Nugraha A, et al. Belitung Nursing Journal. 2017 February;3(1):23-31.

Accepted: 29 January 2017

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ORIGINAL RESEARCH ISSN: 2477-4073

FACTORS INFLUENCING THE OCCURRENCE OF HYPERTROPHIC

SCARS AMONG POSTOPERATIVE PATIENTS IN GARUT,
INDONESIA

Andri Nugraha1*, Rizal Chaidir2, Urip Rahayu3, Santi Rinjani4

1
Department of Medical Surgical Nursing, School of Nursing of Karsa Husada Garut, Indonesia
2
Department of Orthopedics and Traumatology, Faculty of Medicine, Padjadjaran University, Indonesia
3
Department of Medical Surgical Nursing, Faculty of Nursing, Padjadjaran University, Indonesia
4
Department of Medical Surgical Nursing, Nursing Academy of Bidara Mukti, Indonesia

*Corresponding author:
Andri Nugraha, SKep., Ners., M.Kep
Department of Medical Surgical Nursing, School of Nursing of Karsa Husada, Jl. Nusa Indah No. 24, Garut,
West Java, Indonesia, 44151, phone +62262-235860
E-mail: [email protected]
ABSTRACT
Background: Hypertrophic scar causes physical and psychological problems. Thus, understanding the factors
related to the occurrence of hypertrophic scar tissue is needed. Little is known about its influencing factors in
Indonesia, especially in Garut.
Objective: This study aims to examine the relationships between hypertrophic scar and its influencing factors,
and identify the most dominant factor of the occurrence of hypertrophic scars.
Methods: This was an observational case control study using retrospective approach in Polyclinic of Surgery of
Regional Public Hospital of dr. Slamet of Garut Regency. There were 40 samples recruited in this study by
purposive sampling, which was divided to be case group (20 patients) and control group (20 patients). Data were
collected using Stony Brook Scar Evaluation Scale by observation and documentation of the medical records of
patients. Data were analyzed using logistic regression analysis.
Results: Findings indicated that there were significant relationships between the surgical wound infection (p =
0.02), family history (p = 0.026), and type of suture (p = 0.043) with the occurrence of hypertrophic scars. The
most dominant factor on the occurrence of hypertrophic scars was type of suture, acid polyglactin 910. The
variables that had no significant relationships with the occurrence of hypertrophic scar tissue were age (p =
0.34), area of surgical wound (p = 0.177), and smoking habit (p = 0.479).
Conclusion: There were significant relationships between infection of surgical wound, genetic history, the type
of suture, and the occurrence of hypertrophic scar tissue. The most dominant factor that influenced the
occurrence of hypertrophic scar tissue was the type of suture. Therefore, it is suggested to health professionals to
modify the using of acid polyglactin 910 sutures, and nurses particularly need to provide the information
regarding the family history and genetic-related hypertrophic scar, and prevent the infection of surgical wound
after operation.

