Since All Wounds Heal By Scarring, How Do Board Certified Cosmetic Plastic Surgeons Deal With The SCAR PROBLEM?

By S. Larry Schlesinger, MD, FACS

Since All Wounds Heal By Scarring, How Do Board Certified Cosmetic Plastic Surgeons Deal With The SCAR PROBLEM?

Treatment of Scarring After Cosmetic Surgery

  1. The best way to treat a scar after cosmetic surgery is to prevent it or decrease the chance of it ever happening.
    • Cosmetic plastic surgeons often hide scars where no one really looks, for example, chin implants placed through an intra oral incision (in mouth), breast augmentation scars placed in the armpit, and abdominal liposuction scars that are hidden inside the belly button.
    • Tension is the number one cause of thickened scars (hypertrophic scars). Well done abdominoplasty and breast reduction closures have layers of suture material below the skin to take the tension off the final skin incision,and therefore decrease thick scarring. Many cosmetic plastic surgeons place strong suture material in the SFS (superficial fascial system) originally described by Dr. Ted Lockwood of Kansas City.
    • Removing staples and sutures early decreases the cross hatch markings often seen after tummy tucks. Because of the multi layered closure on abdominoplasties, in my practice, we remove all staples and sutures in the abdominoplasty incision at 3 days and rarely do we get excessive scarring.
  2. In the early post suture removal period, one can place strong tape over the suture lines to decrease thickened and/or spread scars. There are several products on the market including Embrace®, silicone sheeting, and strong tape. These products teach the new collagen to lay flat during the wound healing process and prevent thick scars from forming by mechanically teaching the new collagen to come in flat rather than in whirls and swirls.
  3. If hypertrophic scarring forms, historically, cosmetic plastic surgeons have injected dilute solutions of corticosteroids such as Kenalog. Unfortunately, steroid injections can lead to hypopigmentation, scars spreading, and temporary and/or permanent destruction of surrounding fat leading to scar depression which can be less aesthetic than the original scar.
    • Scars are made up of fibroblasts and the collagen they form.
    • Antimetabolites are known to show antifibroblastic activity decreasing the proliferation of infiltrating fibroblasts, ultimately lowering the production of collagen and decreasing the density of the extracellular matrix. What this means is that the 5-FU prompts a quicker, thinner, and more aesthetic scar formation.
    • 5-FU works best when injected into early scar formation within the first 3 months of the surgery. However, scars present for several years can be advantaged by the use of interlesional 5-FU.
  4. Systemic complications associated with large dose cancer chemotheraphy treatments not seen in interlesional scar treatments of 5-FU.
    • A 2002 study by Manuskiatti & Fitzpatrick showed that interlesional 5-FU caused minimal to no complications as did laser treatment. Interlesional injections of 5-FU caused resolution of scars faster, and the incidence of adverse local reactions was only seen with the use of injectable corticostaroids.

In summary, well done plastic surgery attempts to hide incisions in inconspicuous locations, decrease the amount of scar formation through various topical modalities, and if thickened scars do occur, they are best treated by interlesional 5-FU therapy.

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