By Dr. Darshan Shah, MD, FACS
Even the word SOUNDS terrible….SCARS! Sounds like something you want to get out of your life as soon as possible, like a child throwing a loud fit on the airplane, or a dead rat floating in your swimming pool!
But every time the skin is broken for any reason, traumatically or surgically, you WILL ALWAYS get a scar. There is no such thing as “no scar” surgery, or “my scar went away” unless you are a fetus still in the womb (research on intra-uterine surgery on a fetal pigs with cleft lips show they heal with no scar). The trick is to minimize the scar as much as possible by treating it aggressively WHILE it is healing, and to have the understanding that a scar can take a year or two to really fade. I tell all my patients, no matter how well your surgery is done, there is always a chance that you can develop a scar. The trick is to do everything you can to PREVENT IT, TREAT IT, and MINIMIZE IT.
PREVENTING A SCAR
There are many things that can make a scar worse that can sometimes be avoided, and sometimes can not. For example, people with dark skin, hair and eyes are prone to developing worse scars than people with lighter skin…and you can’t change your genetic makeup! Also certain medical conditions, such as diabetes, obesity, and scleroderma can cause scars to heal worse. Smoking is one of the worst possible things you can do before and after a surgical procedure. If you smoke, and you heal well, you just got lucky! Smoking has nicotine in it, which constricts blood vessels, and also carbon monoxide, which depletes your blood of the nourishment provided by oxygen. You should quit all nicotine products at least 6 weeks before your surgery, or else all bets are off! Certain surgeries also have a higher chance of healing problems than others. Any surgery where a flap of skin is developed (for example a tummy tuck procedure or a breast lift augmentation) needs extra special care to achieve good healing and minimal scars. Over activity immediately after a surgery is also bad for scars as it can pull on the scar and cause it to widen. A traumatic scar needs to be cleaned thoroughly and sometimes even cut out and sutured to get optimal healing.
There are different problems a scar can have, and each problem is treated differently. It is very important to understand that there are different types of unsightly scars that require different kinds of prevention and treatment. For the purposes of an organized discussion, scars can be divided up into groups that include: THICK SCARS, RED SCARS, BROWN SCARS, WHITE SCARS, WIDE SCARS, INDENTED SCARS, and POORLY HIDDEN SCARS.
THICK SCARS: There are certain people that are genetically prone to making “bad” scars. Believe it or not, these are actually people that are prone to over healing. A scar is basically a collection of collagen, blood vessels and epithelium (the outer layer of skin) trying to close a defect in the skin layer of the body. Some individuals tend to lay down too much collagen, creating a thick red scar. This type raised or scarring is called hypertrophic scarring. A keloid is an extreme type of hypertrophic scar that grows like a tumor…beyond the borders of the original break in the skin. I often find that many people mistake a hypertrophic scars for keloids, or even normal scars for keloids! Just because you think your scar could look better, doesn’t mean it is a keloid. Hypertrophic or keloid scars do not always occur consistently–a person prone to them can develop them with one surgery and not the next…or they can occur on certain parts of the body (the breast bone and scalp are especially prone) and not others. Hypertrophic scarring usually occurs in people that are genetically prone to it (African American, Asian, Italian, American Indian), basically almost all darker skin types. In fact, if you have blonde hair and blue eyes, you have a much better chance of healing scar with no thickness to it at all. In general, the amount of collagen you have in your scar is at its greatest in 6 weeks to 3 months after the skin injury (or surgery), so this is the time to really make sure you do whatever you can to keep the scar flat. Irritation to your scar (i.e. too much movement in the area or rubbing on the scar by tight clothing) can stimulate the scar to “over heal” and become hypertrophic. THE TREATMENT: Pressure, Silicone, and vitamin E. Constant pressure on the scar (either with tape or silicone gel sheeting) as well as massage in the first 6 months of healing can dramatically reduce the thickness of a scar. In general, I have my patients use a micropore tape for the first one to six months after surgery. Silicone gel sheets are also made which help to accomplish the same goal. These products work especially well in people who are generically prone to making hypertrophic or keloidal scars. Even old scars can be treated by pressure and massage, but remember it can take time. Finally, if all else fails and it has been over a year, consider laser resurfacing or laser removal (using a laser to reduce the thick area) or scar revision (a surgery to remove the scar, re-suture it, and “try again!”).
