Scars are an inevitable consequence of a wound and wound healing. They may be very hard to see and as such be effectively invisible but they are theoretically always there. Scarless surgery is a misnomer. The art of the plastic surgeon is to make the scar as imperceivable as possible, by hiding the scar in areas it can not be noticed, by optimal orientation of the scar and meticulous suture technique.
It is absolutely imperative that you show your plastic surgeon any previous scars especially those that have had an unfavourable outcome. All unfavourable scars must be shown to the Plastic Surgeon and any history of unfavourable scarring in family members must also be disclosed. This will allow the plastic surgeon to make some assessment as to the likelihood of the type of scar you will form in the future.
Dr. Darrell Perkins has successfully minimized the appearance of post-operative scars for many plastic surgery patients from Wollongong, Sydney, and nearby areas, but the final outcome often depends upon patient cooperation.
Normal Wound Healing
Wounds heal in a matter of four to fourteen days, in the sense that the sutures can be removed at that stage. However wound healing is a physiological phenomenon that has a time course certainly over six months and with changes in the actual wound and scar occurring over up to a two year period. The initial phase of wound healing which occurs over the first three months is called the inflammatory phase.; During this process all the building blocks are put in to allow the body to repair the wound that has been made. During this time the inflammatory cells control the process and the vascularity is increased. It is normal for the wound to be red during this period and for the wound to have a thickening or hardening called induration. This phase will persist for a variable amount of time depending on the part of the body. Intrinsically the face due to its good blood supply will heal much more quickly than the lower limb. Similarly the lower limb is also slower to heal than the upper limb.
After the period that averages about three months the wound and scar heads into the period of wound healing called the maturation phase. During this all the building blocks are aligned and reorientated into optimal configuration to best mimic the normal tissues. The inflammatory cells will leave the wound and the vascularity will return to normal. The thickening and hardening of the wound will soften and the redness should start to disappear out of the wound. The time course this is very variable between different sites on the body. This maturation phase extends for up to six months. Certainly a wound or scar will mould, remodel and improve for a period of several years. It is not uncommon to have a patch of numbness around a wound, as division of very tiny microscopic nerves are an inevitable consequence of making an incision or having a wound. This will tend to extinguish over a period of time and relatively normal sensation will usually return though may not always be perfect.
Factors Affecting Wound Healing
There are several factors that can influence scar healing and appearance, including:
Some people intrinsically form better scars than others. This can depend on the skin type or may be independent of it. Abnormal healing responses are genetically controlled and include hypertrophic and keloid scarring.
Patients can suffer from an inherited tendency to form hypertrophic scars. These are scars that become red and raised and hard despite initial good healing. Certain areas of the body are more prone to this type of healing than others. Factors such as tension and infection may contribute to these hypertrophic scars. Hypertrophic scars will tend to flatten, soften and pale with time but this may take up to one to two years.
A keloid scar is an inherent disorder of healing. In a patient who forms keloid scars the wound will initially appear to heal without any problem. After a period of usually four to six weeks the scar will become red, raised, hard and may actually grow beyond the margins of the original wound. As if the scar has become a tumour. There is a defect in the healing mechanism where the scar is not turned off. Scar is continued to be produced even though the wound is healed.
In keloid scars the patient will have the inherited tendency or not. It is a little bit like allergic reaction. All or none. Thus the most powerful risk factors for keloid scarring is a family history or more importantly a personal history. All unfavourable scars must be shown to the plastic surgeon as well as any history of unfavourable scarring in family members also disclosed.
Another powerful factor is the skin colour. The darker the skin the higher the risk. African type skin has the highest risk. The ceremonial marks created by some African tribes are actually keloids. South American and Asian patients have an intermediate risk and Caucasian patients have the lowest. This is a genetic reality. However, no one has a zero risk and even the patient with the palest skin can have a genetic keloid tendency and form them.
The body site of the scar is also extremely important for the formation of keloids. For reasons that are not known the central chest area has the highest risk. Thus it is considered inappropriate to remove moles from the central chest for cosmetic reasons. Any site of the body can keloid however.
There has never been a study that shows any surgeon factor was significant in the production or prevention of keloid scars. So thus such things as orientation, tension, type of sutures and suture technique have not been shown to be significant. They are certainly not powerful enough factors to overcome the absolute influence of inherited keloid predisposition and the body site of the scar.
Factors which have been shown to limit or control the formation of keloids and hypertrophic scars include pressure, (taping, massage, garments), silicone sheeting, intralesional steroids (injected into the actual scar) and radiotherapy of the scar after removal and resuture.
For additional information on how genetics can affect scar appearance, please contact our plastic surgery practice serving Wollongong, Sydney, and nearby areas.
