Surgical Scars

It is obvious that once a surgery is required a scar will result. The first and most obvious consideration is where there is no medical need for the procedure then one should ask – is surgery really necessary?

However when surgery is the option a scar can be planned or steps can be taken to improve or mitigate the appearance of a necessary surgical scar.

The key problem in this case is the lack of forward planning. Especially where surgery is done for cosmetic enhancement. There are a certain things a surgeon can do to optimise a scar such as relieving wound tension, special suturing techniques, minimal access/keyhole surgical techniques and ensuring good post operative instructions and wound care. However there are many factors that cannot be changed such as position of the scar, skin type, mobility and stretching of the scar affected area. Poor wound management by the patient or not following wound care instructions.

Sometimes a scar is placed in an area in order to hide it. This is obviously a logical decision however this then creates a new problem. A typical example is that of an abdominoplasty scar. Excess fat and skin are removed for cosmetic reasons from the abdomen. Logically the plastic surgeon places the scar in an area which is below the bikini line / waistline to hide it. However placement of the scar in this are also exposed it to recurrent friction and trauma from the waistline of trousers or jeans which then exposes the healing wound to constant friction and irritation. This prolongs and increases the inflammatory reaction around the healing scar and makes a poor cosmetic outcome much more likely. The same is true of breast implant scars. These are placed in an area where they are in constant friction with the metal underwire of a bra.

Obviously even though this is not ideal, logic dictates that this is the best position for scar placement.

In essence when a surgery is necessary for a medical or health benefit then the patient will be more accepting of the scar consequences. Sometimes the scar may remind the patient of a traumatic experience and as a result the patient may seek to improve the scar appearance for these reasons.

However where surgery is for cosmetic reasons a good surgeon will help you to plan your procedure by talking about the scar and how to initiate steps to improve it. Afterall it is only a question of time before the excitement of new breasts or a flat stomach is compromised by the appearance of a very obvious scar.

One of the main problems in scar management is that it is not funded by the NHS. As a result there is a lack of surgeons and dermatologists with relevant experience and expertise. If the NHS does not allow scars to be treated surgeons and dermatologists will not be trained adequately in the management of post surgical scarring. Needless to say that expensive laser equipment is often needed in scar management.

Routine access to lasers in many NHS hospital Dermatology and Plastic Surgery departments is not possible. This is not say that there is exemplary burns and reconstructive work happening in our hospitals.

In the UK today we have world class trauma, burns and reconstructive surgery. Unfortunately and understandably keloid scars, hypertrophic scars and post surgical scars are not a priority. Hence treatment for these is left to private external centres.

In the case of post-surgical scar management (such as abdoinoplasty, breast augmentation scars) it is important to identify the scar type. Hypertrophic and keloid scars require certain treatment combinations. Normotrophic scars require different equipment and approaches. Atrophic scars in turn may require certain approaches. Let us be clear the following is required in effective scar management.

• Plastic surgical or dermatological surgical experience in order to revise or debulk scars surgically
• Extensive knowledge of lasers in the management of scarring
• Knowledge of the use of Intralesional injection in conjunction with laser
• Lasers required:
  • Vascular Laser (532nm or 595nm as well as a 1064nm Long pulsed NdYAG)
  • Cutera Excel V / Lutronic Derma V/ Candela V beam Perfecta (taken out of service) / Cynosure Cynergy. This type of laser is required in the management of scar redness, inflammation, and essential in the management of keloid and hypertrophic scars.
  • A deep penetrating Fractional ablative CO2 or Erbium YAG laser with greater than 1mm penetration depth with appropriate density management (Not a aesthetic fractional 30 Watt output laser). An ablative laser with 60 Watt output or more is required eg. Lumenis Ultrapulse Alpha or Sciton Profractional. These types of laser are required to blend normotrophic scars or raise atrophic scars. If the laser is low powered then adequate penetration of the scar will not be possible and remodelling will be unsatisfactory. A surgical ablative laser is also essential in the debulking of scars. Ultrapulsed lasers are important as they have a high peak power which allows for deeper penetration and debulking of scars without unnecessarily high residual thermal damage to tissue. This aggravates inflammation and triggers further unfavourable scarring.
  • A picosecond pigmentation laser to reduce pigmentation. Cynosure Picosure Pro or Candela Picoway. If treating darker skin types the Cynosure Picosure Pro is much more effective. Picosure Pro is a 755nm laser which is much more appropriate for superficial and deep melanin reduction compared to Candela Picoway.
  • Non ablative laser such as Sciton HALO 1470nm and Fraxel Dual !550nm for remodelling of superficial cicatricial scarring (textural scarring).
• Extensive experience in the use of the laser types mentioned above in the management of scars.

Now it is easy to understand that in order to manage scars effectively there are a lot of pre-requisites that are just not met by the majority of private centres in the UK. Understandably because management of scars requires considerable time and financial investment in very specific equipment. So your average injectables clinic or general dermatology clinic is not equipped to deal with this. Plastic surgeons are also usually at this point offering mainly surgical scar revision which often just results in the same issue re-developing.

Important

The overriding factor in surgical scar management is that if possible it should be initiated early after surgery.

It is therefore important that when discussing any planned surgery where you may feel that you wish for the scar to be as inconspicuous as possible. you discuss scar management options as soon as possible.

As seen from medical evidence and international scar consensus papers earlier intervention results in more favourable outcomes in appearance.

In short there are not many UK centres that have the adequate experience, skills and equipment to treat this issue. Dr Hussein is one of the few UK dermatologic surgeons who has the necessary knowledge, equipment and experience to safely and effectively treat all types of scarring. We routinely perform scar treatment safely and effectively.

The methods and techniques used by Dr Hussein are clearly evidenced in medical literature. The following papers have been published in medical literature describing the methodologies used by Dr Hussein in Scar management:

Laser Treatment of Traumatic Scars and Contractures: 2020 International Consensus Recommendations.
Lasers Surg Med. 2020 Feb;52(2):96-116. doi: 10.1002/lsm.23201. Epub 2019 Dec 9. PMID: 31820478.
Seago M, Shumaker PR, Spring LK, Alam M, Al-Niaimi F, Rox Anderson R, Artzi O, Bayat A, Cassuto D, Chan HH, Dierickx C, Donelan M, Gauglitz GG, Leo Goo B, Goodman GJ, Gurtner G, Haedersdal M, Krakowski AC, Manuskiatti W, Norbury WB, Ogawa R, Ozog DM, Paasch U, Victor Ross E, Tretti Clementoni M, Waibel J.

Laser treatment of traumatic scars with an emphasis on ablative fractional laser resurfacing: consensus report.
JAMA Dermatol. 2014 Feb;150(2):187-93. doi: 10.1001/jamadermatol.2013.7761. PMID: 24336931.
Anderson RR, Donelan MB, Hivnor C, Greeson E, Ross EV, Shumaker PR, Uebelhoer NS, Waibel JS.

• Dr Hussein owns all the lasers required to manage scars and has them present in one location
• Dr Hussein routinely performs treatment of post surgical scars, traumatic scars, keloid, hypertrophic, normotrophic, atrophic and acne scars on a daily basis. Dr H Consult is an internationally renowned scar management centre.
• Dr Hussein has over a decade of experience in laser skin surgery. Scar management cases are referred to him from all over the UK by dermatologists and plastic surgeons.
• Dr Hussein is the only UK dermatologist with extensive experience in the use of ablative lasers in darker skin types. This means he is the only specialist in the UK to be able to safely perform scar laser surgery on all skin types.