Can You Really Get Rid of a Scar After Surgery?

Dr. Koehler (00:00):
I was not pleased with the appearance of the scars and that we were considering scar revision, et cetera. And I said, oh, we talked about this last time. I said, "Do you mind if I take a look at your scars?" And she goes, "Oh yeah, no, they look great." And I examined her and her incisions looked beautiful.

Announcer (00:19):
You're listening to Alabama the Beautiful.

Dr. Koehler (00:22):
Okay. Speak into the microphone.

Dr. Gardner (00:26):
Look at her eyes.

Kirstin (00:29):
She's like, "What the heck?"

Dr. Koehler (00:30):
Give me kisses.

Kirstin (00:35):
Oh gosh.

Dr. Gardner (00:37):
Cute.

Kirstin (00:38):
Is this your mentor, Dr. Koehler? Millie? Yeah. Millie Koehler?

Dr. Koehler (00:45):
She's my daughter.

Kirstin (00:46):
Your daughter.

Dr. Koehler (00:47):
My other daughter.

Dr. Gardner (00:49):
You can hear her breathe it into the microphone. That's hilarious.

Kirstin (00:53):
Oh my gosh. We need your dogs and my doodle on here, Dr. Gardner.

Dr. Gardner (00:59):
Next time, will everybody bring your dog to podcast day?

Kirstin (01:02):
Yeah.

Dr. Koehler (01:04):
All right. You sit and behave while we do podcast. Okay?

Kirstin (01:12):
All right. I'm Kirstin Jarvis and I'm here with Alabama Cosmetic Surgeons, Dr. James Koehler and Dr. Vincent Gardner. Hey, Dr. Koehler and Dr. Gardner.

Dr. Koehler (01:21):
Hey, Kirstin.

Dr. Gardner (01:22):
Hey, Kirstin.

Kirstin (01:24):
All right. Today we are going to talk about the C-section line, the old surgery scar, the scar from an accident that you'd rather not explain to anyone. Everyone's got something that they could erase if they could. The honest question is how close a surgeon can get to what people actually want.

Dr. Koehler (01:44):
Well, that depends.

Kirstin (01:47):
Okay. Let's talk about remove versus improve.

Dr. Koehler (01:53):
Well, there is no such thing as removing a scar. Well, potentially you could remove a scar. So for instance, an example of removing a scar, like I've seen many times emergency C-section scars where they make the incision vertically between the belly button and the pubic area, and it can look really bad or maybe they've had a laparotomy scar or something. And maybe with a tummy tuck, we'll end up removing all that skin, but they get a new scar, it's just placed differently. So yes, the old scar has been removed, but now the new scar is in a position that's covered. So with a bathing suit or pants or whatever. And so you sometimes can "remove a scar," but you really are just trading a new scar. There's no such thing as removing a scar completely.

Kirstin (02:41):
One time we talked about this on a podcast and you both almost at the same time said the same exact thing. If there's surgery, there's a scar or something like that.

Dr. Koehler (02:50):
Yeah. Well, I mean, there's just no, again, we try to position the scars in favorable locations. And that's why, for instance, with breast augmentation, I mean, that's why people came up with the transumbilical breast augmentation. They tried to hide the scar in the belly button, but there's still a scar. For what we do as cosmetic surgeons, the scar is very important to us and how that scar heals is very important to us versus, and not to dis any other specialties, but for an orthopedic surgeon, for instance, the scar is not the important part of their procedure. The fixing the bone or doing the joint replacement or whatever, that's the most important part. And a scar is just something that they have to deal with. And I'm not saying they don't pay any attention to it, but it's such a side part of their procedure.

(03:41):
When we have patients that come in, they are very concerned about scarring. And yes, they do want to see the improvements, but the scars are at the top of their mind. So we just have to take a little bit different approach maybe. But yeah, there's always a scar.

Kirstin (03:56):
Okay. Why do some scars fade beautifully and then others just don't?

Dr. Koehler (04:02):
Well, some of it depends on location. So depending on what area of the body it's on, and depending if that scar is sitting in what we call resting skin tension lines, a scar can be very unnoticeable. So I'll give you an example. Let's say somebody had some kind of cyst or something on their forehead. Okay. If we place that incision for removing it right in the natural horizontal creases that we see in people's foreheads and take it out, when that fully heals, it may be almost not even noticeable once it's fully healed. But if I make that incision this direction, it's opposing the resting tension lines of the skin, and that scar will always be noticeable. So again, placement of the incision, choosing which direction to orient the scar and all that is important, but then also the parts of the body. For instance, patients that get sternotomies for open heart surgery, the midline of the chest is notoriously not a favorable place for healing.

