Beauty

How to Heal a Scar

While some scars are sexy, we’d prefer that most cuts—from a small scratch on your chin to incisions made for major surgery—simply disappear as they heal. Many do—and a subset of them don’t. There’s unfortunately little rhyme or reason to why one injury scars, another scars badly, and the other leaves no evidence of ever having been there—says top plastic surgeon Steven Teitelbaum, M.D. Associate Clinical Professor of Plastic Surgery at the UCLA School of Medicine, and president of the California Society of Plastic Surgeons. Here, he walks us through what can and can’t be done—from in-office procedures to at-home remedies—and how to know when to call in a plastic surgeon.

A Q&A with Steven Teitelbaum, M.D.

Q

Is it possible to prevent a scar?

A

My dad has often quipped, “Parents take too much credit for their children’s accomplishments and too much blame for their misbehavior.” So too do surgeons take too much credit for their good scars—and too much blame for their bad scars. Indeed plastic surgeons have created a mythology around their ability to create great scars, and they are happy to take credit when they are imperceptible. But they run away from their bad scars and blame it on the patient. You can’t have it both ways!

Here’s the bottom line: A horrible doctor could create some pretty ugly scars, but the best surgeon in the world will not always have a great scar. There is some finesse in what the surgeon does, but truly bad scars are a matter of patient biology every bit as much as good scars are a matter of patient biology. I always say that if a scar is great at one month, the surgeon has done all he/she could. (Indeed a scar is usually a fine line at that point in the hands of most plastic surgeons.) But after that the patient’s own biology takes off, totally outside of our control.

Q

What are the most common types of scars that people come to you to treat?

A

Far and away the most common scars patients see me for are C-section scars—not necessarily because the scar itself is bad, but because the scar is stuck down to the muscle, creating an indentation and sometimes a little overhang of tissue above. Fortunately these are very straightforward to repair, either on their own or in combination with some sort of a tummy tuck. It is very important for a surgeon to be extremely gentle with the edges of an incision. If they are treated roughly, the scar can be wide because there is more damaged tissue: One of the most important things a surgeon can do is make a clean and perpendicular incision, and take great care to avoid trauma to it during surgery. If the edge gets abraded, a surgeon should trim it back to healthy skin just before closing the incision.

“Far and away the most common scars patients see me for are C-section scars—not necessarily because the scar itself is bad, but because the scar is stuck down to the muscle, creating an indentation and sometimes a little overhang of tissue above. Fortunately these are very straightforward to repair.”

Patients often come to see me for treatment of plastic surgery scars. (The scars that plastic surgery patients most complain about are from breast augmentation using the incision around the areola. These can look like a smiley face on the center of the breast if they do not heal well.) It is very important that after plastic surgery, patients have the option to “maintain deniability.” That doesn’t just mean that the scars should scarcely be visible; it also means that if someone happens to notice, the patient can believably deny they were from plastic surgery: Liposuction scars should be hidden in a crease, stretch mark, old scar, or a tattoo. If that isn’t possible, it is important to make sure that scars on both sides of the body are not symmetrically placed. One should be higher, wider, or at a different angle, so that the eye of an observer isn’t drawn to two obvious surgical scars. A facelift scar is usually thin and fades. But even an excellent scar needs to hug around all the curves of the ear and leave the ear and hairline undistorted. If the scar does happen to thicken, it will at least exist along naturally occurring borders, hidden in shadows, concealed within concave contours, so that only bits of it are visible from any particular angle.

Q

Is there a particular type of injury that tends to scar more, or heal more easily than others?

A

Location and direction are very important factors in distinguishing whether essentially the same-size cut will result in a scar thats nearly invisible or not. Our skin has natural lines of tension, and their orientation varies throughout the body. A patient lucky enough to have a cut in that orientation may end up with a nearly invisible scar, while the identical cut perpendicular to those lines can result in a visible scar. Here’s a clear example: A horizontal cut on your forehead will blend into the natural lines and fade. But one that is vertical will cross those lines and spread and be obvious. Injuries that have a “wide zone of injury”—meaning that tissue is damaged beyond just the cut itself—often have a worse scar because there is more injury than immediately meets the eye.

If there is any critical thing a plastic surgeon does sewing up a laceration versus an emergency room physician, it is the willingness and confidence to trim the wound, even if it at first makes it look larger, in order to put together two clean edges.

Even skinning your knee on the pavement can create a bad scar if little bits of road debris gets buried into your scar, giving you you what is essentially a permanent tattoo. Any wound that gets infected gets more red and inflamed, so it is very important to prevent infection—and treat it right away if this occurs. While superficial burns usually heal perfectly, deeper burns can leave severe scars. A deep burn can remove hair follicles, oil glands, and pigment cells, so the area will always look different than the surrounding skin. And rather than two edges of skin mending together, a deep burn may have to heal from tissue growing in towards the center from the edges; this does not form normal skin.

Q

Are there parts of the body that scar more easily?

A

Thin skin scars well and thick skin scars poorly. The thinnest skin is the eyelid and the thickest is the back. It is almost impossible to get a bad eyelid scar, and it is definitely impossible to get a great back scar. If someone asks me to remove a mole on their back I joke with them that I will only do it if they promise not to tell anyone that I was their surgeon! Scars over the breast bone have a particular tendency to thicken, as well as scars on the side of the chest, such as the end of a horizontal breast reduction incision. Scars where there is always tension tend to widen, like the upper-inner chest in the décolletage area. (Many women develop concerning growths there from sun damage that need to be removed, or they may have this from a breast biopsy.) Scars over a joint, such as the shoulder or knee, often widen. I always ask a patient if they have had previous surgery, so I get a sense how they scar, but a bad scar over a joint or on their back does not concern me.

