Whether I am seeing a patient after a chain saw accident in the emergency department or in consultation for a tummy tuck one of the most common questions I am asked as a Plastic Surgeon is “ Am I going to have a scar?” The quick answer is YES. Whenever an injury goes through the second layer of the skin (the dermis) a scar is formed. OK, so now you know the answer no matter what injury, procedure or surgery you have it will leave a scar if the dermis is injured.
So the next question is how visible or “bad” will the scar be. This depends on a multitude of factors. First the nature of the injury will in part determine how the resultant scar will look. A sharp cut with a knife or scalpel will leave a much less noticeable scar than a crush injury that results from a fall or motor vehicle accident. Crush injuries that result in open wounds do so because the skin has been crushed or scraped to a point that is can no longer handle the force so it splits or tears. Unlike a cut from a blade or sharp object where the location of the skin cut is the only injured area, the area or injury from a crush extends for a good distance around the open wound, this often leads to poorer wound healing and a more visible scar. Contamination of the wound with dirt, gravel or other substances can lead to infection or traumatic tattooing and therefore a more visible scar. Age and overall health status also play significant factors in wound healing. Children heal very quickly which is good but can lead to prolonged redness of scars or hypertrophic scarring. Elderly people heal more slowly and with less inflammation therefore in general produce less visible scars. Factors such as smoking, diabetes, family history of keloid formation and certain medications can inhibit wound healing result in worse scarring. Also some patients just tend to produce more visible scars. Finally location of the injury on the body can also affect the final appearance. Injuries or wounds over joints or high tension areas of the skin can result in more visible scars due to spreading of the scar. This is one of the reasons why incisions over joints are typically oriented longitudinally and not transversely.
The logical next question patients ask is what can be done to improve scarring or make the resultant scar less visible. The good news is there are many things that can be done to improve the final appearance. The first and often most important step to improved scarring is appropriate closure of the wound. This often but not always means stitches (sutures is the medical term) . Does it need stitches? Well depends what you mean by the word need. Many wounds wound heal without stitches but would take much longer to completely heal, have a higher risk for infection, and leave a horrible looking scar. So if you want the best possible chance of having the least noticeable scar the answer is often yes it will need stitches. Placing stitches (sutures) re-approximates the edges of the wound which helps in two ways. If the wound is gaping then the stitches will bring the wound together so that your body does not have to fill in the area in between the wound edges and will therefore heal quicker. The second aspect is to stabilize and realign the appropriate tissues so they heal to each other. It’s not just the stitches though, it is how they are placed, what type of sutures are used (there are over 20 different types of suture material), and how many layers of stitches are placed. Other factors at the time of repair that have an effect on wound healing include cleansing of the wound removal of contaminants, preparation of the wound by trimming crushed skin edges as needed and many other factors.
After the repair of the wound or surgical incision healing has just begun and by providing the right environment for healing scarring can be minimized. Wounds for the most part heal better in a moist environment which can be obtained with a variety of dressings and bandages. Vaseline or petroleum jelly based antibiotic ointments are easy to obtain and apply, and can increase the speed of healing due to maintenance of a moist environment.
Scars mature over the course of 6 months and sometimes up to one year. So that means final appearance can be influenced for six months up to one year. Several treatments have been shown to improve the final appearance of scars in scientific studies when used within this time frame. One the best proven ways you can help is to protect the area from the sun. The injury or incision site will be sun sensitive for 6 months. Either covering the area or using a SPF 30 sunscreen daily and a SPF 50+ for intense sun exposure every day for six months will make a significant improvement in scarring. Unprotected exposure to the sun even if just with daily activities will lead to discoloration or redness of the scar.
Silicone has been shown in research studies when applied near continuously (24hrs a day except while showering) to an injury to significantly improve the final appearance of scars. Silicone scar strips are great for areas where they will adhere and stay in place, most often on the torso. They are now made with opaque backing which will block the sun if used in a sun exposed area. The downside is that as stated they need to be in place nearly 24 hrs every day which is difficult on the face or extremities. In these locations I prefer a silicone scar gel which is typically applied twice a day make sure the area being treated has silicone on it nearly 24hrs a day. Unfortunately not all silicone scar gels are created equally. Also if you do not use one that has a sunscreen in it. You will need to add a layer of sunscreen over the silicone gel as the gels do not block UV. I prefer Silagen scar gel with sunscreen. Silagen has been shown to adhere to the skin strongly giving 24hr coverage when applied twice daily and also contains a non chemical sunscreen safe for children and those with sensitive skin. I recommend to apply an additional coat of SPF 50+ sunscreen and to re-apply this as directed for intense sun exposure such as outdoor sports or beach activities even when using the Silagen with sunscreen.
Finally just massaging the area of injury with anything from cocoa butter to emu oil has been shown improve the final appearance of the scar. It is not really the product at all but the actual mechanical force of the massaging that improves the appearance. Massaging 2-3 times per day 10-15 min is usually what I recommend but the more often the better.
If you have done all of the above or none of the above and still are not pleased with the appearance of your scar, don’t worry there are options. While not all scars can be improved, most can even after they have matured. While it is preferable to do everything possible to achieve the best outcome during the maturation period of your scar. Lasers, dermabrasion, chemical peels and surgical scar revision can significantly improve the appearance of scars but can never erase them. Schedule a consultation with a Board Certified Plastic Surgeon if you wish to discuss options to improve or treat scarring. The best way to prevent scarring is to practice appropriate safety precautions when possible. Stay Safe .