There is no guarantee that any one measure will prevent a scar from forming. This is despite some quite impressive claims made by the manufacturers of certain cosmetic products. The evidence does not back up the vast majority of these approaches. Few have been subjected to the most powerful form of clinical analysis, a randomised, blinded, controlled trial with long term follow up and outcome measures that have been ‘validated’. This means that the intervention – such as an ‘antiscar’ cream – must be compared directly with a cream without the vital ingredient. Ideally such a study must compare the two creams in the same subject with identical scars using tools that cannot be biased by the observer (the observer is ‘blinded to the treatment) for at least two years. As you can imagine, this is very hard to do in practice!
While little evidence exists about which treatments truly work, there is some common sense advice that can be applied to reduce the risk of scarring. If a wound is due to a planned operation, it is worth seeking out an experienced surgeon as many little elements of the wound closure can all add up to worsen the scar. Central pillars of plastic surgery training are removal of all unhealthy tissue, gentle tissue handling and meticulous approximation of wound edges so that all the layers of the skin meet evenly and with minimal tension.
If stitches are placed on the surface, these should not be left in too long as they can act as ‘foreign bodies’ and trigger more inflammation. This causes unsightly stitch marks. There are precisely defined amounts of time that stitches should be left in and this depends on factors like the thickness of the skin and site on the body surface. Usually, stitch marks can be treated with a simple scar revision operation.
For wounds that are left to heal without surgery, such as burns in the top layers of the skin, there is some good evidence that if healing takes more than three weeks, there is a much greater likelihood of angry, hypertrophic scarring. In such cases, it may be that your medical team advises surgical approaches such as skin grafts as the scar is likely to be less angry in the long run.
If you have had some significant scarring in the past and are due an operation, it may be worth telling your physician. There are some pre-emptive measures that can be used to reduce the risk of further significant scarring. These include silicone sheeting and pressure once the wound has healed and, for more severe scarring, the judicious use of corticosteroid injections into the skin surrounding the site of the wound. Patients who are at risk of keloids may particularly benefit from the latter approach.
There is increasing evidence that the amount of tension across a wound is a significant factor in the development of angry scarring. Consequently, new devices are coming onto the market with the specific aim of reducing tension across a wound. Your surgeon can help to reduce the risk of a scar being under tension by the method of closure, for example, with deep, permanent stitches if you have been prone to scar stretching in the past. However, a relatively simple means of reducing the tension across a wound is to apply hypoallergenic skin tape to a healing wound for a minimum of six weeks to give support from the outside. This should be left in place for a week at a time. If it is removed too frequently, it can cause irritation to the top layer of the skin which may cause further inflammation with the risk of worsening scarring.
We feel that there is no substitute for involving a scar team early in your care if you have had significant scarring in the past.