Scar management: your treatment options

In the second part of our investigation into scarring, London plastic and reconstructive surgeon Mr Juling Ong covers your scar management options.

Scar management depends on scar type, size, location, and symptoms like pain or itching. Treatments range from topical solutions to surgical interventions and advanced therapies. Here’s a breakdown of options:

1. Non-Invasive Treatments (First-Line)

A. Topical Treatments

1. Silicone Gel or Silicone Sheets

Best for: Hypertrophic and keloid scars.
How it works: Hydrates and reduces scar height, redness, and stiffness.
Example Products: Mederma®, ScarAway®.
Application: Use daily for at least 3–6 months.

2. Onion Extract (Allium Cepa) Gel

Best for: New, minor scars.
How it works: Anti-inflammatory, may help reduce redness and improve texture.
Example Products: Mederma®.

3. Vitamin E & Moisturisers

Best for: Dry, healing scars.
How it works: Improves hydration but has mixed evidence for scar improvement.
Caution: Some people may develop contact dermatitis (irritation from Vitamin E).

4. Corticosteroid Creams

Best for: Keloid and hypertrophic scars.
How it works: Reduces inflammation, redness, and itching.
Application: Requires prescription for stronger formulations.

B. Pressure Therapy & Massage

1. Pressure Garments

Best for: Large burn scars, hypertrophic scars.
How it works: Applies constant pressure to prevent excessive collagen buildup.
Usage: Worn 12–24 hours/day for 6–12 months.

2. Scar Massage

Best for: New scars to prevent adhesions.
How it works: Improves circulation and flexibility.
Technique: Use gentle, circular motion for 5–10 minutes, 2–3 times/day.

2. Minimally Invasive Treatments

A. Corticosteroid Injections

Best for: Keloid and hypertrophic scars.
How it works: Flattens and softens thick scars by reducing collagen production.
Procedure: Injections every 4–6 weeks for several months.
Side Effects: Skin thinning, hypopigmentation.

B. Laser Therapy

1. Fractional CO₂ Laser & Erbium Laser

Best for: Acne scars, surgical scars, atrophic scars.
How it works: Stimulates collagen remodeling and smooths skin.
Sessions Needed: 3–5 treatments spaced 4–6 weeks apart.
Recovery: Redness and swelling for a few days.

2. Pulsed Dye Laser (PDL) / Intense Pulsed Light (IPL)

Best for: Red scars (vascular scars, post-surgical scars).
How it works: Reduces redness and vascularity.
Sessions Needed: 3–6 treatments spaced 1-4 weeks apart.

3. Surgical & Advanced Treatments

A. Scar Revision Surgery

Best for: Large, deep scars or contractures.
How it works: Scar is excised (removed) and re-stitched for a more natural look.
Types:
– Z-plasty & W-plasty – Changes scar orientation for better blending.
– Skin Grafting – Uses donor skin for burn scars.

B. Microneedling (Collagen Induction Therapy)

Best for: Atrophic scars (acne scars).
How it works: Tiny needles stimulate collagen and elastin production.
Sessions Needed: 4–6 treatments, spaced 4 weeks apart.

C. Dermal Fillers

Best for: Depressed scars (atrophic scars, acne scars).
How it works: Injected fillers (hyaluronic acid) plump up the scar.
Lasts: 6 months to 2 years.

D. Cryotherapy

Best for: Keloids and hypertrophic scars.
How it works: Freezing the scar with liquid nitrogen shrinks and flattens it.
Sessions Needed: Multiple sessions.

E. Radiation Therapy

Best for: Severe keloids that do not respond to other treatments.
How it works: Low-dose radiation prevents keloid regrowth after surgery.
Risk: Long-term exposure may increase skin cancer risk.

4. Emerging & Experimental Treatments

A. Platelet-Rich Plasma (PRP)

Best for: Acne scars, surgical scars.
How it works: Uses growth factors from your own blood to speed up healing.
Sessions Needed: 3–5 treatments.

B. Stem Cell Therapy

Best for: Severe scars, burns.
How it works: Regenerates skin using stem cells.
Still experimental but promising.

