SAUL R. BERGER   M.D.
818.990.4545
PLASTIC, COSMETIC AND RECONSTRUCTIVE SURGERY
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Secrets of Minimizing Scars

August 2017

For so many people, scars evoke an emotional reaction.  It may be simply because of the look, or it may bring to mind a past event, often unpleasant.  Scars result from any kind of cut or injury to the skin that is deep enough to cause the process of repair and healing to leave permanently visible changes.  Scars result from many causes, and they can occur both in body parts that are easy to conceal (like areas covered by clothing) and in parts that are exposed all of the time, such as the face.  Common examples of the kinds of scars that I evaluate frequently include acne scars on the face, traumatic scars from accidents, dog bites of the face and arms, enlarging or growing scars called “keloids,” and scars from surgical procedures.  Sometimes patients have scars after cosmetic surgery that they are not thrilled with, even with otherwise excellent results under the care of highly qualified plastic surgeons.  This guide will help shed some light on scars, and also contains a unique summary of scar treatment options that you may find very helpful (see “A Simple Guide to Scar Therapies” section below).For so many people, scars evoke an emotional reaction.  It may be simply because of the look, or it may bring to mind a past event, often unpleasant.  Scars result from any kind of cut or injury to the skin that is deep enough to cause the process of repair and healing to leave permanently visible changes.  Scars result from many causes, and they can occur both in body parts that are easy to conceal (like areas covered by clothing) and in parts that are exposed all of the time, such as the face.  Common examples of the kinds of scars that I evaluate frequently include acne scars on the face, traumatic scars from accidents, dog bites of the face and arms, enlarging or growing scars called “keloids,” and scars from surgical procedures.  Sometimes patients have scars after cosmetic surgery that they are not thrilled with, even with otherwise excellent results under the care of highly qualified plastic surgeons.  This guide will help shed some light on scars, and also contains a unique summary of scar treatment options that you may find very helpful (see “A Simple Guide to Scar Therapies” section below).

Many people are unaware of the factors that affect how a scar ultimately looks.  Some of the causes of scars are out of our control, such as in the case of an accidental injury or an emergency surgery to treat a serious condition (like appendicitis).  In the case of cosmetic surgery, the common belief is that the scar result is completely related to the workmanship of the treating doctor.  That is not usually the case, especially if that physician is a highly qualified specialist, such as a board-certified plastic surgeon.  Here are four key factors that determine how visible or obvious your scar will ultimately be:

1. Your own genetics determine a lot about your healing characteristics.  Some people heal with flat, pale, or softer scars, while others heal with thick, raised, or darker-colored scars solely on a genetic or hereditary basis.

2. The location of a scar on the body will often influence its appearance.  Areas of greater skin tightness or increased motion can develop a more unsightly scar, and long scars can show differences in healing along different parts of the very same scar.  Examples of troublesome areas include the central chest skin, the top of the shoulder, and directly over the knees, to name a few.

3. The original cause of the scar can significantly affect the scar result.  For example, accidents that result in crushing, tearing, loss of tissue or dirt embedded in the skin will often cause an unfavorable result.

4. Surgical technique can influence the scar appearance, especially if the repair and closure are not provided by a properly trained specialist.  Also, reactions to the stitches used, or the development of infection or separation of the stitches can also lead to “bad” scarring.

Based on these four factors, here are my key tips to help you minimize scarring:

✔ If you are planning for elective (non-emergency) surgery, find out if there are scarless or scar-minimizing approaches available for your procedure.  Many years ago, for example, all patients requiring removal of their gall bladder received a rather large and unsightly tummy scar that was painful.  Now, patients can undergo removal of the gall bladder through laparoscopic incisions of less than an inch and go home faster with less pain.

✔ Do your best to control or avoid those things that cause scars in the first place, before they spin out of control.  For example, aggressive control of acne, especially cystic acne, will reduce the frequency of inflamed areas that can result in scars that are hard to improve.

✔ For areas that are prone to bad scarring, and especially if you have a personal history of poor scarring, you may want to avoid optional treatments that are not medically necessary.  For example, think carefully before asking a doctor to remove that mole from the top of your shoulder that you have had “forever.”

✔ Be sure to seek treatment with a skilled practitioner, such as a board-certified plastic surgeon, since surgical technique and planning are so important in the result.

✔ Follow post-treatment care guidelines carefully so as to reduce the risk of an infection or complication, which can worsen the result.  Remember, guidelines generally include avoiding sun exposure on new scars.

✔ Use products that may help reduce or minimize unfavorable scars (see below).

A SIMPLE GUIDE TO SCAR THERAPIES
Here is my summary of the “winners” and “losers” available for scar treatment.  The guide is based on scientific studies designed to study the effect of various treatments on scars.  If the treatment listed must be provided by a doctor, there is an ” * ” next to it.  Always remember: It is very important to check with your own doctor before beginning any scar therapy to make sure you are using a safe and effective approach:

• Onion Extract (ex. Mederma) – studies show mixed results for effectiveness, but some studies show improvement in color and sometimes height.  WEAK WINNER

• Vitamin E – most studies show no benefit.  LOSER

• Silicone – studies show reduced scar color and height.  WINNER

• Steroids* – studies show good response.  WINNER

• Fat Grafting* – studies show improvement in appearance and softness.  WINNER

• Radiation and certain prescription medications* – studies show improvement with keloids or severe scars.  WINNER

• Cocoa Butter – no effect.  LOSER

• Olive Oil – no effect.  LOSER

• Infrared Energy treatment* – no effect.  LOSER

• Retin-A* – marginal effect.  LOSER

• Scar massage – helpful in burns.  WINNER

• CO2 laser* – helpful for acne scars.  WINNER

• Pressure garments – can reduce scar thickness.  WINNER

• Pulsed dye laser* – most studies show it is effective.  WINNER

In summary, things you can do on your own to reduce scarring include:

1. Use sun block for scars located in exposed areas of the body, especially if the scar is still new.

2. Use a silicone-based topical scar treatment.  Some premium silicone scar treatments also have a sun-block built in.

3. Consider using an onion extract topical treatment, though it seems less effective than silicone.

4. Consider scar massage (definitely check with your own doctor before massaging).

5. Avoid activities that could stress a new incision and possibly cause it to open up or separate.

Things that may be helpful for scars but must be provided by a doctor include:

1. Injecting medication into the thickened scar (many medications are available for this purpose, and your doctor must guide you).

2. Use of laser or light therapy.

3. Fat grafting.

4. Custom pressure garments.

5. Surgical removal of the scar with a new closure (“scar revision”).

6. Use of radiation therapy for severe problem scars, such as keloids (see an example at http://www.drberger.com/gallery/scarcorrection1.html ).

Saul R. Berger, MD, FACS