Invisible Scars 101
Sunday, June 3, 2012 at 06:50AM 
I approach any surgery, whether it's a rhinoplasty or a thyroidectomy, with the idea that ultimately, it's the presence (or the lack of presence) of scars that dictates a patient's opinion on whether the surgery was successful. What are my steps in ensuring a great scar?
1) incision planning: many surgeons are anxious to hurry up and get the surgery started. At this point, they've already gone down the wrong path. The skin has predictable patterns of wrinkling based on relaxed skin tension lines. If you design a scar to lie within one of those wrinkles, you utilize the natural skin physics. TENSION ON A SCAR IS BAD. It will widen the scar and make it more noticeable. If you look at this picture, you can see how approriate scar design is possible.
2) use the right tools. I know it sounds like a given, but incisions should be made with a scalpel. I've seen incisions made with cautery. Pure blasphemy. Also, don't use cautery along the skin edges. It destroys the needed blood flow to make the skin repair itself. Decreased blood flow = decreased oxygen delivery = worse looking scar.
3) close the skin in layers. Numerous layers, if need be. This aids in relieving the tension from inside out and allows the skin to be completely lax.
4) evert the skin edges. If you line up the skin edges with suture so that the edges touch, it'll look great 1 week after surgery. It will look terrible 1 year afterwards. Why? Scars contract and will do so in an inward vector. So the scar will be sunken and won't match up with the skin edges. Picture a lane at a bowling alley. You don't want a gutter because it will create shadows and that draws attention to the scar. So instead, evert (or heap up) the edges using your suture. It'll look odd 1 week afterwards but it's worth it as that heaped up skin flattens with time.
5) get your stitches out by day 4-5 if you can (I'm talking about face/neck sutures here, as sutures elsewhere may need slightly more time because of less blood flow to the skin). This avoids the railroad track or baseball stitching appearance often seen when they stay in too long.
6) don't smoke. I ask my patients who can't stop playing lung darts to stop for 1 week before and at least 2 weeks afterwards. There's no real science behind it - it just makes common sense.
7) minimize sun/UV exposure for at least 6 months. No, this doesn't mean "move to Portland, Oregon". It means to cover the area with sunscreen or clothing because if you don't, your scar will be more pigmented and won't look like the surrounding skin. And that draws attention. I prefer zinc or titanium oxide formulations.
8) use a silicone gel. I prefer Kelo-cote (no, they don't pay me) because it's high quality silicone and it dries quickly into a shell. Once dry, you can apply coverup or sunscreen.
All in all, the key to getting a good cosmetic result from your procedure is to work with your surgeon and do your best to take care of your body afterwards. If you follow some simple rules, you can get a scar that will disappear.
Reader Comments (2)
This is very true and they give us all the information about scares.
I had a few moles removed on my back & I'm left with a large, "squishy" scar. I can't see it but if I wear a V back top, everyone else can!