Scars

I hate scars.  We all do, but I really hate them because they can be difficult to treat.  When I see “scar consult” on my patient list for the day, I get discouraged, not because I don’t want to see the patient, but because I know that I may not have the solution that the patient wants to hear.

The following is a current classification system that I use when evaluating scars:

1) Mature scar: light-colored, flat scar

2) Immature scar: red, sometimes itchy or painful, slightly elevated.  Most will mature normally over time and become flat and similar to the color of the surrounding skin.

3) Hypertrophic scar: red, raised, sometimes itchy scar within the borders of the original surgical incision.  These may increase in size for 3-6 months, and then begin to regress.  The full maturation process may take 2 years.

4)  Keloid scar: large, raised scar which extends beyond the borders of the original injury.  These can be itchy or painful, and will not regress on their own.  Surgical excision often results in recurrence.¹

Scars never go away.  They do get better with time, but once the dermis has been traumatized, that injury will always be present.  This was brilliantly discussed in Kung Fu Panda 2:

Po (the panda): See that’s the thing, Shen, scars heal.

Shen (the evil peacock): No they don’t… *wounds* heal.

Po: Oh, yeah… what do scars do? They fade, I guess…

Shen: I don’t care what scars do…!

Wait at least one year prior to undergoing a surgical scar revision.  If you have dark skin, like me, wait two years, because our skin holds onto scar pigment longer.  Scar revision involves creating a new scar in place of an old one, so it makes sense to allow the healing of the initial scar to plateau.  Many times, revision isn’t necessary after this period of waiting.

The best way to treat a scar is to prevent it from becoming a hypertrophic scar or keloid.  For this reason, I start all of my surgical patients on the following regimen:

1)      Meticulous surgical technique and preventing infection are key; this is what I can provide as a surgeon to help prevent significant scarring.

2)      After the stitches are removed, an occlusive dressing is placed.

3)      When the dressing falls off, patients begin using a scar cream twice daily, with or without a silicone gel patch.  The science behind the action of silicone on scars is unclear.  At this time, we think that silicone works by the process of both occluding and moisturizing the scar.  I rarely endorse products, but for the past 3 months, I have been recommending NewGel+E to my patients.  The results have been frankly remarkable.

4)      If patients have itching or pain at the site of a scar, I will administer a corticosteroid injection which will usually resolve these symptoms within a few days.  Steroids are tricky, though, as too much injected into a site can cause the skin to lighten and thin excessively.  For this reason, I space injections out every 6 weeks.

5)      Additional therapies, such as laser treatment, radiotherapy, and interferon are reserved for scars which do not respond to any of the above and which significantly limits a patient’s daily functions.

As Panda Po finally learned, scars never go away, but like many things in life, they do get better with time.

¹ Mustoe TA et al: International Clinical Recommendations on Scar Management, Plast Reconstr Surg 2002; 110: 560-571.

I hate scars.  We all do, but I really hate them because they can be difficult to treat.  When I see “scar consult” on my patient list for the day, I get discouraged, not because I don’t want to see the patient, but because I know that I may not have the solution that the patient wants to hear.

The following is a current classification system that I use when evaluating scars:

1) Mature scar: light-colored, flat scar

2) Immature scar: red, sometimes itchy or painful, slightly elevated.  Most will mature normally over time and become flat and similar to the color of the surrounding skin.

3) Hypertrophic scar: red, raised, sometimes itchy scar within the borders of the original surgical incision.  These may increase in size for 3-6 months, and then begin to regress.  The full maturation process may take 2 years.

4)  Keloid scar: large, raised scar which extends beyond the borders of the original injury.  These can be itchy or painful, and will not regress on their own.  Surgical excision often results in recurrence.¹

Scars never go away.  They do get better with time, but once the dermis has been traumatized, that injury will always be present.  This was brilliantly discussed in Kung Fu Panda 2:
Po (the panda): See that’s the thing, Shen, scars heal.
Shen (the evil peacock): No they don’t… *wounds* heal.
Po: Oh, yeah… what do scars do? They fade, I guess…
Shen: I don’t care what scars do…!

Wait at least one year prior to undergoing a surgical scar revision.  If you have dark skin, like me, wait two years, because our skin holds onto scar pigment longer.  Scar revision involves creating a new scar in place of an old one, so it makes sense to allow the healing of the initial scar to plateau.  Many times, revision isn’t necessary after this period of waiting.

The best way to treat a scar is to prevent it from becoming a hypertrophic scar or keloid.  For this reason, I start all of my surgical patients on the following regimen:

1)      Meticulous surgical technique and preventing infection are key; this is what I can provide as a surgeon to help prevent significant scarring.

2)      After the stitches are removed, an occlusive dressing is placed.

3)      When the dressing falls off, patients begin using a scar cream twice daily, with or without a silicone gel patch.  The science behind the action of silicone on scars is unclear.  At this time, we think that silicone works by the process of both occluding and moisturizing the scar.  I rarely endorse products, but for the past 3 months, I have been recommending NewGel+E to my patients.  The results have been frankly remarkable.

4)      If patients have itching or pain at the site of a scar, I will administer a corticosteroid injection which will usually resolve these symptoms within a few days.  Steroids are tricky, though, as too much injected into a site can cause the skin to lighten and thin excessively.  For this reason, I space injections out every 6 weeks.

5)      Additional therapies, such as laser treatment, radiotherapy, and interferon are reserved for scars which do not respond to any of the above and which significantly limits a patient’s daily functions.

As Panda Po finally learned, scars never go away, but like many things in life, they do get better with time.

 

¹ Mustoe TA et al: International Clinical Recommendations on Scar Management, Plast Reconstr Surg 2002; 110: 560-571.

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