Management of Surgical

Scars
Grace Lee Peng, MDa,*, Julia L. Kerolus, MDb

KEYWORDS
 Hypertrophic scars  Keloids  Scar revision  Scars  Incisions  Wound healing
 Depressed scars  Microneedling

KEY POINTS
 Meticulous presurgical incision planning and wound closure are the first steps to avoiding the
development of unsightly scars.
 Postoperative care of incisions includes maintaining a clean, moist environment to prevent inflam-
mation and infection.
 Depressed scars can be treated with resurfacing, fillers, and scar revision.
 Hypertrophic scars and keloids are managed with a combination of various modalities including
excision, radiation therapy, and intralesional injection of steroids, 5-fluorouracil, and botulinum
toxin A.

INTRODUCTION This leads to collagen production, and it is these

Surgical incisions will always result in a scar. What
is important, however, is the final result of the scar
after maturation. The goal is to have a scar that is
minimally perceptible, with appropriate color
match to the surrounding skin and be neither
raised nor inverted. To ensure the best possible
scar outcome, preoperative incision planning,
wound tension during closure, and postsurgical
management are all critical. Appropriate patient
counseling and assessment of expectations is
also important because patients often believe
that a scar can be “removed.”
Wound healing is a series of events starting from
initial surgical incision that includes inflammation,
proliferation, and remodeling.1 It takes a year for
the appearance of the scar to mature and even
longer for the full strength of the scar to finalize.
Initial inflammation after injury leads to chemotaxis
of inflammatory cells and neovascularization,
which in turn stimulates fibroblast proliferation.
events that can lead to either wound dehiscence
or hypertrophy of scars.
PATIENT-RELATED FACTORS THAT AFFECT
SCAR FORMATION
There are various patient-related factors that
affect scar formation. Skin texture and color often
predispose patients to different healing patterns.
Thicker and more sebaceous skin often has more
swelling after a surgical procedure. This swelling
can lead to a longer healing time even after the su-
tures have been removed, because the edema
even between where the sutures were placed
may take longer to resolve. Similarly, even within
an individual, the areas of thinner skin often heal
much quicker and with less swelling. In general,
African American and Asian patients are much
more likely to have hypertrophic scarring and
keloid formation in comparison with Caucasian
patients.2 With regard to hyperpigmentation, with
facialplastic.theclinics.com

No financial disclosures.
a
Facial Plastic and Reconstructive Surgery, 120 South Spalding Drive, Suite 301, Beverly Hills, CA 90212, USA;
b
Department of Otolaryngology–Head and Neck Surgery, Division of Facial Plastic and Reconstructive Surgery,
University of Illinois at Chicago-College of Medicine, 1855 West Taylor Street, Suite 2.42 (MC 648), Chicago, IL
60612, USA
* Corresponding author.
E-mail address: drpeng@graceleepengmd.com

