Prior to a Los Angeles Mommy Makeover, many patients’ reluctance to undergo surgery is rooted in a fear of having unsightly scars. For many, the concern is exchanging one physical deformity for another and hence not feeling like it will actually regain their self confidence. With any surgery, scars are an inevitability. However, with a skilled and fastidious surgeon, the visibility of scars can be minimized almost completely.
In most cases, wound healing is very predictable--the healing process is very similar from one patient to the next. There are mild variations, but most patients stick to the same basic timeline. This healing journey is covered below.
The Healing Journey
During the first one to three weeks, provided your surgeon closes you well, your incision will be very thin, flat and narrow. This is known as the inflammatory phase. The edges have been brought together in a precise fashion, and it usually looks very secure. At this stage, however, the incision has not even begun to heal, and if enough force were applied along the wound edges, the wound would separate.
Bad Tummy Tuck Scar
Good Tummy Tuck Scar
Proliferation phase
Between three weeks and six months after surgery, the body moves into the proliferation phase. This is the time you will have scar tissue formation and new blood vessel regrowth. This is your body welding itself closed. It is normally during this period of time that the incisions become redder, thicker and firmer. Patients often also note some itching during this period of time.
Remodeling phase
Finally, between six months to two years, your incisions will transition into the remodeling phase. During this time, your incisions should gradually become flatter and lighter, and in the best of scenarios, become very difficult to see. This is due to your collagen or scar tissue rearranging itself in a more organized fashion, hence the name remodeling.
Bad Breast Lift Scar
Good Breast Lift Scar
How to achieve the ideal scar
Now that we’ve described the natural progression of wound healing, let’s discuss the difference between a desirable scar and a poor scar. People are often misled to think that plastic surgery means no scars. That is not the case. All surgery, including your Beverly Hills Mommy Makeover, will leave you with scars. The goal of good plastic surgery is to leave you with scars that fade over time and are very difficult to see.
While many patients are led to believe that bad scars or unsightly scars are a result of their own biology, this is usually not the case. All too often, Dr. Rahban sees patients who come to him for revisional work with unsightly scars who have been labeled as poor healers or keloid formers. Over years of doing scar revisions, it became apparent to him that, when these patients did not form these scars again, the issue was not their biology but their poorly done surgery. Certainly in some cases a patient will make thicker scars than other patients, but they represent the vast minority of patients.
So what are the factors that lead to a desirable scar? There are many things that your plastic surgeon should do in order to optimize your wound healing. These things include:
- Treating your skin or tissue delicately while performing surgery. Remember that whatever is cut has to eventually be closed. If, during surgery, your tissue is either damaged from mishandling or cauterization, the wound edges will become inflamed and heal poorly.
- Removal of excess tissue either during breast lifts or tummy tucks will lead to too much tension between the edges of the incision. Your body’s response will be to create more scar tissue to hold things together. Because of this, it’s crucial that your surgeon remove the correct amount of tissue as well as place multiple, deep stitches to offset the tension on the skin edge.
- Low grade or overt infections of the wound will lead to increased inflammation and later thickened scars. It is imperative that your wounds be properly irrigated during surgery, and you have appropriate post-operative wound management.
- Minimizing strenuous activity for the first six weeks reduces unnecessary tension on your scars. Remember, as the body begins the proliferation phase, it is responding to the tension on your wound edges to determine how much scar tissue it needs to create. The more tension the body feels along the skin edges, the more cement, or scar tissue, it will form to weld your scar together. Early strenuous activity tells the body to create a greater, thicker scar as it’s undergoing more tension.
- Accuracy of closure of the final skin layer of an incision. While the deeper tissues have to be re-aligned accurately, the final layer of skin is the most crucial in the prevention of scar formation. Many times surgeons close the skin in a rush, with the skin edges not perfectly aligned, leaving the body to correct the gap. The body only has one form of healing, and that is through scar formation. Therefore, the more accurate the skin closure is, the less burden is placed on your body, and the less scar tissue is formed. When Dr. Rahban closes the final skin layer, he does so in two additional layers, whereas many doctors only close with one layer.
Dr. Rahban’s compulsive closure
As mentioned above, one of the most crucial elements for a desirable scar outcome is how the wound is brought together. Once a tissue is incised, many layers have to be separated from the skin all the way down to the muscle layer. When a wound is closed, it is imperative that the same layers that were initially opened are brought back together. While that may seem obvious, many surgeons either omit layers or close them incompletely, therefore leading to less than ideal outcome.
Dr. Rahban’s closure technique includes the use of multiple, deep, under-the-skin, absorbable sutures to close the fat and muscle layers, followed by multiple absorbable sutures to close the dermis, hence creating a tension-free skin layer. The final layer is re-alignment of the skin itself. Because there are so many absorbable sutures placed deep, Dr. Rahban can use permanent sutures to close the skin, as he will be removing them within a week. He uses these permanent sutures to fine-tune the edges, leading to minimized scar formation.
