Surgery & Scars

All surgery results in scars. Every time the skin is cut in surgery, a scar is produced. The ideal end-result of any plastic surgical procedure is a good quality scar which is well placed and able to be camouflaged.

Scars take time to settle. The lumpiness, puckering and thickening in the scar take 2-3 months to diminish, whilst the redness and pigmentation can take up to 9-12 months to fade. Most scars become flat and pale after 12 months. The width of the scar is dependent on the amount of scar 'stretch'; this is determined partly by the area of the body and the genetic trait of the patient.

Scars on the face usually become fine white lines, whereas on the body, they can vary from thin white lines, to widened pale scars. 'Cross-hatching' of the scar (horizontal lines across the length of the scar like rungs of a ladder) can be minimised by removing sutures early and using deep stitches to diminish the tension across the scar; however, in some individuals, these scars are unavoidable.

Numbness in and around the scar is to be expected. Nerves are divided locally with incisions, and this will result in numbness often permanent. Nerve regeneration may occur for several months, giving tingling, pins-and-needles sensations to the scar. Scar numbness often becomes unnoticeable after a few months due to either some nerve regeneration or brain adaptation.

Factors affecting scar formation

• The quality and appearance of scars vary widely with the following factors:
• The individual's healing process
• The position of the scar on the body
• The degree of tension placed on the scar
• Whether the scar is over mobile areas of the body (e.g. joints)

Every individual form very different types of scars, these are determined by:

• Personal factors
  • Nutrition state
  • Protein and vitamin deficiency can impede collagen synthesis, thus wound healing
  • Underlying medical conditions e.g. diabetes, vascular disease
  • Some medications (e.g. steroid therapy, anti-inflammatories) may limit the healing process
  • The age of the patient can also be a factor
  • Bleeding tendencies or vascular diseases can affect wound healing
• Genetic traits in scar formation
• Racial and ethnic background

Many of these factors are beyond the control of the surgeon, and often cannot be predicted before surgery. As plastic surgeons, we try to hide scars in natural body/facial lines, and to camouflage their existence if possible. We also employ particular suturing techniques to maximise the quality of the scar.

Some forms of surgery will predictably produce good scars which are well camouflaged such as the scar in front of the ear when face-lift surgery is performed. However, with certain operations the scar will always be visible; operations such as breast reduction or abdominal surgery produce scars which are visible, and prone to stretching, thickening, redness and tenderness.

Unfavourable scars

Every surgery carries the risk of developing unfavourable scars. These are scars which have characteristics that make it difficult to be camouflaged, such as lumpiness, thickness and significant discolouration.

Some factors which may predispose to unfavourable scarring are:

• Wound infections
• Wound dehiscence (where the wound opens up 2-3 weeks after surgery)

On some areas on the body there is an unpredictable healing response. Some patients can form hard, red, thick hypertrophic scars which cannot be anticipated by the surgeon before the operation. The type of scarring produced by any previous surgeries may give an indication to the type of scarring that might result. In the worst cases, these scars will take one to two years to reduce in thickness and will never end up as thin line scars. The degree of stretching depends on personal healing qualities and the area on the body where the incision is located.

There are many aberrations of scar growth; the most common is called keloid scarring. Keloid is a tumoural scar resulted from the accumulation of excessive amounts of collagen. These typically occur in particular areas of the body, such as ears, midline of the body, over the upper arms and over the joints. Keloids are also more common in individuals with darker skin, such as those with Asian, African or Indian background.

Keloid scarring does not occur straightaway; often it starts to develop 3 months after surgery, and can continue to enlarge over months to years. Early treatment may prevent it from progressing. To find out more about treatment of keloid scars, click here.

Ways to optimise your scars

It is important to follow the post-operative instructions given to you by your surgeon. These are given to minimise the chances of infection, decrease wound breakdown, and unfavourable scarring.

The colour of your scar

Surgical scars, when settled or mature, are always white (they contain no pigment producing cells) but occasionally scars can over pigment (i.e. become darker). This is usually due to sun exposure but can be exacerbated in certain skin types, oral contraceptive pill (and other hormone treatment) and certain drugs. To minimise the colour change, it is always important to protect the scar from sun exposure in its early stages. Covering with clothing and hat, as well as sunscreen containing zinc oxide or titanium oxide is essential.

The texture & appearance of your scar

Scars will nearly always mature and flatten, but the time interval for this to occur is variable, from several months to several years. Lumpiness and thickening of the scar can be due to scarring in the deeper layers of skin, fat and muscle. This is more prominent when the skin or other layers have been separated.

The deeper scars can behave in the same manner as skin scars, becoming thick, lumpy, raised and tender. As with skin scars, deep scarring will settle or mature with time but the process may take many months. The most noticeable areas where this deeper type of scarring can occur are in the cheeks of the face-lifts, in the breasts after breast surgery or in the soft tissues after liposuction.

Often it is recognised as hardness or persistent 'swelling' of the operative site. Both skin and deep scarring are responsive to regular massage and other types of treatment (such as topical silicone), but time is always necessary.

Click here for Dr Vrtik's postoperative instruction for your scars.

Before you decide on proceeding with your surgery, please remember:

• Scars are always visible.
• Scars always take time to mature.
• The appearance and quality of a scar can never be guaranteed.

There are a number of procedures available that can treat an unfavourable scar to minimise its appearance or decrease scar discomfort.

Dr Vrtik can help you determine whether your scar can be improved. Click here for more information on scars and scar revision.