Episode 57: Thursday November 03

Why are plastic surgeons thought of as wizards when dealing with scars? Can we really make them disappear? The 3 Plastic Surgeons tackle one of the constant challenges faced by plastic surgeons - scar management. How do scars heal? How can we optimize scar healing?

Dr. Salvatore Pacella @sandiegoplasticsurgeon leads the discussion with Dr. Sam Jejurikar @samjejurikar and Dr. Sam Rhee @bergencosmetic about tips and tricks to getting the best scar result after surgery or even a traumatic injury.

#podcast #plasticsurgery #cosmeticsurgery #plasticsurgeon #beauty #boardcertified #aesthetic #3plasticsurgeonsandamicrophone ⁠#bergencosmetic ⁠#bestplasticsurgeon #beforeafter #aesthetics #realpatientrealresult #boardcertifiedplasticsurgeon #njplasticsurgeon #njplasticsurgery #nyplasticsurgeon #nyplasticsurgery

2022.11.03 S03E57 SCAR MANAGEMENT

[00:00:03] Dr. Salvatore Pacella: Good morning everyone. Dr. Salvato Pacella here from San Diego, California. I'm joined by my guest, Dr. Sam Ree in er, New Jersey. He's at Bergen Cosmetic, and of course, Dr. Sam Jejurikar in Dallas, Texas at Sam Jejurikar. Good morning, gentlemen.

How are you today? Doing well. Living Dream . Okay. Today we're gonna be talking about a very common issue in plastic surgery or in any surgery for that matter. Scars. So we're gonna go into and take a deep dive into how we prevent visible scars or problematic scars. So it's certainly an issue we have to deal with.

Any surgery that you perform in any given capacity, we'll create a scar. But if. Create that scar in such a way that it's inconspicuous. I think that's gonna be, obviously gonna have a, a better cosmetic outcome. Before we get started, we've got a few housekeeping items to talk about here. So I'm gonna hand it over to Sam.

Notice, not excited, not decided to

[00:01:03] Dr. Sam Jejurikar: choose which Sam notice. He didn't know which one was reading it. So, this show, this show is not a substitute for professional medical advice, diagnosis, or treatment. This show is for informational purposes only. Treatment and results may vary based upon the circumstances, situation, and medical judgment after appropriate discussion.

Always seek the advice of your surgeon or other qualified healthcare providers with any question you may have regarding medical care and never disregard professional medical advice or delay seeking advice because of something you may have seen on the show. Dr. Pacella, Back to you. All

[00:01:35] Dr. Salvatore Pacella: right, sounds good Jan.

So, so scars, certainly a necessary evil in any surgery and I, I think we have to separate the difference between facial scar. And body scars. The, in my mind when I think about this concept, when I perform a body scar obviously I wanna make it look as good as it can, but we have the benefit in a scar on the body to cover that over with clothing.

Correct. Now in the face. Or in the hands or someplace that's visible. It's very difficult to cover any scar. And so I I, in my practice, I have to be specifically careful with any facial surgery to optimize how I'm, how I'm managing that scar. And I think the most important thing is on the day of surgery.

So let's first talk about what we do to minimize scars at the closure. So why don't we, why don't we start.

[00:02:27] Dr. Sam Jejurikar: You, you wanna go for, you go for, Go

[00:02:29] Dr. Sam Rhee: ahead. No, go ahead. Go ahead, Sam.

[00:02:30] Dr. Sam Jejurikar: I, I, the, the one. Slight exception I have is, I, I don't make that distinction. You do about facial body scars because of my patients and I, I'm sure you guys see this as well, tend to be pretty worried about all of their scars.

I agree with what you're saying. Practically speaking though, about, about facial scars. So in terms of your question, you were saying what do we do with the closure? And I think you're looking for a one word answer, which is tension. Tension and avoidance of tension. The skin closure is the most important thing and I'll let Dr.

Re talk about sort of what specific things that he does. But really when we're closing a surgical incision, we want to make sure that the skin closure is not tight. That's a sure fire setup to get a bad scar.

[00:03:09] Dr. Sam Rhee: We've dealt with scars our entire surgical careers, and so there are probably 500 things that we all do automatically without thinking in order to get the best appearance for our scars.

