As Plastic Surgeons, we often get asked about scar and wound management, that is how to make them go away. Unfortunately, when a wound or laceration is deep enough there will be a scar. So far, even with today’s technology, only fetuses heal without a scar. There is no magic technique or scar removal cream available to make scars disappear. It is a frequent misconception that if a Plastic Surgeon operates on a patient, there will be NO scar. However, the Craniofacial Team of Texas surgeons are trained in Pediatric Plastic and Reconstructive Surgery where they are specialty trained to disguise and minimize scars so that they are hidden, but there will always be a scar if you look close enough.
What Causes a Scar?
Your skin has two main layers – epidermis (top layer) and dermis (deep layer). If a wound or cut goes through just the top skin layer or epidermis, then there should not be a scar (like with a skinned knee); however there may be residual skin discoloration. When the wound is deeper or into the dermis then your body responds with normal wound healing to form a scar. Normal wound healing has three main overlapping phases:
- Inflammation: Initially, your body reacts to a new wound by a process of inflammation. During this time, your body activates your immune system to clean up the wound and produce proteins that stimulate healing. This process will cause your scar to be swollen, red and tender.
- Proliferation: In this phase, your body starts making the components it needs to form tissue. Collagen is the main building block of the body. During proliferation, your body makes large amounts of collagen which gets laid down in an unorganized fashion in the wound. The scar during this phase is considered immature and characteristically appears red, slightly raised, and firm.
- Remodeling: Once the building blocks are made (collagen), the body works to remodel the scar. This scar maturation phase leads to the scar becoming softer, flatter, and lighter in color. Scars typically reach final maturation around 12-18 months. Sometimes in children, scars can continue to mature over a longer period of time (years).
Why are some scars more noticeable than others?
Our eyes notice contour irregularities and pigment differences easily. If a scar is too thick and raised or depressed, then our eyes get drawn to that area. Differences in color also make scars more noticeable. If a scar crosses natural wrinkle lines, then they become more noticeable with facial movement because the scar will not move like normal skin. An ideal scar is narrow and has even skin edges with the surrounding tissue, and is hidden in a natural skin crease.
What can make a scar less noticeable?
There are few things that can improve the appearance of a scar.
- Good wound care: In the first week of wound healing, a clean, moist environment is recommended to promote the ingrowth of healthy tissue. After washing the wound with soap and water, application of antibiotic ointment followed by a band-aid or nonstick gauze, regular gauze, and tape 2-3 times a day for 1 week ensures a moist environment. Antibiotic ointment should not be applied for longer than a week to prevent development of a fungal rash. After a week, transition to a petroleum based ointment (e.g. Aquaphor) without antibacterial properties is recommended for 1-2 more weeks.
- Sun protection: When a wound heals, the scar is immature tissue and very sensitive to UV radiation. Sun exposure to healing tissue can result in hyperpigmentation of the scar which may become permanent. While the wound is healing, it can be covered with steristrips or a dressing. Once the skin is healed over, then sunscreen 35 SPF or greater can be applied.
- Scar massage: At approximately 2-3 weeks after wound closure, scar massage can be performed. Scar massage is one of the most effective ways to soften a scar and improve the appearance. It helps to promote collagen remodeling, decrease itching, and increase the flexibility of the scar.
- Silicone: Once the wound is closed and there is no drainage, a silicone dressing can be applied to the wound. Silicone can be applied in the form of a gel or sheeting. It should be worn 23 hours per day for the best results.
- Laser: When a scar is immature, new blood vessels are visible and are at a higher density. Laser can be used to reduce scar redness by destroying these little blood vessels. In more mature scars, lasers can be used to improve the texture and reduce the thickness by promoting collagen remodeling.
- Microneedling: Microneedling can be used to improve the texture of a scar by promoting collagen remodeling.
- Surgical revision: Some scars need surgical revision to improve the appearance. Typically, surgical revision is considered around 12-18 months to ensure the scar will not remodel any further.
How is scar massage performed? (see video below)
Scar massage along with silicone treatment are the only two treatments that have been shown to significantly improve the appearance of scars. Scar massage is performed by using the pads of your fingertips and applying firm pressure to your scar and then moving in a circular motion over the scar. The pressure should cause the scar to blanch (turn pale) but not so hard that it hurts. It is good to start with light pressure and then gradually increase the pressure; sometimes lotion or oil can be used to make the massage process easier. Massage should be performed 4-6 times per day for approximately 5-10 minutes at a time. Scar massage should be done for 6-12 months for best results.
Is there a scar removal cream?
There are many scar creams on the market that aim to reduce the appearance of scars, such as Mederma and Vitamin E oil, but no product can “remove” a scar. There is no one product that has shown significant benefit to improve the appearance of a scar except silicone. Silicone can be applied as a gel or sheeting (like a tape). Silicone is designed to work by flattening, softening and fading red raised scars. It helps to reduce the size and improve the color of a scar and can improve elasticity of the tissue. (see Silicone Sheeting instructions (http://craniofacialteamtexas.com/wp-content/uploads/2017/12/Silicone-Sheeting-instructions.pdf))
Do I need scar revision?
Some scars need intervention early in the healing process if they become thick and overgrow. If the scar is hypertrophic or becomes a keloid, then steroid injections may be needed.
Scars may benefit from surgical revision if there is significant contour irregularities or the orientation of the scar makes it more noticeable. Some strategies that Plastic Surgeons use to improve the appearance of scars are changing the direction of the scar to lie in natural skin creases or breaking up a straight line scar with Z-plasties or W-plasties.
If you would like more information about scar and wound management, please contact the Craniofacial Team of Texas by calling 512-377-1142 or toll free 877-612-7069 to schedule an appointment or complete an online appointment request.