surrounding normal skin unlike a full thickness skin grafts (FTSG) which are better cosmetically due to their thicker nature and inclusion of dermal appendages like hair, sebaceous glands and sweat glands.

Your friend can do certain things to improve the cosmetic appearance of this graft though one cannot expect it to look like completely normal skin.

Using tretinoin 0.05% cream once daily at night at the site of grafted skin. Tretinoin also stimulates synthesis of new collagen as well as remodels existing dermal collagen and therefore would help improve the appearance of graft.
Tretinoin also has skin lightening effects and that would also make the graft look better cosmetically.

Your friend may also use either a silicone gel e.g Kelocote gel Or a scar gel containing allantoin and heparin e.g Contractubex gel, twice daily, which will also help the graft soften and become pliable over a period of time.

These are prescription mediactions and therefore I suggest that your friend visits a dermatologist in vicinity for better assessment and use these medications under his/her supervision.

Regards

---

Brief Answer:
Fractional CO 2 laser is an option; Tretinoin can be continued long term

Detailed Answer:
Hi.

I have reviewed the Images.

The graft appears darker because it is a thin skin graft (epidermis and part of dermis) devoid of hair follicles and appendages (e.g sweat and sebaceous glands) and therefore lacks the translucency and natural color of normal skin.

Fractional Co 2 Laser resurfacing is an option and she can take at least one session before her marriage. Fractional CO 2 Laser would induce thermal injury at the site and thereafter induce synthesis of new collagen in dermis and therefore a cosmetically better scar. One can expect at least 3-4 sittings for a cosmetically good result. These sittings can be taken at a gap of 6-8 weeks. However, since the graft does not contain any appendages like sebaceous glands, hair, sweat glands and also because STSG's are less vascular therefore healing may be slow and moreover Laser resurfacing itself can cause more scaring and post-inflammatory hyperpigmentary changes.

Resurfacing Laser is not without side effects. It can be associated with side effects like wound infection, scarring and post-inflammatory pigmentary changes. However, proper post-operative wound care would minimises chances of these side effects.

Cost would vary between 5k-10k per session.

I would suggest her to start with tretinoin 0.05% cream once daily at night for the time being. Tretinoin has collagen remodelling properties and also induces synthesis of new collagen. Tretinoin can be continued long tem. Tretinoin would also help lighten the scar.

Because grafted skin is devoid of sweat and oil glands therefore it would be dry and flaky hence regular use of moisturizer is advisable, at least twice or thrice daily.
In addition I would suggest that she also uses a good moisturizer at affected site 30 minutes before applying tretinoin cream.
In addition to tretinoin she may also use contractubex gel 2-3 times during day time over the scar.

Swelling is due to lack of vasomotor control of vasculature supplying the graft because it is a superficial graft. She should avoid keeping this part in dependent position for long periods of time. At night she keep foot end of her bed elevated.

Regards

---

Brief Answer:
She can go for fractional Co 2 Laser along with tretinoin and contactubex

Detailed Answer:
Hi.

She can go for Fractional Co 2 Laser. The idea is to get a cosmetically better scar which would be acceptable. Since this is a thin graft and devoid of skin appendages therefore healing would be delayed after laser. Of course there is a risk of complications after fractional CO 2 Laser like infection, delayed wound healing, scaring and pigmentary changes.

Tretinoin and contractubex are for long term use and can be used even with laser. These would improve the grafted skin cosmetically but you cannot expect the grafted skin to be just like normal skin with any form of treatment, even with fractional Laser.

She must also use a moisturizer because the graft devoid of sebaceous glands and therefore would be dry.

Persistent swelling and sweling on prolonged standing/ sitting is due to Lymphedema due to damage to lymphatics during surgery and also due to lack of vasomotor control and I would suggest that she use a compression stockings for the same apart from general measures like keeping the foot end of bed elevated and avoid prolonged standing/ sitting.

Regards

---

Brief Answer:
Specific replies to questions regarding Resurfacing Laser

Detailed Answer:
Hi.

1. Goal of fractional Co 2 Laser is to create a cosmetically better looking scar by resurfacing present scar through controlled thermal injury.
Pigmentation is an expected complication. Pigmentary changes are temporary and would improve with treatment. Scaring is a long term complication but that too can be improved with treatment. Duration of treatment for these compliactions can take weeks or months but they can be managed effectively.

2. Since swelling is more during day because this part is in a dependent position, therefore compression stockings are advisable throughout the day specially when she is ambulatory. They can be taken off at night.

3. Laser would not interfere with the implanted wire and she can take laser session. Co 2 Laser doesnt go deeper than the skin.

Regatrds

---