Getting the best possible scar

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Patients contemplating surgery often ask about scars: where and how long will they be, how obvious they will look and whether they will fade. Some grimly say that “I scar badly”, often adding… “except for that one, that one’s ok”.

It is true that some people are genetically predisposed to forming poor scars, but they are the minority. Such people generally form poor scars every time and may have a formal diagnosis to explain it. For the vast majority of us – and that includes you if you have any reasonable quality scar anywhere – scar quality depends much more on what happens around the time it is healing: for instance, whether it is pulled or stretched, gets infected or if there is dead or injured tissue for your body to deal with. So how can you make your scar as good as possible? Just avoid all those things. Simples. Read on to find out how.

1)    Avoid dead or injured tissue

You might not think there’s much you can do about this, but there is one tiny little thing that makes a massive difference.

Don’t smoke. If you don’t already, congratulations. If you do, stop for two weeks before and after surgery. For many cosmetic surgeons (myself included) this is a deal-breaker, because smoking will result in you having a worse scar than otherwise, and they won’t want to take the blame for your habit.

“But what has smoking got to do with scars?”, I hear you cry. Well, it’s all about blood supply. In the long-term, smoking clogs up your arteries, but even in the short-term it makes them tighten – it has been said that one cigarette tightens your arteries for the next 45 minutes. If you smoke 20 a day, that’s most of the time. This isn’t usually that much of a problem because our bodily bits and pieces (that’s a technical term) have more blood supply than they need. However, much plastic surgery involves lifting and moving body parts and may isolate their blood supply to just one source. Then increase the metabolic requirement by asking it to heal a wound, squeeze the blood supply with your cigarette, pipe, vape or even nicotine patch, and you could be in trouble. At worst the skin end will turn black and die, but more likely it will just be a bit soggier for longer and leave a worse scar. This is 100% avoidable. Put it in your diary: no smoking, 2 weeks before and after surgery.

2) Avoid infection

If a wound gets infected, the body fights back – the redness, swelling, tenderness and pain are all signs of the body’s response, and the infected wound is the battlefield. The result is tissue injury a bit like if you were a smoker, and the consequences can be similar too.

Avoiding infection is mostly about simple common sense. The surgery will be conducted in a clean or sterile environment, bleeding should be minimised (blood clots is a fantastic growth medium for bacteria – ask your surgeon about ‘pre-emptive haemostasis’), and tissue handling should be gentle because damaged tissues are more infection-prone. After the surgery, keep dressings clean and dry and get them changed them if they become too mucky.

3) Avoid scar stretch

This is the big one. All the other stuff should go without saying as normal routine practice, whereas here is where I see greatest variability in scar care.

First a bit of science. One of the cell types involved in scar formation is the myofibroblast, which is both able to contract like a muscle and deposit scar tissue. This is clever, because it not only closes a wound with scar tissue but also reduces wound size by contracting (and stretching neighbouring uninjured tissue). How does it know when to do its stuff? It has stretch receptors built into it: when it is stretched, it does its myofibroblast thing.

Now that’s great if you want your wound to heal as fast and quickly as possible, but too much stimulation (stretch) causes too much scar tissue, which gives you a thick lumpy scar. For pretty, fine pale scars we don’t want too much myofibroblast activation, and for this we need them not to experience any stretch. But since even normal movement causes some skin pulling, that’s easier said than done.

Here you and your surgeon both have a role to play. For the surgeon, this means using lots of good deep tissue support. This means stitching the deep tissues so they are doing all the work of holding the wound together, with the skin edges sitting in pretty much the right place even before they have been closed with sutures. Whenever possible I like to do this with very slowly dissolving sutures, so that support is present until myofibroblasts have left the wound site (a couple of months).

Then it’s over to you: I insist that my patients tape their wounds externally for the same period of time, so even if the surrounding skin is stretched, the important section of skin is not. It’s like a fast-moving road with a single speed camera. Practically it’s important to use the right tape, so your skin can breathe and remain healthy whilst being taped for such a long time, so I like to issue it to my patients at their one week check-up.

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