Keywords: hypertrophic scar, postoperative, related factors

Belitung Nursing Journal , Volume 3, Issue 1, January-February 2017 23

Editor’s Note: This article has been updated on 13 June 2020 in terms of minor changes in the reference format. The update is according to BNJ
Policy on article correction.
INTRODUCTION and self-perception of patients due to the
The hypertrophic scar occurs in every changes of body image that affects to the
hundred million people in the world every psychology of patients.20
year, which is approximately 55 millions The prevalence of patients with
of them are caused by elective surgery, 25 hypertrophic scar tissue in Regional Public
million by post traumatic surgery, and 4 Hospital of dr. Slamet of Garut Regency
million by burns.1,2,3 Meanwhile in the was increased from 160 patients in 2013 to
United Kingdom, hypertrophic scar occurs 200 patients in 2014. In addition, the
in 23 million postoperative patients,4 and number of post-operative wound infection
literature indicated that it occurs in was 10% of the total number of operations
postoperative patients between 40% to with 480 patients per month,21 while
70%.2 Surgery and injury can cause according to the Ministry of Health of the
hypertrophic scar tissue if the damage is Republic of Indonesia, the postoperative
more than 33.1% of the skin, which lead to wound infections should be less than
the change of its function and cosmetic 1.5%. On the other hand, the number of
defect.5 smokers as considered as influencing
The hypertrophic scar causes both factor of hypertrophic scars in Garut
physical and psychological problems. The regency was higher (30% of the total
physical problems are itchy rash, stiffness, population of 2,309,77).22 Therefore, this
wound contracture, and pain,6,7 while the study aimed to identify the factors related
psychosocial problems cause disturbance to hypertrophic scars among postoperative
in social interaction, anger, stigmatization, patients in Garut, Indonesia.
disturbance in daily activities, the loss of
self-confidence, isolation on social METHODS
environment, anxiety, and depression.6 Design
The priority to decrease these This was an observational case control
physical and psychological problems in study using retrospective approach to
postoperative patients is by preventing the determine the relationships between
occurrence of hypertrophic scars.3,6,8 hypertrophic scar and its influencing
Prevention will improve the quality of life factors,23 and to identify the most
of the patients9 and also prevent keloids.10,6 predominant factors on the occurrence of
The hypertrophic tissue can be treated but hypertrophic scars.
it will cost extra money while there is also
bad side effect of the treatment.11,12,13 Sample size
The hypertrophic scar tissue There were 40 samples in this study,
formation is influenced by factors that can which was divided to be case group (20
be modified and unmodified. The factors patients) and control group (20 patients).
that cannot be modified such as genetic14,15 Samples were recruited using purposive
and age2,16, while the factors that can be sampling with inclusion and exclusion
modified such as smoking, infection, criteria as the following: (1) clean wound
location and suture material.8, 17, 18 postoperative patients at Regional Public
In this regard, nurses play roles in Hospital of dr. Slamet of Garut Regency,
reducing the occurrence of hypertrophic (2) postoperative patients with > 14 days,
scar tissue. They provide health education, and (3) willing to be a respondent in this
prevention of wound infection and research. The exclusion criteria included:
advocacy for treatment selection.19 Nurses (1) contaminated wound, and (2) not
also have a role to increase self-acceptance having treatment of hypertrophic scar.

Belitung Nursing Journal , Volume 3, Issue 1, January-February 2017 24

Instruments hypertrophic scar tissue. Of 75% were at
Stony Brook Scar Evaluation Scale was risk of wound area, and 65% were at risk
used to measure the hypertrophic scar of having infection. In addition, 67.5% of
tissue. It consists of five criteria: height, respondents (67.5%) used risky suture
width, color, suture mark and general types (acid polyglactin 910), and 72.5% of
appearance. The score for each criterion them were non-smokers. This also showed
was summed, and if the result is 0 then it that the sample was divided with 20
indicates the occurrence of hypertrophic respondents had hypertrophic scar tissue,
scar tissue, and if the result is 5 then it and 20 respondents did not have
indicates no hypertrophic scar tissue.24 hypertrophic scar tissue.
Another instrument was also used to
describe the demographic data, genetic, The relationship between respondent
smoking, area of surgery, surgical wound characteristics and the occurrence of
infections, and type of suture. hypertrophic scars
Chi square analysis showed that there was
Ethical consideration and data collection a significant relationship between infection
This research had been approved by the of surgical wound (p = 0.02), genetic
Committee and Ethics Review Board history (p = 0.026) and the type of suture
(ERB) Committee for Research Involving (p = 0.043), and the occurrence of
Human Research Subjects, University of hypertrophic scar tissue, while the age
Padjadjaran, Bandung, Indonesia. variable (p = 0.34), the area of surgical
Permission of data collection was obtained wound (p = 0.177) and smoking (p =
from the head of the health department of 0.479) had no significant association with
Garut regency and the director of Regional the occurrence of hypertrophic scar tissue
Public Hospital dr. Slamet of Garut (see Table 2).
Regency. Data were collected between Postoperative patients who had
May 1-June 15, 2015. genetic history of hypertrophic scar tissue
were potentially as much as 10.057 times
Data analysis (95% CI: 1.527 to 66.22) compared to
Chi-square analysis was used to identify postoperative patients who did not have
the relation between factors that can be genetic history of hypertrophic scar tissue
modified (smoking, infections of surgical after being controlled with genetic history
wound, area of surgical wound, and type and type of suture. Postoperative patients
of suture) and unmodified factor (age and who experienced infections of surgical
genetic) that cause hypertrophic scar tissue wound were 18.576 times (95% CI: 1.767
on postoperative patients at Regional to 195.252) compared to postoperative
Public Hospital of dr. Slamet of Garut patients who did not experience infection
Regency. Phi statistical analysis was also after being controlled with genetic history
used to examine the strength of the and the type of suture; and postoperative
relations. patients who used type of suture (acid
polyglactin 910) were at risk of
RESULTS hypertrophic scar tissue 27.524 times
Characteristics of the respondents (95% CI: 2.117 to 357.877) compared to
Data on the Table 1 showed that the patients who did not use acid polyglactin
majority of the patients (55%) were in the 910 suture after being controlled with
age of risk of hypertrophic scar tissue, and genetic history and infections of surgical
they all had the hereditary history of wound.

