All surgical procedures result in scars. One of the main skills of plastic surgeons is to control scar formation. This is done by carefully choosing the incision location and patterns, by gently handling the skin with fine, specialized instruments, and by the skillful and careful repair of surgically or traumatically created incisions and wounds.

For some operations, the development of "minimal incision" (or endoscopic) surgery has been a significant advance in reducing scar formation. However, the extent to which you will form scars depends mostly on the location of the incision, and your racial and genetic predisposition to scarring. People with black African and yellow Asian skin are especially prone to excess scarring, and incisions must be very carefully planned.

Normal scar formation develops according to a rough schedule. During the first few weeks, the scar develops some strength. It usually looks a little pink when the stitches are removed, but it is flat. From 3 to 6 weeks, it becomes thicker and often redder as it gains collagen protein, and it looks its worst at this time. Then maturation begins, which may take from 6 to 18 months or even longer. During this phase the scar continues to get stronger but gradually flattens, softens, and becomes pale.

Types of scars

The location of the surgical incision plays a key role in the outcome of the scar. Incisions in the upper eyelids, lips, groin, and armpits turn out especially well, while incisions in the center of the chest, upper back and the upper outer arm are particularly prone to bad scars. The face, in general, tends to form good scars if the incisions are properly planned. Unsatisfactory scars can be thicker, wider, depressed or raised, uneven, or run in a different direction than the normal skin lines.

Keloids are scars that are very thick, "angry-looking" and red to purple. These scars continue to grow beyond the borders of the original wound or incision. For example, some patients may have large masses of scar on the chest from minor acne pustules, or on the arm from vaccinations.

Hypertrophic scars, on the other hand, are scars that have become thickened during the normal healing period, but do not go beyond the original wound edge. They usually settle somewhat, but over a longer period of time than that of a normal scar.

Treatment of scars

There are many misconceptions about what can be done about scars, and when things should be done. Generally, no surgery should be done to revise or attempt improvement of a scar until maturation has occurred. Revision is generally done to even out the level of a scar, improve the orientation relative to the normal skin lines, or narrow it.

Keloids and hypertrophic scars can be difficult to treat. Patience is usually the best treatment for thickened but non-keloid scars. Vitamin E and aloe vera extract may make the scar look better during the maturation phase, but studies have shown no effect on the final result. Vitamin E may slow down healing if it is used during the early postoperative period (3 weeks). Many other drugs and agents have been and are currently being investigated, but none has proved to be better than time itself.

Injection of thick scars or keloids with cortisone-like drugs may be helpful in many cases, but this has some side effects and should not be used for scars that are only somewhat thick during normal wound maturation. Pressure has been used for many years for burn scars, and recently has been combined with silicone sheeting laid directly on the scar. Pressure is applied by various means, usually by the use of custom elasticized garments, worn 23 or more hours per day for months. Silicone sheeting, when used alone or with pressure, has shown some success, and some surgeons now advise it routinely for certain incisions, such as breast lifts and reductions, and for tummy tuck incisions, however, it must be used 23 hours daily in these situations as well.

In extreme cases, keloids have been treated with low-dose radiation therapy combined with the other methods described above, but with variable success. It is unusual for keloids to result from surgery in people with light skin color, and keloids are rare in cosmetic surgery in general. This is because the location of incisions is carefully chosen, careful technique is used, and most people who may be susceptible to keloids can be warned in advance.

Benjamin Gelfant, MD, 
in association with the MediResource Clinical Team