How to Minimize Surgical Scars – A Surgeon’s Perspective

Whether you sustained a deep cut or a precise surgical incision, there is always risks of scarring. Unfortunately, as surgeons, we cannot control certain factors such as age, skin quality, genetics, chronic illness and therefore surgical scarring and how you heal is so different depending on the individual. A combination of these issues may predispose you to a thicker scar even with pristine surgical technique, a fact of surgery frustrating for the patient and the surgeon.

It is important to know that the scar will continue to change throughout the healing process. At 1-2 weeks the scar often is red and larger due to the inflammatory stage of healing that occurs early after surgery. The inflammatory phase is followed by the proliferative stage, a longer stage in which the body is actively repairing itself. Finally, we enter the remodeling/maturation phase where the collagen alignment within the scar continues to change and can continue to do so for many months.

In theory, scars begin to fade during the late remodeling/maturation phase as the collagen fibers realign. For this reason, we often do not know the overall appearance of a scar until 6-12 months postoperatively.

As the patient, there are certain things you can do to help reduce scar formation, accelerate healing and guide your course toward a more cosmetically appearing scar.

Smoking: Smoking slows healing and increases your risk for scarring so much that surgeons always strongly recommend that patients quit before surgery. Nicotine and smoking act to decrease microcirculation to the wound and therefore nutrients and oxygen do not get to the incision as effectively.

Sleep and rest: Avoid exhaustion.Getting enough rest will help your body do the work of healing.

Nutrition: Your surgeon may also recommend that you eat healthy foods and increase your protein intake because protein helps your skin heal. Supplementation is sometimes necessary to help increase essential nutrients and healing factors.

Activity: Avoid movements that may risk pulling your incision apart and reopening your wound. If given a boot or cast for after surgery, make sure you abide in wearing these devices because they minimize movement at the incision.

Sunlight exposure: Cover your incision while it is healing because getting a sunburn may darken your scar. During the first year after your surgery, keep your scar away from sunlight by wearing protective clothing or using at least a 35 SPF sunscreen after it's healed.

InfectionGood wound care will prevent infection and lessen your chance of scarring after surgery. If you notice signs of an infection, contact your surgeon immediately.

Bathing: Follow your surgeon's instructions for showering. You may need to use a waterproof dressing for the first few weeks you are showering. Whatever you do, avoid soaking in a bath or putting soap on your wound until your incision is healed, and take care when patting it dry.

What are hypertrophic scars? 

A scar that is very thickened, red and raised above the surrounding skin can be considered a hypertrophic scar. This can be due to excessive collagen formation within the scar which can happen due to a variety of the factors listed above. Although not particularly dangerous they are cosmetically unappealing and therefore dissatisfying to patients. Since scars due shrink over time it is difficult to say whether they require any treatment until often 1 year postoperatively. A keloid scar is a more severe form of hypertrophic scar and usually related to genetic predisposition and more common amongst certain ethnicities. Keloids can be more serious and for the purpose of this blog we will focus more on hypertrophic scars. Treatment options are as follows:

Home treatments 

Silicone sheets: Silicone elastomer sheets are noninvasive and can be applied as soon the skin heals after surgery or injury. They’re also considered a first-line treatment for hypertrophic scars. Many silicone products are available, including sheets, gels, sprays, and foams. Many are available over the counter (OTC). A sheet must be worn over the scar for 12 to 24 hours per day for 2 to 3 months. You have to apply the gel multiple times per day.

Pressure and massage: One of the cheapest and most effective ways to help heal the scar is to apply pressure and massage to the area. I finding massing the scar both parallel and perpendicular to the incision is most effective. You can use bandages or tape to apply pressure. Over time, it can help weaken the scar tissue and improve cosmesis.

Onion extract creams: Another OTC option is a topical gel made of onion extract. This product is often under the Trade name Mederma. However, limited clinical data shows its effectiveness in reducing the appearance of hypertrophic scars.

Bio Oil: Bio Oil is marketed as a treatment for all different types of scars. It can be purchased at many beauty supply stores.  Clinical trials  for Bio Oil showed positive results.More research is needed to confirm that Bio Oil can effectively reduce the appearance of hypertrophic scars.

Medical treatments 

Corticosteroid treatments: Injections of steroid are considered a first-line treatment for hypertrophic scars. Over time, these may help flatten and soften the scar.

Laser therapy: Laser therapy is more effective in newly formed scars than in older scars. The lasers work by burning and flattening elevated scars. They also target the red and pink pigments in the scars to lighten them.

Cryotherapy: In cryotherapy, a doctor or dermatologist freezes the scar tissue with liquid nitrogen to help flatten it. Cryotherapy has been shown to be successful, safe, nontoxic, and well-tolerated.

Surgery: After waiting at least a year, a hypertrophic scar can be excised, or cut out, and closed again with stitches. This treatment tries to re-heal the injury while eliminating the issues that may have caused the scar in the first place, such as infection, inflammation, or tension.

To conclude, we try and operate on every patient with meticulous technique to minimize the intraoperative causes that lead to thicker scars. Gentle handing or tissues and suture technique is of utmost importance and we focus on these principles to improve the cosmetics of our incisions. Unfortunately, there as some factors we cannot control and if you know you heal with a thicker scar usually, this should be discussed with the surgeon preoperatively. If you have a history of keloid scars or hypertrophic scars always mention these to your surgeons. If scar hypertrophy does occur, I hope this blog has educated you on some of the many options available we can utilize to improve scarring and help improve your outcome!

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