Belitung Nursing Journal , Volume 3, Issue 1, January-February 2017 25

 Table 1 Frequency Distribution of Respondent Characteristics (n = 40)

Patient Characteristics F %
Age 10-30 years 22 55
Age< 10 years and>30 years 18 45
Having genetic history 22 55
Not having genetic history 18 45
Risky area of surgical wound 27 75
• Neck 14 51
• Extremities 5 18.5
• Chest 4 14.8
• Stomach 2 7.4
• Backs 2 7.4
Not risky area of surgical wound 13 25
• Palms and soles 11 84.4
• Eyelid 2 15.6
Having infection 26 65
Not having infection 14 35
Risky suture type (Polyglactin 910) 27 67.5
Not risky suture type 13 32.5
• Nylon 6 46
• Silk 5 38
• Polyglactin 910 2 15
Smoker 11 27.5
Non-smoker 29 72.5
Having hypertrophic scar tissue 20 50
Not having hypertrophic scar tissue 20 50

The dominant factors influencing the included: the type of suture with OR =
occurrence of hypertrophic scars 27.524, infection of surgical wound with
Logistic regression analysis in Table 3 OR = 18.576, and genetic history with OR
showed that the hierarchy of strength of = 10.057.
correlation or relation of the variables that From OR values of these variables,
affected the hypertrophic scar tissue was type of suture was the most dominant
based on the value of the odds ratio (OR). factor associated with the occurrence of
The result showed the strength of hypertrophic scar tissue at Regional Public
the relationship from the strongest Hospital of dr. Slamet of Garut Regency.
relationship to the weakest relationship,

Belitung Nursing Journal , Volume 3, Issue 1, January-February 2017 26

 Table 2 Relationship between Characteristics and Hypertrophic Scars (n = 40)

Hypertrophic Scar Tissue

Total
Variable Yes No p-value
f % F % F %
Age
Risky 13 59.1 9 40.9 22 100
0.340
Not risky 7 38.9 11 61.1 18 100
Genetic History
Yes 15 68 7 32 22 100 0.026*
No 5 28 13 72 18 100
Area of Surgical Wound
Risky 16 59.3 11 40.7 27 100 0.177
Not risky 4 30.8 9 69.2 13 100
Infection
Yes 17 78.6 9 21.4 26 100
0.020*
No 3 34.6 11 65.4 14 100
Type of Suture
Risky 17 63 10 37 27 100
0.043*
Not Risky 3 23.1 10 76.9 13 100
Smoking
Smoker 4 36.6 7 63.4 11 100 0.479
Non-smoker 16 55.2 13 44.8 29 100

Table 3 The Results of Multivariate Logistic Regression Analysis (n =40)

Variable B S.E. Wald OR (95% CI) P Value

Genetic 2.308 0.962 5.762 10.057 (1.527-66.220) 0.016*
Wound Infection 2.922 1.200 5.926 18.576 (1.767-195.252) 0.015*
Type of Suture 3.315 1.309 6.416 27.524 (2.117-357.877) 0.011*
Constant -4.286 1.454 8.690 0.014 0.003*
Note: *) significant when α = 0.05

DISCUSSION are chromosomal genes that may influence

The results of this research indicated the occurrence of hypertrophic scar tissue,
that there was a significant relation namely chromosome 2q23 and 7p11.25
between genetic history (p = 0.026) and Therefore, patients who have hereditary
the occurrence of hypertrophic scar tissue. history of hypertrophic scar tissue would
It is because hypertrophic scar tissue is have more severe hypertrophic scar tissue
autosomal dominant or a disease that can form and it is growing in more than one
be passed down through the family. There area.26 This occurs due to the increase of

