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Scarless surgical procedures are like the Holy Grail of Plastic Surgery, and much like the Holy Grail, they don't exist. Technically speaking, the only way to prevent a scar is by performing surgery while we are still in the womb (crazy, huh!). But since we are no longer fetuses with perfectly tight and wrinkle-free skin, scars are our unavoidable reality. The goal of any Plastic Surgery procedure is not to avoid scars all together, but rather to create the nicest scars possible.
The Anatomy of a Nice Scar.
So how do we create a “nice” scar? One of the biggest components is good surgical planning. When we are planning out our Plastic Surgery procedures we want scars to be hidden and, in instances when they can’t be, to make anatomical sense. We conceal scars in shadows, skin creases, birthmarks, tattoos, and natural transitions of skin such as the areolar-skin junction or the hairline. We plan scars so they can be camouflaged with clothing such as a bra or bathing suit bottoms. When scars follow the anatomic features of the body such as the crease of the breast base or the bicipital groove of the upper arm, the eye is less likely to identify them.
Small scars don’t always equal a superior outcome.
There are so many gimmicky procedures that people have come up with over the years to try and sell the idea of a “no-scar technique” for this or a “short-scar technique” for that. The fact that these types of procedures wax and wane over time tells you one thing and one thing only--their results are sub-par. The reality is, if there was an awesome way to perform a tummy tuck with minimal scarring that gave amazing results, every single Plastic Surgeon would be performing it that way.
Another factor to keep in mind is that sometimes the procedure with the most scarring will give you the best result. In most Plastic Surgery procedures, we put scars where we cut skin out. In these instances, minimizing the scars simply means not addressing all the excess skin which, in turn, means you get a less than optimal result. Yeah sure you don’t want the scars of a Breast Lift or a Tummy Tuck, but if we don’t perform the correct procedure, you are spending a lot of time and money on a less-than-ideal outcome. No one comes out a winner in that situation.
Focus on things we can control.
The final appearance of a scar is complicated and multifactorial, with some factors being controllable and some unavoidable. The main players are you (the patient) and I (the surgeon). What I can control is how tight I pull the skin (a tension-free closure is best), the sutures I use to close the incisions, and how meticulously I suture the edges together in a seamless fashion. What the patient can control is what they put on their scars, how closely they follow directions for avoiding certain activities after surgery, and keeping the incisions protected from premature sun exposure. What a patient can’t control, however, is their genetic predisposition to wound and scar healing.
Tension is the Enemy of Scars.
Tension is, through movements big and small, a constant source of stress to your healing and remodeling scar. When the skin edges are constantly being pulled apart, the body adapts by making the scar thicker to withhold the stress, and the scar inevitably widens as a consequence. How much tension is on a scar is, just like everything in wound healing, multifactorial with multiple players involved. My job as a surgeon is to ensure a tension-free closure at the time of surgery. This means avoiding pulling the skin too tight and placing multiple layers of sutures that will disperse and position the tension at the deepest and strongest layers of the tissue. Once surgery is done, however, the ball gets passed to the patient. Scar tension in the postoperative period is directly related to patient activity. Remember when we told you not to lift anything for 4 weeks after surgery or avoid core exercises for 6-8 weeks? Well, we had some pretty good reasons for that request. Now, this absolutely does not mean you cannot do any activities in your healing period. But, we need to focus on activities that will place the least tension on your incisions. To illustrate this point, picture that you need to get your Instant Pot off the top shelf of your pantry 5 weeks after a Breast Lift. You have two options: stand on your tippy toes and reach your arms over head to grab it, or get a chair and lift it chest height with your elbows in. The former has reaching, stretching and lifting something heavy. The latter is still lifting something heavy but with no reaching or stretching. You see the difference? Good. With good communication between you and your surgeon, navigating the postoperative healing period will be less about hard, fast rules and restrictions and more about mindful decision making.
The Spectrum of Scar Care.
The trinity of scar care is moisture, massage and avoiding premature exposure to sun. It’s worth noting here that the actual healing period is close to 12 months after surgery. Why is it so long? Well, healing takes place in stages and the longest of those stages is the Remodeling Phase. In this phase, your body is constantly breaking down and rebuilding your scar, and each time making it flatter, softer and less pigmented. If you want an evidence-based approach, Silicone Gel Sheets take the cake. They apply pressure and trap moisture over your scars, creating a cozy little sauna while requiring little to no effort on your part. Silicone-based scar creams have also been shown to be superior to alternative scar creams. I have plenty of patients, however, that stick with non-silicone based approaches and look great. Other popular products are Bio Oil, Vitamin E, Aquaphor, and Mederma. Ultimately, I think it matters a little less what you put on your scars and more the consistency with which you do it. If you can, consistently, have some sort of scar regime for 3-6 months after surgery, you are a rockstar!
While we know that patients stress about their scars in Plastic Surgery, just remember that we as surgeons do everything in our power to keep those scars small, thin and hidden, and that there are multiple factors you have control over during the healing process. If you would like to know more about this topic or other Plastic Surgery topics, please leave a comment or reach out.
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Dr. Megan Dreveskracht is a Seattle-based Female Plastic Surgeon who specializes in Aesthetic Surgeries of the Breast, Body & Face. To schedule your consultation, call 206.860.5582 or fill out a contact form here.