Stars Not Scars

Doreen Wu (00:00):
Welcome to Park Avenue Plastic Surgery Class, the podcast where we explore controversies and breaking issues in plastic surgery. I'm your co-host, Doreen Wu, here with Dr. Lawrence Bass, Park Avenue plastic surgeon, educator, and technology innovator. Today we are talking about scars and how do we erase them. None of us want scars and a bad scar, least of all. But plastic surgery is what makes no scars. Isn't that right, Dr. Bass?

Dr. Lawrence Bass (00:24):
Well, unfortunately, a lot of folks think that, but in fact, that's not true. Anytime we cut deep enough into the skin, we're going to heal with a scar. You know, we have minor scrapes and cuts all the time that don't leave a scar, but something that goes into the deeper levels of the skin always heals with at least a little bit of a scar. But, you know, there are good scars that are really inobtrusive and very difficult to see. And then there are bad scars that are obvious and drastic and attract attention all the time. And we get scars for a bunch of different reasons. I mean, some scars come from surgery where we're making an incision into the skin on purpose for some, some important reason. But of course there's also trauma. There's acne scarring, and then there's major tissue trauma like occurs in combat injuries that not only break the skin, but often in irregular ways, in massive ways, and massively damage the deeper tissues underneath. And all of that makes it much more difficult to heal with any kind of reasonable scar.

Doreen Wu (01:48):
Well, let's start with a good circumstance. Let's say I'm having an elective plastic surgery. I want invisible scars. Is that a realistic expectation? What can I do to get the best result?

Dr. Lawrence Bass (02:00):
You're right that an elective plastic surgery is the best case scenario. So, as I said, the scar is never invisible, but how visible it's likely to be varies by site and by skin response. So getting the best scar starts with good surgery that's low trauma and a very meticulous closure. The suturing, and this is what plastic surgeons in particular excel at, we're really good at putting a lot of very tiny sutures that very precisely approximate the edges, and that helps us get a better scar. That, of course, is in the hands of the surgeon. But then there are things that come afterwards. So a best case scenario for a scar, something like an eyelid incision and some facelift incisions, you may actually need a magnifying glass to see them, but same operation performed by the same surgeon. Sometimes the scar is not going to be as favorable because that individual's skin is just more reactive. Face scars from elective plastic surgery tend to be better. Body scars always tend to be a little bit more visible. Sometimes they're visible but not very prominent, and sometimes they're not quite as good.

Doreen Wu (03:32):
So what should I be doing to get the best scars?

Dr. Lawrence Bass (03:35):
There are a few typical things that help and should be part of every surgery. Scar management and some effort on scar management really ideally should be part of every surgery. So each surgeon has their own approach. They do things a little differently but with some variations. But doing something to work on the scars after surgery is certainly going to help get to the best endpoint. So one thing is scar preparations that are applied starting typically three weeks or so after surgery. And these are preparations that are applied once or twice a day. The three big products in the United States that are most commonly used are Scarguard, ScarAway, and Mederma. These are all very different materials. They're not very much like each other. They all help with scars and they're easy to do and not a risk profile associated with them of any significance. So it's all reward with next to no risk. Gel bandages are another thing. Sort of a silicone gel patch that is placed over an incision, again, typically starting several weeks after surgery, and that helps the scar likewise end up the best looking scar we can get.

Doreen Wu (05:16):
I've also read online about a lot of different home remedies like Vitamin K oil, tea tree oil, coconut butter. Do those actually work?

Dr. Lawrence Bass (05:25):
So it's possible that they're helpful and they don't seem to hurt things. However there isn't a lot of data. So it's probably better to work with the medical products and the medical treatments. A lot of the treatments on scars come out of burn center research and treating major burns and helping to get those scars as soft and flexible as possible. And so that's a more data driven approach, which I think is a better way to go about it.

Doreen Wu (06:03):
Let's talk about timing a little bit. If my incision is sensitive or delicate, can I just wait a month or two and then work on the scars? Will holding off for a little while really make a big difference?

Dr. Lawrence Bass (06:15):
Timing is really critically important for scar behavior. You know, different things are happening at different points during the healing process, and the things that we're doing to help with the scars are focused on modulating those biological responses to wounding and that occurred during healing. So you can't redo the scar a year from now. You might have to surgically revise it and start over. There are things we can do late with scars, but we have much more ability to modulate the scar and get a good scar in the first place if we work early. Now, as I said, we're typically starting at about three weeks because that's usually a point when even minor crusting or open areas in an incision have sealed off. So scar behavior and scar treatment typically starts when the incision is fully closed, but it has not yet matured and added a great deal of collagen. It has not yet remodeled.

Doreen Wu (07:28):
Okay, let's say I had my aesthetic surgery and the scar looked great, but now I'm at one month after surgery and there's some redness and thickening. What should I do? Should I show it to my surgeon at my next visit a month or even six weeks from now?

