A short video by Thomas P. Sterry, MD, a plastic surgeon, describing scar revision of a facial scar followed by dermabrasion.

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In a cesarean birth (C-section), the baby is delivered through an incision in the mother’s abdomen and uterus (womb). C-Section births exceed 30% in USA, Brazil, Italy, Mexico, Turkey, Korea, Portugal, Australia, Thailand, and other countries. China is the only country where C-section births exceed 40%. The number of cesarean sections in the U.S. has risen nearly 46% since 1996.

Every C-Section is a major abdominal surgery that leaves a scar. The size of your C-section scar will depend on several factors: the size and position of the baby, whether the C-section was planned or not, etc. Generally, the C-section scar is around 4-6 inches (10-15 cm) long and 1/8 inch (0.3 cm) wide.

Usually the “bikini cut” incision is used but sometimes the “classical” incision will be made vertically from just below the belly button (naval) to just above the pubic bone. To close the wound, some surgeons prefer to use staples whereas others still use suture; there is little statistical evidence to show that one way or another will increase or decrease the size or the appearance of the scar.

Treatment. Initially, the C-section scar will be red, raised and could itch. After the wound is closed you should start using a silicone based product like Strataderm to make the scar softer, flatter and smoother and to relieve itching. The majority of women will develop “mature” C-section scars by the sixth month after delivery. If you have darker skin and/or are prone to keloids you should consult a physician before the C-Section.

Acne is the most common skin disorder, affecting around 15% of the adult population and up to 80% of adolescents. Facial scarring because of acne occurs to some degree in most cases. The majority of acne scars are flat and depressed below the surrounding skin (atrophic), generally small and often round with an indented or inverted centre. To prevent acne scars, do not pop, squeeze, or pick at acne; do not pull scabs of acne; seek treatment early for acne that does not respond to OTC medications.

Types of Acne Scars:

–          red and/or hyperpigmented marks: a post-inflammatory change that usually disappears in 6-12 months

–          acne scars – icepick: depressed scars, deep, narrow and sharp; usually too deep for dermabrasion or laser skin resurfacing

–          acne scars – boxcar: depressed scars, round with sharp edges

–          rolling acne scars: depressed scars, wavy texture in the skin

–          keloids and hypertrophic scars are raised acne scars that may become larger and more noticeable, sometimes painful and itchy.  

Silicone gel like Strataderm is effective for treatment of acne scars and prevention of keloids and hypertrophic scars. Other effective treatments for depressed acne scars include laser skin resurfacing, dermabrasion, scar surgery (punch excision, punch elevation, punch graft, subcutaneous incision), fillers, chemical peel, microdermabrasion and similar procedures that you should discuss with your dermatologist. For raised acne scars, like keloid and hypertrophic scars, your doctor might consider options like intralesional injections, cryotherapy, surgery, laser and light therapy. Your dermatologist will be able to create a treatment plan based on the type of your acne acne scars, results you can expect, and your medical history.

Acne Scars:

With every wound there are certain individual and environmental factors that influence abnormal scarring (e.g. keloid scars or hypertrophic scars) which make the choice of appropriate scar treatment and scar prevention essential.

Age and Hormonal Influence

Although keloid scars and hypertrophic scars can develop at any age, they tend to develop more readily during and after puberty. Menopause tends to prompt the regression of scarring and pregnancy tends to exacerbate it. Scars from thyroid surgery (thyroidectomy scars) can be problematic due to hormonal changes.

Genetic Factors and Previous History

Abnormal scarring is 15 times more likely to occur in darker-skinned individuals. Keloid scar formation occurs in areas of high melanocyte concentration and is rarely found on the eyelids, genitalia, soles and palms. Individuals with ginger hair and freckles are also at an increased risk of keloid scars. People with a previous personal history of keloid scarring are more likely to scar again in an abnormal fashion and those with a family history are also at an increased risk.

Scar location and surgery technique

Scars over or near muscles that are particularly active often spread or become more visible than the scars formed on less active areas. Skin and wound tension during wound repair is also a contributor to increased scarring.

Wound Infection

Wound infection increases the risk of abnormal scarring.

Type of Skin Injury

A variety of different types of skin injuries can lead to the development of keloid and hypertrophic scarring including surgery, burns and inflammatory skin processes such as acne, psoriasis and chicken pox.

Silicone based products, like Strataderm silicone gel, have been recommended by International clinical recommendations on scar management and have become the standard care for plastic surgeons when it comes to scar treatment and prevention of keloid and hypertrophic scars. Silicone is not only considered first line treatment for scars but it is also recommended for use in conjunction with other scar therapy options, such as corticosteroid injections and pressure garments.