In certain body sites extreme tension may be exerted on the skin as a part of normal daily activities. This tension placed on a healing wound will tend to stretch the wound out in the healing phase and result in a wide and depressed scar. Mobile areas with strong muscles are the most susceptible to the scar stretching and include the knee, shoulder and back regions.
The scars in these areas that are susceptible to stretch and may heal with a fine line initially but over a period of weeks to months may stretch out. This is understandable as a well healed wound at six weeks post-surgery is only 40% as strong as normal skin.
Plastic surgeons are trained to optimise scars by careful planning of the site and orientation of the scar, as well as employing meticulous technique. Where possible designing an operation to place a scar in a hidden area is a great technique for making scars inapparent. Plastic surgeons however do not have magic wands and there may be patient’s genetic factors and site of the incision or wound which may overpower any technical expertise of the surgeon.
Wound infection inhibits wound healing and may produce an unfavourable scar. If an unfavourable scar has formed in the face of infection it may be worth scar revision after the infection has settled and the wound has been allowed to heal. More information on this phenomenon is available from our plastic surgery practice serving Sydney, Wollongong, and nearby areas.
Healing is complex and many substrates and factors are required for normal healing. For example patients who are deficient in vitamin E, vitamin C and protein will not heal normally. However any Australian with a rudimentarily normal diet would not be deficient in any of these. Thus as long as an adequate level of all these nutritional factors are present the patient will heal at 100%. Taking excess will not make anyone more than a 100% healer. If you put more petrol in your car it will not go faster.
Smoking and Nicotine Substitution Products
Nicotine constricts blood vessels and inhibits blood flow to healing wounds. Smoking should be avoided in the perioperative period to optimise wound healing and may be critical in some operations to avoid death of tissues.
As with most things in life the amount of effort that a patient puts in to optimise their scar post-operatively will reflect the result that they get. (“See how to optimise your scar”). Many of the abnormal healing responses such as hypertrophic and keloid scars develop after the wound initially appears to heal satisfactorily. The key to any post-operative scar management is prevention. Measures should be introduced to prevent the scar getting bad, not introduced to try and fix it once it is bad. Thus if a scar is deteriorating, getting red or raised in the post-operative period the patient should inform the plastic surgeon so that appropriate measures can be instigated.
As with many things in life the amount of effort put in by the patient towards post-operative scar management will be reflected in the result they ultimately get. Certainly the ultimate result for a scar has not been determined the moment the last suture is placed.
How to Minimize the Appearance of Scars
Several strategies can be undertaken to minimize the prominence of scars, including:
Applying pressure on a wound is known to flatten it and prevent it getting raised. Pressure can be applied by massaging or taping the wound. Massaging is most effective when it is done often, for long periods of time, and with firmness. The wound can be massaged after sutures are removed and the tenderness is settling down.
aping may support the wound and prevent stretching but probably applies a small amount of pressure continuously. Taping with paper tape is usually adequate and can be very effective.
Ultraviolet light avoidance
Sunlight damages skin and damages healing wounds. Healing wounds exposed to the sun will tend to glow red and may even hyperpigment (suntan darkly). After the wound has healed application of sun block is essential. This sun block may be contained in a cosmetic and used for camouflage of the healing wound.
Scars will improve with time. Sutures may be removed at one or two weeks but the process of wound healing to full scar maturation is six months to two years. Areas on the face will fade quickly, other areas will be slower. The management of scars is a war of attrition not a single battle. Patience is a great virtue when it comes to scars and their maturation.
Dr. Darrell Perkins has helped many plastic surgery patients from Wollongong, Sydney, and the South Coast with scars that healed unfavourably. For these patients, Dr. Perkins was able to surgically revise the scar in order to get a better result. Scars that do not do well with revision are those that are keloid, where the genetic factors can clearly not be altered and may be a more powerful influence than the “tricks of the trade” that a plastic surgeon has to offer. Other scars that do relatively poorly with revision are those that over areas that tend to stretch scars out such as the knees and shoulders. Scars that tend to do particularly well with revision are those that have healed in unfavourable circumstances such as those that have been infected, resulted from blunt trauma or have come apart at an early stage. An expert plastic surgeon is required to really assess each individual circumstance to decide what or may not be appropriate under such a circumstance.
Lasers are not a magic wand. However they can be effective tools under the right circumstance to reduce the redness of scars and in certain circumstances to be used as a resurfacing tool to fade scars into the surrounding tissue. Again the particular type of scarring that has occurred will dictate whether a laser is an appropriate adjunct to optimise a scar or not. An expert plastic surgeon is ideal to assess the scar and determine whether or not laser treatment might be beneficial.
Contact Our Plastic Surgery Practice Serving Kogarah, Wollongong, and the South Coast
Dr. Darrell Perkins is skilled at minimizing scars, but patients will need to follow certain guidelines in order to achieve optimal outcomes. For more information on scar management, please contact our plastic surgery practice serving Sydney, Wollongong, and nearby areas.