An in-depth comparison of current surgical and nonsurgical scar revision treatments

There are many treatment options currently available for patients who want to minimize the appearance of scars. From injections and radiation therapy to actual surgical intervention, there is now an abundance of possible solutions to address scars that concern any patient. While more options for treatment make scar revision more accessible, it can often be confusing to determine which type of procedure a patient and scar is best suited for.

We reached out to ASPS Member Surgeon Suzanne Trott, MD, FACS, to learn more about the exciting field of scar revision treatments and gather more insight into the differences between surgical and nonsurgical options.

ASPS: So many patients have visible scars, whether from a previous injury or surgery that didn't heal properly. However, what many patients don't know is that there are treatment options available to reduce the appearance of scarring. How popular are scar revision procedures at your practice?

Dr. Trott: I honestly don't see that many scars from previous injuries, but I do see quite a few patients who have had surgery elsewhere – whether it was an intra-abdominal or orthopedic or plastic surgery procedure. When I am working on my own postoperative patients, I wouldn't call what I do "scar revisions" but "scar treatment."

I always inform them from the beginning that there will be a scar – that "plastic surgery" does not mean "scarless surgery" – and that while I can't promise it will go away completely, I have multiple nonsurgical modalities to treat the postsurgical scars that I create, and I do not charge my own patients for this treatment. This is why I invested in these technologies, because I felt badly about making scars on people, even when they are "good," and then sending them elsewhere where they would be charged a lot of money to have them treated.

ASPS: Who are the patients that typically come to you for scar revision? Do they typically lean towards nonsurgical or surgical correction?

Dr. Trott: For my own patients, I treat almost all of them with nonsurgical modalities for scar improvement. Unless there has been a wound healing issue, there is almost never a need to surgically revise a scar with more than a minimally invasive technique. Actually, that applies to almost everyone I see from elsewhere as well, whether their scars are due to trauma or previous surgery.

Initially, those patients who are referred to me are looking for a "quick fix" surgical scar revision by cutting it out and redoing it, but I explain to them that it is not that simple. The main factor that determines how discolored or thick a scar is depends mostly on two things – skin type and tension on the scar. Darker skin tends to scar worse – although darker skin usually ages much better than light skin – and increased tension on the wound pulling the edges apart tends to stretch the scar and make it thick and wide and red or brown.

ASPS: Are there any cases in which scar revision treatment would not work for patients? For example, too large a scar, placement on the body, etc.?

Dr. Trott: If a patient has a scar that is under a lot of tension, excising it and closing it is just going to create an equally bad or worse scar. I have turned down multiple requests from patients to revise a breast or tummy tuck scar that is already under so much tension that going straight to excision and closure would be the wrong treatment.

If a patient has a skin excision on the upper chest wall that gets pulled in multiple directions by the neck, breasts or arms, it is going to leave a less-than-desirable scar. If a patient has an orthopedic scar over a hip, knee or elbow joint, the scar will usually become hypotrophic (thinned out) because of the movement of the joint, which creates tension. Most of these are scars that patients expect to be re-excised, but almost none of them should be. However, all scars can be treated with minimally invasive modalities.

ASPS: What are the most popular current techniques for scar revision?

Dr. Trott: Repeated steroid injection into a thick scar is usually the first step for a hypertrophic (thick) scar or a keloid. This can also be done with 5-FU. Intense pulsed light (IPL) is often used for red or brown discoloration. Fractional C02 is a staple modality for scar resurfacing. Keloid or hypertrophic scars that have failed injection can be excised and treated with superficial radiation therapy to the area to give an 80 percent chance that it will not recur.

Massaging certain scars will also help flatten them. Using silicone scar gels and sheets is also a well-known postoperative practice and can be bought online. We recommend starting this at about six weeks. Microneedling and platelet plasma combinations have been shown to help stretch marks.

If a scar is hypopigmented – lighter than the patient's natural skin color – then there is always the option to find a good medical tattoo artist to match the scar to your skin tone. But you should get a recommendation from a plastic surgeon.

ASPS: Are there any promising new technologies or treatments in this area that you'd like to discuss?

Dr. Trott: One treatment that has become popular and may require several sessions but has been proven to work has been "nanofat" injections, where a small amount of fat is harvested from an area of the body that the patient chooses and then turned into nanofat, which is a form of stem cell serum. This can be injected into any kind of adherent (stuck down) scar or thin scar, and the stem cells from the fat will actually improve and soften up the tissue. This can also be used in situations where the patient is going to benefit from a surgical scar revision, but the tissue is not yet soft enough to operate on.

I am fortunate to have the most advanced microneedling/radiofrequency device, the Potenza, which we have been using routinely on postoperative scars or even on patients that come with scars from elsewhere, and it has the advantage of an infusion tip that can be used to inject PRP (platelet-rich plasma) and nanofat directly into the dermis. This is especially helpful for stretch marks.

