Scar Revision

Scar treatment can address specific concerns about the appearance of a scar on your face and/or neck. There are four general categories of treatments for scars, each of which may or may not benefit you. It is important to seek not only a fellowship-trained but also a double board-certified facial plastic surgeon to help determine whether - and which - scar treatment is appropriate for your concerns. Topical Treatments Can Improve Healing and Reduce the Risk of Abnormal Scarring The enemy of surgical incision healing is sun-exposed, dry skin. To that end, topical treatments that keep surgical incisions moist and protected from the sun can improve healing and reduce the risk of abnormal scarring. The first few days after surgery require a topical antibiotic to both keep incisions moist and to reduce the risk of infection. Next, an occlusive moisturize such as Aquaphor© is used to continue to hold moisture in the skin around the incision. Finally, a silicone-based scar gel layered over with a mineral-based sunscreen with an SPF of 30 or greater is applied for months until the incision is completely healed. Injectable Treatments Can Reduce the Risk of Abnormal Scarring and Improve the Appearance of Scars Incisions can (rarely) scar excessively, resulting in discoloration and contour abnormalities. Careful use of dilute steroids injected into these scars starting a few weeks after surgery can soften them and improve their contour, making them flatter and more even. Fluorouracil is a medication that has been used early in the healing process after eyelid surgery (blepharoplasty) to reduce excessive scarring which can result in incomplete eye closure, called lagophthalmos. It is injected deep into scars just as they are starting to form. Resurfacing Treatments Can Improve the Color and Contour of Scars Resurfacing lasers, including the Erbium:YAG and CO2, are potentially excellent tools for treating excessive scarring. Similarly, chemical peels which also resurface the skin can be used to treat excessive scarring. Both lasers and chemical peels can improve the color and contour of scars. But both do involve a recovery process during which the top layers of skin heal. Unfortunately, resurfacing lasers and chemical peels cannot be used on darker skin tones due to the risk of skin lightening associated with these treatments. Surgical Scar Revision Can Remove Abnormal Scars Scars that do not improve with topical, injectable, or resurfacing treatments may require surgical removal. Surgical scar revision involves the excision of the scarred skin and closure of the normal surrounding skin. The purpose of this procedure is to allow the skin another opportunity to heal with more aesthetically pleasing results. Surgical scar revision surgery can also reorient scars in ways that better camouflage them on the face. Botulinum Toxin A (e.g., Botox©) is Used to Reduce Scarring It was first theorized that botulinum toxin A (BoTA) could be used to reduce scarring in 2000. While the use of BoTA for this purpose is considered FDA off-label, more research is being published to suggest that it could be effective when injected either during surgery or shortly after (1, 2). The potential mechanisms of action are the following: Reduced tension on the incision site. Increased tension at the incision site increases the risk of excessive scarring. This is the reason why deep plane facelift surgery, including the extended deep plane facelift, reduces the risk of abnormal scarring compared with other non-deep plane techniques. Reduced fibroblast hyperproliferation. Fibroblasts build connective tissue and excess proliferation can result in excess scarring. Reduced deposition of collagen. Fibroblasts produce collagen. Fluorouracil is Used to Reduce Scarring Fluorouracil is another medication that is used FDA off-label to reduce scarring. It is a chemotherapeutic agent that is commonly used in dermatology to treat pre-cancerous and cancerous skin growths. It functions as an antimetabolite, which means it stops the growth of particularly fast-growing cells. Fluorouracil is probably most used in the lower eyelid after lower eyelid surgery (blepharoplasty) to reduce the risk of and treat scarring that can lead to retraction of the lower eyelid, which can cause problems with eye closure. Like BoTA and steroids, it is important to have a detailed discussion of the risks, benefits, and alternatives to the use of this medication with your physician prior to considering these treatments. Trust Your Face to a Facial Plastic Surgeon It is important to seek a fellowship-trained specialist in plastic surgery of the face and neck when you have concerns about