(05:06):
And so you see a lot of people that have keloided or not necessarily keloided. A lot of people call keloid scars any scar that doesn't look good, but you'll see sometimes hypertrophic scars where they're thickened scars and they just don't look good. Or for instance, in orthopedic procedures, incisions that are over joints where they're under tension and mobile, sometimes those scars don't heal as well. On the face, scars tend to generally heal better than certain areas of the body. So location of scar can determine that. There's just so many things that go into whether or not a scar is going to heal well.

Kirstin (05:43):
I have two things. I hope I never have a cyst on my forehead because I have a really smooth forehead, thank you, to my two bosses that are really good injectors. Number two, I want to make it known that I'm not 55.

Dr. Koehler (06:00):
No, you just turned 56, so that's a happy birthday.

Kirstin (06:04):
I swear 10 people, at least 10 people have been like, "I cannot believe you're 55." So let's just make it clear. I do have a smooth forehead because of Botox, but I'm not 55. I'm not even 40. Okay. So next question about scars, now that that's out in the world. Okay.

Dr. Koehler (06:20):
Nobody's going to believe it, but that's okay.

Kirstin (06:24):
I mean, Dr. Koehler and Dr. Gardner are pretty good, but I'm just saying I'm not 55 on my birth certificate. Okay. Let's talk about different kinds of scars. So you mentioned keloid scars. So there are raised thick hypertrophic keloid or sunken and pitted scars. Some people have flat scars, some people have colored scars, some are white. Do they each need something different to treat them and fix them and make them beautiful? Or how do scars work?

Dr. Koehler (06:52):
Yeah, I mean, all those are separate issues and they are all treated differently. But let's start off with one discussion because I think it's an important point. And actually I hear this from physicians too. I hear physicians call scars like keloids and I'm like, "That's not a keloid." Because again, I think it's just sort of the perception that a scar that doesn't look good that's raised and thickened is a keloid and it's not. There's a big difference. So for instance, a great example of keloids and probably one of the more common things that we see that keloids are ear piercings. And if you've ever seen somebody who had, it looks like they got a ball hanging off of their earlobe and you look at it and you wonder, what happened there? Well, that is a keloid scar. So a keloid scar, so somebody had a piercing done and in the body's response to that is to form very thick, dense scar tissue, but the scar tissue extends far beyond the area of trauma or the area of incision or whatever.

(07:57):
So from that little tiny pierce hole grew this big ball of scar tissue. That is a keloid scar. A hypertrophic scar would be like, okay, so let's say you had a C-section and when it all healed, that scar was kind of thickened and raised. But it really is not, it hasn't expanded and grown to any great extent. That would be more of a hypertrophic scar. So it sort of remains in the area of where the scar was, but it doesn't. It's subtle, but a significant difference. So these really big and thickened scars that grow beyond the boundaries of where the incisions were, those are keloids and they're treated very differently. So in the example of the earlobe, we'll cut those scars off and cut out that whole section really. And then it'll be closed nicely and we tend to use different sutures there to try to really limit the amount of inflammation that occurs in the healing process.

(08:55):
And then postoperatively we'll inject certain things like sometimes a combination of a low dose steroid along with some chemotherapy drug. It's called 5FU. And we use that combination to inject that area frequently to prevent the recurrence of that thickened scar tissue. And in some people where that's maybe been done and failed and they're really challenging scars that continue to recur, we will sometimes even use radiation therapy, low level radiation to prevent that scar from recurring. Now that's not our first line therapy. And that's one where we actually will send them to a radiation oncologist for a consultation before doing that so they can talk to them about all the good and bad about doing radiation treatment to a keloid scar. So we've had to do that in some rare circumstances for keloids. We don't ever use radiation for hypertrophic scars. For hypertrophic scars, it's more a matter of excising all that tissue and then doing a lot of different things in our toolbox that will help to minimize.