Facial Plast Surg Clin N Am 27 (2019) 513–517

https://doi.org/10.1016/j.fsc.2019.07.013
1064-7406/19/Ó 2019 Elsevier Inc. All rights reserved.
514 Lee Peng & Kerolus
all Fitzpatrick levels IV and higher there is a higher
incidence of hyperpigmentation during wound
healing regardless of the meticulous nature of the
incision closure.3
A detailed surgical history obtained during pre-
operative consultation can give information on
the patient’s previous healing patterns after sur-
gery. This information can help when deciding
which intraoperative and postoperative measures
are most crucial. In patients who have a history
of hypertrophic scarring, care must be taken
even with the sutures that are used to prevent
any additional inflammation or irritation to the
area of scar.
INTRAOPERATIVE MANAGEMENT
Incision Planning and Tissue Handling
Incisions should be planned so that they corre-
spond to relaxed skin tension lines as often as
possible.3 Care should be taken to plan incisions
at the junction of facial subunits to further
decrease scar visibility after healing. In cases
where incisions need to be made near hair-
bearing areas, beveling the incision such that the
hair can grow through the incision will allow the
scar to be well hidden. Planning should also be
done so that, for example in the case of facelifts
or brow lifts, there is preservation of natural hair
lines and hair-bearing areas.4
When handling the tissue, care must be taken
not to traumatize the tissue by grabbing skin with
improper forceps or with great force. One should
always be gentle and, whenever possible, grab-
bing the deep dermal layer or subcutaneous layer
is preferred over direct force on the skin surface
itself.
Wound Closure
Skin tension pulls apart the edges of the wound
and is often a reason for poor scar healing. The
body counters tension by trying to hold the wound
more tightly together, which leads to microscopic
collagen deposition and increased scarring.5
Thus, the tissue must be undermined. Placement
of sutures in several layers whenever possible
will help decrease the tension at the surface of
the wound where the scar is visible. Maximal
wound eversion is important to prevent the final
scar from becoming depressed.
The sutures that are used also play a role for
healing of surgical scars. In patients with more of
a predisposition for aberrant wound healing, the
use of less reactive and nonreactive sutures is
preferred. Although Vicryl sutures are useful for
their strength, duration, and ability to cause
some scar tissue formation, some patients may
be more sensitive and develop an allergic reaction.
Although this may not always lead to poor wound
healing and visible scarring, there are ways to
diminish this risk. Monocryl or polydioxanone su-
tures can be used for closure of deeper layers
given their strength and lack of reactivity. In addi-
tion, for closure of the skin, nylon and Prolene su-
tures are less reactive than plain gut, fast gut, or
chromic sutures. This aspect is important espe-
cially when dealing with patients who have more
chance of hypertrophic scarring, prolonged ery-
thema or hyperpigmentation, or postoperative
swelling.
POSTOPERATIVE WOUND CARE
Immediate Postoperative Period
In the immediate postoperative period, the most
important aspects to consider are to maintain
moisture to the incision, prevent infection, and
decrease inflammation.3 All these facets need to
be monitored while the tissue itself is healing the
wound. Moisture can be maintained by an occlu-
sive dressing or placement of ointment. Most
commonly, antibiotic ointment is placed on the
postoperative incision because it not only main-
tains the moisture but also helps to prevent infec-
tion. Prolonged use of antibiotic ointment is
avoided because it may lead to skin irritation and
inflammation. Keeping the incision clean and regu-
larly removing any blood or crusting can further
help to improve the skin healing.
One Week After Surgery
At 1 week, most if not all nonabsorbable sutures
are removed. As the sutures are removed, tape
can be placed on the incisions to decrease the
tension.6 At this time it is still very important to
keep the wound moist. Although antibiotic oint-
ment is no longer needed, especially for clean
healing wounds without signs of infection, use of
other occlusive ointments such as Aquaphor
(Beiersdorf, Wilton, CT) can enhance wound
healing.
Postoperative Care in the First Few Months
Topical treatments
By the second week, all the sutures should be
removed if they have not already been removed.
At this time, many clinicians will discuss the impor-
tance of using silicone sheets and gels to help in
prevention of hypertrophic scarring.7 The use of
silicone gels and sheets appears to increase
hydration to the stratum corneum, leading to
improved wound healing.8
During this time, scars that will become hyper-
trophic may show signs early on. It is important

