Update: Thank you to everyone expressing interest in the clinical trial for tummy tuck scar reduction. The trial has met it’s enrollment goal, so no new participants can be enrolled. If another trial opens up, I will be certain to post the opportunity here on the San Francisco Plastic Surgery Blog.
We are now enrolling patients in a clinical research study to look at an investigational post-surgical incision care dressing used in scar healing. If you are thinking of having a tummy tuck (also called abdominoplasty), you may qualify for the clinical research study. The investigational dressing will be applied to one side of your abdominoplasty incision and the other side will be treated will be treated per the normal standard of care.
To Qualify You Must
To qualify you must:
be a man or woman between the ages of 18 and 65
be willing to participate in the study to evaluate a new dressing 1 week after a tummy tuck procedure
not have any known reactions to medical tapes or adhesives
not have a history of collagen vascular disease, cutis laxica, connective tissue disease, psoriasis, or lupus
not be diagnosed with scleroderma
not have a BMI > 30
not have had weight loss of >100 lbs. within six months of the tummy tuck procedure
not be a current smoker
not be taking steroid therapy within 2 months from the date of study enrollment
Study Participation Involves
Study participation involves:
study-related procedures and investigational dressing at no charge
weekly office visits (lasting approximately 20 minutes) for up to 12 weeks post surgery with application of a new dressing at each visit
photographic record taken of the incision at several visits
follow-up visits and photographic record at six and 12 months post surgery
Enrolled participants will be compensated for their time and travel at the completion of the study. To learn more about this study give us a call, (925) 943-6353, and schedule a free consultation appointment. We are conveniently located in the San Francisco East Bay Area community of Walnut Creek, California.
This is an IRB controlled study. More information about this clinical trail is also available here.
Sometimes weight loss is not enough. I see many patients who have lost hundreds of pounds, who still are not happy with their shape. If you were overweight, and lost 100 pounds, you should be very proud of yourself. It is not easily done. Whether accomplished with diet and exercise or bariatric surgery, it takes a lot of effort to change one’s lifestyle dramatically. Most patients are very happy with the weight loss. Often, however, more improvement is desired.
Where did all this skin come from?
After weight loss, the problem is no longer excess fat, but excess skin. Rolls of skin that bind at the waist. Redundant skin that drapes on the inner thighs. Flaps of skin that keep moving after the arm has stopped waving. Loose skin that can no longer support the breast and keep it on the chest.
The skin is an amazing organ. It is our greatest barrier to the outside world. It keeps us warm. It cools us down. It protects us from the elements and infection. When we gain weight, it grows, and continues to protect us. When we lose weight, it can shrink too, but there are limits. With weight gain, the skin can be stretched too far, and it cannot shrink back to its original size.
Post-Bariatric Plastic Surgery
Post-Bariatric Plastic Surgery can help. As a member of The American Society of Bariatric Plastic Surgeons, I am able to assist my patients in their transition to a happier, healthier lifestyle. By removing excess skin, an tailoring what remains, I can help complete the transformation in ways that weight loss alone cannot.
Below is part two of a discussion about post weight loss plastic surgery that originally aired on KRON4‘s Body Beautiful.
This segment shows before and after pictures for liposuction, mini-tummy-tuck and tummy tuck. While most tummy tuck have only a horizontal scar that runs below the bikini line, I have included a fleur-de-leis tummy tuck. This type of tummy tuck is most often used after massive weight loss. A fleur-de-leis tummy tuck has a vertical incision in the midline in addition to the lower incision, which is used to further reduce the excess skin left after massive weight loss.
Please note, the 800 number appearing on the video is only for the live show. For more information, or to schedule a consultation appointment, please call me at (925) 943-6353, or contact me via the form on the lower left side of this web page.
The previous example of scar revision was a keloid scar revision. Keloid scars tend to be raised and larger than the original injury. The following scar revision is for an irregular, hypopigmented and wide-spread scar. It may have been more hypertrophic in the past, but was mature, soft, flat and pale prior to revision. This patient presented over a year after breast implant placement. The implants were inserted through an incision normally placed around the lower edge of the areola (the pigmented skin around the nipple). In this case, the scar was too high, and did not heal well.
Wide spread periareolar scars below the nipples after breast augmentaion.
This is noticeable because the scar is white, wide and irregular within the tan skin of the areola. This incision was not placed at the edge of the areola, making the white scar even more noticeable. This is also a poor scar. It is very wide for this location. This scar not a fine line, it’s not a line at all, but rather, an irregular blotch.
The periareolar incision is one of my favorite incisions for breast augmentation because a nice, fine, discrete scar is the normal result. The original scar was not of my making. Since I’ve done hundreds, if not thousands of breast augmentations using this approach, I felt very confident that this particular scar could be improved.