(10:01):
So making sure there's not tension on the incision is very important. That's a surgical part. Using suture that's not very reactive. Sometimes we use permanent suture that we remove because dissolvable suture, how it dissolves is through inflammation. And if we do use dissolvable sutures, we tend to use sutures that dissolve more slowly that create less inflammation. So there's a lot of things that go on there and then postoperatively, yes, there's scar creams and other things that we can use. So that to your first question was like, are these scars all treated differently? They are. And so hypertrophic scars are not treated like keloids. And so your surgeon needs to counsel you on that and how it would be done. And sometimes, let's say a patient has a tummy tuck and they come back and they've got a thickened tummy tuck scar. And the surgeon may have performed that surgery to perfection.

(10:58):
But scars can heal in different ways for different people and it may have nothing to do with the technique. And we have people that they're just more prone to thickened raised scars. That's just their nature. And on a side note on that, sometimes people go, "Well, I had this done on my face and I didn't have a problem with the scar. Why is my tummy tuck scar thick?" Well, there can be other reasons. When we do a tummy tuck, we're removing a big section of skin and that incision is under tension. We do everything to minimize the tension on that scar, but you want it tight and we want it tight. And so it is unfortunately under some tension versus maybe just a little something that was taken off your face that has very little to no tension on it. So tension plays a role.

(11:45):
So for instance, a tummy tuck patient that comes back a year later with thickened or raised or widened scars, well, we can now come back and do a scar revision where we completely re-excise the scar and close it. But the difference now is it's not under all that tension. And so even though you may have healed, maybe not ideally from the original procedure, there's things that can be done to maybe make it look better.

Kirstin (12:10):
Okay. And we do, every surgical patient gets a complimentary IPL laser treatment at their six-week follow-up appointment here. And then there's always on top of laser treatment, microneedling and all those other things that they can do to help mitigate those scars. And we can even do that if we didn't do your surgery, but you can still come to our spa and be treated with the lasers and needles and all the things. So when is it worth re-operating on a scar versus just treating it from the outside?

Dr. Koehler (12:38):
Well, every case is different and it's hard to really give you a global, "Oh, these I always fixed or these I don't." I mean, it just depends. Depends on the scar location, depends on if maybe it's already been operated on a couple of times. I have to evaluate each patient individually. But if the scar is not raised and it's not wide and thickened, then topical treatments, lasers, microneedling, and time. Time is a huge thing. I'll tell a little story. I may have said this in a previous podcast, but I'm going to share two stories. So first of all, scars, as we mentioned, are part of surgery. And so part of our job is to educate patients on realistic expectations. And so we like to show pictures and all that stuff and like to show a variety of different pictures. Not everybody heals the same. And as a patient, you should be looking at lots of pictures on lots of websites to get a really good idea of what's expected from a scarring standpoint.

(13:41):
What's the range? What are really good scars look like? What do maybe not good scars look like? And as I mentioned, your surgeon can do a perfect procedure, but you may heal differently than your friend. We don't all heal the same. But I'll share a story. So I had a patient come in for a consultation years ago. She'd had a breast reduction done and she was very distraught. I hadn't examined her yet, but she said, oh, I call them. She called them her Franken boobies. The scars look terrible. And I said, "All right." Well, and I had her get changed and I came back in to do the exam and I looked at her scars and I was like, "Well, whoever did your surgery really did a very good job." Her scars looked very, very good. There was nothing wrong about them. So this was a circumstance where I think in the communication there, she maybe didn't fully understand where the scars would be, what they would look like, or her expectation was completely unrealistic.

(14:43):
And unfortunately, now patients come in and like, "Well, she wants this fixed." And I'm like, "There's nothing else. I could redo all the incisions, but I would just be hoping that they healed just as good as these did. I don't think I can make it look any better." So knowing what you're getting yourself into and where the scars are going to be is important. And so that's the first point. And then that brings me to the other story, which I will not ever forget. It was just kind of one of these things that, I don't know, stuck out in my career, but I did have a patient that I had done, I think it was a breast reduction on or a breast lift, but same scars. Anyhow, she came in for a post-op visit and she was about eight months out from surgery, so pretty well out from surgery.

(15:27):
And I remember her scars were quite red and just not the typical scarring, but they still were kind of looking like they needed more time to heal. And I didn't really feel like doing a scar revision right then was probably the prudent thing to do. So I said, "Well, let's just wait and we'll come back and we'll look at this." And I said, "Why don't you come see me in four months and we'll check it again and whatever." Well, she disappeared. And then she came back to see me a few years later. It was probably about three years later to do a tummy tuck. And I'm reading in my chart, my note that I had written last time, and I had noted about how I was not pleased with the appearance of the scars and that we were considering scar revision, et cetera. And I said, oh, we talked about this last time.

