We do many things to decrease the risk of infection:

• I have my patients wash with antibacterial soap the day prior to surgery,
• We prep your skin with a special solution in surgery,
• We use a sterile operating room with draping, gowns, etc. 
• I apply the dressings and garment in the OR to protect the wound. 
• You get antibiotics IV and orally around the time of surgery. 
• I see you frequently to evaluate your wounds, looking for things like redness, rashes, discharge, etc.



What can you do? 

• NOTIFY YOUR DOCTOR if you have any personal or family history of MRSA, have had a recent surgery, or a recent hospital admission. (Recent= within the last year.)
• Keep your incisions clean. Discuss with your doctor how you can bathe and when.
• Wash your hands before you touch your incisions.  Your skin is not sterile- you don’t need gloves- but you need to use common sense and good hygiene.
• There is no one rule for all patients:  some patients have dry wounds which don’t need any “care”- I just keep them covered with special tape. 
• Some wounds have discharge- this can be totally normal, particularly within the first 24 hours- or it could signal something brewing.  Your doctor should evaluate.  If it is wet, mucky, smelly, greenish, painful, red, tender, voluminous (going through gauze pads)– those are things to alert your doctor of quickly.
• Some wounds need a little TLC- which can involve washing the area gently and applying polysporin, neosporin, bacitracin or a similar ointment.

When I meet with you after surgery, which I do frequently, I am looking at your incisions.  I am evaluating everything.  After being a surgeon for over 15 years, I can see things brewing.  If you aren’t healing how I expect you should, then I want to figure out why and fix it.  Jumping on things early avoids bigger issues- from infection to just better scarring.

NOT ALL WOUNDS NEED THIS.  If you fall off your bike and get a scrape, you do not need to rush out and diagnose your wound bacteria and go on special antibiotic gels and treatments.  This is for wounds or issues that don’t heal and go on for months. 

You can create a window to treat it by debriding the wound.  In English, debriding means getting rid of the top layer, that waxy exudate on your skin, the dead cells and tissue.  As they say on TV shows, YOU SHOULD NOT TRY THIS AT HOME.  Other physicians refer to us plastic surgeons to do this.  Why?  Because there is a fine line between removing what should be removed and removing too much.  If you remove too much you will get scar, contour deformities, and ickiness.

So how to treat biofilm?

• Debride.  Frequently.  You will be seeing your doctor to do this every couple days.
• Selective biocide.  In English, that means  you can use a treatment which helps get rid of bacteria, but not the normal good cells.  An example of a nonselective biocide is peroxide- it kills bacteria, but it also kills your normal healthy cells. 
• Antiobiofilm.  These are enzymes and gels which help break down the biofilm
• Antibiotics.  These are personalized antibiotics tailored directly to what they found on your test.  What bugs you have and what they are susceptible to cannot be gotten from a culture.  This is done by PCR.  You have to treat usually “long and strong,” and you have to reassess and potentially rotate agents if resistance is growing.

So if you have a nonhealing wound, that has gone on for months, you should look into diagnosing the biofilm.  Some of the results they showed for diabetic foot ulcers and other what seemed to be “impossible to heal wounds” was amazing.

I have talked in previous blogs about the big 3 issues for scar: genetics, tension, and inflammation.  So what do sweat glands and hair follicles have to do with anything?

Keratin.  Turns out keratin, which is found in the outer layer of your skin and the lining of the sweat glands and hair follicles is really irritating.  Keratin causes inflammation, which we know from the big 3 above, is one of the things to avoid to get pretty scars.

This is simple, but insightful for us plastic surgeons.  I know from almost 20 years of being a surgeon that certain areas of the body almost always tend to heal well.  Example: eyelid.  I don’t know I have ever seen a keloid or hypertrophic scar there. 

Other areas tend to heal poorly…  Example: sternotomy or Csection wound.  But in these areas I see variability.  Some people heal well, and others don’t.  Why? Is it tension? Genetics? That is always what I chalked it up to.  But perhaps it isn’t.  Perhaps it has to do with how oily is their skin? Do they have more sweat glands?  Did the incision go within the hair for their C section (so in the midst of hair follicles)? Or at the top of the hair border?

Also I know from practice that people with thin, fair skin tend to heal better than those with thicker, more oily sebaceous skin.  Again, we could chalk it up to genetics, but maybe it isn’t.  Maybe it is the thin skinned patients who have that  “dry” skin may have less glands, so they have less keratin irritating the scars as they heal.