abnormal scarring in the face and/or neck. Why Choose Dr. Harmon The mission of Harmon Facial Plastic Surgery is to help people along their journey towards self-confidence, to feel good about feeling good. Dr. Harmon is a double board-certified facial plastic surgeon. Dr. Harmon values making patients feel welcomed, listened to, and respected. Dr. Harmon graduated with honors from Cornell University with a Bachelor of Science degree in molecular biology. Dr. Harmon earned his medical degree from the University of Cincinnati. Dr. Harmon underwent five years of extensive training in head at neck surgery at the prestigious residency program at the University of Cincinnati. Dr. Harmon then underwent focused fellowship training in cosmetic facial plastic surgery through the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) with the world-renowned surgeon, Dr. Andrew Jacono, on Park Avenue in New York City. Request a Consultation Request a consultation with Dr. Harmon at Harmon Facial Plastic Surgery in Cincinnati. Visit our clinic. You will learn more about Dr. Harmon's credentials, style and approach. Build a relationship with our dedicated team. Do not stop at searching "plastic surgery near me." Get in touch with us to learn more! Contact Us References 1. Bi M, Sun P, Li D, Dong Z, Chen Z. Intralesional Injection of Botulinum Toxin Type A Compared with Intralesional Injection of Corticosteroid for the Treatment of Hypertrophic Scar and Keloid: A Systematic Review and Meta-Analysis. Med Sci Monit. 2019 Apr 22;25:2950-2958. 2. Kasyanju Carrero LM, Ma WW, Liu HF, Yin XF, Zhou BR. Botulinum toxin type A for the treatment and prevention of hypertrophic scars and keloids: Updated review. J Cosmet Dermatol. 2019 Feb;18(1):10-15.

You are likely aware of silicone-based scar gels by seeing ScarAway© or another over-the-counter brand in your local pharmacy. Surgeons in all specialties as well as dermatologists recommend these scar gels after procedures to promote healing and reduce the risk of scarring. But how well do they work? I reviewed the literature in order to determine whether silicone gels, placed post-operatively after surgical incisions have healed, can help reduce the appearance of incisions. Not surprisingly, quality studies are difficult to find. It is important to seek not only a fellowship-trained but also a double board-certified facial plastic surgeon if you have aesthetic concerns about your face and/or neck. There are two ways of describing an abnormal scar, hypertrophic and keloid. There may seem to be little distinction between the two. However, the underlying process that causes them to form is radically different. Basically, a hypertrophic scar remains within the boundaries of the original incision or injury. A keloid, on the other hand, expands beyond it. The goal of silicone gels and patches are to not only reduce the risks of hypertrophic scar or keloid formation, but also to reduce the redness of an incision and accelerate the fading of the appearance of a scar. The two major problems with the studies I reviewed are 1) few of the incisions examined were located on the face and 2) silicone gels were usually compared with another treatment rather than no intervention at all (placebo). The second problem is unavoidable because it would be unethical to allow the control group to heal without an accepted alternative treatment to reduce the appearance of a scar. One of the most promising studies was a randomized, placebo-controlled, and double-blinded clinical trial evaluating whether silicone gel prevents hypertrophic scar development on chest (sternotomy) incisions. The researchers found that silicone gel application resulted in a better-appearing scars 3 months after surgery. However chest (sternotomy) incisions are notorious for poor healing and frequent scarring (1). This is unlike the skin of the face, which is widely understood to heal much better than other parts of the body. Also, most of the patients, in addition to heart problems requiring a chest incision, had other medical problems that could lead to poor wound healing such as diabetes. It is possible the silicone gels are more effective in patients with a much higher risk of poor healing. That being said, another quality study found no difference in healing with the addition of silicone gel to the incisions of those considered similarly "high risk" of forming an abnormal scar (2). The only randomized, placebo-controlled, double-blinded clinical trial focused exclusively on facial incisions I found was from 2018. The researchers looked at the use of silicone gel on forehead incisions for brow lifts (3). Only 13 patients participated, which is a very