The Truth About Scars: What Actually Works (and What Doesn't)

SPEAKER_00 0:00

No, I think I think uh a lot of patients there there's a lot of marketing and a lot of products out there that are geared towards scars. I think again, you know, going back to the evidence base, you know, we we want to use what's what's beneficial. And I think silicone is the key. Even things like vitamin E, you know, my understanding is there's not a ton of proof of it.

SPEAKER_01 0:18

The evidence is actually clear that it's not helpful. Yeah.

SPEAKER_00 0:24

Thanks again for tuning in to our latest episode of Beauty and the Beast Podcast. I'm here with my good friend, Dr. Sam Jajurikar from Dallas, Texas. And of course, I'm Dr. Sal Pachella from San Diego, California. Today we're going to be talking about the most necessary evil in plastic surgery, which is scars, right? And so, Sam, tell us, you know, is there any operation you do that doesn't have a scar? None whatsoever.

SPEAKER_01 0:53

Yeah. And that is actually a great lead-in because patients will sometimes say, look, I want you to do this surgery, but I just want to make sure I can't see a scar afterwards. And you have to explain to them, look, you can't do surgery without creating some form of scar. Our goal is to make a cosmetically acceptable scar, but you can't do scarless surgery. Do patients care more about scars than surgeons do? Yes. It's not that we don't care, but but um, you know, scars are um, you know, scars, scars are important to you, to me, to our patients, but the patients are living with the scars. And so it's their goal to make the scar as imperceptible as possible.

SPEAKER_00 1:36

Right. And I think, you know, the the I think the concept really to understand when it comes to scars are, you know, in in life there are four dimensions. There's length, width, and height, right? Those are the physical dimensions. And then there's the fourth dimension of time, right? And I think, you know, we can stress in the operating room about all of those three dimensions, but what we don't really know about is that time component of things. And that's even less of what patients know about, the timing of scars. So I think the best job we can do as surgeons is to really educate our patients on the time component of scars and what that means in evolution for the appearance of the scars.

SPEAKER_01 2:16

Exactly. And I think that requires an understanding of how your body heals. And so with any um injury to the body, and we'll we'll put an incision in that category, there's an initial phase of wound healing in which your body is depositing lots of collagen into that wound. And basically, from day zero to day 21, the body is is just dumping collagen more and more and more and more. So when you get to day 21, the the um the scar looks like a jumbled haystack if you were to look at it under a microscope. What does that mean? Well, it means the scar is thick because the body is delivering all of these inflammatory mediators and inflammatory cells to the scar, it's red as well. So typically when you see a scar at three, four weeks postoperatively, it is thick and red, and that's a normal part of the healing process. Next part's the remodeling process. How long do you tell patients remodeling lasts? I usually tell them it can take up to one and a half to two years.

SPEAKER_00 3:18

Yeah, I think, you know, anywhere from eight months sometimes to 14 months. I mean, it really depends on the location and the texture of the skin. So, you know, I think one of the things we I probably could spend a bit more time on with patients is understanding anatomically the difference in scars based on areas, okay? Based on anatomic areas. So, for example, a good rule of thumb is the thicker the skin, the worse and the longer the scar is. And that makes intuitive sense. If I'm doing an upper blephroplasty, an eyelid procedure where the skin is two millimeters thick, that's gonna heal a lot quicker. It's gonna have a better scar sooner than if I did a scar on the breast or the abdomen where the skin is much thicker. And so I think that really comes to fruition when we're talking about how to revise scars. But let's hold off on that for a second here. What do you tell your patients on how to best optimize their scar appearance?

SPEAKER_01 4:16

There's one tried and true thing that is better studied, and that's silicone. Um, silicone sheets are sort of, I, in my opinion, particularly for body contouring surgery, the best thing that are out there. Silicone works by changing the um the basically the electric field around um a scar, and it causes your body to take the cells that remodel that collagen that we were talking about before to do it at a faster rate. So silicone sheets are are um the key. What I will tell patients is look, it doesn't matter how frequently you change the silicone. What matters is the amount of time that your body has in contact with those silicone sheets. You know, the studies to show you should do at least 12 hours a day. My preference is 24 hours a day for you know days on end. There are also silicone gels and silicone creams that are out there that I that I will use, um, particularly in facial aesthetic surgery and some regions of the breast that requires more patient involvement, more patient compliance. Patients that are highly motivated and remember to do it two or three times a day, that's great. For those who don't think about it so much and do it zero to one times a day, it just doesn't work as well as silicone strips. How about you?