The plan was to excise the previous scar, and obtain a narrow scar that follows the contour of the areola. With the new scar placed at the junction between the areola and the normal skin, the scar’s location is disguised.
After scar revision the periareolar scars are thin, fine and follow the natural contours.
This scar revision was performed in the office, under local anesthesia, without complications. The resultant scar is narrow and follows the natural contour of the areolas. Close up views are included below for comparison.
Before scar revision - Right breast with wide white irregular misplaced scar.
Before scar revision - Left breast with wide spread hypopigmented scar.
After scar revision - Right breast with thin soft pale scar following the natural curve of the areaola.
After scar revision - Left breast with less noticeable and improved scar.
Scar revision can be a very rewarding procedure. The scars cannot be completely erased, but by making scars less noticeable, they can be forgotten.
So how can hypertrophic and keloid scars be improved? What options are available to treat unsatisfactory scars? Here are some of the different scar treatments utilized.
Excision and Primary Closure
This is probably the most common scar revision technique. It often involves making a lens-shaped excision, to remove the scar and a small amount of the surrounding normal skin, then careful re-closure of this new wound. Wide undermining is sometimes employed, to reduce the tension across the repair.
Z-Plasty or W-Plasty
These are techniques for rearranging the scar. Their names are derived from the pattern of the resultant scar. Z-plasty may be used to lengthen a scar if it is pulling too tightly, or to change the direction of a scar, to make it less conspicuous. Both can be used to align scars with an existing wrinkle or landmark and make the scars less noticeable.
Deep, dissolvable sutures (stitches) are used to bring the edges of the skin together. These do not need to be removed. Thinner sutures are used for the fine tailoring, to line-up the two edges of the wound. The superficial sutures are sometimes not dissolvable. Non-dissolvable sutures decrease the amount of inflammation at the surface. Non-dissolvable sutures need to be removed. How long before removal depends on the location and nature of the scar. For example, sutures on the face often can be removed in less than a week, while those on the sole of the foot may need to stay for two weeks.
Buried Dermal Flap
Sometimes the scar is indented (concave). If this is the case, something is needed to fill in the missing volume beneath scar. Several options are available including: a portion of the original scar, deeper layers of the surrounding normal skin or occasionally an artificial filler can be used. The filler brings the level of the revised scar up to that of the surrounding skin.
Occasionally a discrepancy in the length or positioning of the sides of a wound result in a raised portion at the ends of the scar. These are referred to as “dog ears”, as they stand up and are often found in pairs (one at each end of the incision). Revision requires lengthening or changing the direction of the original scar in order to smooth out the ends.
Skin Graft and Flaps
Skin grafts and flaps are not needed for most scar revisions. They are reserved for scars, such as burn scars, that cover a large area. Sometimes scars are too large to simply excise and close. More complicated techniques like tissue expansion, composite flaps and microvascular transplantation (free flaps), have evolved to move “normal” skin into the proper position.
This is the same technique use for treating wrinkles, and is useful for surface irregularities, or scars with obvious shadows or highlights. Dermabrasion can be performed shortly after a scar revision, or after the scar has matured. Dermabrasion appears to work better if used at 4 months rather than 8 months after the revision. This has led some plastic surgeons to use dermabrasion at the time of the revision.
There are many types of lasers. The CO2 and Erbium lasers work very similarly to dermabrasion. They remove the outer layers of the skin, and can be used to take down high points.
The blue-green Argon and flashlamp pumped dye lasers, are more selectively absorbed by blood vessels and skin pigments, and can be used to treat red, purple or pigmented scars.
Pressure and Massage
These modalities can be used alone or in conjunction with the methods listed above. Pressure and massage cause realignment of the fibers in the scar and surrounding skin, and can dramatically flatten and smooth raised scars. This may be why Vitamin E works – the continuing replication ensures adequate scar massage is performed.
Both Mineral Oil and Silicone Gel impregnated sheeting seem to decrease the time needed for a scar to soften and mature, and as a result may lead to the accelerated formation of smoother scars. Sheeting can also be used alone or with other treatments. The drawbacks include the possibility of dermatitis (irritation of the skin), foliculitis (irritation or infection of the hairs) or scar ulceration. The sheets must be worn 12 hours a day and treatment may be needed for as long as 18 months.
Occasionally injectable steroids are used to slow scar formation. Drawbacks include the possibility of lightening the color of the surrounding normal skin. If steroids are used at the time of repair/revision, the wound will require extra support. Frequently this means sutures must be left in longer.
Topical skin bleaches, such as hydroquinone, can sometimes fade a darker scar, or even prevent its occurrence. It takes several months for its effects to be seen and longer to reach optimal results. This can be used separately or with a surgical scar revision.
