SCAR MANAGEMENT

 

Introduction

Any wound that damages the deeper layers of the skin, whether this be a burn, an operative incision (cut) or an injury will leave a visible scar. It is not possible to cut through the skin without leaving some form of scar. Plastic Surgery techniques are all about minimising scars but do not prevent them. The quality of your final scar depends partly on the age you are, the way that your body heals and the circumstances of healing of that scar. A wound that heals quickly without any complications such as infection will leave the best scar. Any wound that takes more than 3 or 4 weeks to fully settle down is at much greater risk of forming a poor scar. Therefore if you have complications such as poor wound healing or infection this will often result in a scar that is less than perfect. Once the wound has healed much can be done to improve the scar quality, particularly if the circumstances are such that you are likely to end up with a poor scar.

Natural History of Scars

After the wound has healed the scar will, to start off with, be level with the remaining skin, and will have a scab over it. After the scab separates the wound will be red and in some cases this will become increasingly lumpy, itchy and will develop a definite texture. This process of lumpiness gradually increases over a period of 3-6months, and if no active treatment is undertaken can take up to two years to settle down.

Scar management techniques such as massage, silicone and pressure garments all speed up the process of maturation, although there is little evidence that the final result is any better. They certainly improve the speed of the maturation, and therefore your scar will become a lot less noticeable more quickly if you undertake these techniques.

Types of Scarring

Abnormal, problem scars are described as immature, but also the terms ‘hypertrophic scarring’ and ‘keloid scarring’ are used. Although an immature scar and a hypertrophic scar are the same thing a keloid scar is a different entity. Keloid scars tend to run in families and in this situation the lumpiness and the overgrowth of the scar becomes much bigger than the original wound that caused the scar. Whereas a hypertrophic scar or an immature scar is simply lumpy in the area where the original wound was. If you think you have a personal tendency or you have a strong family history of keloid scarring it is important to inform your surgeon of this prior to any routine surgery, as these scars can be incredibly difficult to manage and often require more advanced treatments, including radiotherapy etc, to settle them down and often the best thing to do is to avoid surgery in the first place

General Scar Care

All scars can be improved with careful scar management, and the amount of attention and effort that you put in will determine the final result and how quickly you get there.

After the wound is nicely healed and any sutures have been removed that need to be removed the area should be massaged regularly. This can be done with an ‘over the counter’ product which does not have to be particularly expensive. The most commonly recommended products are E45 or Diprobase, although Bio-oils are now becoming increasingly popular. It doesn’t really matter what you use to massage and moisturise as long as you are doing this regularly. A cheap aqueous cream purchased from your chemist is just as effective as very expensive products, as long as it is applied carefully and regularly.

Moisturising cream should be applied twice a day, and the amount of massage required will depend on the severity of the scaring process. Normal scars following surgery, where there is not high risk of a scar problem do not need a prolonged period of massage. However, scars that are at high risk of getting lumpy or that are already developing any signs of lumpiness should be vigorously massaged for at least 10minutes twice a day. This should be done firmly enough to blanch the area (remove the blood so that the pink scar looks white) which stimulates the blood flow. This can simply be done with the fingers and thumbs, however, this is often tiring, particularly if there is a large area of scaring, and it is often helpful to use an old roll-on deodorant bottle to carry out the massage. The empty roll-on is opened, the moisturising product placed inside the container and the ball replaced. The roll-on can then be used to apply constant pressure and moisturising cream at the same time.

It is important to remove the old cream, if any is left, prior to starting the treatment the next time, so that there is no build up of old cream in the area.

Sun Protection

It is very important to protect the areas from direct sunlight, and a high factor sunblock should be applied. This both prevents any blistering and burning of the skin, which is more sensitive than usual, but also exposure to sun can result in pigment change within the maturing skin, which can result in a brown staining that is permanent.

The colouration of your eventual scar should reflect your normal skin colour, however particularly in intermediate skin colourations, there can often be darker or lighter pigment in the scar. Skin pigment colour change can often take two years to settle to its final colour, during which time it should be protected from the sun.

Silicone

Silicone comes either as a gel, a spray or as a tape or jelly sheet. This is applied to the area of scaring and provides a good healing environment to encourage the scars to mature and settle down more quickly. Silicone products are expensive and can be obtained on prescription from your General Practitioner as well as over the counter in most chemists. There is little difference between the different silicone products, although in practice the sprays are good for larger areas and the tapes for areas where clothing would rub away the ointments and gels. Silicone is well tolerated in the majority of patients and needs to be in place for ideally 23hrs per day. Being removed simply for the purposes of massage and washing.

To start off it is important to introduce your silicone treatment slowly, gradually increasing the numbers of hours per day that it is in contact with the skin, and this improves the tolerance. If you develop itchiness, redness, a rash, or the surrounding skin breaks down you should discontinue the silicone, as it is likely that you are sensitive to it. The symptoms should settle over the next few days, once you are no longer using the silicone.

Pressure Garments

If your wound is at high risk of developing lumpy scars then it is often necessary to prescribe a pressure garment. Sometimes these are used as a preventative measure although the can be used as an active treatment if the scar has already become lumpy. These garments are very specifically made for an individual patient by an occupational or physio therapist, and are made by a pressure garment technician or ordered from a garment supplier. It is important that these are fitted carefully and checked regularly to ensure that they apply the correct amount of pressure to get the best possible result, and without causing other problems such as swelling of the limb, etc.

Pressure garments, like silicone, should be worn for the majority of the time, and you would normally be supplied with two, so that one can be worn while the other one is being washed.

Pressure garments are usually required for a period of 6-9months as a preventative treatment, and for treating active scars may need to be worn up to 24months.

If you think your pressure garment is no longer necessary it is reasonable to gradually reduce the amount of time that you wear it for, and if you notice that the scars are becoming lumpy again then it is necessary to increase the amount of hours that you are wearing it for.

Steroid Injections

It is very occasionally necessary to inject a difficult scar with a steroid and this can trigger settling down, although this is very painful and requires a General Anaesthetic in children or a Local Anaesthetic in adults. This process normally needs to be repeated at 6-8 week intervals and usually a course of 6 treatments will be required. The steroid injections, however, are not essential and in the majority of patients silicone, massage and moisturising are just as effective if carried out carefully over a sustained period of time.