Reducing scarring after skin procedures

All procedures leave scars. Fortunately, the most severe scars can usually be prevented by the right management after the procedure. Old overgrown scars can usually be treated to improve their appearance.

You may not be concerned about the appearance of the scar, but looking after your wound properly can help prevent:

• The wound from pulling open in the weeks after a procedure.
• An overgrown, raised scar (sometimes called a keloid scar) which can be very itchy and difficult to treat once it has formed.

What causes scarring?

All procedures leave scars. They are a normal result of skin growth and repair after an injury. The new skin has a different composition from the surrounding undamaged skin and will usually look different.

In the early stages after a procedure and for about a year after, the scar will be red or pink. This is normal and usually fades.

After that, the scar usually returns to the approximate colour of the surrounding skin, but its surface consistency and pigmentation pattern remain different so the scar can still be seen.

Large scars

Large or overgrown scars may be raised above the level of the surrounding skin or extend sideways further than the original incision. This type of scarring is called hypertrophic or keloid scarring.

Hypertrophic scars are more likely when:

• The original excision procedure is large.
• The spot was removed from an area of the body that stretches, such as the chest, back or shoulders.
• The skin needs to be stretched slightly to close the wound.
• The patient is a growing child or teenager.
• A skin graft is used.
• The wound becomes infected or breaks down.
• The patient has a darker skin type.

Some people are simply more prone to develop hypertrophic scars even when none of these factors apply.

Suture marks

Some scars have crossing lines from where stitches were inserted. These are more likely if the stitch material was thick (sometimes necessary for stitches on the back) or if the skin was stretched tightly to close the wound. In these cases, the doctor will sometimes use two layers of stitches where one is buried beneath the surface of the skin. This makes the wound stronger and reduces the risk of scarring.

In the short term

Follow the aftercare instructions provided by your doctor or nurse to reduce the risk of wound infection, breakdown and dehiscence (edges pulling apart).

If you have any concerns about your wound, such as pain, bleeding, bruising, or infection, see your doctor as soon as possible.

If your dressing is blood-stained or coming off, or you have other concerns, we are happy to replace it at our clinic.

In most cases, after 3 days, you can remove the dressing and leave Steri-Strips across the wound until you return to the clinic to have the stitches removed.

LED Low-level light therapy

You may wish to undergo a course of LED low-level light therapy. This treatment helps the wound heal significantly faster by providing energy to the healing cells (Min 2013, Calderhead 2015).

Wounds treated with low-level light therapy are softer and more elastic when they heal (Calderhead 2015) and less likely to develop keloid scars (Barolet 2010).

A recommended treatment course would be:

• 1-2 days before the procedure.
• Immediately following the procedure.
• 2-3 days after the procedure.
• 2-3 days later.

Reducing scarring after stitches are removed: what you can do

You can reduce the risk of an overgrown scar by following these principles:

• Avoid stretching the wound.
• Cover the wound tightly to stop it becoming raised.
• Apply a product that reduces inflammation and stimulates wound healing.
• Promote blood flow to the wound and improve healing by massaging it.

Avoid stretching

Your skin will take up to twelve months to return to maximum strength (which is still less than the strength of intact skin). For the first few weeks after the stitches are removed, the wound is relatively weak and may pull apart if the skin is stretched.

Minimise movements that involve stretching the area for about a month after your stitches are removed.

Be especially careful when lifting heavy weights or moving suddenly. If you routinely do gym work, Pilates, or yoga, talk to your instructor or trainer about ways to exercise that reduce tension on the affected area.

Wearing tape over the wound can help you be aware of stretching in the area and act as a warning to be careful.

Silicone gel

Apply a silicone gel twice daily. This can help keep the wound soft and flat, and prevent excessive redness or discoloration. For best results, the wound should be treated twice daily for at least two months. We recommend Epicyn gel, which is available at our clinic. Other silicone gels such as Dermatix, Kelocote and Strataderm are available at pharmacies.

Silicone gel forms a film over the wound, which stops it from drying out and applies pressure to stop the scar from becoming raised.

Wounds covered with silicone gel are significantly less likely to develop into hypertrophic scars (Mustoe 2007).

Epicyn gel (silicone in combination with hypochlorous acid) has been shown to lead to superior results compared with plain silicone gel. (Gold 2017, Sakarya 2014).

Tape

To further flatten the wound and reduce stretching, apply a surgical tape such as Micropore. For best results, keep the wound covered with tape for 4-6 weeks after the stitches are removed.

Massage

Massage can increase blood flow to the wound and promote wound healing. For best result, after 2 weeks (and only if the skin is clean and dry) massage daily with Bio-Oil for at least 10 minutes at a time. This further reduces the risk of hypertrophic scarring, as well as improving the softness and flexibility of the skin. Maximum benefit is obtained if you continue massaging for 6 months or more.

Sun exposure

Sunburn may cause healing scars to become darker. Avoid unnecessary sun exposure to your scar for at least 6 months by applying tape or sunscreen.

What not to do

Smoking

Smoking impairs wound healing. Improving the outcome of your procedure and reducing the risk of scarring might be the incentive you need to help you stop.

Vitamin E cream

Do not use vitamin E cream. There is no evidence that it improves wound healing and it causes contact dermatitis in many cases.

Antiseptics

If your wound is red or weeping, do not apply any antiseptic such as Dettol, Betadine or tea tree oil.

Wound redness is common and it can be a normal part of the wound healing process. It doesn’t necessarily mean the wound is infected. Antiseptics can help treat infections, but they are toxic to new, healing skin as well as being toxic to bacteria. If you think you have a wound infection, you should see your doctor for assessment and advice.

If your wound is red or weeping, do not apply any antiseptic such as Dettol, Betadine or tea tree oil.

Treating existing scars

If you have a pre-existing keloid or overgrown scar, multiple treatments are available including fractional laser or microneedling, steroid injections, broadband light/IPL and low level light therapy.

References

‍Min P, Goo B 2013 830 nm light-emitting diode low level light therapy (LED-LLLT) enhances wound healing: a preliminary study Laser Ther 2013;22(1):43-9.

Calderhead RG, Kim WS, Ohshiro T et al 2015 Adjunctive 830 nm light-emitting diode therapy can improve the results following aesthetic procedures Laser Ther. Dec 30; 24(4): 277–289

Barolet D, Boucher A 2010 Prophylactic low-level light therapy for the treatment of hypertrophic scars and keloids: a case series Lasers Surg. Med., 42: 597-601