Will it leave a scar?
That’s one of the most frequent questions patients have for their plastic surgeon before a procedure. And no wonder. We’re a little obsessed with scars. Tabloids, news feeds, and social media painstakingly examine celebrities in high definition for the smallest glimpse of a scar then speculate what procedure they might have had done.
And our obsession with scars isn’t just superficial.
Imagine that you’ve recently undergone a procedure and you’re really happy with the results. You’ve addressed something that’s been bothering you for a while and did the procedure for yourself.
Except there’s a noticeable scar. Suddenly, everyone you didn’t plan on telling suspects you’ve had ‘the’ procedure and something you meant to keep private is out in the open.
It’s no wonder at all that scars top of the list of patient concerns.
So how do you prevent scars from forming in the first place?
We’re educators and spreading misinformation just isn’t the way we roll. A scar is a product of the skin healing. It’s a good thing. A scar means that your skin (the largest organ in the body) did it’s job closing a wound. We can’t prevent a scar entirely.
But there are things your surgeon can do during surgery and care you can give afterwards to minimize a scar to the point where only you and your surgeon know.
But first we need to better understand why scars form.
With proper surgical technique and diligent aftercare, unsightly scars can be minimized. The skin is composed of three layers, the epidermis, the dermis, and the hypodermis.
What is a scar?
A scar is the remnant left behind that tells us where skin was wounded. Your skin is composed of three important layers that all play an important role during the healing of a wound. The epidermis is the protective, waterproof top layer that gives your skin color. Think of it like a blue tarp from the hardware store keeping the elements out. The dermis lies just underneath, and is the layer that gives your skin thickness, toughness, and structure (through the extensive cross-linking of collagen). Think of it like the foundation of a building. The basal layer (wedged between the two) continuously replicates, pushing dying keratin to the surface. Think of it as your own personal skin factory.
The first thing that happens when the skin is wounded is hemostasis (blood clotting) to stem bleeding. Next, emergency first responder cells rush to the site so they can seal the wound closed. A lot is happening on the cellular and biochemical level. There’s platelet adhesion and aggregation, release of VEGF (Vascular Endothelial Growth Factor), constriction followed by the dilation of the blood vessels, all in the pursuit of getting the wound sealed off fast, which is the goal of this inflammatory stage. Luckily the epidermis (that tough waterproof tarp layer) is a wonderful scaffold for all these rapidly migrating emergency cells to seal things off.
The problem is that the epidermis, where the initial wound healing takes place, isn’t particularly strong. After 1 week, it only has 10% of its tensile strength.
That’s where the dermis comes in. The dermis is where the bulk of your collagen is stored and, through extensive crosslinking of collagen units (like linked Lego blocks), it provides the skin’s support. It’s stronger than the epidermis and capable of making a scar look pretty (more like the surrounding skin) but the caveat is that this collagen takes much longer to assemble – not until after the wound has closed and rebuilding has begun underneath a scab.
And this is where things can start to go wrong.
The better the environment, the prettier the scar
A desert is a really bad thing for wound healing. A dried-out scab can really impede beautification of the scar.
Wounds heal much better (and prettier) when they’re kept moist with the appropriate dressing. This is because the moist environment allows for better cell migration and healing of the epidermis and dermis. Though a scab works well to protect a wound from infection, they’re prone to drying out. When that happens, the cells underneath trying to rebuild just can’t migrate to where they need to be. The skin doesn’t heal as well and necrosis can occur in the weaker, healing epidermal layer (the waterproof tarp). This results in a more visible scar.
Luckily the environment a scar forms in is something we can control.
What can you do to help the process?
There are things outside your control that can go wrong with the natural healing process, some of which require surgical intervention (Ex: atrophic scars and keloid overgrowth scars). There are also other conditions which can impede healthy wound healing, including diabetes, hypothyroidism, radiation treatment, retained foreign sutures, and tobacco use. If you want to learn more about those, see Dr. Linkov’s video on scar treatments here. But today we’re going to focus on the steps we can take to control the scar’s environment and help the healing process.
The first step in wound care is to keep things CLEAN. Infections can wreak havoc on the healing process and set you back, which is why surgical wounds need to be covered with an antibiotic ointment during the early stages. Reducing movement that involves the wound and sutures is also critical. Remember what we said about the epidermis being weak? After a week of healing, the wound only has 10% of its tensile strength. Too much movement can really put scar beautification at risk. When the sutures do come out (5-7 days for the face, 7-14 for the scalp) is roughly when you can transition from an antibiotic ointment to Aquaphor or a water-soluble ointment to continue keeping the forming scar moist, maintaining that ideal environment for cell migration and continued healing.
At roughly day 10-12, the incision is tested with hydrogen peroxide. If it fizzes, keep the ointment for another few days then retest. Once there is no fizzing you can transition to a scar gel.
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Why do you need a scar gel?
A few weeks out from surgery, the topmost layer of your healed epidermis (the stratum corneum) is still immature. There’s a LOT of healing left to be done and water loss at the scar tells keratinocytes (a nearby cell type) to produce cytokines, an inflammatory signal. The product of this inflammation is more collagen. This might sound great, (yeah! more collagen!) but this inflammation-triggered over production and can lead to complications. A scar gel inhibits cellular feedback and makes the keratinocytes think the scar is normal tissue. By keeping collagen production normal, the scar has a better chance of healing less noticeably. How long do you use a scar gel for? At least 3-6 months and up to a 12 months as tissue remodeling can take a year or longer. Think of it this way - you have a year to help your scar heal to the best of its ability!
What about that redness?
Inflammation and vasodilation can last for months, and it’s related to cell proliferation and new blood vessel formation. So how do you treat it? We’ll let you in on a secret. This redness always goes away on its own with time. You can use lasers, like IPL (Intense Pulse Light), to hasten this process but as Dr. Linkov points out, the cost can be significant for something that is temporary. Sometimes leaving well enough alone is the better option – for your skin and wallet.
What scar gel should I use?
Ideally a gel specifically developed for scar healing that will keep the area moist and that you will use consistently on a twice daily basis. Dr. Linkov’s surgical specialties (facial plastic surgery and hair restoration surgery), involve procedures that generate scars so it’s no wonder he’s an expert. Another thing no one on Dr Linkov’s team wants you to do is waste money on products that can’t work, won’t work, and – worst of all – could cause more damage. At feelconfident.com you can find the scar gel Dr. Linkov has developed based on the best research available on wound healing. It contains medical grade silicones, jojoba oil, calendula extract, and sunflower seed oil, all proven effective in wound healing.
If you like what we do, want to support our efforts, and are considering a scar gel please check it out.
The content of this newsletter is for entertainment and educational purposes only. This content is not meant to provide any medical advice or treat any medical conditions. Patients must be evaluated by an appropriate healthcare provider on an individual basis and treatment must be tailored to meet that patient’s needs. Results and particular outcomes are not guaranteed.