Q

Are there other factors that can make a person scar more easily or visibly (weight, skin tone, age, etc.)?

A

While certain parts of the body naturally have thin skin such as the eyelid, skin that has stretched and thinned after significant weight loss usually scars very well. I’d much rather do a breast lift on a woman whose breast skin is thinned and stretched after nursing a few kids than a woman with thick and tight, young skin. Generally, the fairer and drier the skin, the better the scar. So a young, thick, tight, more oily Asian or Mediterranean skin may be more likely to have a bad scar than Northern European skin, but I have also seen many Irish patients with red and thick scars.

It is interesting that up to about twenty-four weeks gestation, a fetus heals totally—without a scar. Even newborns have privileged scarring, which is why the belly button doesn’t scar after the umbilical cord falls off and why a circumcision done on a baby scars well. But this state rapidly is replaced by normal adult healing.

Q

How do you tell when a potential scar is major enough that you should probably see a plastic surgeon?

A

Scars are not just aesthetic; sometimes they can inhibit function. The movement of a joint can be restricted or an eyelid might not close. Sometimes the initial cut may have caused an unrecognized injury to a deeper tendon or nerve, so any dysfunction in the area should be recognized. Cuts along the border of the lip must be properly aligned, so if there is a “step-off” after a lip cut, it may need to be revised.

It is also normal for scars to thicken and redden during the first six months and not start to fade until after that. But the bottom line is that if you are looking in a mirror and worried about a scar, it is worth the visit to a plastic surgeon to see what can be done to help. In most cases there is something they can do. It might just be reassurance that it needs more time, a cream, a silicone patch, or a laser treatment. In some cases, the scar might need to be excised and the wound more carefully put back together.

Q

In terms of less-severe, treatable-at-home cuts, is there anything people can do to minimize the scar?

A

The most important thing is to decide whether it needs stitches at the time it happens. Is there a gap? Can you see fat? Is the skin at the edges smashed and damaged? Those are signs that stitches are probably necessary. For any cut, it is very important to wash it well and remove any germs. Even though it can hurt, be sure to scrub out any dirt or gravel because those particles can be trapped inside and literally permanently tattoo the scar.

In the early period, minor cuts are best treated with just occlusive ointment, Aquaphor. Burns are best treated with aloe—it’s one of the few natural ingredients that has been shown in valid clinical trials to be helpful. Limiting sunlight is important; vitamin E theoretically helps because it inhibits the collagen production that is a part of a scar, but its effectiveness has never been validated in a trial. The same is true of Mederma, and of massaging a scar with oil.

“For any cut, it is very important to wash it well and remove any germs. Even though it can hurt, be sure to scrub out any dirt or gravel because those particles can be trapped inside and literally permanently tattoo the scar.”

Q

What causes a keloid and are there any products or techniques to avoid it happening?

A

Patients will often call any scar they do not like a keloid. In fact, a true keloid is very rare; it is defined as the scar tissue growing beyond the boundaries of the actual incision, almost like a tumor. More commonly, a bad scar that is raised, thick, ropey, and itchy is actually a hypertrophic scar. That just means that the scar is bigger and thicker than it should be.

There are certain types of sutures that may reduce the chance of this happening, but I have seen hypertrophic scars occur even when I’ve used the identical technique that produces nearly invisible scars in almost anyone else. Reducing trauma at the edge of the incision can help, but, again, I’ve seen hypertrophic scars with my most perfectly made and closed surgical incisions. I’ve also seen horrible traumatic injuries that were never treated heal near-invisibly. The point is that even if a surgeon were asked to create a keloid or hypertrophic scar, there is nothing they could do to knowingly create it. The issues are at a fundamental microbiological level. After surgery, though, treatment with silicone sheeting can reduce the likelihood of it occurring.

Q

Is it better to keep a wound covered or “let it breathe”?

A

Wounds heal better in a moist environment. But sometimes a wound can get “waterlogged” and needs to be allowed to dry out.

Q

Are there effective treatments for old scars that won’t fade?

A

There are creams that can reduce pigmentation in scars, and lasers can be very effective even years after the formation of a scar, though they’re often more effective if instituted earlier. The problem with old scars is not the scar itself, but blood vessels around them: I frequently see well-healed scars that are totally faded and flat, but there is a rim of red around them. That red can be treated with a laser. At other times, there is a very pale line in a patient with a brown or sun-damaged complexion, so that it looks like there is a white line. Sometimes those patients might get a small bit of permanent makeup (tattooing) skillfully done into the scar.

Q

For patients getting plastic surgery, are there steps you have them take pre- and post-op to minimize scars?

A

Some surgeons sell expensive nutritional supplements for before and after surgery, but that’s either a matter of greed, giving the patient something to do, or making them feel that you are open-minded and au courant. I believe they don’t do anything. After surgery, I encourage various scar therapies, such as tape, silicone sheeting, silicone-based ointments or creams, laser, and injections of certain medicines that soften and flatten scars. The key is to stay on top of it and treat at the first sign of something going awry.

Plastic surgeon Steven Teitelbaum, M.D. is an Associate Clinical Professor of Plastic Surgery at the UCLA School of Medicine and president of the California Society of Plastic Surgeons. He practices in Santa Monica, and works extensively with (and is a past president of) the Aesthetic Surgery Education and Research Foundation.

The views expressed in this article intend to highlight alternative studies and induce conversation. They are the views of the author and do not necessarily represent the views of goop, and are for informational purposes only, even if and to the extent that this article features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment, and should never be relied upon for specific medical advice.

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