to educate patients on the possibility that the
appearance of the scar may change, and it is
equally important to closely follow the healing of
the scar. If the scar appears to be increasing in
size or turning red and raised, the patient should
be examined.
The use of intralesional injections with steroids
or 5-fluorouracil (5-FU) can be used to decrease
swelling and is discussed later in the section on
treatment of hypertrophic scars and keloids.
Dermabrasion
The goal of dermabrasion is to even and blend
the skin level in the raised area of scar; this can
be achieved using diamond burrs, wire brushes,
or sandpaper. The aim is to injure the papillary
dermis to allow re-epithelialization and new
collagen formation while preserving the deeper
layers of skin. Any injury deeper than the
papillary dermis, such as to the reticular dermis
or below, leads to a greatly increased risk of
scarring. Dermabrasion can be performed, with
local anesthesia or topical numbing cream for
comfort.
Constant reminders to the patient to decease
direct sun exposure should be made. The patient
should also be very diligent about sun protection
in general to diminish the chance of increased
inflammation or hyperpigmentation of the wound.9
VARIOUS TYPES OF SCARS AND THEIR
MANAGEMENT
Depressed Scars
Depressed scars can often be prevented with
careful and maximal eversion of every tissue layer
during wound closure. When a depressed scar
nevertheless appears, there is an indentation rela-
tive to the surrounding tissue. There are several
ways to approach a depressed scar, such as
resurfacing, filling the indentation, or performing
a scar revision.
Microneedling
A depressed or inverted scar can be resurfaced
by microneedling with platelet-rich plasma or
hyaluronic acid. Microneedling, also known
as collagen induction therapy, is a procedure
whereby multiple small oscillating needles create
damage to the area of the depressed scar. The
body’s response is to deposit collagen where the
small punctures are created, hence increasing vol-
ume in the area of the depression. When paired
with platelet-rich plasma, naturally occurring
growth factors can further stimulate collagen pro-
duction.10 When the patient does not desire or is
unable to use platelet-rich plasma, hyaluronic
acid can be paired with microneedling.
Management of Surgical Scars 515
Fillers
Depressed scars can also be filled in with either
autologous grafts such as fat, collagen, or syn-
thetic materials.11,12 Some fillers can be perma-
nent, but most lack permanence and thus over
time may need reinjection. Subcision of a scar,
depending on the location and length, may be
helpful before filler placement to release any
fibrous connections between the superficial scar
and deep tissue. This approach allows for more
effective filling of the area.
Scar revision
The other definitive treatment of depressed scars
is scar revision and excision of the area of the
scar. The goal is then to redo the closure such
that with proper undermining and eversion of
layers, the new scar will heal without an indenta-
tion. This method is the gold standard for repairing
a depressed scar, although it usually cannot be
done immediately after the initial procedure. More-
over, patients must be informed that the timeline
for wound healing and all the precautions start
anew with a scar revision.
Hypertrophic Scars and Keloids
Hypertrophic scars and keloids are due to abnor-
malities in the wound-healing process that lead
to excess fibroproliferation as well as disorganized
collagen deposition.13,14 This process occurs
more frequently in darker-skinned patients and
can recur even after treatment. Whereas hypertro-
phic scars stay within the realm of the original inci-
sion and injury, a keloid actually extends beyond
those original boundaries.3,13
Hypertrophic scars often appear reddish in color
and can start growing as early as 3 months after
the incision or injury.15 Keloids may develop
several months to even years later. Patients with
a personal or family history of keloids should be
followed closely for their incisions. Despite similar
pathophysiology between hypertrophic scars and
keloids, keloids have much lower rates of improve-
ment when treated and a high recurrence rate after
treatment.
Injections
Steroid injections can be used to manage or pre-
vent hypertrophic scars and keloids. Corticoste-
roids can also decrease swelling, allowing for
quicker wound healing. This injection is typically
intradermal or transdermal, taking care not to
inject any deeper to avoid causing tissue atrophy.
There are many dilutions of triamcinolone that
range from 5 mg/mL to 40 mg/mL. The strength
used will depend on whether the goal is just to
decrease swelling or to soften a hypertrophic
516 Lee Peng & Kerolus
scar or keloid.16 Intralesional injections can inhibit
collagen synthesis and increase degradation.17,18
These injections can be repeated monthly.
5-FU injections have also been used in the treat-
ment of keloids and hypertrophic scars. This
approach can be taken even initially for swelling
after surgery because the antimetabolite can pre-
vent scar hypertrophy as well as decrease the
