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Happy Saturday!!! Today is the third and final installment of Dr. Jack sharing with us her wealth of knowledge on the topic of scars. Today she’s going to share information about scar revision surgery as well as other non-surgical options to treat a scar that you aren’t happy with. I find this is particularly helpful for all of my beautiful Mom friends out there who have had Cesareans!
SKB: “So now another topic that I know is very interesting to many people is scar revision surgery.”
DJ: “Patients who are candidates for scar revision are going to be people who have a scar that they don’t like. Either it’s in a bad spot, it’s too visible, it’s not straight, it’s indented or the opposite- it’s raised- so in other words it just doesn’t look very nice and it’s not going to respond to non-surgical options. A great example of this are tummy tuck scars. Tummy tuck and C-section scars- those are probably the ones that I see most commonly. I will also see patients going to the ER for a cut or laceration on their face and they’ll either not get stitches because they didn’t seek treatment or the stitches just didn’t turn out great and so the scar just doesn’t look right. The tummy tuck scars- those are tough. They do have to be revised sometimes and that might be because they are just too high so the skin retracts up a little bit and raises the scar after everything settles out. On some occasions patients may complain that they’re not quite even, or sometimes we will do a scar revision when we see something that’s called ‘dog ears’ where the scar ends but then there’s sort of this out pouching of tissue at the end of the scar. C-section scars tend to heal quite well, but in the event they don’t. . .don’t worry—scar revision can help!! For most people, I would wait at least 4-6 months after their initial surgery and they’re completely healed, because a lot of times it gets better on its own or with non-surgical intervention such as laser. Sometimes we start with these non-surgical interventions and if we don’t see the improvement we’d like then we talk about a scar revision surgery.”
SKB: “And that sounds good to me- a more conservative approach.”
DJ: “Yes! I’m kind of more conservative, I don’t like to put people under the knife when it’s not necessary. Sometimes it’s one of those things that if you wait long enough the scar ends up looking great! Sometimes it looks worse before it gets better and you just have to be patient and give your body time to heal itself.
That being said, sometimes there can be a problem with wound healing post surgery. So for example part of the incision will open up, or you get a little infection and there’s a problem with drainage from the site or something like that that causes just a small portion of the scar to be discolored or raised up and in those situations you might think about doing something a little earlier because you know it’s probably not going to get better on its own. Part of the healing process is inflammation and if you go and try to intervene too early and there’s still a lot of inflammation in place all that’s going to do is cause the skin to break down. The tissues just won’t hold any sutures at that point. You want all of that inflammation to be resolved before you even touch it.”
SKB: “That’s really smart. So what is a scar revision surgery and what does it involve?”
DJ: “Ultimately it is cutting out the old scar and starting from scratch. You remove 100% of the scar tissue, or if you’re just focusing on a smaller abnormal area of a scar then you just remove that abnormal area and then you put new stitches in. Sometimes you’ll change the technique for stitching based on what happened the first time. So for example a patient will come in and say ‘Oh you know, I had XYZ surgery done and they used dissolvable sutures that “spit” and it left me with hyper pigmented little round spots on my scar that I don’t like.’ That’s a reasonable thing to do for scar revision. So, if they had absorbable sutures the first time and left with spitting sutures where they get these little abscesses where the stitches start coming out through the skin and they get a lot of drainage there or hyper pigmentation, the second time you may want to go with a different kind of suture that’s less likely to cause problems- a suture under the skin that still dissolves and is less likely to have any infectious issues or suture spitting, and then using a non-dissolvable stitch on top that has to be removed. That just tends to have a lower incidence of problems with healing and inflammation. If somebody has an issue with hyper pigmentation we may switch and use a permanent suture that has to be removed because that type of suture is less likely to cause hyper pigmentation. There are lots of different adjustments that we can make based on how they responded to the first surgery and based on what they had during the first surgery if they know.
Most of the time this is successful and most of the time it can be done under local anesthesia (just numbing medicine in the office). Obviously it is still done sterilely, it’s just that you don’t necessarily need to go to sleep or have general anesthesia or anything crazy like that. The recovery period is going to typically be next to nothing and really just involve being careful to not have any trauma to the revision site, keep it clean, following the surgeon’s instructions- I always tell people no swimming for at least two weeks.”
SKB: “Wow. That’s so amazing that you can do that! Now, is there anything special involved with let’s say a C-section scar, where there’s multiple layers of tissue- is there anything special that you have to do?”
DJ: “It kind of depends on what the issue is when you examine them and what their concerns are. A lot of times with C-section scars they turn out great and they look beautiful. And sometimes they don’t! And that’s okay and it happens, and it might be because they had a little infection or they have a little bit of leftover ‘Mommy bump’ over the scar and so the scar is sort of flat and they have a little bit of extra cushion up above the scar so it makes it look indented. Sometimes it’s just a matter of removing a little bit of extra tissue underneath the skin.
Anytime a surgeon closes a wound they are going to close it in layers. There’s a layer called Scarpa’s Layer which is a deep layer underneath the skin which is in the fat layer but it’s a stronger fascial tissue and we’ll repair that first, especially for deeper wounds. Then you put a layer in the deep dermis (deepest layer of the skin) and that’s really your tension layer-it holds the skin together and takes tension off of the epidermis (top, thin layer of skin). Last, you do your epidermal layer and that’s sort of the “pretty layer”. People always ask- why do you do layered repairs of incisions? It’s important because you want to remove any dead space or open areas underneath the skin where fluid could accumulate as this could cause infection, so you have to close that space down. This also prevents indentation-if you don’t have normal healing underneath the skin and you have that fat layer not repaired then you can get an indentation where the fat actually doesn’t heal together and then the scar heals down to the muscle underneath- so that leaves you with an indentation. The deep dermal layer with sutures is probably the most important layer, because that layer really is the strength layer and it’s going to take tension off of the epidermis while everything is healing. That’s really an important layer in keeping the scar thin and not widening it.”
SKB: “This is great! Now as far as non-surgical revision, can you tell me a little bit more about IPL and Fraxel?”
DJ: “So for IPL and Fraxel, it really depends on what you’re doing for the patient and what the issue is. Sometimes you’ll layer the laser treatments if they have both a pigment issue and a thick scar issue for example. The IPL treatment really addresses the pigment. IPL is only going to address a pink or a brown pigment in that scar. If they have a thick scar where we’re trying to kind of fade the scar faster or blur it in so it’s a little less perceptible, then you’re going to choose a Fractional treatment.”
SKB: “Oh okay! So more of a resurfacing versus addressing pigment..”
DJ: “Yes, yes exactly.”
SKB: “Dr. Jack, thank you SO much for sharing all of your incredible and in-depth knowledge about scars with us this week!”
Dr. Jack graduated with a medical degree from the University of Kansas and completed her general surgery residency at the University of North Carolina Chapel Hill. During her residency, she was named Plastic Surgery Intern of the Year and gained the highest score among her peers in the Fundamentals of Laparoscopic Surgery. Dr. Jack then relocated to Florida to complete her plastic surgery residency at the Cleveland Clinic Florida and is certified by the American Board of Plastic Surgery and is a Fellow of The American College of Surgeons. She chose to remain in South Florida to practice and attained her licensing there as well.
Twitter: @DrMegan Jack