Given scars are often an inevitable part of surgery, how can we minimise the hallmarks of an operation?
Most scars fade over time, usually over a period of a year to 18 months, although scars can mark our bodies permanently – whether it is apparent or barely visible. We live in a world where smooth, youthful skin is prized and sought after. Therefore, it’s not surprising to find that the psychological impact of scars can be distressing for those who bear them, particularly if they’re marked on visible areas.
The facts are ugly. Studies suggest one in three scars becomes a permanent, often unsightly fixture with a raised ridge of hard tissue. Some can even continue to grow long into the healing process. One study found that nine out of 10 people who had undergone a routine surgical procedure within the past six to 12 months were unhappy with their residual scars.
The possibility of managing scarring is a new area of interest for surgeons and clinicians in the medical industry. Combining this recognition with promising new approaches to scar avoidance could mean disfiguring scars following surgery may soon be a thing of the past.
One scar-prevention drug is in its final development phase and claims to be the first of its kind on the market. Made from a naturally occurring human protein known as transforming growth factor, it helps the skin weave back naturally. It has been shown to dramatically reduce the risk of scarring when injected immediately after surgery.
Still, what should we do while we wait for these advancements to catch up to our demands? Luckily, far more can be done than most of us realise to prevent abnormal scarring and to treat existing scars.
What is a scar?
Any wound that penetrates through the epidermis and into the dermis will cause scarring. However, the severity of the scar depends on the success of the skin’s repair response and the behaviour of your collagen.
Collagen is the fibre-like protein that aids healing of skin and wounds by adhering together. In normal, healthy skin, the bundles of collagen are in a woven criss-cross pattern. The best case is when the epidermis around the edges of the wound closes together with the gluey collagen, staying flat and occupying the narrowest possible level surface.
The worst-case scenario is when cells that repair the hole in the skin, known as fibroblasts, go into overdrive and a whole new system of blood vessels is set up to cater to the scar – triggering a collagen overload. Instead of neat criss-cross patterns, bundles of collagen form rigid, parallel lines, sometimes glueing layers of tissue and tendon together and forming lumps. The collagen also overflows onto the skin surface, creating rubbery scars that smother healthy tissue.
Exactly why this happens with some scars and not others is not fully understood. A wound does not become a scar until the skin has healed completely. After the wound has healed, a scar continues to alter as new collagen is formed and the blood vessels return to normal. This is the reason most scars will fade and improve over the two years following an injury to the skin. However, there will always be some visible evidence of the injury, and hair follicles and sweat glands do not grow back.
Why do we scar?
There are a number of possible answers to this question when it comes to undergoing a surgical procedure and bearing subsequent scarring. Poor surgical technique can contribute, so it’s important to select an experienced doctor with a good reputation. An individual’s genetic predisposition also weighs in, as does the location of the wound. Certain areas are likely to trigger worse scars, particularly those above moving joints.
What are the different types of scars? There are lots of different causes of scarring, but not all scars are the same. Some types of scars include stretch marks and chicken pox scars, whereas scars that are deemed problematic include hypertrophic and keloid.
Flat, pale scars are most common and are a result of the body’s natural healing process. Initially, they may be red or dark and raised after the wound has healed but will become paler and flatter naturally over time.
Sunken scars are recessed into the skin and are usually a result of injury. They may be indented due to the skin being attached to deeper structures (such as muscles) or to loss of underlying fat. Another reason for sunken scars is residual pitting from acne and chicken pox.
Stretch marks develop when the skin is stretched rapidly, for example during pregnancy, weight loss or gain or a growth spurt. Initially, stretch marks appear red but become paler over a number of years.
When a normal wound heals, the body produces new collagen at a rate that matches the breakdown of old collagen. A hypertrophic scar is formed when the collagen is able to build up on the surface of the wound. The scar remains within the confines of the original injury but is hard, raised and red. They may itch, though are not usually painful.
Hypertrophic scars are more common in young people with darker skin and those with an inherited tendency to this type of scarring. It is not possible to completely prevent hypertrophic scars and they do come as a risk of surgery. Anyone who has suffered one should inform their doctor prior to a procedure. Scar therapies that may speed up the process of change from a hypertrophic scar to a flatter, paler one are available.
