Summer in the sun, fall in the plastic surgeon's chair: What can you do about skin cancer scars?

The smell of pumpkin spice is already in the air, and that means the summer is quickly coming to a close. You may already feel a little bummed because vacation season is almost over and the cold weather is right around the corner. Not to kill the buzz even further, but multiple summers spent baking in the sun could mean that it is time to get your skin checked for signs of cancer.

Statistics from the Skin Cancer Foundation show that skin cancer is the most common cancer in the United States today. At least one in five Americans will develop some form of the disease by the age of 70. Having five or more sunburns also doubles your risk for the most aggressive form of skin cancer – melanoma.

The prospect of combating skin cancer is frightening enough. Yet, many individuals, especially those diagnosed with skin cancer in prominent areas of the body, like the face, fear what skin cancer treatments, like surgery, will do to their features. If you've spent summer in the sun, will spending fall in the plastic surgeon's chair be the answer to your cancer scar woes?

The facts about skin cancer

Like other forms of the disease, skin cancer occurs when abnormal cells in the epidermis, or the outermost layer of skin, grow out of control. Cell mutations, typically caused by damage to the DNA, can trigger skin cells to multiply unchecked. There are different types of skin cancer: basal cell carcinoma, squamous cell carcinoma, melanoma and Merkel cell carcinoma. Merkel cell carcinoma is extremely rare and can develop due to sun exposure and a weak immune system.

Basal and squamous cell carcinomas are the most common types of skin cancer. Most spots develop on areas of the body frequently exposed to the sun's harmful rays, such as the face, ears, neck, scalp, shoulders and back. Basal and squamous cell cancers are slow-growing and respond well to treatment.

Melanoma is a much more aggressive form of skin cancer. Although highly treatable when caught early, melanoma metastasizes quickly, spreading to other parts of the body and making treatment more complex. While it is one of the rarest forms of skin cancer, the American Academy of Dermatology indicates nearly 20 Americans die from the disease every day.

Skin cancer treatment and minimizing the appearance of scars

ASPS Member Surgeon Sara Dickie, MD, has a practice that is slightly different from most of her colleagues because many of her patients come to her from dermatologist referrals.

"We touch every other specialty somehow, some portion of everything, and specialties bleed into one another," said Dr. Dickie.

She works extensively with patients seeking a skin diagnosis, those recently diagnosed with skin cancer who need surgery and those who just received surgery to remove cancer and need her to repair the defect.

Although numerous options may be available to treat cancer, for skin cancers, Dr. Dickie said, "They all need to be managed surgically because surgery for all skin cancer is the gold standard."

By and large, surgery is the mainstay treatment for nearly all types of skin cancers. With surgery comes scarring, and that can be a tough pill to swallow for someone working through a cancer diagnosis. Thankfully, working with a board-certified plastic surgeon who is an ASPS member, there are ways to minimize the appearance of skin cancer surgical scars.

First, it is crucial to understand that the most essential part of any skin cancer removal surgery is to remove all cancerous and potentially cancerous tissue. Scarring will depend on the location and depth of the cancer. There are different surgical techniques physicians can use to remove cancerous tissue. A standard excision means the surgeon removes the tumor along with a portion of healthy tissue. The amount of healthy tissue that needs removal varies. Mohs surgery is another technique that can be used, especially in cases where there is a significant risk the cancer may return.

There is a big misconception about surgical scars Dr. Dickie wants to help dispel.

"So one of the biggest misnomers about scars that I try to re-educate people on all the time is to get an understanding that a shorter scar is not a better scar," said Dr. Dickie. "That is so not true. So, as much as I want to have the patient undergo a tissue-sparing cancer resection, it's not because I want the scar to be shorter. It's because I want the defect to be cancer-free – 100 percent without question. Then I want the freedom to close that defect in the way that is the most ideal for the cosmesis of it."

What exactly does that entail? For Dr. Dickie, that may mean adding a curve or shape to the incision. It may mean adapting the incision to the contours or folds of the face or body.

"The ideal scar has no tension," said Dr. Dickie. "It follows the resting skin tension lines and is closed in layers. All of these things make the ideal scar."

However, plastic surgeons also admit the technique used to close a wound is only one part of the scar-healing equation. Patients need to do their part to help manage incision recovery.

