We plastic surgeons do not do scarless surgery.
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.