small number. No difference in the appearance of the incisions was identified at 6 months. Other, similar studies have shown no clinically meaningful difference in scar formation with the use of silicone gels on breast reduction incisions (4) and cesarean section incisions (5). The bottom line: First, it is important to note that we still do not know how silicone gels work to reduce the appearance of surgical incisions. It may be that silicone gels function like an occlusive dressing, holding moisture in and keeping bacteria out. It may also modify the underlying inflammatory process that occurs with any incision during healing. Either way, the end goal is to have an incision as soft, smooth, and flat as possible. There are few studies of quality design available to review. Those available are plagued by the same problems with other studies of this type, including small numbers of subjects. To make matters worse, these studies rarely focus on incisions on the face or on the most important outcome to me, the appearance of incisions after surgery - not simply the prevention of abnormal scarring (e.g. hypertrophic, keloid). On the other hand, there is little risk with the use of silicone gel, barring some limitations around the eyes and mouth as well as for those who are allergic to silicone. And silicone does help keep healing incisions moist, which is essential to healing. As a result, I encourage almost all of my patients to start using silicone gels after all sutures are removed twice daily for weeks to months as the incisions heal and blend in with the rest of the skin. I expect additional studies may result in evidence that this approach can help improve the appearance of incisions. In the end, factors other than whether or not silicone gels are applied are more important to the healing process, including proper closure technique, tension-free skin re-aaproximation, a healthy diet, adequate sleep, and sun protection with mineral-based sunscreens. References: Chan KY, Lau CL, Adeeb SM, Somasundaram S, Nasir-Zahari M. A randomized, placebo-controlled, double-blind, prospective clinical trial of silicone gel in prevention of hypertrophic scar development in median sternotomy wound. Plast Reconstr Surg. 2005 Sep 15;116(4):1013-20; discussion 1021-2. Gold MH, Foster TD, Adair MA, Burlison K, Lewis T. Prevention of hypertrophic scars and keloids by the prophylactic use of topical silicone gel sheets following a surgical procedure in an office setting. Dermatol Surg. 2001 Jul;27(7):641-4. Cadet N, Hardy I, Dudek D, Miszkiewicz K, Boulos P, Nguyen Q, Wong J. Prospective case-control trial evaluating silicone gel for the treatment of direct brow lift scars. Can J Ophthalmol. 2018 Feb;53(1):29-33. Niessen FB, Spauwen PH, Robinson PH, Fidler V, Kon M. The use of silicone occlusive sheeting (Sil-K) and silicone occlusive gel (Epiderm) in the prevention of hypertrophic scar formation. Plast Reconstr Surg. 1998 Nov;102(6):1962-72. Lin YS, Ting PS, Hsu KC. Comparison of Silicone Sheets and Paper Tape for the Management of Postoperative Scars: A Randomized Comparative Study. Adv Skin Wound Care. 2020 Jun;33(6):1-6. Trust Your Face to a Facial Plastic Surgeon It is important to seek a double board-certified, fellowship-trained specialist in plastic surgery of the face and neck when you have concerns about your face or neck. Why Choose Dr. Harmon The mission of Harmon Facial Plastic Surgery is to help people along their journey towards self-confidence, to feel good about feeling good. Dr. Harmon is a double board-certified facial plastic surgeon. Dr. Harmon values making patients feel welcomed, listened to, and respected. Dr. Harmon graduated with honors from Cornell University with a Bachelor of Science degree in molecular biology. Dr. Harmon earned his medical degree from the University of Cincinnati. Dr. Harmon underwent five years of extensive training in head at neck surgery at the prestigious residency program at the University of Cincinnati. Dr. Harmon then underwent focused fellowship training in cosmetic facial plastic surgery through the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) with the world-renowned surgeon, Dr. Andrew Jacono, on Park Avenue in New York City. Request a Consultation Request a consultation with Dr. Harmon at Harmon Facial Plastic Surgery in Cincinnati. Visit our clinic. You will learn more about Dr. Harmon's credentials, style and approach. Build a relationship with our dedicated team. Do not stop at searching "plastic surgery near me." Get in touch with us today to learn more! Contact Us