They did an experiment:  They looked at C-section scars.  In those which formed bad scars they found a lot of inflammation.  Many also had ingrown hairs.  So they thought to reduce the hair follicles.  They did laser hair removal, cut out the bad scar, and reclosed.  Result: better scars.  The rationale was they reduced the keratin by damaging the hair follicle.  (Laser hair removal works by targeting the melanin pigment in the hair, heating it up to cause scarring of the follicle and preventing regrowth.)

Simple thing, not revolutionary.  But this simple premise of glandular and hairy tissue leading to poorer scars is one we see in practice.  This may mean if we can do things to minimize them (?laser hair removal, ?try to make incisions outside of the hair bearing area ? other ideas) we may be able to improve scars.

The belly button.

It has no use after you are born, yet we are quite obsessed about it.  Are you an innie? Outie? Many of my young patients pierce it.  Many of my moms have one which “winks” after being stretched by babies.  Some pregnant women get a small umbilical hernia, so the innie is now an outie.

Egads!  When that happens I think you need counseling.

Such a small thing. Such big issues.

Belly button shape after a tummy tuck is a tough thing.  I recently fielded a question from a patient who has a slit like belly button after a tummy tuck.  That can happen.  If your belly button is pulled, it can look stretched.

How can you make a belly button look pretty?

When we do a full tummy tuck, you have a scar going 360 around the belly button.  We doctors do all sorts of little tricks to try to tuck the belly button, get it to indent, and hide the scar.  I went to a talk once on “aesthetics of the belly button” at our national plastic surgery meeting. (Yes, yes. These are the kind of talks we go to as plastic surgeons.)  But belly buttons are important.  The belly button shape voted “the best” by the study was slightly hooded on the top and fanned out a little on the bottom.

I try to simulate this.  Most of my patients look great.  I have patients who’s scars overall are fantastic- hairline, barely visible.  If your belly button doesn’t look great, what happened and what can you do?

If your belly button looks too small, it contracted on itself because it is a round scar.  I changed the way I inset the belly button to improve this by creating a little advancement flap into the belly button.   Also you can try the marble trick to enlarge and round it out.

If your belly button formed a raised scar (keloid or hypertrophic scar) you can try scar creams, massage, silicone gel sheeting, steroid injections, and cutting it out and starting again.  In general, I always try to close under little tension. Tension is bad and can lead to raised scars.  Keloids though tend to happen more often along the midline.  And belly buttons tend to be in the midline.

Funny belly button shape.  I find women who are super skinny and have no fat around the belly button are tougher to get pretty belly buttons in because they don’t indent as much, and it is harder to hide the scar.  The toughest are women with no indent anymore, where the belly button looks like a shallow saucer.  These women are tough as they have blown out their belly button.

But I try.  Because what point is having a beautiful flat tummy if you can’t show it off  a bit?

We make pretty scars. We hide scars. We try to make small scars.  But anytime you cut through skin you will have a scar. In our training, plastic surgeons learn how to make a good skin closure.  To do this, we have multiple layers of closure under the skin which you don’t see.  We undermine and advance the tissue (a fancy way of saying we loosen the tissue up and move it), so when we close the skin it isn’t under tension.  We try to orient the scar with a wrinkle fold (which helps it hide) or put it into a crease or other hidden area.

What can you do to make a scar prettier?

1. Start when the scar is new.  When people come in with a scar 6 months or older, there isn’t a lot of change occurring in the scar.  It is harder to reverse bad changes, ie it is better to nip it in the bud before it happens.  This doesn’t mean you have to put creams on the scar on day one.  I usually recommend letting the initial scar heal first, and starting the treatments 2-3 weeks out.

2. Sunscreen.  Sun is bad for scars.  Particularly here in sunny Palo Alto, we are constantly exposed to the sun.  Sun can essentially tattoo the scar, so the color never fully fades.

3. Don’t irritate the scar.  (Who would want to irritate a scar? That sounds as bad as waking a sleeping baby.) But we irritate scars without thinking about it: clothing, bras, waistbands, picking at it.  When a scar is trying to heal, I think it needs to be left alone.  For this reason I found covering the scar with simple paper tape helps.

4. Too dry or too moist is bad. Studies show scars heal better in a moist environment.  So the alcohol, hydrogen peroxide cleaning of a scar in general is bad because it dries it out too much. (There are cases where it helps, but usually not.) Too moist and goopy is bad.  I see people glop on the neosporin, or cover the scar with a bandaid they don’t change for days on end. One reason I love paper tape is it breathes better than bandaids. 