Also, I have the DEKA Fractional CO2 Laser, which has very low settings like the CoolPeel, which can be used with minimal downtime, which is especially helpful on the face or other visible areas.

Internal scar-like firmness after a liposuction, facelift, neck lift or breast procedure can be treated with massage and ultrasound. I have an especially effective Aspen Ultrasound, which I use on all of my patients postoperatively and can be used to treat and prevent capsular contracture of breast implants.

ASPS: What is the typical recovery process for nonsurgical scar treatment?

Dr. Trott: The recovery process for nonsurgical scar treatment is really not much at all. These treatments are done in the office with really no downtime. The area is just covered, and we usually give the patient a serum to put on the treated area if it has been ablated by something like the CO2 laser.

Q: What is the typical recovery process for surgical scar treatment?

Dr. Trott: This is a very difficult question to answer. If it is a straightforward scar excision where there is loose skin, there shouldn't be much downtime unless it is a very large scar. As I previously stated, scars over joints or the upper chest are not usually successfully treated by surgical revision.

In addition, if a scar is in an area that had poor healing and that is why it is under tension, another type of procedure, like a rotation of a skin flap, may be required to revise the scar. If another surgical procedure is required, the recovery could be up to two weeks of no strenuous activities, and you might have drains in.

ASPS: Do you have any tips or advice for patients who are considering pursuing scar revision?

Dr. Trott: Patients need to understand that a scar that is a thin white line is generally considered by almost every plastic surgeon "the best it's going to get." If it still bothers you, then the suggestion would be to locate a medical tattoo artist to match your skin tone.

A scar is going to be invisible at first because it hasn't started healing yet. You can't just put the edges of the skin back and expect them to stick together. The wound is not strong. It could easily be pulled apart. The skin has to knit itself back together. It is normal for it to start turning red because it is going through the inflammatory phase of healing that makes it strong. This starts becoming evident around six weeks, when the scar starts to turn red – and is about 50 percent of the strength of normal skin – and will continue to be the worst it is going to be for a year, possibly up to 18 months. Of course, during this healing time, the above-mentioned treatments can be done to decrease the discoloration, and steroids can be injected to flatten a raised scar.

Sometimes, what a patient is looking at is not the scar itself but the shadow around the scar. For instance, I have seen several tummy tuck patients who were at a year. The area above the scar has more fullness than below the scar and casts a shadow. This is something that happens because the skin of the abdomen is thicker than the groin skin, and it can be risky to try to defat that skin flap to match the skin thickness below. If that is the issue, your plastic surgeon can usually liposuction the above area under local anesthesia or excise some recurrent stretched-out skin if necessary.

ASPS: Do you have any additional insights around this topic that you'd like to share?

Dr. Trott: I often have patients showing me scars and calling them keloids. The word keloid is misused and overused. A keloid is a scar that not only gets thick but grows outside of the boundaries of the original incision. Keloids generally only happen in Black and Asian patients. The scars that most people think are keloids are actually hypertrophic scars. They are initially approached the same way, but the surgical revision is slightly different.

The most important thing is that a patient goes into surgery understanding that if there is skin excision or any incision, there is going to be a scar. If you are concerned about a scar and your surgeon brushes it off, saying, "It will become invisible," please get another opinion. It is true that many scars, especially those on the face and neck, become "nearly invisible," but nobody can promise an invisible scar. While they can be hidden, your surgeon should make it clear to you that the scars of arm lifts, thigh lifts, tummy tucks and breast lifts can fade to "almost nothing," but they could also be the worst scars you ever have. These procedures can make incredible improvements in body contour, but always remember that the trade-off for that shape is a scar.  I will only do those procedures on patients who come in knowing what they want or understand what the trade-off is. Nobody should sell you a scar telling you it will be invisible.

Besides skin tension, the biggest variable that contributes to the extent of a scar is the patient's own skin and how they heal. In general, the darker someone's skin is, the thicker the dermis, the more potential there is for a worse scar. However, by the time someone decides to have elective surgery, they have probably had a few small injuries on their skin here and there, and most patients already know if they "make" bad scars. One good thing to do is to show your surgeon any previous scars that you have so they can see how you heal in general.

Speaking of dermis, I have a lot of patients come to me about stretch marks they have developed over the years. A stretch mark is an actual rip on the inside of your skin that went through the dermis (inner layer), but not the epidermis (outer waterproof layer). Like any cut, it is going to leave a scar, and it will leave a permanent scar in the dermis. This usually happens when skin is stretched quickly, whether with pregnancy, a growth spurt or even a large breast implant on someone who has little room for it. That is why stretch marks feel thinned out in addition to being discolored – they are actually indented at the site of the cut. As I mentioned earlier, the best way to treat them is with a microneedling or radiofrequency device and some kind of volume like fat or filler.

To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.