Thick scars after plastic surgery- hypertrophic scars
One of the topics that I am constantly trying to explain to my cosmetic plastic surgery patients is the occurrence of hypertrophic scars. A recent study showed that 50% of scars will become hypertrophic after surgery and that the majority will decrease with time. Making patients understand that hypertrophic scars are a condition due to their skin type and reactivity and not due to what their cosmetic plastic surgeon can control is challenging.
Causes for Hypertrophic scars
There are many theories as to why Hypertrophic scars occur. The short answer is that no body knows why some patients develop hypertrophic scars or even Keloid scars. Hypertrophic scars are scars that produce extra collagen and become thicker and inflamed. Keloid scars are the same process but occurring on skin on the outside of the area of trauma and also having even greater collagen deposition.Patients also have itchiness and sometime pain in the scars. The scars occur commonly at injury sites to the skin dermis layer such as occurs with burns or trauma, but also occur along surgical incisions.
Hypertrophic scars are known to be more prevalent in patients with darker skin color. Why? Again no body knows but that fact has allowed people to study the differences between darker and lighter skin and to look for other differences which may also be involved.
It turns out that darker skin individuals have more sebaceous oil glands in their skin than light individuals. That may be one of the causes.
More importantly, it appears that hypertrophic scars occur more commonly in areas of the body that have higher concentrations of sebaceous glands; the arm pits, around the areola and under the breast, around the umbilicus and the pubic areas. Unfortunately all of these are areas where we plastic surgeons have to put our scars for cosmetic surgery!
If sebaceous gland are in fact a contributor for hypertrophic scars then what are they?
Sebaceous glands are a type of oil gland in our skin that produces sebum- an oily discharge that lubricates the skin and hair . Each hair follicle has a sebaceous gland attached to it which lubricates the hair. Those of you who have greasy skin have a lot of sebum production. These glands are also the ones involved in causing acne and other skin conditions.
Typically they will get larger and grow with puberty. The sebum also has a bit of an odor which like any oil can become rancid and cause you to become smelly . The sebaceous glands are found in all areas of the body except the soles and palms; these areas do not have hairs.
… and one other thing, sebum produced by the sebaceous glands is the food source for the Demodex skin mite that lives in the shafts of hair follicles. That’s right we all have millions of insects living off our skin oils and dead cells. These mites normally do not cause much bother but can at times grow in population to cause itching ,irritation, and redness of skin. All of these are what is seen with hypertrophic scars. They have also been associated with various forms of acne.
Treatment of hypertrophic scars
The treatments available for hypertrophic and keloid scars have had poor results. When we don’t know why something occurs its obviously difficult to find a treatment.
- Steroid injections ; Steroids injected into the scars can decrease the swelling, redness and itchiness in some patients. injections are given three times with six week intervals. In many patients it does not work.
- 5-Flurouracil ; An old cancer drug that reduces the rate of collagen production. I usually mix this with steroids.
- Excision; Cutting out the scar and re-closing with steroid injections at the same seems to work in some patients- and not in others!
- Silicone cream; has been shown to help flatten the scars. I tell patients to use it on all scars.
- Pressure; has been shown to help in some cases.
- Radiation therapy: an old treatment rarely used today
Treatments and causes for hypertrophic scars are plainly a shot in the dark. Plastic surgery patients need to be aware that scars may become hypertrophic and though in most the hypertrophy will disappear with time, some patients may need other treatments that may or may not help. Its not the surgeon’s fault but it might be the fault of the skin bugs.