5. Pigmentation.  Anyone who has any color in their skin runs the risk of depigmentation (fancy way of saying the scar turns white) or hyperpigmentation (fancy way of saying it turns dark). Other than what we plastic surgeons do at the time of surgery to get a pretty closure, you may need a cream like hydroquinone to help even out color.  There may be some lasers which help, but you must always be careful when lasering anyone with colored skin- there are many pitfalls associated with it.

5. Massage.  Wait til you are healed, and then you can massage the scar to help it flatten and soften.

6. Mederma, Kelocote (a liquid silicone gel) are my favorite over the counter to help reduce scars.  No one knows why silicone gel helps scars, but using silicone gel sheeting on major scars has been done for years.

Other notes:

• I am not a fan of vitamin E for normal scars (not elevated, ropey hypertrophic scars).  Vitamin E has been shown to break down scar.  It is great for when you have a scar which is too much scar, but on a normal scar it can cause the scar to indent or widen. 
• Keloids are out of the scope of this talk.  If you have a personal or family history of keloids let your doctor know.  A true keloid is difficult to treat.  Many patients tell me “I keloid” when they don’t. 
• Scars in certain places never heal well.  High movement areas like the shoulder and knee, places where you don’t have loose skin like the calf and back, and areas which get constantly irritated like the foot tend to be worse.

When you choose to do a breast augmentation, we must get the breast implant inside. (Unfortuantely, it is not magic.)  This is the scar you will see when you are done.  There are pros and cons to each incision.

There are three basic common incisions:

• Armpit (also known as axilla)
• Periareolar (at the bottom of the areola, the colored portion of the breast skin)
• Inframammary fold (also called IMF, the under part of your breast where an underwire goes)

There are other incisions  you hear about such as through the umbilicus (TUBA), through an abdominoplasty incision, and through the base of the  nipple. These are not as common (for real reasons).

IMF: This is the most common incision used.  The scar can go in the crease of the underwire or just above the crease on the bottom curve of the breast.  PROS: On the breast, so only someone seeing you naked will see it.  Preserves ability to breastfeed.  Can use as an open door- when you need a revision surgery due to deflation or capsular contracture, you can fix it through the old scar.  CONS: If you wear a bikini which doesn’t hug your underwire, you may see the scar.  For patients who don’t scar well (read: hyperpigment, keloid, hypertrophic scar) you can see the scar.

AXILLA: Scar goes into the armpit.  PROS: Preserves ability to breastfeed.  No scar on the breast.  CONS:  Scar in a place visible when you wear tank tops or bathing suits.  Usually more of the pocket is done by blunt dissection, so may get more bruise.  More difficult pocket dissection, may lead to implant malposition and upward migration of implant.  Difficult to place gel implants.  Usually need to make a second incision when you need revision surgery for implant replacement.  For patients who don’t scar well (read: hyperpigment, keloid, hypertrophic scar) you can see the scar.

PERIAREOLAR: Scar is at the transition between the areola and the breast skin.  It does NOT go all the way around the areola.  It is at the bottom of the semicircle.  If you see a scar going 360 around the areola, then a breast lift was done.  PROS: I find this incision hides the scar the best, particularly in my patients with darker skin tones: Asian, Phillipino,  Latina,  and Black.  If your scar turns darker / brown, then it tends to blend with the areola.  It is an open door- you can reuse the old scar for any revision surgery.  It does NOT interfere with sensation. (Will go into sensation details below.) The scar is on the breast, so only someone seeing you naked will see it.  It gives the best access to making an accurate pocket dissection, important for smaller implant sizes, which is important for my natural aesthetic in my Bay Area patients.  It allows access to have meticulous bleeding control, important to limit bruising and potentially capsular contracture.  This is my favorite incision as I find the scar fades in most patients to nothingness.  I like it particularly for women who are done with pregnancy and breastfeeding, women with constricted or tubular breasts, and women who may need a lift down the road, so you limit future scars.  CONS: It does cut through some of the breast ducts, so for women who have not had children yet and want to breastfeed, it may impair breastfeeding.

