Scarring – What You Need to Know

Every surgical procedure results in the permanent presence of a scar, and its final appearance is the result of a long maturation process that takes months, or even years.

In the plastic surgery field, we use special suturing techniques and materials to produce a scar that is as inconspicuous as possible. However, in some cases, there may be factors that invariably lead to a pathological maturation of the scar, with noticeable worsening of its aesthetic appearance.

As a general rule, patients with fair skin tend to develop good-quality scars long term, as opposed to dark-skinned patients. In addition, scars tend to be more noticeable in certain areas of the body than others.

Unfortunately, the risk of a scar being of poor quality does not depend on the level of skill on the part of the surgeon, but on the way the skin reacts, producing an altered scarring process.

Normal scars

Luckily, scars with a normal evolution and of good quality constitute the vast majority of cases, thanks to the technical intra-operative and post-operative approaches used in plastic surgery.

In the initial stage, which can last for a few months after the wound has completed its healing process, the scar will appear inflamed (pink or red) and itchy.

During the subsequent process of maturation, which can last from a few months up to a year, the scar becomes softer, flatter and lighter in colour, until it matches the colour of the rest of the skin.

Pathological scars

Hypertrophic scars

Hypertrophic scars are caused by an excessive and continuous production of collagen and small blood vessels. They are red, dark (hyperchromic), of fibrous texture (hard), itchy, sometimes sore, and appear raised above the healthy surrounding skin.

These scars can be the result of local unfavourable conditions that occur during the healing process (infection, haematoma, excessive tension on the skin edges), or can be the result of an individual predisposition.

It can take a few years before the maturation and regression process is complete, with a minor aesthetic improvement, and a lasting result of poor quality.

All of the scar treatments currently available – including creams, gels, silicone shields, cortisone injections, lasers and surgical scar revisions – lead to an improvement that is minimal at best.

Cheloid scars

Cheloid scars, as with hypertrophic scars, are the result of an excessive production of collagen and small blood vessels, but they are more severe and more significant. They have the same morphologic features (appearance) as hypertrophic scars, but with cheloid scars the dimensions exceed those of the scar they originated from.

Cheloid scars are always caused by an individual predisposition, often recurring within a family, and they can develop on any body part, even following minimal lesions. Treatments are almost completely ineffective for this type of scarring.

Hypotrophic scars

These scars appear wide and depressed, compared to the surrounding skin surface, and are covered by extremely thin, soft and stretchy skin.

Hypotrophic scars can sometimes be associated with other diseases (Marfan syndrome, collagen tissue diseases, diabetes), or they can be caused by local conditions that do not allow an adequate strength of the wound edges.

In my personal surgical experience of more than 2500 cosmetic breast procedures, the percentage of cases observed with poor-quality scarring is approximately 2%. Nevertheless, it is extremely important for any patient considering breast surgery to be fully aware of this risk – however low it might be.