General advice for new scars

Many strategies to improve the appearance of a scar are most effective when started early in the healing process. Obviously, you should always follow the advice of your doctor, but some good general points to follow are:

1. Keep the wound clean: This is best done through showering & fully drying the wound afterwards. Avoid the use of perfumed products and always dab rather than rub dry. Do not submerge the wound for a long time (e.g. by taking a bath), and always dry the wound fully afterwards. If you have stitches, be sure to follow the instructions you have been given carefully.
2. Do not use antiseptics or powders. Certain ointments can be useful & your doctor or pharmacist should be able to provide information on these products.
3. Start scar massage early: this can help your scar settle down more quickly & prevent problems with hypersensitivity.
4. Wear SPF: Scars take at least a year to mature. An immature scar that is exposed to excessive sun or gets burned as it tries to heal is more likely to end up hypertrophic or with abnormal pigmentation.
5. Follow advice on heavy lifting & exercise! Many people wonder why they are told to avoid heavy lifting, etc. for weeks after a seemingly small surgical procedure. Typically, the skin will have regained only 10% of its previous strength by the time stitches are removed. Lots of heavy lifting/ physical activity too early can put excessive tension on the healing scar, resulting in a stretched appearance in the long term.
6. Avoid further trauma to the area.
7. Always tell your surgeon if you have a history of hypertrophic or keloid scarring prior to surgery being performed.

General advice

When a patient sees me for advice on a scar, my first advice is often to adopt the strategies in the self-treatment section. This is because these strategies are effective, and most likely will need to be continued in combination with any additional intervention.

Surgery

It may be possible to improve a scar through surgery (“scar revision”). This usually involves reopening all or part of the previous scar, and may involve further cuts or moving skin to improve the orientation and appearance of the scar. Other less invasive surgical options may be appropriate for indented scars. It is not possible to completely remove a scar, and there is always the possibility of an unsatisfactory result (including making the appearance of the scar worse). As a general rule, I will not offer a surgical revision unless I feel that there is a strong chance that the scar appearance will be improved by this intervention.

If I see you before a scar is fully mature, you may be told that it is best to wait until the scar has fully healed and settled before any surgery is appropriate. This is because operating on an immature scar gives less predictable results. However, it is often worth seeking a specialist opinion early, for general scar advice, as well as to pick up on the development of hypertrophic or keloid scars which often respond best to early intervention

Laser

A common question plastic surgeons are asked is whether it is possible to remove a scar with laser. The short answer is no – however the appearance and behaviour of a scar may be improved using various types of laser. Results that are possible include fading redness out of scars, improving pigmentation, and blending the scar with surrounding tissue making it less noticeable. Advanced laser techniques can be used to improve the suppleness of scar tissue and even improve the ability to move joints where contraction of the scar limits this.

As the use of medical lasers is almost completely unregulated in this country, you should exercise caution when choosing a practitioner for laser treatments. By choosing a doctor who is on the Specialist Register in plastic surgery or dermatology, you are guaranteed a specialist who has extensive training in the structure and function of skin. Often these doctors will work closely with nurse specialists, who have extensive experience and knowledge of laser treatments.

Injections

Injections of steroid directly into the scar are one of the most commonly employed and effective treatments for lumpy red scars (usually hypertrophic and keloid scars). A course of four to six injections spaced four to eight weeks apart (depending the scar and the response seen) is commonly employed. Steroid injections are most effective at reducing the bulk of a scar, but may also be associated with a reduction in redness. Many patients report a reduction in itching and pain in their scar before the bulk reduces. Side-effects may occur, and include changes in pigmentation in surrounding skin (particularly noticeable in darker skin types) and hollowness of the area if the steroid is injected into the underlying fat.

Other drugs that work to reduce the abnormal activity of scar cells may be combined with steroid or used alone to treat scars. 5-fluorouracil is one such drug, & used in combination with steroid, it has been shown to be more effective than steroid alone. This is generally my first choice on injection therapy. 

Fat injections

Purified fat, taken from elsewhere on the patient’s body, is a substance that is revolutionising the field of plastic surgery. It can help improve the appearance of damaged, scarred skin, and in highly effective in improving the contour if indented scars. Fat injections have also been shown to be effective in the management of chronic pain associated with areas of scar.

Botulinum toxin

Botulinum toxin injections are used to relax muscles, often to reduce forehead wrinkles, etc.. Depending on the location of a scar, these injections may be used to relax surrounding muscles, thereby making a scar appear less obvious.

Fillers

Dermal filler injections, more commonly used for cosmetic purposes, have been used to improve the appearance of sunken scars. Unfortunately, results have been somewhat disappointing, & as fillers are designed to dissolve after a period of months, even the best result will be short-lived.

Radiotherapy

Radiotherapy has been shown to be effective in reducing the recurrence of keloid scars, and is usually combined with surgical removal of the scar. Its use is reserved for difficult cases, owing to the long-term side effects of radiation on skin (which include development of skin cancers). 

Pressure garments

Medical-grade pressure garments are generally used in the treatment of extensive areas of scar. These garments are customised for each patients from measurements taken by Occupational Therapists. Their use is often combined with a silicone product. Although they have been observed clinically to be effective in reducing bulk and redness of scars, we do not yet have a scientific explanation for why this is a case. Because they fit very close to the body and need to be worn 24/7 for many months, patients may find it difficult to complete a course of treatment.