The “plastic surgery stitches do not leave scars” and “fine stitches do not leave scars” are what drive parents to come all the way to plastic surgery hospitals, but what a big misconception it is. In fact, plastic surgeons know that no matter how the wound is treated and carefully sutured, a scar will form when the wound reaches a certain depth, which is an unchangeable fact. Let me explain why scarring is inevitable no matter how the sutures are applied. All skin damage repair follows a pattern of three ironclad stages of wound healing: the inflammatory phase, the proliferative phase, and the remodeling phase. After the skin breaks during the inflammatory phase, the body first initiates a hemostatic process to prevent the wound from bleeding all the time; after that, the body sends its own defense forces to fight against external aggressions. These faithful guards are what we know as “white blood cells”, whose mission is to remove necrotic body tissues from the injury and to destroy the invading enemies of the environment – bacteria. After the proliferative phase, other cells join the battle, and their mission is to build a temporary wall to defend against the enemy, which scientists call “granulation tissue”. In this process, different cells work together to build the temporary wall quickly, including those responsible for building the framework (type III collagen fibers), those responsible for supply (blood vessels), and finally the superficial layer (epidermis), which marks the completion of the temporary wall. The process is quick, it only takes 21 days and the body is back to its integrity without the fear of outside invasion. Remodeling period You can understand this period as post-war reconstruction, a relatively long process that takes about 1 year. During this period, the body calls a halt to the construction of the temporary wall and replaces it with a stronger material – type I collagen fibers, which have the same composition as the previous wall’s framework, but their arrangement is no longer the same. Eventually, the body’s repair process is complete, but the reconstruction is distinctly different from the surrounding normal tissue, and the new wall is so inconsistent with the original wall structure that it can be clearly seen as a “scar”. If you are lucky, the scar will be minimized by the body after 2-3 years; on the contrary, if the body’s command to stop is not accepted and the proliferation continues, the new wall will always be conspicuous and we call it “proliferative scar”. In short, scarring is the end result of tissue healing. So why does our body react this way? Although the mechanism of scar formation has not been thoroughly studied, here is a popular hypothesis: If evolution is correct, then this type of healing must have had an irreplaceable advantage at some point in human evolution. Our ancestors faced many threats from the external environment in nature, and trauma was commonplace. The ability to resist the intense physical reaction of bacteria and the fastest healing of closed wounds was then a condition that ensured human survival. In other words, scarring is the price we have not waited to pay in order to survive in the evolutionary process. So since it is ultimately a scar as well, can it be left unstitched? Of course not, surgical debridement sutures help the body to remove necrotic tissue and quickly close the wound, reducing the body’s inflammatory response and thus the incidence of proliferative scarring. So, since plastic surgery sutures also leave scars, there is no need to travel all the way to the clinic. Yes, all general hospitals can perform effective debridement sutures in the emergency department, but plastic surgery is about non-invasive operations, i.e., focusing on reducing trauma to normal tissues, which can reduce inflammatory reactions and also reduce scar proliferation. At the same time, small needles and fine threads do reduce trauma and irritation to the tissues. In addition, early removal of stitches can avoid the appearance of stitch scarring, but only if reliable subcutaneous sutures are used, which is generally less of a focus in general emergency surgery. More importantly, scarring is something that requires active intervention after suturing, i.e., preventive treatment of scarring. Effective prophylaxis minimizes the risk of scar proliferation, and plastic surgeons can provide treatment recommendations, follow-up observations and appropriate treatment adjustments for emergency patients, something that is currently difficult to do in general emergency surgery in China. Therefore, it is recommended that skin injuries to exposed areas of the body are best managed by plastic surgery, especially the face.