And we could take, I mean, literally if we talked about every single factor that we automatically take into consideration for a scar closure. , we could talk about it for 12 hours, but I think the number one thing, Sam hit on the head is certainly tension. you could talk about techniques for closure and sutures for closure and all, all sorts of other things that we do automatically for every procedure.

Cuz obviously as Sal says, a facial procedure is different from a body procedure. Different body procedures also necessitate different types of closure. If you're doing a breast dog, the way you close that might be different from a tummy tuck or from, say, small, very small incisions for liposuction.

So, So there's so many different factors that are involved. And, the type of patient also makes a huge difference. So when we're closing our incisions it's almost mind boggling how many different things we have to take into consideration, but we automatically do it just because we're so used to doing it.

[00:04:23] Dr. Salvatore Pacella: Right. So, so let, let's kind of break that down for a second. So, so, Sams, I, I respectfully vary in this topic from you as far as face and body goes and, and to me, Anatomically there is a major difference between the anatomic location of where that scar is located. So, for example, to me, in being around the block, and I've never necessarily seen this written or documented anywhere, but the thicker the skin, the worst the scar becomes.

Okay? So when I'm closing scars in the eyelid, okay. I close them much differently than I do for scars in the. And to me, when you have a scar from a skin cancer on the shoulder where there's an extensor surface and the skin is very thick, I think that scar somet many times looks a lot worse than a tiny scar or a thin scar, right in a natural line.

In the face or the neck. And so I, I approach these anatomically very different. And, and I think the first step I think for me in, in creating a good scar is, is the, the start of the surgery. Okay? So what, what I mean by that is, When we're making cuts scars that we make in surgery are much, much different than scars you may get from a traumatic injury when you trip and fall and you cut your chin.

And, and I think, there's c there's a common misconception out there when, when patients sort of say, Well, I go to the er, I don't want the ER doctor or the PA closing me because, know, I want a plastic. To close me. And, and to some extent there's some validity to, to that, but some, to some extent there is not.

And, and why that's different is many times from a traumatic standpoint, it, it doesn't truly matter who closes the incision, but it's the mechanism of injury that's, that's the problem. So for example, in a traumatic injury, You, you don't get the ability to choose where you're gonna make that cut. And so when we make it in surgery, if we make it along the line, we know that cut is gonna be very, very thin and very a traumatic.

But when you have a traumatic scar on the nose, the forehead, the eyelid, It's really not just the laceration or the cut in the skin, it's the blast component or the blast injury or the bruising that we see that can cause very bad scarring. And, and the benefit we have in surgery is that we, we handle the tissue very well and there's not a, a sort of peripheral injury that we have.

So, comments on that, Jess?

[00:06:45] Dr. Sam Jejurikar: Yeah, I actually think you, and I don't disagree at all on this. I, I think we're actually very similar. I think some of what we bring to this conversation is the differences we have in our practice. You are very well known in both traumatic reconstructions as well as facial skin cancer reconstruction.

You wrote a textbook on it for God's sake. My practice is entirely aesthetic at this standpoint. So if I'm doing a body procedure, which is what sort of I think led to this conversation, it's an elective fine line incision that's being made. If it's a tummy tuck, it's falling a skin crease. If it's a breast, It comes back to minimization of tension.

So I completely agree with that. I think my comment about just a differentiating face from body is in my practice, which is cosmetic. I talk, I talk to every patient usually based off of what they're bringing up, more so than what I'm bringing up about their scars because they're worried about it and a broader discussion of what we'll do during surgery and then what their postoperative regimen will look like.

But I agree with you completely.

[00:07:44] Dr. Sam Rhee: I slightly disagree in the sense that I think we actually do a really good job for traumatic injuries that say others might. Do in the er and, and the, and you're right, the, the mechanism in of injury plays the biggest role. That soft tissue damage that's associated with a lot of ti traumatic injuries.

You see that maceration of the edges a lot of times. It's not a sharp. Injury. It's usually a blunt force that literally splits the st the skin open like a grape. And you have this, as you said, blast injury surrounding soft tissue injury that as it heals, it can, it can heal very poorly. But the way, we evaluate it, the way we manage it, the way we, we treat the tissue and close it.