SPEAKER_00 5:24

What are the same sort of concept? I I prefer to have them 24-7 if they can. Um, I'm a big believer in silicone ointments above the neckline. I think when you use ointments on the body, it just go gets all over everything, right? And so I deal with a lot of skin cancer reconstruction where we're not able to really hide scars as well as we do in aesthetic surgery. And so scar maturation, scar treatment is a really important concept uh that I have to really hammer into the education for my patients. Um, so we talked about uh silicone. What what about massage? How do you do do you have a is does massage have a role in scar tissue formation or reduction?

SPEAKER_01 6:04

Yeah, I mean, I I think if you have areas where the scar is hypertrophic, massage can be very important, which requires an explanation of what is a keloid and what is a hypertrophic scar. And so um, a lot of patients will tell me, you know, I got a keloid after this injury, or I got a keloid after this previous surgery. And I'll look at it and I'll see something that I don't think is a keloid, I think is a hypertrophic scar. So, what's the difference between a keloid and a hypertrophic scar and why is that delineation important?

SPEAKER_00 6:36

Well, let me ask you this first. How many times do you have a patient that says I keloid afterwards, and then they show you your scar and it's just a very faint white line?

SPEAKER_01 6:44

I think more often than it not being a keloid, than it being a keloid, yeah.

SPEAKER_00 6:48

I think that word gets tossed around quite a bit. Um, so a hypertrophic scar is a scar that is essentially a scar that does not where the collagen does not go beyond the scar dimension. So if I have a linear scar uh right in front of my ear, a hypertrophic scar will look like a red line, a red worm that's elevated, but it'll be it'll be right at the level of the scar and not beyond it. A keloid is a much tougher beast. So keloids form when there is a jacked up reaction to collagen deposition. Keloid scars, you see this a lot in kind of scalp in scalps, okay, after haircuts and things like that. Um, those scars look like masses. They look like tumors, if you will. And those go well beyond. And then those things are extremely challenging to deal with.

SPEAKER_01 7:41

So hypertrophic scars can oftentimes be improved non-operatively, non-excisionally, keloids, not so much. And I think that's why it's important for us to sort of perseverate over um, you know, which category a scar falls into, which goes back to your question about scar massage. I think when you see little bumps in the scar where the scar is a little bit thicker, or if a scar is just, you know, mildly thicker and more elevated in a fashion of a hypertrophic scar, massage can be incredibly useful. Firm pressure shouldn't be pleasant. You know, massage has a connotation of being a kind of a pleasant experience. This is more of an extreme pressure, almost like you're trying to pulverize the scar, but it can be very effective if done for a few minutes, a couple of times a day, to help the scar flatten much faster.

SPEAKER_00 8:32

An analogy I like to use for patients is you know, if you're not, if you're not causing yourself some discomfort, you're probably not doing it hard enough. And I say, you know, if you've ever sprained your ankle and you're trying to stretch your ankle out, you have to get that range of motion. Same sort of thing. You know, it's not just going to magically move. You got to, you gotta stretch that tissue, you gotta kind of add pressure to it. Yeah.

SPEAKER_01 8:53

Um and there's other things that I like for hypertrophic scars as well. I think um microneedling can be really effective for people that have scars that are either immature, meaning they're in the process of still healing, but it can help them lose some of the thickness a little bit faster. For hypertrophic scars can be effective to help. I think topical retinoids can be and retino and retinols for that matter can be helpful with the texture when the scars a little bit thick. Um, and I think some, you know, some um ablative lasers, um, like CO2 lasers or beam lasers can be really useful when the scars are a little thick as well. All of those can be really helpful to help speed up the maturation of the scar. Tell me about injecting scars. You inject scars? What do you think? You know, I I do. I'll I'll sometimes use a mixture of uh triumphone, which is a which is a steroid, and then um 5FU, which um, you know, typically, you know, we think of it as being a chemotherapy agent from years ago. And that combination can help scars that are hypertrophic. Um I used to just use uh steroids, but what you'll find with steroid injections is that it can cause some lightening of the skin and um it can actually cause some thinning of the skin as well. And so you've got to be judicious in terms of how you do it. I think in a hypertrophic scar, it can help, but you gotta be conservative. In a keloid, it can be helpful, but usually you've got to excise the keloid and then and then also inject. How about you? Yeah.

