The skin is amazingly self-sufficient. Though it requires lifelong care and protection, it has its own complex healing process to deal with trauma. Scar formation is a normal part of the skin’s natural healing after surgery, and with proper care and vigilance by both patient and doctor, this healing process can be monitored without damage to the skin.
My philosophy for scar management is three-fold: Use proper clinical judgment, follow the patient closely and intervene as soon as possible if signs of problematic scarring occur. As a surgeon, my first priority is to ensure the best medical and aesthetic outcome for my patient. This may mean making a larger incision in order to achieve a better contour; however, I can take necessary steps afterward to control scar formation. The goal is management, not prevention, of scars.
Scar tissue forms as the skin’s natural healing response to trauma, whether from a cut, puncture, burn or controlled injury to the skin as the result of surgical incision. The skin reacts by contracting and closing over the open wound (or sutures) and rushing collagen-producing fibroblasts to the site of the injury to produce the new skin cells that form a scar.
The skin can reveal the whole general condition of the patient—and in the case of scarring, it also allows me to ascertain how well a patient will heal. A host of variables affect the severity of scarring, including the area of the body, skin laxity, age, ethnicity and skin tone. For example, darker skin tones and redheads are both more susceptible to problematic scarring, while most fair skins tend to scar very well.
Patients with loose, saggy skin and decreased elasticity due to age or significant weight loss will develop very little scar tissue because there is less tension when closing the skin together after surgery. And on the contrary, if you have taut, tight skin, you will be more apt to develop noticeable scars because of the tension that occurs when stretching the skin back together during the suturing process.
The ideal scar develops into a flat, thin line that fades over time. However, scar tissue may become hard, raised, itchy or red as a result of excess collagen growth. This fibrous tissue extends above a scar site in the form of a raised growth known as a hypertrophic scar. Hypertrophic scars are fairly common and respond well to treatment when caught early.
A similar type of scar called a keloid is indicated by uncontrolled collagen growth beyond the trauma site. Keloid scars most commonly occur on the earlobes, jaw line, face and sternum; because of their severity, they typically require an aggressive treatment plan combining surgical excision with steroid injections to stop collagen growth.
The primary goal of scar management is to control collagen fibroblasts and stop the growth of additional scar tissue. Steroid injections effectively treat raised or hard scars by paralyzing fibroblasts. If the patient has a history of keloids, I focus on preventative measures to keep the scar under control, often doing a steroid injection at the time of surgery. It’s important not to overcorrect with steroids, as this can lead to hypopigmentation, or lightening, of the skin.
After an elective surgery on the face, abdomen or breasts, patients apply a pressure garment to the scar site and firmly massage the scar several times a day. I also suggest a series of in-office laser treatments to treat redness. I use a vascular laser that targets the red pigment in the skin to effectively reduce discoloration.
Patients should play an active role in the healing process. It is crucial to avoid sun exposure and commit to vigilant use of sunscreen, as any burning of the skin will cause additional redness and irritation. Smoking decreases microcirculation and is the worst thing patients can do to delay healing. Most importantly, any itching, increased redness or significant change in a scar should prompt a call to your doctor.
As with most skin conditions, there is no singular approach to scar treatment. A qualified doctor understands the anatomy of the skin and can develop a clinical plan of action to manage scarring and help you achieve the best result from your surgery.