Like hypertrophic scars, keloids are the result of an imbalance in the production of collagen in a healing wound. Unlike hypertrophic scars, keloids grow beyond the boundary of the original wound, affecting healthy tissue and creating lumpy scars that can continue to grow indefinitely. They may be itchy or painful and may not improve in appearance over time.
Anybody can get a keloid scar and they can occur anywhere on the body. However, young people, whose skin has a tendency to over-repair, and those with darker skin are around 15 times more prone to this type of scarring. It is also more common on certain parts of the body such as the ears, chest, shoulders and back.
Those who have developed one keloid scar are more likely to be prone to this condition in the future and should alert their doctor when undergoing a cosmetic procedure.
An internal scar is an adhesion that can be formed deep inside the body or just below the skin’s surface. They occur when the tissue that has been operated on develops a scar that sticks organs to tissues. Those just below the skin surface can cause problems with muscles and tendons.
The most common site is on the chest where the scar can connect to the sternum, however hands are generally the most problematic. When the top layer of skin becomes attached to the muscle or tendon beneath, it can cause other symptoms, such as rigidly fixed curled fingers.
How can we prevent scars?
Discuss this with your medical practitioner prior to undergoing a procedure. You can better manage scarring by being educated and prepared. Communicating that scarring is a key issue with your surgeon may affect where they make the incision or the techniques utilised, especially in procedures such as breast augmentation.
Any wounds should be covered with a light, compressive dressing or pad post-procedure to keep it moist and prevent a scab forming. A scab can create a barrier to healing, so by keeping the wound moist you can steer the collagen away from the surface of the skin.
Once the dressing is removed, use a moisturising lotion to hydrate the skin around the scar. This improves the healing process and helps ensure a balanced release of collagen. You don’t need an expensive moisturising cream, just something you know you have no reactions to initially.
Gently massaging the scar for 30 seconds to a minute several times a day, from the time the wound has healed over, will assist in breaking up the scar tissue and help prevent the collagen from becoming lumpy.
What can we do to treat scars?
No scar can ever be removed completely, though they may improve naturally over a period of time or respond to methods to improve their appearance. It is best to treat scars early when they are more susceptible to less invasive treatments, as older scars tend to respond better to more involved treatments such as laser or surgical removal.
Laser works either by targeting the blood vessels that feed raised red scars or, in the case of CO2 lasers, removing the surface layers of the skin. Fractional CO2 lasers work by ablating discrete columns of tissue to remove some of the scar and stimulate collagen remodelling to create healthy new skin in its place. It is important to establish that a fully trained medical practitioner carries out any laser therapy with experience in improving scars.
However, smaller gestures can be made to improve scars. A course of steroid injections can help to soften and flatten a hypertrophic or keloid scar.
Pressure garments are most often used for burn scars, under supervision, once the wound has healed. They are made to fit like a second skin and it is thought the continuous pressure on the surface blood vessels allow the scars to become softer, flatter and paler.
Low-dose, superficial radiotherapy may reduce the recurrence rate of hypertrophic and keloid scars after surgery, and cryotherapy uses specialist equipment to freeze the scar tissue using liquid nitrogen. Dermabrasion can be used to reduce irregularities by removal of the surface of the skin with specialist equipment. It may be helpful where the scar is raised above the level of the surrounding skin but is less useful when the scar is sunken or pitted.
In the case of pitting, collagen can be injected to build up the level of the skin. However, the effect is temporary and injections need to be repeated at regular intervals.
Both waterproof and flexible, silicone gel sheets look and feel like transparent gelatine and work by flattening, softening and fading red and raised scars. They are comfortable to wear and easy to apply, even on awkward areas such as joints, and can be cut to fit. It works by moisturising and covering the scar area, helping to reduce size and improve the colour and elasticity.
Although Vitamin E creams may be recommended for the self-management of scars, there is no empirical medical evidence to suggest that it has an effect. However, it remains good for nourishing the skin and the action of massaging it into the scar tissue is beneficial for helping to keep the tissue flat and free of lumps. For those who are self-conscious, cosmetic camouflage with makeup can also be a very effective way of disguising a scar.