All of those things can play a huge role in how that traumatic injury heals. And I've seen many. Colleagues, mine, other plastic surgeons approach traumatic injuries and how we close them. Very different than how other providers might. So you're right, some things we can't prevent as plastic surgeons, but everything else that is within our control, I think we do a really good job with.

[00:08:57] Dr. Salvatore Pacella: Okay, so, so let's break this down. So let's say we're doing a body procedure or some sort of other deeper procedure on the neck down. I, I, I would agree. We all try to close these wounds under minimal tension. The lesson for our re for our listeners out here is if we're doing an abdominalplasty or tummy tuck comic language, when we pull that tissue and we take it.

We don't want to pull it to excess. We want to put it so it lays down very flat under, a little bit of tension, but not a ton when we're doing a facelift. Okay. Same sort of concept if we're tru, really, truly trying to jack that. Skin as high as we can behind the ear, in front of the ear, that's gonna lead to a bad scar cuz tension equals bad wounds.

So how do we dissipate some of the tension in, in, in wounds where we're pulling things? So, Deeper layers of sutures. So gents, let's, let's kind of talk about that a little bit. What do you, what do you use, How do you approach it? You

[00:09:53] Dr. Sam Jejurikar: know, what's, what's your philosophy? Well, I'll stick with your first example, which is it was a tummy tuck.

There's two. Two common methods that, that I will utilize that are, that are well described. The first are progressive tension sutures. So those are gonna be sutures that go that along the under surface of the skin flap, which basically help march along the tension so that that skin flap that you're closing instead of the tension just being at the, the very, suture line that you're closing, it's evenly distributed throughout the flap.

The other thing is closure of the deep fatty layer, which is called Scarpa's fascia. But basically it's a, it's. A layer that has some tensile strength within the fatty layer that I like to put some sutures into that will basically minimize the tension on the closure. Those are the two, I think, things that I add to it.

Facelift, similar principles particularly with, with some deep procedures in what's called the mass.

[00:10:45] Dr. Sam Rhee: I think this is where experience comes into play and when you're deciding how much tissue to resect either or how tight you want that facelift, how tight you want that belly a good surgeon knows you can't bite off more than you can chew if you're too aggressive with it.

And no matter what you do, you're gonna have problems cuz it's just gonna be too tight and you're gonna end up with a bad scar. If you go too loose and you're too conservative, your result won't be as good because it'll be too lax. So it really does take experience for surgeons to understand how. Tight, how much tension is acceptable, even regardless of all the techniques and tricks we have, as Sam said, where we try to reduce that tension by taking the load off of the superficial tissue and, and using the deep tissue to hold it.

There's only so much that, that work, that can do. So really experience, experience counts for, for all of this stuff.

[00:11:36] Dr. Salvatore Pacella: Right. And so, and sometimes both, I'm sure you're both agree, less is more. You can always take off more tissue if you need to. Right. But you can't ever put it back,

Right. So, now as far as the, the type of stitch you use, so you know, my in deeper, deeper parts of the body. I, I oftentimes use a vical or a braided stitch, but in my experience when, and, and that the reason for using a braided stitch is, I think it unravels less, but, but it's a little bit of a double edged sword.

When that braided suture is towards the surface of the skin, it oftentimes can spit, It creates a little bit of bacteria. So, I, I've tried to shift towards either running. Braided suture to avoid knots or a interrupted sutures that are not braided or what are called monofilament sutures.

So, and then on the skin surface, Oftentimes in the body, I'll, I'll use a subcuticular, which is where for our listeners, it's a, it's a suture that you don't see any train tracks. It's hidden underneath the skin. And usually there's a, there's a piece of the suture either buried deep to nod it or it's coming out of the skin at either end.

So there's no that kind of train track line.

[00:12:44] Dr. Sam Jejurikar: I, I think it depends on what part of the body we're we're talking about. If we're talking about autonomy again, which seems to be where I keep going with this I use all monofilament sutures, even deep. But I use a, what's called a barb suture for our listeners. So I use. A suture that won't unravel.

It's basically one continuous stitch, but it has little, little barbs in it. So with each stitch that you put in, it locks. So it sort of eliminates that unraveling issue that Dr. Pacella was talking about. The, there, there is it's a little bit easier for the body to break down these monofilament sutures than the Barb sutures.

