Scarring

The hypertrophic scar

This patient presents with a “bad scar” after previous abdominoplasty procedure. The ideal scar is a line that is difficult to see. This scar is a hypertrophic scar. Some people might call this a keloid. A Keloid scar grows beyond the original borders of the laceration/incision area. A hypertrophic scar is typically a thick and possibly wide scar that can be itchy or painful; but grows within the original borders of the incision area.

There are many reasons why a hypertrophic scar might form. A traumatic laceration (where the skin edges have a poor blood supply).  A surgical access incision where there was a lot of pressure against the skin edges from an instrument could cause “skin edge necrosis”; this can lead to a hypertrophic scar. If a patient put ice on a fresh surgical incision site, this could also lead to skin edge necrosis, leading to the hypertrophic scar. If a scar is over a joint, where there are constant pulling forces on the scar, this can cause it. If the patient were to apply a topical cream or lotion that the body ‘determined’ that it is ‘allergic’, then that cream could make the scar hypertrophic (this is particularly true for adhesive applied to the scar).  If there is a foreign body, such as hair – or pubic hair, growing in the middle of the scar, this can lead to the body ‘thinking’ that a lot of collage needs to be deposited around the hairs. And there are other causes.

Typically, the treatment is scar revision. The scar is cut out and reapproximated with minimal tension.  There are other techniques such as Z-plasty that sometimes need to offset the lines of force, to prevent the return of a hypertrophic scar. After the scar is removed, there is typically an opportunity to prevent the return of the scar, if it starts to return at 6-10 weeks after closure. A fresh steroid, Kenalog, can be injected intralesionally, and this can slow the progression and sometimes stop the progression of collagen deposition.

This patient had a hypertrophic scar most likely from the hair follicles growing in the scar. At the time of scar revision, the hair follicles were burned, thus preventing their return. She also used a home laser hair reduction device along the scar for the first 3 months after scar revision.  

The best care for a scar is to leave it alone. Do not apply any product or cream. The first 3 months the scar is the maturation phase and is vulnerable to topical creams. The body has evolved to know how to heal, without help. Ensuring that you are eating enough protein and staying healthy is enough to heal a surgical incision healing through primary closure.