The treatment of scars is complex and often requires multiple modalities of treatment, including lasers, chemical peels, topical medications, injected medications, and even surgery. For more information on the treatment of scars, please visit the linked blog post. One proposed treatment for scars is Botox© and similar medications which are also referred to as Botulinum Toxin-A. A recent study sought to answer the question of whether Botulinum Toxin-A is an effective treatment for scars by combining the data from multiple previous studies to perform something called a systematic review and meta-analysis, which is a qualitative and quantitative study of the effects of an intervention. For more information on how physicians review the literature, please visit the linked blog post. It is important to seek not only a fellowship-trained but also a double board-certified facial plastic surgeon if you have aesthetic concerns about your face and/or neck. A Systematic Review and Meta-Analysis Demonstrated the Effectiveness of Botox© and Similar Medications in Treating Scars A systematic review and meta-analysis published in medical literature reviewed approximately 20 studies to evaluate the effects of Botulinum Toxin-A on scar formation. This study demonstrated an improvement in the appearance of scars with treatment with Botulinum Toxin-A when compared with incisions that were not treated, also known as the control (1). A more recent systematic review and meta-analysis confirmed these findings, especially for the use of Botulinum Toxin-A in the forehead and upper lip (2). Typically, the best method to assess scar formation is with what is called a split-scar study. A split-scar study involves the treatment of half the scar with the other half of the scar serving as the control. Many of these papers included split-scar studies and utilized methods of assessing the appearance of scars that have been approved as being objective enough to be included in medical studies. The Mechanism of Action by Which Botox© Can Improve Scar Appearance is Not Known The mechanism by which Botox© and other similar products can improve the appearance of scars is not yet clear. It may be that the medication affects the cascade of signaling molecules that affect the healing process. It may also be that, by reducing the contraction of muscles around the incision, there is less tension on that incision, thereby improving the appearance of the scar. More research is required to determine the mechanism of action of Botulinum Toxin-A on scar formation. Botox© and Similar Products are a Promising Treatment for Scars but Remain FDA Off-Label While the potential benefits of the treatment of scars with Botulinum Toxin-A is promising, It is important to note that the FDA has not yet reviewed and approved the use of Botox© and similar products for the treatment of scars. However, as with many other interventions, the road to FDA approval starts with research demonstrating the effectiveness of the treatment, as evidenced by the above study. Trust Your Face to a Facial Plastic Surgeon It is important to seek a fellowship-trained specialist in plastic surgery of the face and neck when you have concerns about your face or neck. Why Choose Dr. Harmon The mission of Harmon Facial Plastic Surgery is to help people along their journey towards self-confidence, to feel good about feeling good. Dr. Harmon is a double board-certified facial plastic surgeon Dr. Harmon values making patients feel welcomed, listened to, and respected. Dr. Harmon graduated with honors from Cornell University with a Bachelor of Science degree in molecular biology. Dr. Harmon earned his medical degree from the University of Cincinnati. Dr. Harmon underwent five years of extensive training in head at neck surgery at the prestigious residency program at the University of Cincinnati. Dr. Harmon then underwent focused fellowship training in cosmetic facial plastic surgery through the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) with the world-renowned surgeon, Dr. Andrew Jacono, on Park Avenue in New York City. Request a Consultation Request a consultation with Dr. Harmon at Harmon Facial Plastic Surgery in Cincinnati. Visit our clinic. You will learn more about Dr. Harmon's credentials, style, and approach. Build a relationship with our dedicated team. Do not stop searching "plastic surgery near me." Get in touch with us to learn more. Contact Us References Rammal A, Mogharbel A. Effectiveness of Botulinum Toxin-A on Face, Head, and Neck Scars: A Systematic Review and Meta-Analysis. Facial Plast Surg Aesthet Med. 2023 Nov 7. Rammal A, Mogharbel A. Effectiveness of Botulinum Toxin-A on Face, Head, and Neck Scars: A Systematic Review and Meta-Analysis. Facial Plast Surg Aesthet Med. 2024 Jul-Aug;26(4):379-385.