(16:14):
I said, "Do you mind if I take a look at your scars?" And she goes, "Oh yeah, no, they look great." And I examined her and her incisions looked beautiful. So yes, a lot of people can look good at, and we'd expect people to be looking really good at eight months, but I was actually shockingly surprised because I'd written a note. I knew what my thoughts were about this. And so time is a great healer too. And unfortunately, that's different for every person. So a lot of people will look good at six months to a year. Some people will take several years for their scar to fully mature and look good. So something to think about.

Kirstin (16:52):
Okay, perfect. When we talk about topical treatments, are drugstore scar creams equal to what people would buy here, like a Silagen or something similar?

Dr. Koehler (17:05):
Well, I don't know all of the ingredients in a lot of these things. All I can tell you is I've tried a lot of different creams over the years. Now there are certain over-the-counter, and I don't want to use brand names, but there's certain of those, and they actually may work quite fine, but some of the ingredients in those have a high incidence of a dermatitis. People can get an allergic reaction from some of those creams. So I don't have anything. I don't care if people want to use over-the-counter stuff, that's fine. Whatever works best for you. And I have people tell me, "Oh, I use emu oil or something." I'm like, "Okay, well, whatever you want." And people swear by certain home remedies of certain types. My experience is definitely the silicone scar gel that we use, and the current one that we currently use, I've actually been very, very pleased with, and I've tried a number of them over the years.

(18:08):
So yeah, we do sort of have things that we recommend, and that's just based off of years of experience. Silicone sheeting can also be very effective. Some people, it can get hot under topical tape, like silicone tape. It can get dirty, so you got to keep it clean. But there's a lot of different things. And we talk to patients about different options, but most of the time we recommend the Silagen scar gel is what we use. And we usually tell people whatever they're going to use, even if it's over the counter, they need to use it for a minimum of three months. And you don't start using scar gel right away either. So if there's glue or tape on the incisions, we take that off. And then we'll typically tell people to use a topical antibiotic ointment or Aquaphor or something like that on their incisions for at least a couple of weeks because you don't want a red or irritated scar and then start putting silicone or other scar gels on there.

(19:07):
It may just create more irritation. So once it's a little maybe three, four weeks out from surgery, then you start your topical scar treatments. And then you want to do that for at least three months. And longer is fine too, but at least three months if you want to see the benefits. And some people are fortunate they don't put anything on and their scars heal great, but if you are worried about it or you're one of these people that you just tend not to heal as well, well then that's what we generally recommend.

Kirstin (19:36):
Okay. For someone who's been self-conscious about scars, what do you want them to know before they book a consult with you?

Dr. Koehler (19:44):
All I can tell you is we're going to do all the little things. You don't have to ask us to do this. You don't have to say, oh, I have a problem with scarring. Would you do something special for me? We're already going to do that, but you will have a scar. So if you're coming expecting a scarless surgery, that I can't promise you because it's just not possible. But certainly if you have issues, we can talk about it because there are certain things that we can institute early. Usually at the six-week point from surgery is probably the earliest that we can start doing sometimes injections or we can do certain topical treatments or microneedling or laser treatments, things like that. But yeah, we can certainly have those discussions and certainly bring it to our attention, but understand that we're already going to be very cognizant of the placement of the scar and how it's managed in the early postoperative period.

Kirstin (20:35):
All right. Do you have a burning question for Dr. Koehler or Dr. Gardner or me? You can leave us a voicemail on our podcast website at alabamathebeautifulpodcast.com. We'd love to hear from you. Thanks Dr. Koehler and Dr. Gardner.

Dr. Koehler (20:48):
Thanks Kirstin.

Kirstin (20:49):
Go back to making Alabama beautiful.

Dr. Koehler (20:52):
All right.

Announcer (20:55):
Got a question? Leave us a voicemail at alabamathebeautifulpodcast.com. To learn more about Eastern Shore Cosmetic Surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcasts, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram @easternshorecosmeticsurgery. Alabama The Beautiful is a production of The Axis, T-H-E-A-X-I-S.io.