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    3 Plastic Surgeons and a Microphone – scar management

    There is nothing more uncomfortable than scar that won’t heal properly. Can plastic surgeons really make scars disappear?  The 3 Plastic Surgeons tackle one of the constant paradigms faced by plastic surgeons today – scar management and what you can do to get rid of them.

    Dr. Salvatore Pacella leads the discussion with Dr. Sam Jejurikar and Dr. Sam Rhee  about what procedures help alleviate scars and how to have the best result.

    Dr. Salvatore Pacella: Good morning, everyone. Doctor Salvatore Pacella here from San Diego, California. I’m joined by my guest, Doctor Sam Rhee in Grahamisburg, New Jersey. He’s at Burgent Cosmetic and of course, Doctor Sam Jejurikar of Dallas, Texas “@samjejurikar” Good morning, gentlemen. How are you today? 

    Dr. Sam Rhee: Doing well.

    Dr. Salvatore Pacella: Alright. Okay. Today, we’re going to be talking about a very common issue in plastic surgery or in any surgery for that matter, Scars. So, we’re going to go into a 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 will create a scar but if we can create that scar in such a way that it’s inconspicuous. I think that’s going to be obviously have a better cosmetic outcome. Before we get started, we’ve got a few housekeeping items to talk about here. So, I’m going to hand it over to Sam.

    Dr. Sam Rhee: Notice.

    Dr. Salvatore Pacella: Notice which Sam.

    Dr. Sam Jejurikar: Notice. He didn’t know which one was reading it. So, 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 judgement after appropriate discussion. Always seek the advice of your surgeon or other qualified health care 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. Doctor Pacella back to you.

    Dr. Salvatore Pacella: Alright, sounds good, gents. So, Scars are certainly unnecessary evil in any surgery and I think we have to separate the difference between facial scars and body scars. My mind, when I think about this concept, when I perform a body scar, obviously, I want to 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 some place that’s visible, it’s very to cover any scar and so I in my practice I have to be specifically careful with any facial surgery to optimize how I’m managing that scar. I think the most important thing is on the day of surgery and so let’s first talk about what we do to minimize scars at the closure. So why don’t we start from go ahead? Now go ahead. Go ahead Sam.

    Dr. Sam Jejurikar: The one slight exception I is that I don’t make that distinction you do about facial and body scars because of my patients and 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 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 on the skin closure is the most important thing. I’ll let Dr. Rhee 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.

    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 which Sam hit on the head is certainly tension. You could talk about techniques for closure and sutures for closure and all sorts of other things that we do automatically for every procedure because obviously, as Sal says, a facial procedure is different from a body procedure but different body procedures also necessitate different types of closure. If you’re doing a breast dog, the way you close that be different from a tummy tuck or from say small, very small incisions for liposuction.

    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.

    Dr. Salvatore Pacella: Right. So, let’s kind of break that down for a second. So, Dallas, I respectfully bury in this topic for you as far as face and body goes. And to me anatomically there is a major difference 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 worse 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 abdomen. And to me, when you have a Scar from a skin cancer on the shoulder where there’s extensive surface and the skin is very thick. I think that scar many times looks a lot worse than a tiny scar or a thin scar right in a natural in the face or the neck. So, I approach these anatomically very different and I think first step I think for me in in creating a good scar is the start of the surgery.

    Okay, so what I mean by that is when we’re making cuts scars that we make in surgery are much different than scars you may get from a traumatic injury you trip it fall then you cut your chin. I think there’s a common misconception out there when patients sort of say, well, I go to the ER, I don’t want the ER doctor or PA closing me because I want a plastic surgeon to close me. And to some extent there’s symbolidity to that, but some to some extent there is not and why that’s different is many times from a traumatic standpoint it doesn’t truly matter who closes the incision but it’s the mechanism of injury that’s the problem. So, for example in a traumatic injury you don’t get the ability to choose where you’re going to make that cut. So, when we make it in surgery if we make it along the line, we know that cut is going to be very very thick and very atraumatic. But when you have a traumatic scar on the nose the forehead the eyelid it’s really not just the less erasure of a cut in the skin, it’s the blast component or blast injury or the bruising that we see that could cause very bad scarring.

    The benefit we have in surgery is that we handle the tissue well and there’s not a a sort of rifle injury that we have. So, comments on that, gents.

    Dr. Sam Jejurikar: Yeah, I actually think you and I don’t disagree at all on this. I think we’re actually very similar. I think some of what we bring to this conversation is the differences we have in our practices. You are very well known and both traumatic reconstructions as well as facial skin cancer reconstruction. You wrote textbook on it for god’s sakes. 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 in a skin crease. If it’s a breast lift, it comes back to minimization of tension. So, I completely agree with that. I think my comment about just for a differentiating face from body is in my practice which is cosmetic. I talk to every patient, usually based off of what they’re bringing up more so than what I’m reading 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 post-operative regimen will look like but I agree with you completely.