Belitung Nursing Journal , Volume 3, Issue 1, January-February 2017 27

transforming growth factor (TGF-β) gene inflammatory reaction of the body,
expression, collagen type I and IV that increase the affinity or tye up against
have an effect on the increase of microorganisms, which stuck to the
proliferation and the decrease of interstices of braided suture that results in
apoptosis.27 The roles of nurses to these infection and delayed wound healing.31,32
patients are to do prevention by doing In this regard, the management of
genetic counseling to provide information operation will be better using absorbed or
to individuals or families who have the not absorbed monofilament and
possibility of having hypertrophic scar multifilament sutures that have
tissue, and also the information of the antibacterial properties. If there is no other
treatments. On the other hand, the type of suture, it can also be done by
therapeutic treatment is to inhibit the giving hydrogel or silicone gel in the
production of extra cellular matrix and treatment of wound to accelerate the
excessive inflammation by providing anti- granulation process, reducing strain injury,
inflammatory drugs such as and preventing infection in order to reduce
corticosteroids, inhibit DNA transcripts by the risk of hypertrophic scar tissue.32
providing antimetabolic drug mitomycin-c The findings also showed that there
and 5-fluorouracil, and using gene therapy was no significant relation between age
by using RNA Enzyme.28 and the occurrence of hypertrophic scar
Infection of surgical showed a tissue. Literature indicated that
significant relationship with the occurrence hypertrophic scar tissue could occur at any
of hypertrophic scar tissue. It is because an level of age. Therefore, it may occur at any
infection delays wound healing and results age with many characteristics in the area
in long inflammatory process so fibroblast that contains collagen.33 However, this
proliferation and synthesis of ECM study showed that the proportion of age of
(Extracellular Matrix) process becomes patients who had hypertrophic scar tissue
slower, and more synthesis and collagen were at age 10-30 years. This can happen
deposits 2-3 times formed resulting in because trauma often occurs at that age,
hypertrophic scar tissue.29,30 The infection and there are also enhancements of
occurred in hospitals were marked by production of glycosaminoglycan, collagen
wound with ooze pus, red, edema and and matrix structure of the skin that make
wounds for >14 days postoperative. It is the skin becomes more elastic.34
mentioned that postoperative patients are Area of surgical wound in this study
recovered up to 10 to 14 days after had no significant with the occurrence of
surgery, it should be no increase of the hypertrophic scar tissue. Literature showed
synthesis of collagen.29 that hypertrophic scar tissue could occur
Another factor is the suture had a anywhere within the human body that
significant association with the occurrence contains collagen.19 This study also found
of hypertrophic scar tissue, especially acid that the majority of the respondents had
polyglactin 910 suture. Postoperative hypertrophic scar tissue in the areas which
patients who used multifilament suture in are frequently contracted and contain
the form of acid polyglactin 910 can cause collagen fibers, namely in the area of the
high skin strain, thus increasing the neck (51%), the extremities (18.5%), the
synthesis of collagen that causes chest (14.8%), the stomach and the back
hypertrophic scar tissue, and the type of respectively (7.4%), and the most widely
multifilament suture in the form of performed surgery in the hospital was in
polyglactin 910 will enhance the higher the neck area.

Belitung Nursing Journal , Volume 3, Issue 1, January-February 2017 28

 Another variable that had no polyglactin 910 sutures are 2 times more at
relationship with the occurrence of risk of the occurrence of hypertrophic scar
hypertrophic scar tissue in this study was tissue.40 Therefore, the use of the suture
smoking. Findings showed that the 910 polyglactin acid sutures should be
majority of patients who had hypertrophic avoided or modified by the treatment of
scar tissue were non-smokers. Literature wounds which can prevent infection and
said that young and nonsmoker patients are enhance granulation process.
more susceptible to hypertrophic scar
tissue compared with those who smoke.35 CONCLUSION
It is likely the patients who smoke could There were significant relationships
reduce the systemic inflammatory between infection of surgical wound,
response, while cigarettes also contains genetic history, the type of suture, and the
nicotine which is a vasoconstrictor that occurrence of hypertrophic scars. The most
reduces the proliferation and migration of dominant factor that influenced the
macrophages and fibroblasts, the occurrence of hypertrophic scars was the
deposition of collagen type 1 and III, and type of suture. Therefore, it is suggested to
the formation of growth factor β1 (TGF- health professionals to modify the using of
β1); while also increases the growth factor acid polyglactin 910 sutures, and nurses
β3 (TGF -β3) so that smoking increases particularly need to provide the
the risk of surgical wound complications information regarding the family history
but it reduces the risk of hypertrophic scar and genetic-related hypertrophic scar, and
tissue.36,37 However, smoking cannot be prevent the infection of surgical wound
used as an intervention because it has more after operation.
negative than positive effect.
Multivariate analysis in this study Declaration of Conflicting Interest
showed that three factors influence the None declared.
occurrence of hypertrophic scar tissue,
Funding
namely genetic history, wound infection This study was supported by School of Nursing
and type of suture. The most dominant of Karsa Husada Garut, Indonesia.
factor was the acid polyglactin 910 suture,
which is made by synthetic materials that Authorship Contribution
can be absorbed and can be degraded by The authors contributed equally in this study.
hydrolysis.38 The advantage of this suture
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