Scarless Surgery: How close can we get?
A scar marks the final stage of a coordinated healing process after your skin suffers a wound. It’s an amazing, but imperfect operation that creates a replacement that never quite measures up in strength or color to its original counterpart. When your body recognizes injury, it initiates healing through a complex cascade of signals. Inflammation, which is seen as redness and swelling attracts wound healing cells that form a blood clot to stop bleeding and make a provisional protective covering over the wound. Overtime, this layer thickens and remodels into its final form, a shiny discolored scar.
From the moment we are born, every injury has the potential of leaving a scar. While some scars may be of purely cosmetic concern, others cause itching, pain, or significant disfigurement and psychological distress. Although the desire to improve and prevent scars has fueled a multi-million dollar industry, it’s hard to know what’s hot, what’s hype, and what actually works, so we asked Dr. Jennifer Herrmann, a board certified, fellowship-trained dermatologic surgeon in Beverly Hills, CA for advice. Here is your go-to list for preventing surgical scars.
Can any surgical incision result in NO scar?
Technically, the answer is no. Surgical wounds that require stitches are large enough and penetrate deeply enough to stimulate our less than perfect healing response that results in a scar. But, by optimizing the pre-operative and post-operative skin, there are many ways to accelerate the healing process to make scars nearly invisible.
What can I do before cosmetic surgery to minimize scars?
A first and important consideration is maximizing nutrition. “Consuming foods with numerous vitamins and anti-oxidants before your surgery will give your skin the building blocks it needs for optimal wound healing,” says Dr. Herrmann. Vitamin C and zinc, for instance, are important in collagen synthesis, and deficiencies result in conditions with poor wound healing and suboptimal scars.
Stress reduction is also key. Stress increases the production of cortisol, the fight-or-flight hormone. “Cortisol shifts internal emphasis away from reparative processes like healing and preps our bodies for survival,” explains Dr. Herrmann. In fact, patients on oral long-term corticosteroids for medical conditions show slower wound healing and worse appearing scars. To decrease stress and promote zen, consider 5 minutes of meditation or a cup of chamomile tea nightly before going to bed.
A topical retinoid or retinol can also be applied to the skin pre-surgically to speed wound healing by increasing keratinization (skin forming) and collagen production. Several convincing studies have shown that pretreatment with tretinoin cream, a type of retinoid, speeds wound healing1-2. Dr. Herrmann reminds, “But it’s important to start any retinoid 2-4 weeks before surgery, because these agents take time to induce their effects and can cause initial irritation.” Usually, any irritation resolves after a couple of weeks of their use.
Because excess inflammation results in poorer and slower wound healing, it’s also important to stop non-prescription aspirin and other pain medications like ibuprofen and naproxen that can worsen bleeding and bruising. Other supplements, such as ginko, garlic, ginger, turmeric, fish oil, flax seed oil, vitamin E, and glucosamine that can promote bleeding should be stopped as well. Finally, pre-operative alcohol is a no-no because it, too, also acts as a blood thinner.
Are there ways to reduce scarring during surgery?
Yes! It’s important to choose a board-certified surgeon who has significant experience working on the skin. Dermatologic surgeons who specialize in facial plastic reconstructive surgery have an intimate knowledge of facial anatomy that allows him or her to best hide lines and create the most natural look.
During surgery, ablative CO2 laser resurfacing can also be performed to decrease scarring. “Our practice has shown that using the CO2 laser at the time of surgery results in less visible scars after healing. I often combine this laser when I stitch close wounds on the face to optimize cosmetic results,” says Dr. Herrmann. “It’s painless because patients are already numb, and it adds only a few extra minutes. It’s a no-brainer for improved cosmetic outcome and minimized scarring.” The CO2 laser uses heat energy to create micro-wounds in the skin that recruit reparative factors, speed overall wound healing, and better blend scars into background skin.
What can I do after surgery to minimize scarring?
Infection can seriously impair the wound healing process, leading to worse scarring, so it’s important to follow your doctor’s recommendations to keep wounds clean. “I often encourage patients to clean wounds with soapy luke-warm water daily or use a dilute white vinegar water solution for wounds on the body.” Avoiding ocean water and pools when stitches are in the skin is important as well because these environments are teaming with bacteria.
Excess tension or pull on the surgery site as it’s healing can also worsen scarring. For at least 3 weeks after surgery, minimizing exercises that pull on the wound’s edges is key. Botox can also be used to reduce tension. “In certain locations like the forehead, I use a muscle relaxant like Botox or Dysport to decrease muscle movement that can lead to pull on surgical wounds,” explains Dr. Herrmann. “A perfectly sewn straight line on the forehead can spread into a gaping scar, if someone repeatedly raises their eyebrows, literally pulling apart the wound’s edges during healing. For the first week after surgery, scars are only 5% the strength of normal skin, so it’s not that difficult to separate the wound if you try. Botox and Dysport soften muscle movement and make it impossible to pull apart the scar line through facial expressions alone.”
Just like it is important for pre-operative scar minimization, both nutrition and stress reduction are also important after surgery. But, topical retinoids like tretinoin should be avoided for a couple of weeks because they have been shown to slow healing. Other products to avoid are acid peels that can sting and any creams or ointments with fragrance and numerous preservatives. These chemicals can more easily cause allergic reactions in newly formed, healing skin. There is also no good evidence to support the use of Vitamin E, and it has actually be shown to slow healing in at least one study4. Although there is anecdotal support for arnica, large clinical trials have not shown it to be effecting in improving outcomes.
Do topical creams, gels or pads work to decrease scarring?
“Many patients ask about topical pads and scar creams to diminish scars. Of the products on the market that have been studied in research trials (and most have not), many are sponsored by the companies selling the products, which may introduce bias,” answers Dr. Herrmann. Silicon is a major ingredient in many of these products, and it has been shown to be equally effective as petrolatum jelly when it comes to scar reduction. In the immediate post-operative period, Dr. Herrmann recommends something simple like Vaseline or Aquaphor, because these create a moist, protective healing environment. She also recommends skin care products with DNA repair enzymes (DNA EGF Scar Cream) and growth factors, which can both aid in wound repair.
What’s on the horizon for scar-less surgery?
An amazing observation is that before we are born, we heal without scars. In utero early-on, we’re able to regenerate tissues in a scar-less fashion much like a lizard can regenerate a leg. Active research is identifying the key players involved in this type of wound healing, and we will continue to improve our methods, as we better understand this regenerative process. Research-on!
- Aesthetic Plast Surg. 1995 May-Jun;19(3):243-6.
- Plast Reconstr Surg. 2011 Mar;127(3):1343-5.
- J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S79-81.
- Br J Dermatol. 1995 Jan;132(1):46-53.