    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 not do in the ER and you’re right. The mechanism of injury plays the biggest role. That soft tissue damage that’s associated with a lot of traumatic injuries. You see that maceration of the edges. A lot of times it’s not a sharp injury. It’s usually a blunt for that literally splits 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 heal very poorly. But the way we evaluate it, the way we manage it, the way we treat the tissue and close it, all of those things can play a huge role in how that traumatic injury heals. I’ve seen many colleagues, mine, other plastic surgeons approach injuries and how we close them very different than how other 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.

    Dr. Salvatore Pacella: 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 would agree we all try to close these wounds under minimal tension. The lesson for our listeners out here is if we’re doing an abdominoplasty or tummy tuck comic language. When we pull tissue and take it out. 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 face lift, okay, same sort of concept. If we’re trying to really truly try to jack that skin as high as we can behind the ear, in front of the ear, that’s going to lead to a bad scar because tension equals bad wounds. So, how do we dissipate some of the tension in wounds where we’re pulling things. So, deeper layers of suture. So, gents, let’s kind of talk about that a little bit. What do you use? How do you approach it? What’s your philosophy?

    Dr. Sam Jejurikar: I’ll stick with your first example which is it was a tummy tuck. There’re two common methods that that I will utilize that are well described. The first are progressive tension sutures. So those are going to be sutures that go that along the under surface of the skin flap which basically help merch along the tension. So, that that skin flap that you’re closing instead of the tension just being at 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 scarpus fascia. But basically, it’s a layer that has some tensile strength within the fatty layer that might 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 is similar principles particularly with some deeper sutures in what’s called the mask.

    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 face lift, 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 going to have problems, because it’s just going to be too tight and you’re going to 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 two lakhs. 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 using the tissue to hold it. There’s only so much that work that can do. So really experience counts for all of this stuff.

    Dr. Salvatore Pacella: Right and sometimes I’m sure you both agree less is more. You can always take off more tissue if you need to, right. But you can’t ever put a vet.

    Dr. Sam Jejurikar: Right.

    Dr. Salvatore Pacella: So. Now as far as the type of stitch you use. So, in deeper parts of the body I often times use a vicro or a braided stitch. But in my experience when in in that the reason for using braided stitches I think it unravels less. But it’s a little bit of a double-edged sword, but that braided suture is towards the surface of the skin. It often times could spit it creates a little bit of bacteria. So, I try to shift towards either a running braided suture to avoid knots or an interrupted sutures that are not fraided or were called monofilament sutures. So, and then on the skin surface, often times in the body I’ll use a subcuticular which is where for our listeners it’s a suture that you don’t see any train tracks. It’s hidden underneath the skin and usually there’s a piece of the suture either very deep. It’s a knotted or it’s coming out of the skin at either end. So, there’s no that kind of train track line.

    Dr. Sam Jejurikar: I think it depends on what part of the body; we’re talking about if we’re talking about atomy 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 the barbed suture for listeners so I use a suture that won’t unravel. It’s basically one continuous stitch but it has little barbs in it, so with each stitch that you put in and locks. So, it sort of eliminates that unraveling issue that Doctor Pacella was talking about. There is it’s a little bit easier for the body to break down these monofilament sutures than the barb sutures. Little bit less of an inflammatory reaction and so it’s my sub-position that that helps the final scar.

    Dr. Sam Rhee: There’s a secret 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 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 material. 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 responses Sam has said. I try to do running but I can’t stop myself from doing a few interrupteds just to sort of tack things together just so that I feel like I can approximate it a little bit better before I start my runnings. But it’s a constant tension like I want to get done and get the patient off the as quickly as possible but I still want to maintain the best quality that I can. So, every surgeon is a little bit different because 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 approaches for a patient.

    Dr. Salvatore Pacella: And then 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’m sure we all have kind of dip a ways, we put bandages on, or Dermabond, or glue, or this or that. But the key here I think is understanding the patient expectation about how that scar is going to look on day one on day two on a week three week three weeks three months etcetera. So, how do you counsel your patients as to how the scar is going to look? Because honestly sometimes patients they expect the scar to be immediately healed within two weeks and look perfect. So, what do you do?

    Dr. Sam Jejurikar: The really good question. In the healing response goes through multiple stages. In the first three weeks basically, the body is laying down a bunch of collagens in the scar. Scar looks kind of, it doesn’t look great in the first few weeks. So, there is the scars 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 short as six months or as long as 2 years.

    What I’m sort of 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 to create hyperpigmentation or a brown discoloration around the scar and then doing treatments to try to speed up that remodeling phase. I’m sure we’ll get into what that’ll be a little bit later on. Doctor Rhee.

    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. Honestly, a lot of my initial dressings just cover everything up so that they can’t really look at it and obsess. So, 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 I think that helps.

