Next month sees a joint summer scientific meeting taking place between the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and their Finnish colleagues.
Many fellow Members of the Association will be travelling from the UK to the meeting in Helsinki in June to listen to presentations the latest developments in aesthetic and reconstructive surgery. Among other topics discussed on the first day is a Skin panel, mainly reviewing new approaches to the treatment of keloid scarring and wound healing.
Scars and cosmetic surgery
During my Leamington cosmetic surgery consultations, I always give an in-depth and comprehensive evaluation of all possible risks and complications and what the patient can expect from their operation. The one definite outcome, though, is that there will be some scarring: any incision into the skin will result in a scar forming.
Certain areas of the body can produce worse scars than others, depending on the composition of the skin. The good news for the facelift patient, though, is that the face and neck tend to heal better. And the thin skin on the eyelids typically heals very well which is why a blepharoplasty is such a highly satisfactory procedure.
Some people heal better than others and it’s rare that the plastic surgeon can predict exactly how a patient will scar. However, patients with black skin are more likely to produce hypertrophic or keloid scars, white ‘Caucasian’ skin being least likely to do so.
Scarring: what can the surgeon do
The face and the body is a map of skin tension lines, known as Langer’s Lines, and they correspond to the direction of the collagen and muscle fibres in the body. As a cosmetic surgeon, a high degree of anatomical knowledge is a must: choosing where best to place an incision and in which direction to make the cut can make a significant difference to the scarring outcome.
Incisions that are made parallel to skin tension lines will usually heal better than those that cut across. There is also more chance of developing keloid scarring when an incision is made across skin tension lines. Hiding a scar in a ‘hidden’ areas of the body or in the natural folds and creases of the skin can also make them much less noticeable when healed.
Hypertrophic vs keloid scarring
There are many different types of scars – for instance from burns to acne scarring – but the most unfortunate form of scar misbehaviour is of scar hypertrophy or keloid formation. During the wound healing process, the body produces and then breaks down collagen as it repairs the wound site. A good scar is one that heals flat, remains thin and fades over time. However, sometimes more collagen is produced that can be broken down and the scars become a thick and raised in the line of the scar but not beyond it (scar hypertrophy) or may also spread into adjacent skin (true keloid scar – commonest in young black boys).
The microscopic processes in the skin are different in the two types, the collagen being contained in hypertrophic scars but ‘invading’ normal surrounding skin in keloid behaviour where the scars can become very thickened and raised.
Unfortunately, there is a tendency, even amongst doctors who should know better to call all thickened raised scars ‘keloid’. However, whilst they may initially look quite similar, the distinction is important as hypertrophic scars, which tend to form and therefore become noticeable during the initial healing process, are more likely to improve spontaneously over time and also to respond much better to treatment. Keloid scars, by contrast, may form later and are much less likely to improve with time or to respond well to treatment.
Exceptionally amongst Plastic Surgeons, I am almost always present to take all of my patients stitches out (or to be at the first dressing after surgery when dissolveable stitches have been used. In this way, I can assess healing from the earliest opportunity onwards, this experience built up over many years giving me a ‘nose’ for unusual or abnormal healing so that steps can be taken early to minimise the development of adverse scarring.
Thus, at my Warwickshire cosmetic surgery practice, I can advise on topical silicone treatments that can help, as well as surface pressure where possible (on the limbs for instance) and additional aftercare information covers massaging scars and how best to promote scar healing with lifestyle changes – smoking has a significant impact on wound healing.
Lectures at the Summer Scientific Meeting that I look forward to learning more from include the therapeutic potential of regenerative medicine – stem cell transplants, the use of bio materials and growth factors and tissue engineering – in promoting better wound healing. Any developments that could reduce the risk of scarring in the future is of interest to the plastic surgeon.