"I use techniques in surgery for suturing with the goal of minimizing the scarring that occurs, but for overall scar appearance in the long term, there is a lot the patient can do to help," said ASPS Member Surgeon Peter Krasniak, MD.

For patients undergoing surgery to address skin cancer, Dr. Dickie typically recommends taking enough time to recover and let the skin settle after surgery.

"As far as activities go, usually with the face, you don't have to worry so much about people raising their heart rate or sweating, but I definitely have people who are involved in contact sports or sports where anything might contact or harm the repair area," said Dr. Dickie. "Just take two weeks off of anything that's going to traumatize the area."

She also said that the first phase of the healing process is particularly critical.

"I always have people keep the incision covered with a small bandage and moisturized either with Aquaphor, Vaseline, or some sort of ointment coverage," said Dr. Dickie.

ASPS Member Surgeon Karen Horton, MD, MSc, FACS, said during the initial healing process, an incision is a wound, not a scar.

"The first six to eight weeks and sometimes longer after surgery, an incision is considered a 'wound' rather than a scar," said Dr. Horton. "There are inflammatory cells that travel to the wound to help form a clot, white blood cells, red blood cells and other inflammatory cells that digest wound products and suture material. The next stage after wound formation is deposition of collagen by cells called fibroblasts, then the incision is considered a 'scar.'"

Once the stitches are removed from the wound, Dr. Dickie said, "I'll have them do another week of Aquaphor, but then we'll switch to usually silicone-based scar management systems, which can be ointments or strips."

One of the most critical recommendations from all the physicians? Keep the scar out of the sun!

"Protecting your scar from the sun is also very important in the first year after surgery, as sun exposure will often make your scar darker in color, and scar skin is more sensitive to UV light than your normal skin," said Dr. Krasniak. "Add to this that the places where a previous skin cancer tends to be high sun exposure areas, often making this more difficult, but also more important."

Dr. Horton and her team focus on teaching patients "scar therapy."

"Scar therapy involves applying a topical scar gel twice a day from six to eight weeks after surgery until the scar is mature – six months to a year or longer," said Dr. Horton. "Most scar gels contain medical-grade silicone, which has several purported mechanisms of action and has been used for burn scars for many decades. Many products also have SPF 30 to 50 to avoid sun exposure as well."

Another way you may be able to minimize the look of a fresh skin cancer surgery scar is with gentle massage.

"There are a few therapies that have been shown in studies to improve the appearance of scars," said Dr. Krasniak. "First is scar massage, which is simple and only takes one finger and 30 seconds a few times a day. This can usually be started after a month, but your surgeon can guide you on timing. Massage can soften and decrease the projection of your scars over time."

Dr. Horton also works with patients on gentle massage techniques.

"Light pressure over a scar can help to flatten it sooner and break up thicker collagen," said Dr. Horton. "There are some products such as scar strips or silicone sheets that can be a convenient way to achieve both silicone and pressure."

For bothersome scars, Dr. Krasniak also said, "Lasers have been effective for both softening dense scars as well as decreasing pigment or coloring of scars."

Dr. Dickie also noted that in some cases, microneedling can also improve scarring and may be done in as little as six weeks after surgery once the scar is past its inflammatory phase.

If you are long past the initial point of surgery, you may still have options to decrease the appearance of your post-skin cancer surgery scar.

"For bothersome scars that are more than a year old and that these other therapies have not helped with, or the patient is not otherwise a candidate for, scar revision surgeries are an option," said Dr. Krasniak. "Scar revision surgeries involve cutting out the old scar and using different techniques to try to improve the healing process and scarring for the new incision that was made."

The procedure for scar revision can be done while conscious. While it is impossible to remove a scar completely, the goal is to make that new scar much less noticeable.

"A surgical revision can often be done awake under local anesthesia," said Dr. Horton. "The entire scar is excised down to the underlying fat, constricting scar bands are released, and a three-layer or four-layer closure will properly reoppose each layer of tissue to its matching counterpart on the other side. I describe this to patients as reestablishing the layers of a three-layer cake, while an indented scar is similar to the icing or frosting getting stuck down the cake pan."

Getting a skin cancer diagnosis can be devastating. The last thing you should worry about is how you will look postop. Working with a board-certified plastic surgeon who is an ASPS member can help give you peace of mind that as you navigate cancer treatment, you also have someone in your corner working to mitigate the look of your scar and giving you the freedom to put your best face forward.

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.