Local anesthesia is usually all that is necessary to perform scar revision. Occasionally for larger scars, or younger patients, regional or general anesthetic is needed. If so, this will be discussed prior to surgery. Many times epinephrine (adrenaline) is added to the local anesthetic, to minimize any bleeding.
For scar revision, as with any surgical procedure, there are potential risks that accompany the potential benefits. Here are some of the more common risks:
Fluid tends to collect in the operative site. A small amount is normal. If a large collection of fluid accumulates, then it must be removed. Usually this is easily treated in the office by aspiration; occasionally the wound may need to opened temporarily. It is important to remove large fluid collections as these may become infected or put too much tension on the wound.
As with any scrape or cut, an operative site can become infected. A dose of antibiotics can be given just before surgery to minimize this risk. Occasionally antibiotics may be continued for several days after surgery. Even with these precautions, an infection can occur.
Dehiscence (Reopening) of the Wound
This can occur if too much tension is placed on the wound, before it has fully healed. If dehiscence occurs the wound must be cleansed, and if appropriate, sutured again.
Milia frequently occur around scars. These represent blocked glands, or trapped surface skin cells. They can be treated in the office, by gently unroofing them. Once adequately treated, they tend not to recur.
The resultant scar can become darker (hyperpigmented) or lighter (hypopigmented) compared to the surrounding skin. Too much pigmentation can occur as a direct result of exposure to the sun. A sunblock, no less than SPF 15, is recommended until the new scar is fully matured (approximately one year). If the scar is under clothing, this is less of a problem. If the scar is on the patient’s face or neck, a hat is recommended. Skin bleaches are also available to lighten a darkening scar. A light scar on a dark skinned person is more difficult to treat, but options such as make-up and tattooing can be utilized.
Despite the most meticulous, careful repair, there is always the possibility that another unsatisfactory scar may result. This is why a careful dialogue between you and your plastic surgeon is critical. You need to know the chances for improvement, and which aspects of the scar are likely to improve. Knowing where we are going can be as important as getting there.
The evaluation of a scar encompasses the following ten points, the first and last may be the most important.
1 – Time Since Injury
Scar revision is usually performed on mature scars. Depending on your age, this normally requires one to two years of healing. In general, the younger you are, the longer it takes for a scar to mature.
A mature scar has entered the “resting” phase of healing, and can be recognized as a soft, pliable scar in which the redness has faded. Sometimes the maturation process can be accelerated with the use of pressure, massage, steroids or silicone gel sheeting.
There are times when waiting will not help; however, this is the exception rather than the rule. Examples include cases of gross misalignment, i.e. a step-off at the border of a lip, or an injury causing severe distortion, i.e. exposure of an eye or inability to straighten a joint.
2 – Nature of the Injury
The type of injury and the mechanism of injury can influence the treatment. Whether an injury is from a surgical scar or an animal bite is important in planning a revision. A carefully planed operative incision is more likely to heal in an optimal fashion, and as a result, is less likely to require a scar revision. A injury which is not planned, such as an animal bite, or a wound which was infected, tends to give a worse scar and will be more likely to require from revision.
3 – Location of the Injury
Scars of the head and face, in general, respond more favorably to revisions. Areas below the clavicle can often still be improved; however, they are less likely to improve. A triangle on the chest, formed by the shoulders and the lowest portion of the sternum, is a “danger zone”. The thicker skin in this area, and the pull of the underlying muscles, can produce a widespread and darkened scar, even under otherwise ideal conditions.
The orientation (direction) of the scar can also be important. When possible, the scar revision is positioned perpendicular to the underlying muscle to provide a narrower scar and improve its appearance. Wrinkles tend to run in the same direction, and this may also disguise the scar.
4 – Age of the Patient
Older people tend to require scar revisions, less often than younger ones. Younger people heal more exuberantly, and over a longer period of time. This leads to a higher incidence of hypertrophic (excess) scars in the young. Because of this exuberant wound healing, it is also necessary to delay scar revision longer if you are younger.
5 – Ethnicity
The darker the hair, skin, and eyes, the more likely a noticeable scar is to form. Wounds in darker skin tend to be darker, wider, lumpier and more problematic than wounds in lighter skin. The biochemical reasons for this are still largely unknown. It is due in part to innate differences in the healing, and in part to how the scar appears as light reflects off of it. This is outlined below.
6 – Skin Tone and Light Effects
For someone with fair skin, light reflecting off a scar may go unnoticed, but the same scar in darker pigmented skin will be easily spotted. What catches the eye is the difference in brightness between the reflected light, and the surrounding skin’s color.