    Dr. Salvatore Pacella: I see this routinely in in any facial surgery I do particularly in the skin cancer reconstruction that I do. I have this kind of feel like if every single patient regardless and I say, to me when the scar looks exactly the worst is about four to six weeks afterwards. It looks the most red and the most irritated. And I found that when I tell patients for the first week your scar is going to look perfect, it’s going to look like a little thin line. There’s going to be no redness, you’ll be very happy with it. And then four to six weeks later, I’m going to see you back again and you’re going to say, what is this guy doing? This looks terrible. This is the worst scar I’ve ever seen. But that’s exactly what we’re talking about with the remodeling phase and end of the collagen deposition phase. 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 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 scar management. Gents, your thoughts.

    Dr. Sam Jejurikar: Yeah, I think silicone is the gold standard by which we must measure all other forms of scar treatments. 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. You look just comes down to patient preference. I find that in my fractures, patient compliance is a little better with silicone 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 time where you’re going to do it. If you are the sort of patient that’s not going to be able to remember to do something twice a day, then, silicone strips are the key. 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 going to go use some concoction that my friend recommended to me. Silicone required lots of time lots of diligence over a prolonged period of time to see the results

    Dr. Sam Rhee: It’s so funny. I I’m the same way with silicone now. 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 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 silicone or not and that makes all the difference in the world for me.

    Dr. Salvatore Pacella: And Doctor Sam from Dallas hit on a good point is he said that silicone is the gold standard for scar management and actually there’s a data behind that. There arguably no other modality has been proven more than silicone to assist scar management make scars better and ladders. And there’s a biomechanical reason for that. Silicone is an 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 an acidity standpoint. It has a negative our skin has a negative inherit charge to it. So, it makes a lot of steps when you place a something that’s negative on the surface of something else that negative that’s negative. There’s a repelling. So, it’s almost an electrostatic that occurs with silicone. So, it is critical for vanish.

    Dr. Sam Jejurikar: Now, is there anything else you guys might consider adding around that six-week phase?

    Dr. Salvatore Pacella: I do as well. So, I would say that when we look at patients in my practice, facial patients at least. So, there’s kind of a delve curve 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 often times tend to be less red than somebody who’s younger and so there’s a bell curve. The patients who are kind of on the top third of that bell qualitatively, the ones with the reddish scars at about 5, 6 weeks often times recommend a laser modality for that. And I found that laser treatments really can tend to help and it’s usually a fraxal or an ablative type of laser that can really assist with reducing the scar prominence and reducing the redness. I know that lasers for everybody but usually that critical time period I think is about five to six weeks to get started it.

    Dr. Sam Jejurikar: Yeah, I agree with that. We 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 try to help with that. What I do find is also really helpful. In Doctor Pacella the further along we get in this conversation the more I’m agreeing with his distinction between facial and body scar. I’m like not sure why I disagree fat in the beginning but particularly in the body where the scars tend to get a little bit thicker. 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 use a non-ablative laser. That’s the reason one we’re using is one by a company called Styton that we can use on all skin types. We used to use micro needling before that as a way to try to again sort of use a non-ablative mechanism by which to speed up the rate of. And basically, just remove the top layers of collagen.

    Dr. Salvatore Pacella: Let me just clarify there with Mark for a second. When I said when I mentioned the reddest of the lasers, I refer to those are like super keloid or hypertrophic scar type of lasers.

    Dr. Sam Jejurikar: That’s 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. And again, it’s all being done with the attempt to try to shorten the amounts 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 where in Texas, San Diego, maybe not so much New Jersey. The sun is fierce. There’s a potential to take a star that’s in an inflammatory phase in 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.

    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. Doctor Rhee, when is this scar going to disappear on me? It’s been a year. Tell me. Is this ever going to get better? Is this the way it looks?

    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 patient your scar is going to disappear and you’ll never see it. 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 going to 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 appearance scars and that again probably might be a whole another topic in and of itself but I would hope by a year I could confidently tell a patient we’re sort of pretty close to what that final appearance is going to be at that point.

    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. Year or two. Best case scenario 6 months. Worst case scenario 2 years. Somewhere in that time range. A younger patients’ certain ethnicities of patients tend to take longer. Older patients with paler skin tones tend to be a little better.

    Dr. Salvatore Pacella: But like everything in life it’s a tradeoff, right. You get the benefit of the cosmetic surgery. You get the benefit of the breast implant, the tummy tuck, the new face, but it doesn’t come without some sort of sacrifice, right. And if we can manage that in such a way to make the scars look as inconspicuous as possible, then I think we’ve done our job. So, gents, anything further to add on the scar side of things or?

    Dr. Sam Jejurikar: I mean I think that’s a really comprehensive discussion. It shows that, I kind of agree on the principles of everything but do everything differently and I mean I think that’s the key though. You’re either going to 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 guys see.

    Dr. Sam Rhee: That’s true.

    Dr. Salvatore Pacella: Right. And I think for our listeners out there we want to stress. You could see that all three of us have had a strategy and we’ve kind of thought about this topic I think throughout our entire careers. Because scars can be for patients and 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 the bad part of that sort of scar. So, I think it’s important we’re in tune to that and we want you to know that. So, well gents, thank you so much for a wonderful discussion. I always learn the most chatting with you and we’ll sign off till next time.

    Dr. Sam Jejurikar: Peace out, homies.

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