Scar Management

Serving Chattanooga, Tennessee

s plastic surgeons, we are frequently asked to consult with patients regarding unacceptable scars. These scars may have been caused by an accident or by a planned surgical intervention. Not long ago, the principle academic journal of plastic surgery discussed scar management at length, and this article serves as the basis for modern scar treatments.

Firstly, the manner in which the scar was created is important. For example, a poor scar from a surgical procedure is less likely than one from a car accident with windshield breakage. Secondly, there are those who seem to be more predisposed to significant scarring. The most significant example of this is a keloid. A keloid is a tumor of scar tissue, not just an ugly scar. A classic keloid is a golf ball sized scar which can develop from as little a trauma as an ear piercing. True keloids are more likely with darker skin tones. Lastly, the technique of skin repair can lead to unacceptable scarring. Thorough cleansing and removal of significantly injured tissue accompanying fine closure is a standard of care, not just specific to plastic surgery, but well known in all surgical specialties.

So, when the newly closed cut or laceration patient is examined, we first observe the closure technique. If this has been adequately accomplished-and it typically has been, then we determine the appropriate time for suture removal. On the face, skin sutures are removed in 5 or 6 days. With suture removal completed, a regimen of taping begins. I use "Steri-Strips" and instruct the patient to use the strips for up to a month. As tenderness permits, the patient is instructed in wound massage. Massage of the scar is crucial for the best appearance.

Any number of substances has been credited with the capacity to improve the appearance of scars. I suppose the most famous of these is vitamin E. What we do know is that the simple application of any substance to date (with controlled scientific trial) has not been affective at improving scars in the long run. Massage of the scars with a moisturizer of choice is a much better bet.

Research has, however, borne out the utility of silicone onlays. This treatment is simply a sheet of silicone which covers and puts pressure on the scar for 12 hours a day. I begin this treatment at about a month after injury. These onlays have been an important part of burn management for years and are now available over the counter. I have seen silicone bandages manufactured by "Curad" and the makers of "Neosporin".

Ultimately, if a scar persists in redness or appears to be increasing in size, then a controlled use of steroid injection may be indicated. Downsides of steroid injections include loss of pigmentation and the creation of thin, wide, bluish scars, which may be no better looking than the original scar. I always caution the surgeons I train to be very careful with steroid injections. Safe treatment should require multiple injections.

True keloid management would be a subject for another article, but I do revise scars. There should be a reason for revision. Is there retained suture, foreign body, deep skin tones, suboptimal closure? Once the scar is revised, the regimen starts again. I am very clear with scar patients that despite our best effort, the scar may not improve. Occasionally, it could be worse. So, scar revision should also be used judiciously.

Scar management can be a very difficult problem, but with this bit of knowledge, and most of all patience, reasonable improvements can be expected.