Since the wound is not relying on these outermost stitches for integrity, he is able to remove these stitches after seven days without any separation. He uses permanent sutures because they are less inflammatory than absorbable sutures and lead to less scar formation. This is a time consuming process, both to place the sutures and to remove them in the office. The reason many surgeons do not do this step is because it requires lots of time in the office to remove these sutures.
Additionally, Dr. Rahban firmly believes that the surgeon himself should be the only one closing the patient. While this may seem obvious, it is far from the case in today’s world of aesthetic surgery. More often, the scrub technician or an assistant surgeon, unbeknownst to the patient, will assist during closure. This is done in order to accelerate the time of surgery, hence increasing profit for the surgeon. Dr. Rahban will only do as much surgery as he can himself close. It is for all of these reasons that Dr. Rahban is trusted by hundreds of Los Angeles, Beverly Hills & international women to provide some of the best mommy makeovers Beverly Hills can lay claim to.
What actually works
So much emphasis today is placed on wound management once a bad scar is formed. As you have read above, Dr. Rahban’s philosophy regarding scars is focused on prevention rather than treatment after the fact. However, many patients feel strongly or have been sold on the idea that there are special creams, potions or lasers that can make their scars better. Dr. Rahban is very academic about the way he practices medicine. He is a big believer of science and evidence-based medicine. As such, the overwhelming majority of scar management treatments today have no evidence that they work. There are only several things that do actually work, and these are as follows:
- Massaging scars. This is the cheapest and probably the most effective method of wound management. As we mentioned above, during the proliferation phase, the body is placing collagen and scar tissue in a disorganized fashion. By massaging, you are telling the scar to reorganized into a more flat and narrow arrangement. This leads to a more desirable scar.
- Avoiding sun exposure for nine to twelve months is crucial, as the scar is very vulnerable and reactive during this period of time. Unnecessary sun exposure will lead to formation of pigment and darkening of your scar.
- High grade medicinal silicone, either in the form of sheets or creams. Historically, doctors used silicone sheets in the area of burn care. Patients who are burned often make the worst scars, and a lot of the science in wound care comes from those patients. The science is a little bit unclear as to why silicone works, but we know that it definitely helps with scar management. As silicone sheets are difficult to wear, we’ve now advanced to liquid silicone which can be applied on the wound. It is crucial to understand that liquid silicone is merely a small adjunct to wound management and can definitely not take the place of good surgical closure.
- Steroid or kenalog injections. Be very careful when it comes to injecting scars with steroids. While many surgeons and dermatologists routinely do this when a scar begins to thicken, it is extremely risky. Steroids are intended to change the biology of the wound healing process, reducing the amount of scar formation. However, this process is incredibly inaccurate. In addition to thinning out undesirable scar formation, steroid injections are notorious for causing damage to surrounding healthy tissue. This is most commonly seen by thinning out or atrophy of adjacent tissue like skin and fat. Dr. Rahban has had many patients present to him after their surgeon or dermatologist injected them with several rounds of steroids, only to be much worse than they were prior to the injections. Dr. Rahban seldom injects steroids in scars for this reason.
Scar Myths
Lasers. Daily, Dr. Rahban hears patients coming in for revisions, asking if lasers can improve their scars. Despite marketing and mass media, the effect of lasers on unsightly scars is limited or none. They may help slightly with wounds that have color issues, as lasers are designed for pigmentation issues. They will not, however, help with thick or wide scars, as that is not what they are designed to do.
Mederma. Mederma is a very well-known scar cream being sold with thousands of claims. There is no real science that has proven that Mederma has significant clinical benefit. Understand that all scar creams will show you before and after photos with scars that appeared unsightly and became flat and thin. Remember that if nothing had been done, those scars would most probably have improved without the treatment over time. Therefore, the claims that the ointment produced that effect is unsubstantiated. In order for a cream to be proven to work, they need to compare it with controls, which very few manufacturers are willing to do.
All other lotions and potions. Just like Mederma, there is no actual proof that ointments or creams are effective in minimizing scars. For this reason, we cannot stress enough that you vet your surgeon to ensure his closing technique is exquisite. Closure of your incision is the number one factor in scar prevention.
All in all, Dr. Rahban believes strongly that the only two elements that are relevant in your wound healing are:
- Your surgeon and his skill
- Your biology
As your biology is not within your control, and as Dr. Rahban mentioned, most people’s biology is favorable, then the only thing you can chose is your surgeon. All too often, patients forego the skill of their surgeon in hopes that some special scar management treatment will help them get the results they want. In reality, ninety-nine percent of their outcome is determined by their surgeon’s closure technique.
Don’t be fooled by surgeons who tell you that they they have a post-surgery scar management protocol. That is all marketing. All too often, patients are misled to think that their doctor has some special scar management technique that allows him to get great results, when in reality there are very few things, other than his own technique, that have been PROVEN TO WORK. This technique is to get a leg up on another doctor, giving the impression that he has a treatment that no one else has. It doesn’t exist except to close the deal.
