Minimizing Scars After Surgery
Whenever there is an incision, there is the possibility of a scar; a fact many forget when undergoing plastic surgery. Whether you are looking to correct a scar from years ago or are taking preventative measures for an upcoming procedure, there are treatments that can help prevent and heal surgical scarring. We asked plastic surgeons and dermatologists about their proven recommendations to remedy scars, from prevention to correction.
But first, what is a scar? When skin is injured, either in a controlled way like during a surgical incision or in an accident, the body produces collagen fibers to repair the injury from the the middle layer of skin (dermis) to the outer layer (epidermis) and then from the edges inward to close the wound. While this healing process is taking place, a scab will form over the area to cover the wound and protect it from infection and further injury. It is important to not pick at scabs because it can slow the healing process and re-open the wound. A scar forms when the fibrous tissue that heals the wound is not the same texture or tone as the skin surrounding it.
Types of scars
Board certified plastic surgeons are experts at performing their procedures with scars in mind, doing their best to create the cleanest incisions in places that can hide a scar if one occurs. For instance, with facelifts, incisions are made along the hairline or in front of the ear lobe. During a breast augmentation, implants can be inserted through a small incision made under the breast, in the armpit, or underneath the nipple-areolar complex. In these areas, any scars that may form can be easily hidden in skin’s natural lines. However, no matter how precise a skilled surgeon is, if you are genetically prone to scarring and growing excessive scar tissue, you may still find yourself with an unsightly scar. Knowing what type of scar you have can help you find treatment.
- Hypertrophic scar: This type of scar is typically raised, red in color, and can be a different pigment from the rest of your skin. These scars are common in areas of tension or movement, like around joints, or if the area was not properly sutured.
- Keloid scar: This type of scar occurs when your body does not stop healing itself. A keloid forms when the body thinks the wound has not yet been healed and continues generating scar tissue around it. This results in a raised, bumpy, and even bulbous scar. The difference between a keloid scar and a hypertrophic scar is that keloids go beyond the boundaries of the original wound. Genetics and a darker skin tone can make someone more prone to keloid scarring. Compared to other skin types, darker skin has larger fibroblasts, both in quantity and size, as well as larger mast cell granules (a type of white blood cell involved in wound healing). Both of these properties are believed to cause darker skin types to be susceptible to scarring and keloid formation.
Scar prevention: what to do at home
The bad news is there is not much one can do before surgery to prevent scarring other than staying away from the sun as tan skin is more prone to discoloration due to sun damage. "In my office we do recommend taking Arnica for bruising, but for scarring, it is really all about proper post-care,” explains Dr. Julie Russak, FAAD., founder of Russak Dermatology Clinic and Russak+ Aesthetic Center in Manhattan. The good news is there are multiple tested at-home scar treatment methods to prevent surgery scars. Proper wound care is important and must be administered before treating the resulting scar. You can begin scar care once the wound is closed, and in-office treatments can start as soon as one month after it is healed.
- Avoid creating tension in that area: Dr. Russak recommends, “one should minimize any activity on the area to prevent any tugging of the skin post-surgery.” Tugging or tension can cause the area of the incision to widen and the wider the wound that needs to heal, the higher the risk of scar formation.
- Protect yourself with SPF: Sun protection should always be a priority but, post-surgery, limiting sun exposure is at an all-time high of importance. Dr. Gregory Buford, F.A.C.S., Denver, Colorado plastic surgeon and author of Eat, Drink, Heal, explains that “scars can tend to darken when exposed to sunlight as a direct result of melanocyte activation. As such, we recommend that all of our surgical patients cover their scars for at least one year following their procedure to avoid this issue.”
- Moisturize: Keeping the scar moisturised can help prevent a worse scar from forming. When scar tissue is hydrated it helps to regulate fibroblast production, resulting in a softer, more even-toned scar. Vitamin E is a moisturizing favorite for wounds and is probably what your mother told you to use. While research has not shown a correlation between vitamin E oil application and scar prevention, it does block free radical damage and has anti-inflammatory properties, in addition to hydrating and calming skin. Not everyone reacts well to vitamin E oil, so try it on a patch of skin first before applying to a clean wound.
- Apply an over-the-counter treatment: "We love SkinMedica Scar Recovery Gel," says Dr. Russak. "We always recommend it to our patients post immediate trauma to the skin and even for minimizing aged scars." SkinMedica Recovery Gel uses a Centella asiatica complex to soften the appearance of red or pink scarring. Dr. Joubin Gabbay, plastic surgeon and Medical Director of Gabbay Plastic Surgery in Beverly Hills, recommends Biocorneum, a silicone gel to protect wounds from sun exposure and prevent the formation of hypertrophic scars.