SPEAKER_00 10:25

So um I love 5FU. I think it it works phenomenally. And I oftentimes use the combination when when I'm um operating in and around the eye and I have a hypertrophic scar, some scar tissue, I actually avoid the use of steroid um mixed in with it and just simply use 5FU. I think the oculoplastic or the eyelid literature really supports that. Um I think injecting scars can be uh can be an art. Um the I remember you probably remember in residency they used to have these dermal pins where they, you know, it's just extremely painful for patients going in, um, where you sort of have to inject into the scar. I think the thing is the tougher the scar, you inject the steroid, it it doesn't stay in the scar, it just goes to other parts, and that causes a lot of soft tissue atrophy and it never really treats the scar, right? So um, so I think that's that's important. And, you know, my threshold for injecting scars, if it's if it's a bit too very simply, if it's a bit too red for my comfort or the patient's comfort, then I'll inject it. You know.

SPEAKER_01 11:30

Yeah. Yeah. I mean, I and I I think it illustrates there's lots of ways that sort of help the scar mature a little bit faster.

unknown 11:37

Yeah.

SPEAKER_00 11:38

So, okay, so let's talk about um, you know, you've gone through this process here. Now it's 14, 18 months after surgery, you've done this procedure, and you know, the patient's just not happy with the scar. It's uh indented, it's tethered a bit. What do you tell them? What what uh what are your strategies here?

SPEAKER_01 11:56

That's a more straightforward scenario than if they're coming at me four to eight months afterwards and they're coming like that. You know, if they're 18 months out from surgery, their scar is thick, we think it's as good as it's gonna get pretty much at that point. Typically at that point, I'll offer them a scar vision. So scar vision is a double-edged sword. It's a way to excise the scar and recreate a better scar under more optimal conditions. Because if you think about it, one of the biggest reasons why scars don't heal the way that we want them to do are related to the tension around the closure. So let's say we're talking about a tummy tuck or a body lift where there's a lot of tension. Now, when you do a scar vision, you can go back under a low tension environment, sometimes get a better result. The bigger dilemma is when someone comes to me and they're upset and they're six months out. Because at six months out, you you have to try to preach patience, like you have to give it an opportunity to fully mature and heal. One, I feel kind of hypocritical for doing that because I'm not particularly patient. I don't really like waiting. Two, it's you know, you can only tell people you gotta wait a certain number of times before you feel as though you're losing credibility. So it's ideal for people to realize that if you do it too soon, well, you may not have the same low retention environment. There's a higher likelihood of the scar vision not being as successful. Um, and you may be doing a procedure that may not be necessary if you give it enough time. What's the soonest you'll do it? Uh the soonest I have done it's probably three months. Because I've been pressured. You know, sometimes, sometimes, you know, we sit here and we pontificate and we talk about what's the right thing to do for people, but there are sometimes pressures where you recognize that, well, you're not going to make it worse if you do it and it'll make the patient happy. So I've done it.

SPEAKER_00 13:44

I've done it sooner. Yeah, where I see this as a big struggle is in and around the eyelid, because um, you know, the eyelids, no, particularly the lower eyelid, is notorious for holding on to swelling. And if I'm planning a little revision and, you know, I'm trying to push patients out longer and longer, um, just because I know that when I try a scar revision that early, you're just adding swelling on top of swelling on top of swelling. And then you're just you're you're setting the patient up for a for a problem that they didn't have with they didn't have in the first place. Yeah.

SPEAKER_01 14:12

So and the and the lower eyelid is an even bigger issue because the tissue is so fragile when it's swollen that if you're trying to put sutures into it, it's you know, you're holding any deep structures, it's less likely to hold. If I'm talking about the tummy or the breast, it's not as big of a deal. Yeah. And you can be a little bit more aggressive. So are there any other things that you think can be useful for scars? You know, we've talked about silicon, we've talked about lasers, microneedling, anything else that you find to be useful for it?

SPEAKER_00 14:38

No, I think I think uh a lot of patients, there's a lot of marketing and a lot of products out there that are geared towards scars. I think again, you know, going back to the evidence base, you know, we we want to use what's what's beneficial. And I think silicone is the key. Even things like vitamin E, you know, my understanding is there's not a ton of proof of that.

SPEAKER_01 14:56

The evidence is actually clear that it's not helpful. Yeah. So yeah, vitamin E is not. Well, great. Well, you know, not a topic that surgeons find to be all that scintillating, but it's important for patients. Um, the key is patience, you know, give it its full time to mature, use silicone.

SPEAKER_00 15:12

And leave you with this. You know, one surgeon once told me every scar tells a story. So be proud of your scars. Not the cosmetic surgery ones, but the other ones. So all right. Thanks, everybody.