POST-OPERATIVE SCAR AND INCISION MANAGEMENT OPTIONS
Any type of surgery will produce a scar. Most scars fade very nicely, but occasionally they may thicken, widen, or remain red. The normal course of healing of any scar is that it will start out firm and red, but then soften and fade over time. This is a process that starts soon after surgery, but may take a year or longer to complete, and scars in light-colored skin can take two or even three years to finish fading.
The final outcome is determined by several factors, but probably the most important factors are your genetics and the location and direction of the scar. Vertical scars in the midline of the chest (as seen after open-heart surgery) or on the back often thicken and widen, whereas horizontal scars in the abdomen tend to be softer and thinner. Often the best way to predict what kind of scar you will have is to look at any other scars you may have on your body; if your other scars are thin and soft, there is a better chance that your surgery scars will be thin and soft as well. If your other scars have tended to thicken, then your surgery scars might thicken as well.
Other factors include how the surgery is performed and how you take care of your incisions after surgery, but the genetic factors dominate, regardless of how carefully the surgery is performed or how you take care of it afterwards.
However, there are some things you can do to help the scars heal better and more quickly. Some patients will do all of these things, and some will not do any of them. Even if you do not do any of them, the scars usually heal well.
The first thing, of course, is the surgery. I will design and execute the surgery as carefully as I can. After surgery, depending on the area, I may place surgical strips to help support the incisions. These are adhesive, and in some areas, like the back, they tend to cause blisters, so I do not use them there. In other areas, such as the sides of the face, they do not hold very well, so I do not use them there, either.
If I do place surgical strips on the incisions, you can take care of them by generally keeping them dry. It is OK to shower with them and get them wet in the shower, but then try to gently dry them off afterwards. Some patients have used a blow drier to help dry them off, and that can work well. Often, the strips start peeling off after a week or two; if they do, you can trim the portion that has peeled off with a scissors. If the strips completely peel off, you can leave them off; there is no need to try to replace them. If you notice any blistering under the strips, then those strips should be removed as soon as possible to prevent more blistering. If the strips are still on after four weeks, they should gently be removed. We are always happy to help you with any of those steps at our office.
Sutures That Become Visible
After the strips have been removed, it is not uncommon for some of the deep absorbable sutures to work their way to the surface. Ultimately, all of these absorbable sutures will dissolve, but for the first three months or so you may see them come to the surface. If that occurs, we can hasten the healing by removing those in the office. This is so common after surgeries such as breast reduction or breast lift that we normally schedule visits for this at one, two, and three months after surgery. You can try to remove these sutures yourself with forceps, but they will not usually come out easily unless it has been six weeks or more after surgery.
During these first few months, you should avoid submerging the incisions in standing water, such as a bathtub or swimming pool, if there are any open areas along any of the incisions. This would include scabbed areas or openings where a piece of suture is visible, although clean water from a shower is not a problem.
After The Strips Are Gone
Once the strips are off, there are a few options. Unfortunately, there is a lot of misinformation out there, including from surgeons who should know better but also widely on the Internet. As a general principle, when there are lots of different ways of doing anything, it usually means that none of them work that well, and that is certainly true here. As I mentioned before, your genetics are the biggest factor in healing, and most scars will heal well regardless of how they are managed, so just because you used a product and your scar healed well, that does not mean that the product itself actually had any effect.
Two treatments that have been shown effective for minimizing scarring are massage, usually with a lubricant of some sort, and silicone sheeting. However, it can be hard to do both massage and use silicone sheeting, because you cannot really massage the scars with the silicone sheeting in place.
Massage has long been known to help soften scars. It works best to use a lubricant of some sort; good choices are Mederma, a commercial scar product available at the drug store, and Vitamin E oil, obtained by cutting a liquid-cap of Vitamin E. Massage should be done fairly firmly, and ideally for fifteen minutes, three times a day. Although this is one of the most effective scar management techniques, it is also one of the most work-intensive, and it is often difficult for patients to do massage three times daily. Each patient will decide how much scar massage is practical.
