Surgical scars are the unfortunate, but necessary, trade-off of many plastic surgeries. Many of these scars heal as only a feint white line. Some scars are unsightly, raised or even tender. There are four major factors that contribute how a scar will heal:
- Surgical technique – Tension and alignment of the scar are important. Dr. Yates pays a great deal of attention to precisely close the incisions in a manner to help them heal with the best scar possible
- Genetics – Some people create great scars and some people heal with poor scars. Generally, elderly patients heal with good scars. Generally, individuals with darker skin and younger people heal with less favorable scars
- Location of surgery – some areas on the body are prone to poor scarring such as the sternal area, shoulders and back. Areas with tension or motion such as the knees generally heal with poor scars
Of these, only the surgical technique and post-operative care are controllable. Many patients swear by a certain cream or ointment for scarring because their previous surgical scars faded. In reality, scars generally fade over the first year after surgery no matter what you do. Post-operative care of scars include prevention of bad scars and treatment of bad scars. Scars can often be improved, complete scar removal is unfortunately not possible.
Early treatment to help prevent bad scars
- Limit motion/ tension on the scar – This is particularly valuable in the first 6 weeks. Common locations of tension include the knees, back and neck. Often after removal of sutures or dressings, Dr. Yates will apply tape or steristrips to reduce tension on the scar.
- Avoid sun/ UV rays – This tends to pigment maturing scars. Protect with SPF 15 or higher for at least 1 year after surgery
- Antibiotic ointment – (Neosporin, Bacitracin, Triple antibiotic ointment) – Studies have shown that moist wound healing is quicker and results in better scars. Antibiotic ointment helps to hydrate the wound with the added benefit of decreasing bacteria in dirty wounds. Antibiotic ointment is beneficial when a wound in not completely healed (abrasion injury, cut, scrape, recently closed incision) but is no longer valuable after epithelialization has occurred. This is within 24-48 hours of a surgically repaired wound.
- Mederma– A topical gel that is rubbed into the scar. A dressing does not need to be applied over it. Reported to help soften scars. Some studies show that petroleum ointment (Aquaphor) is just as effective at improving scars. The active ingredient is onion extract (alium cepa) which in some Asian countries has been used for years for scar treatment. Mederma is easy to use and easy to find in stores. Rub it into your scar 2-3x/ day for 8 weeks. It also comes in a pleasant smelling children’s version and more recently with SPF 30 sun protection. A 1.76 oz tube should last for 8 weeks and costs $25 to $30. Dr. Yates recommends Mederma or scarguard for every scar after the dressing and sutures have been removed for 8 weeks or more.
- Scarguard– expensive but attacks the scar from multiple angles (see below).
- Adhesive tape – studies have shown an improvement when paper tape is applied to a scar. Scar hydration and possibly pressure may account for this effectiveness. Dr. Yates will often place hypoallergenic paper tape on an early incision for a few weeks, particularly after a tummy tuck or breast surgery.
- Vitamin E – Topical Vitamin E is used extensively in scar therapy. There is little to no evidence that it improves scars. There is some evidence that it has been occasionally associated with worsening of scars. Dr. Yates does not recommend Vitamin E for his patients unless they have had a favorable experience with it in the past.
- Silicone sheeting – see below. Early application of silicone sheeting in the first 2-3 months after surgery has been shown to decrease the risk of hypertrophic scarring. Particularly helpful for patient prone to hypertrophic scarring.
Treatment of bad scars after they have formed
- Silicone dressings – Silicone gel sheeting has been shown to improve scar appearance and symptoms. The mechanism is thought to be related to scar hydration, pressure, and an ionic charge of the silicone. These are available at drug stores and online and are relatively expensive. Generally, the sheets are self adhering and placed on the problematic scar for 12-23 hours a day. Each sheet can be reused several times. There are several options including sheets and ointments:
- Epiderm by Biodermis – Several options for shapes and sizes (perfect for breast surgery and tummy tuck surgery) ranging from $14 to $97 per sheet. Dr. Yates current preference.
- Circa-Care – about $50 for a 6″x6″ square, can be cut and reused for about a month.
- Scar away – 12 sheets (3″ x 1.5″) for around $50 or (7″ x 1.5″) for about $60
- Xeragel by Biodermis – 100% silicone gel ointment for areas where silicone gel sheeting would be difficult
- Scarguard – Topical “brush on” application. In addition to silicone – has cortisone, and Vitamin E. Available in most drugstores for $25 to $65.
- Kelo-Cote – comes in a silicone gel ointment or spray of various sizes from $17 to $100.
- Pressure – Pressure therapy has been used for years in burn and plastic surgery centers for the treatment of raised or hypertrophic scars. There is actually little true science demonstrating effectiveness, however, plastic surgeons have all seen raised scars that have been significantly improved. This is most beneficial in areas where pressure is possible. For example, on the earlobe to protect keloid scars from reforming after scar removal and with Jobst pressure dressings on raised burn scars
- Steroid injection of scars – Steroid (such as Kenalog or Hydrocortisone) injected into the scar can decrease symptoms such as pain and itching. Steroid injections can also help to flatten raised scars. A drawback of steroid injection into scars is that they can widen the scar.
- Cryotherapy – “freezing the scar” with liquid nitrogen. Can be used with or without steroid injections. Some studies have found more effective steroid treatment when combined with cryotherapy.
- Laser treatment – Has been shown to improve scar appearance and reduce scar symptoms such as pain and itching. Pulsed-dye laser appears to be the most promising laser for treatment of hypertrophic scar.
- Dermabrasion – mechanical removal of the top layers of scar, results in modest scar improvement
- Surgical scar revision – surgical scar revision is most effective when there is a specific reason that the scar healed poorly in the first place such as wound separation, infection or tension. Generally wait at least 6-12 months after initial injury or surgery.
Treatment of Stretch marks
Stretch marks are a unique type of scar in the dermis. Click here for a discussion about stretch mark treatment.
Dr. Yates scar treatment recommendations can be summarized as follows: Use sunscreen. Apply neosporin for the first two days if the wound is uncovered. If surgical tape is applied, keep it on as long as possible. Apply Mederma or scarguard once the dressings have been removed (either can be purchased online or at a pharmacy). If the scar is red or pink but otherwise flat, be patient. If the scar begins to become raised, see Dr. Yates to initiate silicone gel sheeting therapy. In the patient known to be at high risk of hypertrophic scarring silicone sheeting can be used instead of Mederma for the first 2-3 months.