Dr. Lawrence Bass (07:43):
So, as I said, you know, timing is critical, and if you see a scar heading in a bad direction, call your surgeon immediately. It's much easier to break a cycle of misbehavior in early healing scar than trying to undo a well-established hypertrophic scar or widened scar any of any of the bad things. So that's really important. And some of these bad scar departures are really medical problems. Hypertrophic scars, which is a red thick scar that stands up off the surrounding surface of the skin, is a product sometimes of the amount of inflammation present, but also of your wound healing biology as an individual and how your skin behaves. And keloid scars, which not only stand up off the skin, but actually become wider and bigger than the original wound, are the result of specific genetic mutations that cause people to scar in that fashion. And these things need medical treatment immediately to keep things to the best possible outcome.

Doreen Wu (09:05):
Could that be why we get bad scars? It's really a problem with our skin type or biology?

Dr. Lawrence Bass (09:10):
That's the foundation or baseline. So your body is going to react a certain way to wounding and it's going to heal a certain way, and that's your genetics or your biology. Overlaid or intersecting with that are outside factors. You know, if a scar is not well approximated, if it broke down because there was too much tension, if there was a wound infection or some kind of a skin injury aside from the basic surgery, like there was some crush to the tissue from trauma or something else, these things can produce partial skin loss. But even without any skin loss they're more likely to produce a bad scar. So the surgeon has to take a careful look at the scar and decide what the problems are, and that then leads you to think how to treat it.

Doreen Wu (10:13):
Let's talk about some of these typical problems and issues with scars.

Dr. Lawrence Bass (10:17):
So scars are different from normal skin in several ways. The texture of the skin is different than normal skin. Typically, scars have a very smooth texture. The color of the scar is different in early scars, often red, it's sometimes hyper pigmented or very dark brown. A late scar typically has no pigment, so it may look whiter than the surrounding skin. And the contour of the scar is different. The scar may be more or less level with the skin, or it may be raised up or it may be depressed, and anything that's raised up or depressed is going to be much more visible and make the scar more obvious.

Doreen Wu (11:08):
I didn't realize the specifics. Why are these differences important to understand?

Dr. Lawrence Bass (11:13):
So as I said earlier, what's wrong with the scar is going to tell us what treatments are needed. So a widened scar, a scar that instead of being paper thin or a millimeter thin might be a half an inch or an inch. There's no way to get that scar narrower without a surgical revision. So a surgical scar revision, which is typically delayed for six months or more until the scar has matured, involves going back, trimming out the old scar in a small procedure and resewing the skin edges. And the hope is that doing that where that's the only thing happening, you're just doing a scar revision, not some kind of a big operation underneath your chance of landing up with a better scar is, is good. And we only do surgical scar revisions when we think we're likely to be better and obviously visibly better. So if we think we're, you know, you could always end up better, the same, or worse anytime you do a scar revision. So we'd only like to go ahead if we think we're likely to be better and make a real obvious change. For other issues with the scar issues of redness, thickening, we're more likely to chase the scar with injection therapies, the gel bandages that I mentioned, compression therapy or with some of the lasers and energy based devices.

Doreen Wu (12:56):
As usual. Let's take these one at a time.

Dr. Lawrence Bass (12:59):
So gel bandages and compression are things that are very commonly used. Silicone gel bandages, both because of the occlusion and a mild degree of compression, they provide help model a scar softer and flatter, help the scars lose the redness more quickly. An early scar typically looks red, and in a typical middle aged adult it takes six months or so in round numbers for the scar to lose the redness become a white scar. Teenager might take longer. Someone who's elderly might do it a little more quickly. Their body calms down and stops the healing process sooner. But those are averages and each individual is different. So that's the first step. It's the least invasive, it has the least risk and will get us where we want. Next, we go to injections. And you know, what's happening in a scar is that fibroblasts. The healing cells are adding collagen, and that's important at first to get strength in, in the repair.

Dr. Lawrence Bass (14:09):
But like Goldilocks and the three bears, it has to be the right amount, not too much, not too little, just right. If the process doesn't turn off, once the scar is closed and strong, the quality of the scar will continue to degrade, and we need to inject anti-inflammatory medicines into the tissue of the scar itself to try to stimulate the body, to break the cycle of inflammation and healing. Now that the scar is closed, these medicines are typically either steroid, anti-inflammatory medicines or anti metabolite, anti-inflammatory medicines, or some combination of the two. And treatments are typically done once every four to six weeks for several injections in the hopes that that will break the cycle and get the scar to calm down. Finally, we go to lasers. And these are lasers that do two different kinds of things. One, lasers that target vascular in the skin, so they knock back some of the blood supply, which slows down metabolically the healing response and can break the cycle of hypertrophic changes.

Dr. Lawrence Bass (15:40):
These are typically used early. Most commonly it's the pulse dye laser, but sometimes IPL and other kinds of vascular lasers are also used. And then both early and late to remodel the scar get its softer, flatter, and get it to lose redness. We use either ablative or non-ablative fractional lasers. Lasers that put little pinpoints of light in that can often go quite deep into, let's say a thick scar. And that gets some tissue removal that allows the scar to remodel in a flatter, smoother, better matched configuration. And it likewise can help knot back some redness, particularly with the non-ablative options.

