Surgical Scarring

	This month's topic will be scarring. With any surgical procedure, including the various techniques available for chest reconstruction in female to male gender confirmation surgery, a scar of some type will result. The degree of scarring will vary with the type of procedure used, the techniques employed by the surgeon and the attention to detail given by the surgeon, the amount of tension on the incisions as they heal, the type of suture used, and probably most important, genetics. The process of wound healing following surgery is complex and scar is an inevitable consequence of healing following any surgical procedure. Scar will be visible, even if minimal, where an incision has been made through the skin. For the first six weeks following surgery the body heals by making more scar tissue. This involves depositing collagen into the wound to effect healing. As this collagen accumulates, the scar becomes somewhat raised and thickened. This is a natural process. At the same time new vessels grow into the scar to nourish this process. That is why scar becomes temporarily reddened or darkened. These processes explain why scars are usually their most conspicuous at about six weeks following surgery. In normal healing, following this six week period, scars mature and become less and less prominent. This is because the amount of collagen decreases and the components become more aligned. The scar tends to flatten. During this time the nutrient vessels diminish in amount and prominence and the scar tends to fade in color, blending more with the surrounding skin. This entire process of scar maturation may take six months to one year. At times, surgical scars do not have this ideal outcome; they may remain thickened to a degree and have more redness than desired. We call this hypertrophic scarring and attempt to prevent it or improve it when it occurs. A scar is a tradeoff a patient must accept to achieve form and function from a surgical procedure. It is fortunate if a procedure is available which limits the amount of scar created. But it is equally, if not more important, to achieve more acceptable form and contouring, and if possible to preserve function, such as sensation. It is important to try to preclude the need for secondary revision surgery or limit the extent of it. In the future I will address the various procedures available for chest reconstruction based upon existing breast size and shape, the use or non-use of hormone therapy, and patient desires. For this discussion, I shall just address techniques available to attempt to obtain the best possible scarring, whatever the procedure performed. Technique: The surgeon should attempt to design the procedure to minimize the amount of tension upon the closure of incisions. Whatever tension does exist should be addressed by suture techniques which can help alleviate that tension. Layered closures with absorbable (dissolving) sutures at various layers under the skin can decrease tension on the skin closure itself. The skin may be approximated with relatively inert, fine suture material placed through the skin in continuous fashion, or placed in a subcuticular plane (within the skin layer itself, but not through the outer layer). This subcuticular suture can be left in place a longer time and not cause "track" marks in the skin. Sutures which do go through the skin should be removed early enough to avoid those track marks. After sutures are removed, additional methods are available which may serve to minimize the degree of scarring in terms of spreading or thickening. The use of skin adhesive and paper tape is often very helpful in alleviating tension and providing a modicum of pressure. This is effective as long as the skin tolerates it. Occasionally skin irritation prevents prolonged use of this technique. The surgeon should also try to place incisions where they may be disguised. This would be in areas where there is a color change to hide the presence of the scar, such as in the areolar area, either with a periareolar incision if it is appropriate, or surrounding an areolar graft, if that technique is used. Also, if incisions are placed in natural skin tension lines or countour lines where they do not seem to be so prominently displayed, their presence may be less detectable. Pressure is known to be effective in minimizing scarring and is often used in burn victims. It is difficult to apply prolonged pressure on the chest without prolonged use of restrictive binders, which is usually objectionable and difficult for patients. Additional Postoperative Techniques: Available now are any number of topical applications which can be applied to scars, after the tapes are removed, to try to minimize scarring. These include topical and systemic Vitamin E preparations, silicone gel topical creams or sheeting (expensive), proprietary over the counter preparations such as Scar Fade, Mederma, ScarGo, etc. These contain various natural extracts and seem to be effective in some patients, and not at all in others. One known effective treatment is radiation, though this would not be suitable in these cases. A recent extensive article in the Journal of Plastic and Reconstructive Surgery evaluated the many techniques for reducing the amount of scarring in terms of spreading and especially thickening and darkening, and the thrust of the conclusions was that there were no techniques that were universally reliable and that 25% to 50% effectiveness would be the most that could be expected. Please understand that we, as surgeons, do not like adverse scarring any more than you do. We try to work with you to achieve the best possible result from our surgeries, but we know that we have only so much control over the degree of scarring that results. We must accept, as must you, that scarring is a natural result of surgery and must be taken into consideration in deciding upon any particular procedure. We must also consider that the scar may be a reasonable price to pay for form and contour. Society seems to be accepting of scars on other individuals, as long as they are not extreme. What seems to draw adverse attention are asymmetries and disproportions, and that is an important consideration in deciding upon a surgical procedure. The next installment of this newsletter will discuss the indications and relative contraindications of the various procedures available for chest reconstruction as well as descriptions of the techniques. Again, please contact me if you have any questions concerning this topic or have any suggestions for topics you would like me to discuss. Thank you. Michael L. Brownstein