7 – Healing of Previous Injuries
Healing varies from area to area. A previous injury can be an indicator of what type of scar to expect. If nearby scars are all widespread, raised and darkly pigmented, then chances are higher that a revision will also be widespread, raised and darkly pigmented.
8 – The Nature of the Scar
As a simplification, scars can be separated into four groups: a fine line scar (the desired result, flat and thin); a widespread scar (flat but wide); a hypertrophic scar (raised and wide); and a keloid scar (raised and extending outside the original zone of injury). The more the original scar is like a keloid scar, the less likely a revision of this scar will result in a fine line scar.
9 – Loss of Skin
If a significant amount of skin is lost at the time of the original injury, then closure of that wound may result in increased tension at the site of repair. Tension is the enemy of fine line scars. The greater the tension, the higher the risk of a wide scar.
10 – Perceptions and Expectations
This may be the most important part of the evaluation. If your expectation is that your scar will become completely invisible, you will be disappointed, no matter how much improvement is achieved. However, if you understand what makes their scar more obvious, and understand which of these features can be expected to improve (and conversely which will not improve) then an informed decision can be made. If your decision to proceed with the revision is based on realistic goals, then we all achieve greater satisfaction with the results. A scar will always remain a scar. If we improve its appearance, we can make it less noticeable.
Before I get into the details of how to evaluate a scar, I would like to provide a quick example of scar revision. Scars that present for revision come in two categories: Keloids and Hypertrophic scars.
Keloids scars are scars that grow larger than the area of injury. They tend to be raised, and are often itchy. They frequently continue to grow with time, and are different, on a cellular level, than hypertrophic scars.
Hypertrophic scars are wide or raised scars that maintain the pattern of the original injury. They may be wide-spread, and can range in color from white to red or purple. Often after a year they stop changing.
The scar in the picture is from a single clean piercing of the upper ear. In response to a small injury, a relatively large raised itchy red/purple scar has formed. This scar is larger than the original piercing, so it is clinically consistent with a keloid scar.
Keloid scar at 1 o'clock on the helix of the ear.
Keloid of the ear - view from behind.
This keloid scar was treated with depo steroid injections combined with direct excision and repair. This may sound simple, but realize, that resecting this keloid causes an injury which is hundreds of times larger than the small needle stick that started the keloid. In this case, an excellent result was achieved.
Side view of ear after resection of keloid.
Keloid scar revision - no recurrence.
The keloid was removed, the base remains smooth and flat with no itching, and most importantly, there has been no recurrence. Keloids are among the most challenging scars to revise, due to their high rate of recurrence.
Next time, the details on how to evaluate a scar, so that the correct treatment can be initiated.
As a Walnut Creek Plastic Surgeon, scars are something I am frequently asked about. Here I will try to help you understand the indications, goals and likely results of scar revision. This information is for general information purposes. This may provide a framework to help you with discussing scar revision; however, it cannot replace an in person consultation. In order to pick the best plan for you, a careful history and examination would need to be performed first.
What Makes a Good Scar?
A good scar matches the surrounding skin. It is smooth, flat, thin and matches the surrounding tissues in color and texture. It is painless, soft and does not restriction motion or cause distortion of adjacent structures.
The ideal scar revision would remodel a scar into a smooth surface, resembling the surrounding skin in all respects. If this were possible, a scar would be virtually invisible. Unfortunately, a scar cannot be completely erased, but a scar can often be improved, by reducing the qualities that make it obvious.
The Goals of Scar Revision
The goal of scar revision is to get as close as possible to the ideal result, and make the scar less noticeable. Here are some as some qualities that plastic surgeons try to create in the revised scar:
A fine line scar (narrow is best)
Falling within, or parallel to, naturally occurring lines, wrinkles, contour junctions, or resting skin tension lines (perpendicular to the underlying muscle fibers).
Free of contour irregularities (no lumps or depressions).
Without abnormal pigmentation (not too dark, not too light).
Void of contractures or distortions of the surrounding tissue. (not too tight)
In planning a scar revision, it is important to first determine what makes the scar apparent, and focus on the methods most likely to improve these attributes. For example, if a scar is raised, silicone gel sheeting can help to flatten it. However, using silicone gel sheeting on a dressed scar is not likely to help. The correct tool for the job can only be selected after deciding what the job is.
How Does Scar Revision Help
There are many different ways to treat a scar, and most help in at least one of the following ways:
Improving the direction of the scar.
Decreasing the width of the scar.
Dividing the scar into smaller segments.
Correcting misalignment or distortion of adjacent tissues.
Improving surface irregularities.
Improving pigment discrepancies.
There is too much information to cover it all in one post, so I will leave it here for now. Next time, I will provide some more details about how to evaluate a scar, and to see if a revision is likely to help.