Doreen Wu (16:35):
All right, I have another scenario for you this time. Not as pleasant as elective plastic surgery. Let's say it was icy out and I fell down the stairs and smashed my face. Now I have all these cuts, scrapes and a big bump. How is that going to be treated?

Dr. Lawrence Bass (16:51):
These are not surgical scars, but traumatic scars and they're much less likely to heal. Well, of course, we didn't get to manufacture the incision or the scar. It was an unexpected injury. So this is probably best evaluated by a plastic surgeon and managed early in the healing process to get the best result because as we said, timing matters. So showing up six months or a year later with a bad scar, we can still do a lot of things for that, but we'll do better early in the game and early as the abrasions and the open areas are healing, we often apply ointment or medicated ointments or occlusive dressings that keep the area moist and that can create a lot of remodeling and smoothing and a quicker point to get that closed. So the sooner an area is closed, the less time the body is going to be upregulating or spiraling up on the level of inflammation. And the longer a wound is open or the longer the body is trying to slough off dead or damaged tissue, the more inflammation is going to be produced and the greater the likelihood of things like hypertrophic scarring. So early it's ointments, medicated ointment, seclusive dressings to protect the area and seal it off soonest. And then we go on to the same kinds of modalities once that wound is closed, the medicated application products, the gel bandages, and then if need be the bigger interventions.

Doreen Wu (18:51):
Previously you alluded to combat injuries and major trauma. What is the role of these treatments for these devastating problems?

Dr. Lawrence Bass (18:59):
So all of this gets used, but what's really been revolutionary is the fractional ablative and non-ablative laser. So they've had the ability to take thick scars and remember, scars are not just about appearance, they're also about functional issues. So if you have a really thick scar across your elbow, you may not be able to bend your elbow or you may not be able to have the full range of motion that normally takes place so that scar is interfering with your ability to use your your arm. The same is true of hand injuries where motion is critical to having function eyelids, lips, things like this where a bad scar can really disrupt the normal function of that part of your body. The fractional lasers have shown a tremendous capability to blend the scar and improve it cosmetically, but also to soften the scar, make it behave more like normal compliance skin so that motion is restored. And so it's played a big role in the military and in treating veterans who have sustained combat injury,

Doreen Wu (20:19):
I have a pretty good sense of where we are now with scar treatments. What about the future? What is coming down the pipeline?

Dr. Lawrence Bass (20:25):
There's a lot of examination of how to optimize the device based treatments. I think we understand how to do it, but I don't think we necessarily have optimized it yet. And so that's something that more investigation will help us with. But there are also a whole host of biological things that are being investigated. So there are medicines that bind and prevent RNA expression for proteins that we know promote scarring as part of the inflammatory process in healing. And there are all kinds of growth factor things as well as platelet rich plasma and even stem cells that are under investigation for their potential to help us with improved healing, improved scarring, or even scarless healing.

Doreen Wu (21:23):
Lastly, before we wrap up, what are some important takeaways for our listeners?

Dr. Lawrence Bass (21:28):
Really just to review what we've said throughout the episode, the first step is accurate diagnosis. If you identify exactly what's bad about the scar, you can pick the appropriate treatments to rapidly address it. Timing is critical, better to jump in early, You have less to correct. So it's an example of a stitch in time saves nine never truer than in treating problem scars. You can make dramatic effects on scars, but the expectation should not be that we're going to get to an invisible scar. I understand why people want that, but that's not currently within the capability of what we can do. It's work to chase one of these scars. It's multiple steps, often many steps over months, but if the steps are completed, you can reap the benefits of a great scar, which you know, lasts forever. So the total time and number of treatments may be significant. It's not ideal. We'd like to do it in one or two treatments, but experience has shown that more treatments create more refinement of the scar until it gets to an acceptably faded point. So it's important to chase that and do it because then you get, you get to be the result and not the scar being the result. So you get to be a star, not a scar.

Doreen Wu (23:07):
Thank you, Dr. Bass, for sharing your insight and expertise about scars with us. And thank you to our listeners for joining us today to hear about how scars can be minimized, if not totally eliminated. Thank you for listening to the Park Avenue Plastic Surgery Class podcast. If you enjoyed this episode, be sure to share it with your friends. Follow us on Apple Podcasts and Spotify and leave a review. We'll see you next time.

Speaker 3 (23:31):
Thank you for joining us in this episode of the Park Avenue Plastic Surgery Class podcast with Dr. Lawrence Bass Park Avenue plastic surgeon, educator, and technology innovator. The commentary in this podcast represents opinion. This podcast does not present medical advice, but rather general information about plastic surgery that does not necessarily relate to the specific conditions of any individual patient. No doctor patient relationship is established by listening to or participating in this podcast. Consult your physician to advise you about your individual healthcare. If you enjoyed this episode, please share it with your friends and be sure to subscribe to our podcast on Apple Podcasts, Google, Spotify, Stitcher, or wherever you listen to podcasts.