Choosing the Right Treatment Based on Scar Type

Scar Type Best Treatments

Hypertrophic Scar: Silicone gel, steroid injections, laser therapy
Keloid Scar: Steroid injections, cryotherapy, laser therapy, surgery (with radiation)
Atrophic Scar (Acne Scars): Microneedling, laser therapy, dermal fillers, PRP
Burn Scars (Contractures): Pressure therapy, surgery, skin grafting
Surgical Scars: Silicone gel, laser therapy, steroid injections

Takeaway

Early intervention (silicone gel, massage) improves scar healing.
Hypertrophic & keloid scars benefit from steroid injections & laser therapy.
Depressed scars (atrophic scars) respond well to microneedling, lasers, and fillers.
Severe scars may need surgical revision or advanced therapies like PRP or stem cells.

How a Plastic Surgeon Optimises Scarring

Plastic surgeons use advanced techniques before, during, and after surgery to minimise scarring and ensure the best possible aesthetic outcome. Here’s how they optimise scarring:

1. Pre-Surgical Planning

A. Incision Placement & Tension Reduction

Hiding the Scar in Natural Lines:

Incisions are placed along natural skin folds, wrinkles, or shadowed areas (e.g., behind the ears, in the hairline, or in the crease of the eyelid).
For breast surgery, incisions are hidden in the under-breast fold or around the areola.

Avoiding High-Tension Areas:

Incisions in areas of high movement (e.g., joints, chest) are designed to reduce stress on the healing wound.
Large wounds may use tissue expanders or local flaps to close with minimal tension.

Z-Plasty or W-Plasty for Camouflage:

For unavoidable scars, Z-plasty or W-plasty techniques break up linear scars, making them less noticeable.

2. Intraoperative Techniques to Minimise Scarring

A. Precise, Minimal-Trauma Incisions

Fine scalpel or laser incision: Reduces tissue trauma.
Gentle tissue handling: Minimises bruising, swelling, and inflammation.
Cold saline irrigation: Reduces heat damage and prevents excess scarring.

B. Layered Closure (Deep & Superficial Suturing)

Why? Reduces skin tension, prevents wide scars.
How? Uses multiple suture layers:
– Deep absorbable sutures in dermis for strength.
– Fine, superficial sutures on top layer for cosmetic finish.
– Avoids external stitches if possible (to prevent “railroad track” scars).

C. Use of Tissue Glues or Adhesives

For delicate areas (e.g., face): Medical adhesives (Dermabond®) provide seamless healing with no suture marks.

D. Hemostasis (Minimising Bleeding & Bruising)

Why? Less bruising means less inflammation & pigmentation.
How? Precise electrocautery or fibrin sealants to stop bleeding.

3. Post-Surgical Scar Optimisation

A. Early Wound Care & Protection

Steri-Strips or Micropore Tape
– Provides gentle compression to reduce tension and prevent scar widening.
– Worn for 4–6 weeks post-surgery.
Avoid Picking Scabs
– Scabs should fall off naturally to prevent deeper scarring.
No Smoking & Minimise Alcohol
– Smoking reduces oxygen supply, impairing healing.

B. Scar Management Treatments

1. Silicone Gel or Silicone Sheets (Gold Standard)

Reduces thickness, redness, and stiffness.
Used 24/7 for 3–6 months post-surgery.

2. Sun Protection (SPF 50+)

Prevents hyperpigmentation and dark scars.
Scar tissue is UV-sensitive for up to a year.

3. Scar Massage

Improves blood flow, flexibility, and collagen remodeling.
Done once the scar is fully closed.

4. Advanced Scar Treatments for Stubborn Scars

A. Laser Therapy (For Thick or Discolored Scars)

Pulsed Dye Laser (PDL) or Intense Pulsed Light (IPL) – Fades red scars.
Fractional CO₂ Laser – Smooths raised or atrophic scars.

B. Steroid Injections (For Raised, Hypertrophic, or Keloid Scars)

Reduces excess collagen production.
Given every 4–6 weeks as needed.

C. Microneedling (For Depressed or Uneven Scars)

Stimulates collagen regeneration.
Combined with platelet-rich plasma (PRP) for better results.

D. Scar Revision Surgery (For Old or Wide Scars)

Excises the old scar and re-sutures it with better techniques.

