Prospective patients ask me this question every week. I don’t blame them for wanting an invisible scar, but it is not possible. Instead, the goal should be to obtain the best scar possible. Most people have unrealistic expectations of what surgical scars should look like. In this article, I will dispel some of the myths regarding surgical scars and their treatments, and I will answer most of the questions I hear in the office on a regular basis.

Many patients believe that the appearance of a surgical scar is related to the level of skill of the surgeon. While this may be true in comparing scars created by doctors outside of the field of plastic surgery to scars created by plastic surgeons, all board certified plastic surgeons are well trained in surgical techniques to minimize scarring. The real variation in the appearance of scars comes from the patient’s genetics and the area of the body on which the scar is placed. Ethnicity plays a role, too, in that darker-skinned people have a higher propensity to form thick, raised, or dark scars. However, a patient from any race can form problematic scars.

Raised, thick scars are called hypertrophic scars. Keloid scars are also raised and thick and frequently pink or brown. Both of these scar types represent an abnormally abundant response to wounding. There are descriptions as far back as 2000 B.C. of these types of scars. Keloid is a derivative of the Greek word for “crab’s claw.” The terms keloid and hypertrophic are frequently used interchangeably, but they are different. Keloids overgrow the boundaries of the original wound and hypertrophic scars do not. Hypertrophic scars tend to fade with time and keloids do not. Both types of scars reveal an abundance of collagen. An aberration of the mechanism of growth factors interacting with collagen-producing cells may also play a major role in this type of scar formation.

While scarring has been studied for many years, we have little reliable data to determine what the best prevention or treatment for scarring is. Many treatments that have been touted in the lay press, such as aloe vera and vitamin E, do not stand up under scientific evaluation. In fact, topical vitamin E was found to cause a rash in one-third of the patients who used it, while their scars were not improved compared to patients who used a placebo.

One topical treatment that has been proven to reduce the incidence of hypertrophic scars is silicone gel sheeting. These are clear adhesive strips of pliable material made of silicone. The exact mechanism of action is still not clear, but it appears to decrease cellular activity that stimulates excessive scarring. It has to be worn for 12 hours a day for about three months following surgery. I have all of my patients wear these strips, starting two weeks after your procedure.

While there are no long-term controlled studies on botanical topical creams, there is supportive evidence that some of these plant-based extracts have positive effects on scars. Beta-glucan has been shown to stimulate collagen deposition and maturation in new scars. It also stimulates growth factors that are beneficial to wound healing. Centella asiatica also falls into the botanical category and is an extract that increases hydration in the scar and is anti-innflammatory and anti-bacterial. Epidermal repair is a topical cream that is part of the Skinceuticals skin care line that I carry in my practice. This product contains both beta-glucan and centella asiatica. I have my patients massage the cream into their scars twice a day and wear the silicone gel sheeting on top. I have been pleased with the reduction in difficult scars I have had to treat.

When scars are refractory to treatment with topical agents, steroids can be injected into the scar in very low doses. These very low-dose steroids do not result in effects on other organs. They work by breaking down collagen, so raised, thick scars become flatter and frequently less pink. Most commonly, the scar is injected two to three different times at eight week intervals.

Lasers have also developed a roll in treating difficult scars. The pulse-dye laser in particular targets blood vessels in the scar, resulting in less oxygen delivery to the scar. The scar subsequently shrinks and softens. Super-heating the collagen in the scar stimulates re-organization of the collagen bundles, which also leads to softening and flattening of raised scars. There have been low recurrence rates with this treatment as compared to some others.

Surgical excision of problematic scars should be reserved for scars that are causing functional problems such as restricted movement. When scars are re-excised it is important to treat with steroids and the topical treatments described above to minimize the incidence of recurrence.

While there is no such thing as an invisible surgical scar, early proactive topical treatments have been shown to decrease the incidence of problematic scars, and that is why I encourage all of my patients to wear silicone gel sheeting and massage their scars with epidermal repair cream.

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