A little bit less of an inflammatory reaction. And so it's my supposition that that helps the final.

[00:13:23] Dr. Salvatore Pacella: There's a secret

[00:13:23] Dr. Sam Rhee: that we don't tell you as plastic surgeons, we're trying to get your closure done as fast as possible, but still with , like a good amount, like with a good result. So we're constantly balancing like, how long is it taking us to close versus how good is the result going to be?

And that's something that, again, experience counts. When you see Really expert surgeons, they are efficient, they close fast, They are not wasting any time or excessive suture or excessive materials. So, I've gone in my career. From going to, Yes. I think for bellies, I use monofilaments, I use barbed.

I've kind of starting to move away from barbed. I'm not sure about some of the like inflammatory response that Sam has said. I try to do running but I can't stop myself from doing a few interrupts just to sort of attack things together just so that I feel like I can approximate it a little bit better before I start my runnings.

But it's, it's a constant tension. Like I wanna. Done and get the patient off the table as quickly as possible. But I still wanna maintain the best quality that I can. And so, every surgeon is a little bit different because, they're, how much tissue they're taking off, how they're doing it, what sutures they use, all of these things, put a little bit of variation into what their final approach is for a patient.

[00:14:45] Dr. Salvatore Pacella: Okay. And then so, so we've closed it now we've closed the incision and we're sort of going through the process of, how we put a bandage on. And I, I'm sure we all have kind of different ways we put bandages on, or, or derma bond or glue or this or that. But, the key here I think is, is understand, understanding the patient expectation about how that scar is going to look on day one, on day two on a.

Three, three weeks, three months, et cetera. So how, how do you counsel your patients as to how this scar is gonna look? Because, quite honestly, sometimes patients, they, they expect the scar to be immediately healed, within, within two weeks and look perfect. So what, what, what do you do?

[00:15:24] Dr. Sam Jejurikar: The really good question.

The, in the, the healing response goes through multiple stages stages. In the first three weeks, basically the body's laying down a bunch of collagen in the. Scar looks kind of, kind of, doesn't, it doesn't look great in the first few weeks. So there is, the scar is getting thicker as it's getting thicker and the body's laying down more collagen, it's getting more inflammation to it, so it's red as well.

And over the first three weeks, if you were to look at the total amount of collagen in a wound closure, it's just increasing more and more. Once you hit about that three to six week mark, the body undergoes a process of remodeling. And that remodeling process can be as, as short as six months or as long as two years.

What I'm sort of focusing focusing on is, number one, protecting the scar during that remodeling phase. That means avoiding things like. Sun exposure, which can take a scar that's otherwise healing well and create hyperpigmentation or a brown discoloration around the scar. And then doing treatments to try to speed up that remodeling phase.

And I'm sure we'll get into what that, what that'll be a little bit later on. Dr. Re?

[00:16:27] Dr. Sam Rhee: Yeah, I think. It doesn't look awesome for those first couple weeks, and a lot of what I do is try to mitigate patient expectations by talking to them beforehand. And honestly, a lot of my initial dressings just cover everything up so that they can't really look at it and, and obsess.

So some of, a lot of it is protection as Sam has said, but a lot of it is just to help the patient psychologically not freak out because they're staring at something all the time. And, and I think that helps.

[00:17:00] Dr. Salvatore Pacella: Right. And I, I, I see this routinely in, in any facial surgery I do, particularly in the skin cancer reconstruction that I do.

And, and I. I, I, I have this kind of spiel. I give every single patient regardless, and I, I say, To me, when the scar looks exactly the worst is about four to six weeks afterwards, it's, it looks the most red and the most irritated. And I found that when I tell patients for the first week, your, your scar's gonna look perfect.

It's gonna look like a little thin line. It's gonna be no redness. It's, you're gonna be very happy with it. And then, Four to six weeks later, I'm gonna see you back again and you're gonna say, What is this guy doing? This looks terrible. This is the worst scar I've ever seen. But that's, that's exactly what we're talking about with the remodeling phase and the end of the collagen deposition phase, and.

And to me that's the optimal time to really use any additional modalities that we may have. In my practice at about four to six weeks is when I, I really try to aggressively have patients massage or just start to initiate once the wound is healed and it's airtight to start to use silicone products.