The biggest issue women bring up when discussing breast augmentation incisions, tends to be sensation.  Will my breast sensation change? What affects it?  There is a common perception that cutting at the areola will cause more sensory change.  This is not true.  Funny.  It seems like if you cut at the areola then the nipple sensation should change more than if you cut at the armpit, eh?  A study published in our white journal (the plastic and reconstructive surgery journal- a big deal in my world) showed there was no difference in sensation based on where you cut, but there was a difference based on how big you go.  The sensory nerves come up from the sides.  As you stretch the skin the nerves stretch.  This is what causes the sensory change.  Think about how your breasts feel when you are pregnant- or better yet -when your milk comes in.  That tingly, numb, or hypersensitive-don’t-touch-my-breasts sensation.  Many women report right after augmentation feeling like they did when their milk came in.  This feeling goes away, though your final sensation may be the same, less, or more than prior to surgery. I tend to find sensory change is less for women after having kids, and my thought is they have essentially “prestretched” their breast skin.

SO. Bottom line on sensation? The bigger you go, particularly if you are stretching the skin, the more sensory change you will get.

For photos, check out my gallery.  Most of the incisions you see are periareolar, and most photos are 6 weeks out.

I know. Shocking the “doctors” on shows like Nip Tuck and every soap opera out there can fix a major accident with not a single scar, but real doctors cannot.  In the real world, anytime you cut through the skin there will be a scar.

Our goal is to make that scar as fine, hair lined, tiny, well placed, and invisible as possible.  But even a scar which will be a good scar (and fade to nothingness) starts as a scar you can see.  I show scars when they are new.  Most of the photos on my website are of scars at 6-8 weeks. On some surgeries, like eyelifts or breast augmentations, these scars are almost invisible quickly.  Why? Breast augs and eyelifts have small scars, which are hidden and under no tension.

The common surgeries I do with larger scars are breast lifts and breast reductions (both of which I use a shorter, lollipop scar) and tummy tucks.  You may be thinking, good heavens woman, why would you show those scars?!?  Why are you not like the other plastic surgeons who only show scars at a year when they have faded or have every tummy tuck scar hidden under underwear?  I could be cheeky and say, I am not like other plastic surgeons. But the true answer is you pay a price for surgery.  I feel strongly you need to know that price, or I guess I should say potential price.  I expect most of my patients will have scars which fade well.  I don’t have many issues with ugly raised scars, keloids, etc.  But I do have some patients who don’t scar well….usually it is a part of the scar…and for their surgery that patient paid a bigger price.

When you lift your breasts so they don’t hang to your knees after breast feeding three kids, the price you pay for cute perkier breasts is a scar.  Many years ago I converted from the inferior pedicle technique, where we had a large anchor scar (where it is like the lollipop WITH an additional scar running the entire length and position of an underwire) to the vertical technique.  Why? It shapes and holds better, and it is a smaller scar on the skin. If you are trying to limit a scar, why not go all the way and do the cute little donut lift where the scar only goes around the areola? (Excellent question from my educated Bay Area crowd…)  That procedure is fraught with issues, and the scar though smaller frequently wrinkles, elevates, and bunches.  A larger flat hairline scar is less noticable than a smaller wrinkly one.

Tummy tucks are a great operation to tighten the muscles and get rid of the loose, stretch-marked, muffin top skin, but the price you pay is a scar.  Again, particularly in my fair skinned patients, I expect the final scar will be a hairline almost invisible scar.  But what if it isn’t?  My Bay Area patient base is very well educated.  We had our children at older ages, so many of us got used to having a fit, healthy, tighter body.  The changes after pregnancy can be tough. When you were hit hard by pregnancy, to get your muscles and skin tight again with a tummy tuck, you need to be okay with the scar.  I find the patients who focus on the other changes- the flatter tummy, waist definition, tight skin, no stretch marks, smaller size- will be happy.  The patients who are really bothered by the scar have a lower “price” they are willing to pay.  I advise these patients to take a black sharpie marker and draw the scar on their belly.  Wear underwear, your swimsuit, low rider jeans.  If you had a tummy tuck and you were one of the few who did not heal well, would you be okay?

Here may be a place where being a female plastic surgeon who has had kids, pregnancies, and (eek) looser belly muscles and (sigh) looser skin, here may be a place where I am different in how I advise my patients.  I watched my body change.  I knew it was coming.  I wanted these children more than anything.  But my body will never be the same.  Every person has what price they are willing to pay for perkier-lifted-firmer breasts or a flatter-tighter-waist-defined belly.  What amount of risk? sensory change? scar?  I can sense when I have a patient who has a low price they are willing to pay.  They need a surgery to go perfectly and scarlessly or they will regret it.  For these patients I advise them what you have now sucks, but it is G-d given.  You earned it with your kids.  Do you want to do this?

So I show scars.  I show them when they are new and red and visible.  The patients who can see these and go forward will be happy.  The ones who can’t are usually the ones who had too low of a price and should stick with what they have.