size of some keloids.3 5-FU targets rapidly prolifer-
ating fibroblasts, which in turn lead to a decrease
in collagen production and the formation of scar
tissue.19,20
Recent studies have shown the benefit of intra-
lesional injection of botulinum toxin type A in the
treatment of keloids and hypertrophic scars.21,22
The mechanism by which botulinum toxin A acts
to prevent and treat hypertrophic scars is still un-
clear. Several theories have evolved from animal
experiments. The theory is that botulinum toxin A
decreases wound tension by paralysis of muscles
and wound edges, downregulates fibroblast gene
expression, and leads to thinning of collagen fi-
bers.23,24 This modality can be used alone or in
conjunction with the aforementioned therapies.
The risks associated with intralesional steroid in-
jection, including skin atrophy, hypopigmentation,
and telangiectasia formation, are nearly absent
when botulinum toxin type A is injected alone.
The amount injected varies among practitioners,
types of scar, and purpose of injection (either pre-
venting or treating scars). The dose range is from
2.5 to 100 units/cm3.22
Radiotherapy
Low-dose fractionated radiotherapy after surgical
excision of a keloid can be efficacious and safe.8
Many times radiotherapy is avoided or used as a
last resort owing to the small risk of malignancy.
However, to date there have been no cases of ma-
lignancy reported after this use.
Pressure therapy
Pressure therapy can help both hypertrophic scars
and keloids. After the wound has healed, physical
pressure leads to a hypoxic environment and sup-
presses collagen production.25 The recommended
pressure exceeds 24 mm Hg for at least 30 min for
upward of 12 months.25,26 Although there have
been some advances to make the pressure dress-
ings easier to use and less burdensome, compli-
ance has always been somewhat low because of
the inconvenience and discomfort. Magnetic pres-
sure earrings may be able to help keloids on the
ear and earlobe if they are small and can be
applied after large keloids are debulked. Keloids
always run the risk of recurrence even after treat-
ment has been completed.
Scar revision
When hypertrophic scars and keloids are nonre-
sponsive to injections, they can be revised through
excision scar revision. Using a Z-plasty or a
W-plasty can help change the tension lines to alle-
viate any predisposition toward scar hypertrophy.
Keloids have a high rate of recurrence despite
surgical excision, and consequently need to be
carefully monitored.
Hypopigmented Scars
Hypopigmented scars, or scars that are lacking in
color, become noticeable because of a usually
white and shiny appearance compared with the
surrounding tissue. Hypopigmented scars can be
covered with cosmetics which, although they
may not permanently alter the scar, can have
good results with easy achievability. If the patient
desires a permanent solution, skin tattooing can
produce good color-matching results.
Hyperpigmented Scars
Hyperpigmented scars can be of various colora-
tions depending on the patient’s native skin color
and texture. Although hyperpigmentation is most
often transient, long-term hyperpigmentation can
draw more attention to the postsurgical scar.
Much of hyperpigmentation is patient specific,
but it can be influenced by external factors such
as sun exposure after surgery.9 UV light affects
melanocyte proliferation and melanin deposition,
leading to color change in the scar. Hence, avoid-
ance of direct sunlight as well as good sun protec-
tion in the weeks to months immediately following
the healing of a surgical scar leads to a decreased
chance of hyperpigmentation.
Laser treatment
Traditionally, using pigment-specific lasers such
as pulsed dye, potassium titanyl phosphate, or
Nd:YAG lasers have had reasonable success.5
However, microneedling or collagen induction
therapy with platelet-rich plasma has also been
known to show improvement in decreasing the
pigmentation of scars. Topical remedies such as
hydroquinone can also be used to lighten scars.
SUMMARY
Scarring is a significant source of morbidity for pa-
tients. Clinical management of postoperative scars
begins preoperatively with through workup of
each patient and understanding each individual’s
predisposition to poor scarring. The management
and monitoring of surgical scars should continue
for a year after surgery because the wound and inci-
sion can continue to change as it heals.

Postoperative visits should always be used to
educate patients about scar care as well as to
screen for any hypertrophy or hyperpigmentation.
Patients who are prone to hypertrophic scarring
should be treated aggressively with injections of
5-FU, steroids, and botulinum toxin A. Careful
identification of early development of hypertrophic
scarring or keloid formation should be made and
followed for an extended period of time.
As we continue to gain better understanding of
wound healing, there are several options to improve
postsurgical scars. However, there is no guarantee
with any modality, either during or after surgery, for
complete prevention of aberrant scar formation.
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