So for me silicone and massage are really two pillars of, of scar management. Jens your thoughts.

[00:18:14] Dr. Sam Jejurikar: Yeah, I think silicone is the gold standard by which we must measure all other forms of scar treatment. I think on the face you're probably using silicone ointments more in the body. I think it's more of a choice between silicone ointments or silicone strips.

There's pros and cons to both. Usually just comes out in the patient preference. I find that in my practice, patient compliance is a little better with silicon ointments. People do have to be really good about using it twice a day though you can't just sort of pick and choose your your time where you're gonna do it.

If you are the sort of patient that's not gonna be able to remember to do something twice a day and silicone strips. Are the key. And the important thing is the more you use silicone, the better it works. Don't decide after a week or two this isn't really working and I'm gonna go, use some concoction that my friend recommended to me.

Silicone requires lots of time, lots of diligence over a prolonged period of time to see the results.

[00:19:03] Dr. Sam Rhee: It's so funny. I I'm the same way with silicone now. It the, I, I'm leaning towards ointments just because I think compliance is better, but you're so right. The awesome scars, the one that look really inconspicuous, that heal really nicely.

Those are the patients that have really put the regular diligent time in, like you said, twice a day. Extended periods of time, you know the difference. You, you don't have to even have the patient tell you. You can just look at a scar and you will know whether or not a patient has been good with their treatment regimen with with silicone or not.

And, and that makes all the difference in the world for me.

[00:19:45] Dr. Salvatore Pacella: And, and Dr. Sam from Dallas hit on a good point is, he, he said that silicone is the gold standard for, for scar management. And, and, and there's. There's some data behind that. There are arguably no other. Modality has been proven more than silicone to assist with scar management, making scars better and flatter.

And, and there's a, there's a biomechanical reason for that. Silicone is a, is a inert substance, but it has a negative charge to it and our bodies. Are basic. What I mean by that is not simple, but basic in, in an acidity standpoint, it has a negative, Our skin has a negative inherent charge to it, so it makes a lot of sense When you place a something that's negative on the surface of something else that's negative, that's negative, there's a repelling.

So it's a, it's almost an electrostatic compression that occurs with silicone. So it, it is, it is critical for manage.

[00:20:39] Dr. Sam Jejurikar: Now, is there anything else you guys might consider adding around that six week

[00:20:43] Dr. Salvatore Pacella: phase? I, I do as well. So I would say that, when, when we look at patients in my practice facial patients at least, so you know, there's kind of a bell curve of, of patients who are.

Going to be red and patients who are not going to be red. And I found that, older patients with a tremendous amount of skin laxity or loss of collagen in their skin oftentimes tend to be less red than somebody who's younger. And so there's this kind of bell curve and the patients who are kind of on the top third of that bell.

Qualitatively, the, the ones with the red is scars. At about five, six weeks, I'll oftentimes recommend a laser modality for them, and I, I found that laser treatment really could tend to help. And it, it's usually a fraxel or an ablative type of laser that can really assist with reducing the scar prominence and reducing the redness.

I don't think lasers for everybody, but usually the critical time period I think is about five to six weeks to get it started.

[00:21:41] Dr. Sam Jejurikar: Yeah, I, I agree. With that, we we use a la use lasers a different, I tend for patients that have red scars, I tend to use more of a pulse dye laser, so a different laser that's more geared specifically for redness, or I'll use a broadband light treatment to, to try to help with that.

What I, what I do find is also really helpful. And Dr. Pacella, the further along we get in this conversation, the more I'm agreeing with his distinction between facial and body scars. , I'm like, not sure why I disagreed with that in the beginning, but particularly in the body where the scars tend to get a little bit thicker.

I, I, I'm much more Proactive in treating the scars around six weeks, all scars with lasers. A little bit of a different approach as opposed to using an ablative laser or for our listeners, a heat generating laser. We'll use a non-ablative laser. Most recent one we're using is one by a company called Sciton that we can use on all skin types.

We used to use microneedling before that as, as a way to try to again, sort of use a non-ablative mechanism by which. Speed up the, the rate of, and basically just from removing the top layers of collagen. What's

[00:22:44] Dr. Salvatore Pacella: that? Let me just, let me just qualify that remark for a second. When I said, when I mentioned the reddest of the lasers, It I refer to, to those, those are like super ke or hypertrophic scarring type of lasers.