Plastic Surgeon’s Approach by Scar Type

Scar Type Optimised Treatment

Fine Surgical Scar: Silicone sheets, sun protection, scar massage
Hypertrophic Scar: Steroid injections, silicone gel, laser therapy
Keloid Scar: Steroid injections, cryotherapy, surgical excision with radiation
Atrophic (Depressed): Scar Microneedling, laser resurfacing, dermal fillers
Burn Scar/Contracture: Pressure therapy, surgery (Z-plasty), skin grafting

Key Takeaways: How Plastic Surgeons Optimise Scarring

✅ Precise incision placement in natural folds.
✅ Layered closure with minimal external stitches.
✅ Silicone therapy & sun protection for 6+ months.
✅ Massage & laser therapy for better scar remodeling.
✅ Early steroid or laser treatment for problem scars.

What can I do as a patient to get the best possible scar?

To ensure you get the best possible scar after surgery, you need to focus on proper wound care, scar prevention techniques, and long-term scar management. Here’s a step-by-step guide to optimise healing and minimise scarring:

1. Immediate Post-Surgery Wound Care (0–6 Weeks)

A. Follow Surgeon’s Instructions

Keep the wound clean and dry as instructed.
Avoid removing stitches or sutures early.
Do not pick at scabs—let them fall off naturally.

B. Minimise Tension on the Wound

Avoid stretching, bending, or pulling near the incision site.
If possible, tape the wound with surgical tape (e.g., Steri-Strips or Mircopor tape) to keep it stable.
For joint areas, use a brace or limit movement as advised.

C. Protect the Wound from Infection

Signs of infection: Redness, swelling, pus, warmth, pain.
If infected, see your doctor immediately to prevent worsening scarring.
Use antibiotic ointments if prescribed.

D. Moisturise & Hydrate

Once the wound has fully closed, apply a fragrance-free moisturiser (e.g., Aquaphor, CeraVe).
Hydrated skin heals better and reduces scar formation.

E. Laser Therapy

Can be used as soon as the sutures are removed to optimise scar healing and remodelling
Types:
– Pulsed Dye Laser (PDL) – Reduces redness.
– Fractional CO₂ Laser – Helps remodel the new healing scar
Sessions Needed: 3–5 treatments.

2. Scar Prevention Strategies (6 Weeks – 6 Months)

A. Silicone Gel or Silicone Sheets (Most Effective)

Why? Reduces thickness, redness, and stiffness of scars.
When? Start 2 weeks after stitches are removed (or as advised).
How? Apply daily for at least 3–6 months.

B. Sun Protection (Essential)

Why? UV exposure darkens scars and makes them more visible.
How? Use:
– SPF 30–50+ sunscreen (even under clothes).
– Wear UV-protective clothing over the scar.
– Avoid direct sun exposure on the scar for at least 1 year.

C. Gentle Massage Therapy

Why? Helps break down thick collagen fibers and improves scar flexibility.
How? Use circular motions with light pressure for 5–10 minutes, 2–3 times daily.
When? Start 4–6 weeks post-surgery (once the scar is closed).

D. Keep the Scar Flat & Flexible

If prone to hypertrophic scars or keloids, use:
– Silicone tape or pressure dressings to flatten scars.
– Steroid creams or injections (if necessary).

3. Long-Term Scar Improvement (6 Months – 1+ Year)

A. Laser Therapy (For Red or Thick Scars)

Best for: Raised, red, or discolored scars.
Types:
– Pulsed Dye Laser (PDL) – Reduces redness.
– Fractional CO₂ Laser – Smooths atrophic (depressed) scars.
Sessions Needed: 3–5 treatments.

B. Microneedling (For Depressed or Uneven Scars)

Creates tiny injuries to stimulate collagen production.
Works well for surgical scars, acne scars.
Sessions Needed: 4–6 sessions, spaced 4–6 weeks apart.

C. Steroid Injections (For Raised Scars & Keloids)

Best for: Hypertrophic scars or keloids.
Reduces thickness, itching, and discomfort.
Given every 4–6 weeks until improvement.

D. Dermal Fillers (For Sunken Scars)

Best for: Depressed or atrophic scars.
Uses hyaluronic acid or collagen stimulators to plump up the scar.

4. Lifestyle & Diet for Optimal Healing

A. Stay Hydrated & Eat Nutrient-Rich Foods

Drink plenty of water (supports collagen formation).
Eat:
– Protein-rich foods (chicken, fish, tofu) – Helps tissue repair.
– Vitamin C (citrus fruits, bell peppers) – Boosts collagen.
– Zinc (nuts, seeds, lean meats) – Enhances wound healing.
– Omega-3 fatty acids (salmon, flaxseeds) – Reduces inflammation.