The silicone sheeting can be applied either as a sheet or a self-drying gel. If used as a gel, it should be applied twice daily, and should be applied after any scar massage. Therefore, if you do the massage three times daily, you will apply the gel three times daily as well. The silicone gel product I recommend is BioCorneum. It is produced by Sientra, one of the breast implant manufacturers, and is readily available on Amazon for less than we could sell it in my office. It is applied as a very thin layer, and then allowed to dry for a few minutes. Again, it should be applied at least twice daily, or after any scar massage.
Another way to apply silicone sheeting is as an actual sheet of silicone rubber. These typically have some adhesive to them, and lightly stick to the scar, putting pressure on it. When silicone sheeting is used, it works best if left on close to 24 hours per day, although you will need to take it off to shower and to do scar massage. Again, this is widely available on Amazon. Each sheet can be used many times, basically until the adhesive is no longer effective.
Embrace® Active Scar Defense Dressings
One of the best scar prevention treatments is the Embrace® dressing, which the manufacturer calls Embrace Active Scar Defense. This is a silicone sheet with two adhesive trips provided on a carrier that allows you to place it so that when the carrier is removed, the tension between the adhesive strips is released, and this results in taking tension off of the scar itself. Ideally, it is started about four weeks after surgery. Each dressing is left in place for ten days, then removed for a day, with the next dressing placed the following day for another ten days. Typically, a total of six dressings is used in each area, for sixty days of treatment with the Embrace dressing. You won’t be able to swim with the Embrace dressing in place, but showering is not a problem.
Unfortunately, the Embrace dressing works best in only a few areas, and I have seen the best results from it in the abdominoplasty area. Some patients have used it in brachioplasty (arm lift), but occasionally the adhesive will cause blistering in this thinner skin. The Embrace dressing can be a little difficult to put on yourself, so you can have a family member help you with it, or we are always happy to help you put it on. The Embrace dressing is available online less expensively than we would be able to provide it in our office.
I would also note that Embrace also has a product that they call Embrace Minimize, which is a silicone sheeting that will work as I described above for other silicone sheeting.
Microneedling with Platelet-Rich Plasma (PRP)
When scars are further along in the healing process, they may become a little firm, enlarged, or stiff. Some of that is expected in the normal course of healing, and will improve over time, but even scars that have been present a long time can benefit from Microneedling Treatments along with PRP. We can do those in our office; first, we draw a small amount of your own blood, which provides the best natural healing factors known to man. Then, we concentrate those factors with the platelets in a centrifuge, and then, after applying a topical anesthetic, we infuse directly them into the skin through microscopic openings made with very tiny needles.
The Microneedling/PRP works well both on scars and on the face to brighten up the skin. Of all the skin treatments I have seen over the years, most of which do not actually do very much, Microneedling with PRP has worked the best. Ask us if you want to know more about Microneedling/PRP treatments.
Laser Treatment for Scars
There are many kinds of laser treatments that have been tried on scars. Different lasers have different wavelength (color) light, and the effect is determined by the wavelength, because different wavelengths are absorbed differently by different components of the body. For example, the CO2 laser produces light in the infrared region and is absorbed by water and so is very effective in removing the outer layer of skin. Similarly, laser light in the green color range is absorbed preferentially by red cells, and therefore targets the tiny capillaries of blood in a pinkish scar. As a result, these green lasers can help the pink color go away more quickly.
Ointments, Creams, and Other Remedies
Often, I am asked about using ointments and creams, such as Bacitracin or Neosporin. Even more often, I see patient who have used these and wonder why their skin looks so red and weepy. Unfortunately, more often than not, these simply macerate and irritate intact skin, and many patients will develop an allergy to the antibiotics in these and will get little red bumps. The problem is that these are designed for short-term use on open areas and abrasions, and do not work well on intact skin, including skin that has an incision that has been closed.
On occasion these can be helpful, but when used they should be carefully applied with a q-tip to limit the ointment only to the open area and avoid getting it on the skin. I ask that you not use these ointments on any surgical incisions unless we discuss it first to make sure that they will be helpful and will be applied correctly.
If you have any questions about scar management (or anything else!), please feel free to ask me at any time.