That's, that's where an abl Got it. Okay.

[00:23:00] Dr. Sam Jejurikar: Got it, Got it. Okay. Got it. Okay. So yeah. But we for proactively will get people going with non-ablative lasers to just basically try to get off those top layers. Again, it's all being done with the attempt to try to shorten the amount of that remodeling phase. I think if a scar is healing, normally the laser treatments that we're doing I don't think are necessary, but what I do think they do is I think they speed up that remodeling phase once a scar reaches this point of maturation where it's a pale line.

At that point, I'm not worried about the scar ever getting bad, but while there's active inflammation around it, if you go to the beach or if you are out, at your pool for a long time or you're going to a cookout, or in Texas, San Diego, maybe not so much New Jersey, the sun is fierce. There's a potential to take a scar that's in an inflammatory phase and it, and it can turn really bad.

So the shorter we can make that remodeling phase, the less anxiety I feel about the long term results.

[00:23:56] Dr. Salvatore Pacella: Excellent. Okay, so let's fast forward now. We've kind of done the laser treatment. We're kind of well on the road to recovery. Dr. Re, when is the scar gonna disappear on me? It's been a year. Tell me, is this guy ever gonna get better? Is this the way it looks?

[00:24:15] Dr. Sam Rhee: Another secret. Scars never actually very rarely ever disappear.

Like I never tell a patient, Your scar will disappear. I will say our goal is to get it to fade, to be as inconspicuous as possible. And honestly, in some patients it's really hard to see some of those scars, but I will never guarantee or tell a. Your scar is gonna disappear and you'll never see it.

That's, that's a fallacy. So, I will say that after about a year, as you said, we get to that final phase where things are fairly mature with a scar and there's, you're not gonna see so much change with it. You sort of reach the end of that curve. It's slow. And at that point, hopefully you've achieved what you really want in terms of that scar appearance.

If you haven't, that's when you start going down that big, cycle of, managing bad appearing scars. And, and that again, probably might be a whole nother topic in it of itself. But I would hope by a year, I, I could confidently tell a patient we're sort of pretty close to what that final appearance is gonna be at.

[00:25:20] Dr. Salvatore Pacella: Right.

[00:25:22] Dr. Sam Jejurikar: Yeah. The goal is never to make the scar disappear. It's to make it cosmetically acceptable, But I agree with Sam a year or two. Best case scenario, six months, worst case scenario, two years, somewhere in that time range, younger patients certain ethnicities of patients tend to take longer, older patients.

With hail or skin tones tend to be a little better,

[00:25:42] Dr. Salvatore Pacella: but like, like everything in life, it's a trade off, right? You get, you get the benefit of the cosmetic surgery, you get the benefit of the, the breast implant, the tummy tuck the new face, but it doesn't come without some sort of sacrifice. Right. And if we can, if we can manage that in such a way to make the scars look as, as inconspicuous as possible, then I think we've, we've done.

So, Jen, any, anything further to add on the scar side of things or,

[00:26:10] Dr. Sam Jejurikar: I mean, I, I think that's a really comprehensive discussion. It shows that we kind of agree on the principles of everything, but do everything differently. And, and that's, that's, I mean, I think that's the key though. You're gonna, there's, you're either gonna come to one of us or one of, 10,000 other plastic surgeons out there, and you'll get slight variations, but the principles don't change depending on who you go see.

So true.

[00:26:32] Dr. Salvatore Pacella: Right, Right. And I, and I think for our listeners out there, we want, we wanna stress, we've, you, you can see that, all three of us have, have a strategy and we've kind of thought about this topic, I think, throughout our entire careers because, scars can be problematic for patients.

And we, when, when you have a great scar, it's a win-win for everybody, right? We want you to be happy about your surgery and kind of. And not concentrate on, on the bad part of it or the scarring. So, I think it's important we're, we're in tune to that and, and we want you to know that so well.

Jen, thank you so much for a wonderful discussion. I always learn, learn the most chatting with you and we'll sign off till next

[00:27:10] Dr. Sam Jejurikar: side. Peace out homies, . Alright.