Posted by Dr. Hardesty on February 26, 2019
For example, procedures such as a breast augmentation, tummy tuck or facelift.
The goals of this post are to describe…
- The genetic implications of scar formation
- Classic phases of wound healing
- Preoperative optimization
- The effects of smoking on wound healing
- Surgical technique
- Postoperative incision care
- Abnormal scar treatments
The ultimate and final appearance of surgical incisions is multifaceted. Our personal genetic propensity plays a significant role and is unfortunately unable to be changed at the present time.
As in life some of us are born with blonde hair and others with a dark brunette, black or red hair color. With all factors being equal, the quality, appearance and final scar results are probably 80 percent genetic — how you heal is based on your own body and how your biological parents healed.
Which means if a careful skin closure was performed, and you have a favorable genetic disposition, your ultimate scar will mostly be a fine, almost non-visible, line. Conversely, if the same identical meticulous skin closure was performed and you have inherited non-favorable wound healing genetics, your ultimate scar may be wide, firm and noticeable.
Also, because normal components of skin (elastin) are replaced with scar tissue (collagen), tensile strength is reduced, and scars tend to stretch similar to that of stretchmarks after pregnancy or rapid weight gain.
Fortunately, today, with the scientific knowledge of the other non-genetic factors, we can optimize, modulate, modify and improve the ultimate appearance of the scar.
The process of wound healing begins at the time when the incision is closed and ends
approximately nine months later. The classic phases are as follows:
Inflammatory phase: 1-7 days — Dominated by white blood cells, the building blocks of wound healing; the wound’s strength is held in place by sutures and the body’s fibrin.
Proliferation phase: 3-30 days — Characterized by random collagen deposition with bumpy feeling scars; scars temporarily thicken (hypertrophic) and become progressively pink.
Remolding phase: 30 days to months — The collagen begins to align, and normal scars begin to soften and lighten while absorbable sutures have been absorbed; further remodeling continues, scar lightens, feel softer to the touch and flatten; during this time, the scars unfortunately tend to stretch and widen.
We can optimally modulate the environment for would healing by making sure of the following:
- In good general health (non-steroid medications)
- Don’t smoke
- Healthy, high-protein and balanced diet
- Use of vitamins (in moderation)
- In patients who have under gone a bariatric procedure and have had significant weight loss, it’s recommended to have laboratory testing for pre-albumin, albumin and protein completed before surgery and to be within normal limits.
Smoking has shown by many scientific studies to do the following:
- Deprive your heart, tissues and skin of oxygen
- Increase your chance of forming blood clots in your veins
- Cause a greater difficulty to breathe during and after general anesthesia
- Increase your risk of infection
- Impaired wound healing, for example loss of skin or dead tissue
- Poor scar formation and appearance
- Alteration in effectiveness of some medications
- Postoperative smoking is worse than preoperative smoking
Multiple studies support, and I strongly suggest, stopping four weeks before surgery (minimum of two weeks) and eight weeks (minimum of four) after your planned surgery — hopefully forever! It’s not just the smoke, but the contents within tobacco that are similar are found in e-cigarettes. It’s only fair to be truthful and honest with your plastic surgeon before surgery about your smoking habits. It’s your body, it’s how you heal, it’s your final scar, and you are making a significant financial investment as well as desiring the best result.
Incision location varies based on the procedure to be completed and is based on the patient’s desires and the surgeon’s experience. “Langer’s lines,” established many years ago, describe natural wrinkle lines about the face where incisions are best placed to minimize final scar appearance. In general, incision on the extremities are made perpendicular to the flexion of the underlying muscle action, because the flexion of the underlying muscles can cause the scar to spread when incisions are placed parallel to the muscle. An example of such is when performing an abdominoplasty (tummy tuck). I personally ask patients to bring their smallest bathing suit bottoms or panties and then we design an incision that can be covered by those pieces of clothing types.
- Tension-free closure (when possible)
- Gentle tissue handling
- Precise and judicious use of electro cautery for hemostasis (to stop bleeding)
- Use of a meticulous “multilayered complex closure” (using multiple layers of appropriately sized sutures) to reduce tension and improve final scar appearance.
- These different layers are often a combination of absorbable and permanent sutures.
- To approximate the deeper layers and align the superficial layers of the skin.
- Correct size and tension of non-absorbable sutures in the skin or when indicated use of skin glue (Dermabond is one brand).
- Tension free; this is relative— in an abdominoplasty, it’s the most difficult because we are wanting to achieve a flat and tight abdominal contour.
The importance of smoking cessation after surgery cannot be over-emphasized here!
Immediate incision care
- Placement of tension relieving sterile paper, or “steri strips”
- Dry absorbent dressings
Early (1-3 months)
- Embrace — a device to reduce early tension on incisions that are prone to tension and poor scars; for example, we routinely place on abdominoplasty (tummy tuck) incisions several days after surgery.
- Silicone gel sheeting (Biodermis New Gel is one of several brands)
Mid (3-6 months)
- Lasers (like the V-Beam vascular laser by Syneron/Candella) that reduce abnormal vascularity of scars.
- Steroid injections (reduces all phases of scar formation) for hypertrophic and keloid type scarring
Late (6 months and beyond)
- Steroid injections (reduces all phases of scar formation)
- Recalcitrant scaring such as keloid formation (if resistant to above treatment protocols) can call for superficial radiation after excision.
Scars are usually a small trade for a desired cosmetic improvement. Only in the Hollywood movies can surgery be performed without scars. However, by understanding the role of genetics, the principals of wound healing, proper preparation, avoiding both smoking and second-hand smoking, using tried and true surgery techniques, placing incisions in optimal locations, and applying current postoperative scar modulators, can scars be minimized and final scar appearance be optimized.
One Goal, Many Options
The most important factor to consider for your procedure or treatment is seeking the opinion and services of a skilled, experienced and Board Certified Plastic Surgeon who are experts in techniques. The Imagine Plastic Surgery team uniquely provides the full array of both non surgical and surgical alternatives thus filling our motto of “One Goal, Many Options.” For over 30 years Dr. Hardesty, an award winning, Board Certified Plastic Surgeon, has proudly been serving Riverside and San Bernardino counties of the Inland Empire and the communities of Rancho Cucamonga, Ontario, Upland, Corona, Chino Hills and Redlands. For over 30 years Dr. Hardesty and the Staff of Imagine Plastic Surgery have provided comprehensive Cosmetic Plastic Surgery services and procedures to Riverside and San Bernardino counties of the Inland Empire and the communities of Rancho Cucamonga, Ontario, Upland, Corona, Chino Hills and Redlands.