B. Avoid Smoking & Alcohol

Smoking delays wound healing and increases scarring risk.
Alcohol dehydrates skin, affecting tissue repair.

C. Maintain a Healthy Weight

Rapid weight gain/loss can stretch the scar, worsening its appearance.

5. When to See a Doctor

A. If the Scar Becomes Thick or Raised

Early steroid injections or laser therapy can prevent worsening.

B. If the Scar is Painful, Itchy, or Tight

May need scar revision surgery or specialised treatments.

C. If the Scar is Discolored (Dark or Red)

Laser therapy, chemical peels, or microneedling can improve discoloration.

Key Takeaways for the Best Scar Outcome

✅ Start scar care early (as soon as the wound is closed).
✅ Use silicone gel/sheets for at least 3–6 months.
✅ Protect from the sun with SPF 50+ for at least a year.
✅ Massage the scar daily to keep it soft and flexible.
✅ Stay hydrated & eat collagen-boosting foods.
✅ Consider laser therapy or microneedling for stubborn scars.

Is laser treatment useful soon after surgery to achieve the best possible scars?

Yes, early laser treatment after surgery can improve scarring, but the timing and type of laser therapy depend on your scar’s characteristics and healing progress.

When can laser therapy be started after surgery?

Earliest: 1–6 weeks post-surgery, but only if the wound is fully closed and no complications (e.g., infection, delayed healing).
Optimal Timing: 1-8 weeks post-surgery for best collagen remodelling effects.
For Mature Scars: Can be treated even months to years later.

Types of Laser Therapy for Early Scar Treatment

1. Pulsed Dye Laser (PDL) or Intense Pulsed Light (IPL)

✅ Best for: Fresh, red scars (vascular scars, hypertrophic scars).
🔹 How it works: Targets excess blood vessels, reducing redness and inflammation.
🔹 When to start: As early as 1–4 weeks post-surgery often at the removal of sutures.
🔹 Sessions needed: 2–5 treatments, 4–6 weeks apart.

2. Fractional CO₂ Laser or Erbium:YAG Laser

✅ Best for: Preventing thick, raised scars and smoothing texture.
🔹 How it works: Stimulates collagen remodeling and breaks down excessive scar tissue.
🔹 When to start: 1–8 weeks post-surgery often at the removal of sutures
🔹 Sessions needed: 3–6 treatments, spaced 4–8 weeks apart.

3. Non-Ablative Lasers (e.g., Nd:YAG)

✅ Best for: Reducing inflammation and scar thickness without damaging surface skin.
🔹 When to start: 1–6 weeks post-surgery often at the removal of sutures
🔹 Sessions needed: Multiple treatments over 3–6 months.

A combination of pulsed dye laser and fractionated laser can be useful for optimisation of scarring following surgery by reducing redness and helping to remodel the scar to improve the appearance, thickness and pliability of the final scar.

Benefits of Early Laser Treatment

✅ Reduces Redness & Pigmentation → Prevents dark or discolored scars.
✅ Prevents Hypertrophic & Keloid Scars → Reduces excess collagen production.
✅ Improves Scar Texture & Flexibility → Enhances smoothness & elasticity.
✅ Speeds Up Scar Maturation → Faster transition from raised/red to flat/pale.

Precautions Before Early Laser Treatment

🚫 Do NOT start if the wound is still healing, infected, or inflamed.
🚫 Avoid laser too soon (before 2 weeks) as it can disrupt early healing.
🚫 Use SPF 50+ → Laser-treated skin is highly sensitive to sun exposure.
🚫 Mild redness/swelling is normal post-treatment but should subside in a few days.

Bottom Line: Can You Start Laser Early After Surgery?

✅ Yes, if the scar is fully closed and healing well.
🎯 PDL/IPL → Best for early treatment (from 1–4 weeks).
🎯 Fractional CO₂ Laser → Best from 1–8 weeks for remodeling.
⏳ Longer treatment intervals (3–6 months) may be needed for mature scars.

If you’re concerned about the appearance of a scar and want to discuss your options, call 020 7927 6528 or email info@julingong.com to arrange a scar management consultation with Mr Juling Ong.