- Cover with silicone gel sheeting: Silicone sheeting or bandages can be used on new scars as a preventative measure and on old scars to minimize their appearance. They improve the appearance of surgical scars by retaining hydration and applying pressure to the area. That pressure makes silicone sheeting a commonly prescribed preventative treatment for those prone to keloid scarring as it slows potential keloid growth. Silicone sheets are often used on burn scars since the affected area is usually wide and can even be used on the site of a biopsy or skin cancer removal. Try Cica-Care Silicone Gel Sheeting or Mepitac Silicone Tape for plastic surgeon- and dermatologist-recommended options.
How to minimize the appearance of raised or indented scars
Raised or indented scarring results in uneven skin texture and is often addressed with similar treatments; smoothing skin texture and minimizing pigment differential.
- Laser treatments: Lasers resurface the affected area by removing damaged skin cells and causing tiny injuries to the skin, stimulating new skin to form. Lasers can be ablative, fractional, or non-ablative, with ablative being the strongest type and requiring the most recovery time while non-ablative is the gentlest and requires no downtime. A consultation with your dermatologist or practitioner will help determine the type of treatment needed for your specific scar and the amount of recovery time that can be expected.
- Microneedling with PRP: PRP (platelet rich plasma) has so many uses that it comes as no surprise that scar fading is one of them. PRP is derived from the patient's own blood, eliminating the risk of allergy or rejection. The platelet rich plasma that is cultivated contains growth and healing factors that stimulate tissue regeneration and healing. PRP has been used for treatments ranging from athletic injuries, like tendon tears, to aesthetic treatments, like hair growth. When it comes to raised or indented scars, Dr. Buford explains “combination therapies such as microneedling and PRP have shown significant promise in not only reducing vertical height of scars but also promoting scar remodeling.” Microneedling uses a tool with many tiny needles at the head that penetrate the top layer of skin, creating micro injuries and stimulating collagen production. When microneedling is combined with PRP, it allows PRP to penetrate even deeper into the skin, maximizing its benefits and capabilities.
- Massage: Massage is a type of pressure therapy that aids scar remodeling by softening and flattening scar tissue while also enhancing circulation. “Regular massaging of the site with Aquaphor healing ointment is a great option with proven track record for minimizing the appearance of old scars,” recommends Dr. Russak.
- Filler: Indented scars may need the help of filler to decrease their depth and make them level to surrounding skin. Bellafill® is a long-term filler that can be used on scars to even skin texture.
How to minimize the appearance of discolored scars
Hyperpigmentation (uneven darkening of the skin caused by deposits of melanin) and hypopigmentation (the loss of skin pigment) are both risk factors when a wound heals into a scar.
- Tattoo: When a scar is flat and lighter than the surrounding skin, the simplest solution might seem like the most surprising: medical tattooing (also known as scar camouflage). The cosmetic treatment uses flesh tone pigments to camouflage the scar into the rest of your skin. Scar camouflage can also be used for other skin pigmentation conditions, such as vitiligo and stretch marks.
- Retinoids: Retinoids increase cell turnover so skin generates healthy, new cells at a higher rate, diminishing hyperpigmentation in scars. Retinoids have also been found to have anti-inflammatory properties but can cause irritation due to increasing dryness.
- Vitamin C: Vitamin C is a powerful antioxidant that inhibits the overproduction of melanin thus brightening skin and combatting hyperpigmentation in dark scars.
- Laser treatments: Dr. Joubin Gabbay recommends laser treatments for hyperpigmentation, as they “correct pigment in scars and work by minimizing either the red or brown pigments in the skin.”
How to treat a keloid scar
Keloid scars, the over-producing type of scar we talked about earlier, requires its own specific kind of approach. There are several ways to treat them that your doctor will determine based on the size and growth of the keloid.
- Removal: “Many practitioners will begin by directly excising the keloid and then using silicone sheeting over the scar to help reduce the chance for recurrence,” says Dr. Buford.
- Steroid injections: In smaller keloids, steroid injections reduce inflammation and soften the tissue. Dr. Gabbay expounds on this treatment, “Steroid injections work by taming the inflammatory process which can cause hypertrophic or keloid scars. Steroid injections can reduce the raised or full scars, and is best employed within the first few months after the scar forms. These injections must be performed with a degree of caution, as side effects can include pigmentation changes, thinning of the skin and loss of the tissue underneath the skin.” Kenalog is a commonly used corticosteroid for this type of treatment.
- Radiation therapy: Within 24 hours of surgical excision of the keloid, radiation therapy is recommended to reduce the chance of keloid scar recurrence. Radiation therapy works by inhibiting cell growth and collagen production in order to slow the scar tissue formation. It is considered controversial if used alone for keloid treatment because of the risk of radiation side effects but it has been found to be effective when employed as a secondary treatment in conjunction with surgical removal.