of color (Figure 4). Prompt identification and management with topical steroids and adhesive avoidance is paramount.
Keloids
Keloids are a common post-operative complication in patients with skin of color. While a personal and family history of keloids should be obtained pre-operatively, it is important to note that a negative history does not preclude the development of keloids post-operatively. Tissue injury, aberrant wound healing, and wound tension have all been implicated as major drivers of keloid pathogenesis. Surgeons should consider these key mediators during reconstructive planning, with the goal of accomplishing a tension-free closure.8
Suture Selection in Skin of Color
We recommend that suture selection be given the highest consideration during reconstructive planning for patients with skin of color – specifically the reactivity of suture material. Synthetic suture materials are degraded by simple hydrolysis.11,12 For this reason, we recommend non-absorbable epidermal sutures with low tissue reactivity such as nylon and polypropylene (Prolene®) in FST IV, V, and VI patients. It is important that sutures are removed promptly. Prolonged implantation of non-absorbable sutures produces a significant in vivo tissue response known as “frustrated phagocytosis” characterized by fibroblast encapsulation and attempted enzymatic degradation of synthetic non-absorbable suture material mediated by macrophages and foreign body giant cells. Clinically, this presents as an inflammatory suture reaction leaving residual track marks and PIH in skin of color.13
Natural absorbable sutures induce the highest degree of tissue reactivity due to neutrophil-mediated degradation. Since cutaneous inflammation is a trigger for PIH, we avoid natural absorbable sutures in skin of color whenever possible - namely gut sutures. Anecdotally we observe higher rates of PIH with gut sutures in skin of color including chromic and fast absorbing due to the robust inflammatory response (Figure 5). Our observations are supported by the literature. Eisen and colleagues performed a split wound trial comparing 5-0 polypropylene to 5-0 fast absorbing gut and found that polypropylene resulted in small but statistically significant better outcomes. Though the skin types of the study participants were not reported, scar pigmentation was assessed at 3 months and poorer outcomes were associated with fast absorbing gut sutures compared to polypropylene.14 Clinical studies are needed to confirm this observation in skin of color.
Poliglecaprone-25 (Monocryl®) was introduced in the 1993 as a subcutaneous monofilament suture with “very low” tissue reactivity, exhibiting less reactivity than polygalactin 910.15 As an absorbable synthetic suture, it is absorbed by hydrolysis. Recently, poliglecaprone-25 has gained popularity as an epidermal suture.16