RED SCARS. All scars are initially red. This is a totally normal phenomenon and is due to increased blood flow to the area and extra blood vessels forming to bring all the good things in your blood to the area that needs to heal. More blood flow, means more redness, which is totally normal. In fact, the scar can sometimes even take on a purplish hue. It is important to realize that even in the best of circumstances, redness only starts going away after seven months. It can take a year or longer for it to totally fade. People who have trouble with redness for a longer period of time are usually light skinned, and are the same people whose entire face turns a bright red when you point out that their fly is open. Vitamin E and C can decrease the amount of red in a scar. If you are in a hurry, you can get rid of redness quicker with an IPL pulsed light treatment. But patience is usually the key, and with time it will get better. TIP: avoiding sun and tanning bed exposure also helps to reduce the redness of a scar.
BROWN SCARS: People with darker skin are also prone to produce more of the brown pigment called melanin. This deposits preferentially around scars, and causes what is known as hyperpigmentation of the scar. It can get worse with time and sun exposure. To minimize melanin deposition on a scar a few things can work: you can use a lightening cream such as hydroquinone, or you can peel the scar with products that contain onion extract or glycolic acid. It takes several months of this treatment to lighten a scar, and it may never totally lighten to the same color of the surrounding skin.
WHITE SCARS: Usually, a thin white scar is the goal of any surgery … unless your surrounding skin is not white. If the white really stands out (for example a scar around your areola), one option is to perform cosmetic tattooing of the scar. Scar camouflage is performed by matching the color of the surrounding skin with a tattoo done directly over the scar. It can take more than one treatment to adequately camouflage the scar, and it requires an artistic touch.
WIDE SCARS: Having thin skin, or just putting too much pull on a scar immediately after surgery, can cause a wide scar. Plastic surgeons are especially good at preventing this from happening by using special suturing techniques to distribute the tension on the scar and provide it with the most support. The classic example of a widened scar is the stretch marks a woman gets after pregnancy. Bad news for everyone that has stretch marks: there is NO GOOD TREATMENT for stretch marks. Unless the collagen can somehow be rebuilt from the inside out (science hasn’t figured that one out yet), your only chance is to remove the scar surgically. In plastic surgery, we call this an abdominoplasty (a tummy tuck). Any scar can become widened like a stretch mark. Too much tension on a scar after surgery (i.e. not resting!) during the critical first month of healing can lead to a scar widening. I like to use a special kind of tape to provide additional support to a scar during this first month. The tape helps to hold the scar together, and reminds you not to pull on it too much. If a scar still turns out to be wide, you can try an ablative laser (such as a CO2 or an Erbium laser), or have it revised (re-done) in surgery.
INDENTED SCARS: A scar that indents catches light and creates a shadow in such a way that it becomes very noticeable. This usually occurs because there is additional scar tissue underneath the scar that is attaching it to deeper structures such as muscle or bone. In the initial stages of scar formation you can massage a scar to prevent it from attaching to these deep structures. However if it has been more than a year that the scar is indented, you will need to have the scar surgically revised to make it better.
POORLY HIDDEN SCARS: Some scars, even though they have healed great, are just in a bad spot. Typical examples include the face or the décolleté. Sometimes the only thing you can do with these are camouflage them with makeup (there are several brands of camouflage makeup that are specially designed to cover up scars), or employ some very special plastic surgery techniques (a Z plasty is one example) to change the direction of, or to hide, these scars.
In summary, remember that with every scar on your body, the key is to prevent it from occurring in the first place. Be healthy, follow these tips, and be patient. Your scar will usually get better. If genetics and health are not on your side, there are many options available to help you get rid of the many kinds of scars out there…. work with your doctor to find out what will work the best for you!