Read more about how to avoid abnormal scars.

The incidence of new scarring per year in the developed world is estimated to be at least 100 million; a large percentage will be affected by abnormal scarring, which can be categorized mainly as hypertrophic scars and keloids. There is also good evidence to suggest that atrophic scars and striae distensae (or stretch marks) are categories of abnormal scarring.

Abnormal Scar Types

Hypertrophic Scars

Hypertrophic Scars are typically raised, red or pink and sometimes itchy but do not exceed the margins of the original wound. Hypertrophic scars usually subside with time. Histologically, hypertrophic scars have flatter type III collagen bundles, with fibers arranged in a wavy pattern, but predominately oriented parallel to the epithelial surface.

Collagen synthesis is 6 times as great as in normal unscarred skin and the ratio of type I to type II collagen is also higher. Hypertrophic scars also have nodular structures of alpha-smooth muscle actin, which expresses myofibroblasts, small vessels and fine collagen fibers.

Keloids

Keloids on the other hand range in consistency from soft and doughy to hard and rubbery. They do not infiltrate into the surrounding normal tissue and continue to evolve over time with no regress phase. Histologically, collagen bundles are not present but instead the collagen type I and type III fibers lie in a haphazardly connected loose sheet randomly orientated to the epithelial surface. In addition, the collagen synthesis is approximately 20 times greater as that in normal unscarred skin and the ratio of type I to type II collagen is also higher. Keloids  also have an overproduction of the growth factors TGF-B and PDGF produced by fibroblast proteins.

In comparison to the above two abnormal histological feature, normal skin contains collagen bundles running parallel to the epithelial surface.

In 2002, an International Advisory Panel on Scar Management published Clinical Recommendations on Scar Management, based on a qualitative overview of 300 published references and expert consensus on best practices. Silicone was recommended as first line therapy for prevention of scarring and first line treatment for the initial management of scarring, in addition to the recommended management modality with adjunct therapies for secondary management.

Sources:

1. Wolfram D et al. Dermatol Surg 2009; 35:171–181

2. Babu M et al. Mol Cell Biol 1989; 9:1642–1650

3. Niessen FB et al. Plast Reconst Surg 1999; 104:1435–1458

4. Haisa M et al. Invest Dermatol 1994; 103:560–563

5. Luo S et al. Plast Reconstr Sugr 2001; 107:87–96

Some key points by Dr. Adrian Richards about keloid and hypertrophic scars and about scar treatment options:

– Hypertrophic scarring occurs within the normal scar, is limited. Hypertrophic scars tend to get better with time.

– Keloid scars occur in people with darker complexion, and can be started by minor trauma, like piercing or ingrown hair. Keloids grow outside the area of the original scar.

Treatment options: massage; next stage: you can use silicone gels (like Strataderm, Dermatix) or silicone sheets (Cica Care); next stage: steroid injections. Keloid scars are more difficult to treat. Another option for keloids is radiotherapy.

International Advisory Panel on Scar Management consisting of leading leading dermatologists and plastic surgeons, led by Thomas A. Mustoe, M.D. (Division of Plastic and Reconstructive Surgery, Northwestern University School of Medicine) compiled International Clinical Recommendations on Scar Management which provide evidence-based recommendations on prevention and treatment of abnormal scarring and, where studies are insufficient, consensus on best practice.

Some of the recommendations for scar treatment and prevention related to silicone based products like Strataderm include:

Primary role for silicone: “Recommendations support a move to a more evidence-based approach in scar management. This approach highlights a primary role for silicone gel sheeting and intralesional corticosteroids in the management of a wide variety of abnormal scars.”

Effective Treatment: “The efficacy of two scar management techniques, silicone gel sheeting and injected corticosteroids, has been demonstrated in randomized, controlled trials.”

Effective Treatment: “Good evidence of [silicone’s] efficacy and silicone gel sheeting has now become standard care for plastic surgeons.”

Combination Treatment in Keloid prevention: “Surgical excision of hypertrophic scars or keloids is a common management option when used in combination with steroids and/or silicone gel sheeting.”

Safe and Effective: “Results from at least eight randomized, controlled trials and a meta-study of 27 trials demonstrate that silicone gel sheeting is a safe and effective management option for hypertrophic scars and keloids.”

Ideal for Children: “Silicone gel sheeting may be especially useful in children and others who cannot tolerate the pain of other management procedures.”

Scar Prevention: “Silicone gel sheeting, which should be considered as first-line prophylaxis. Use of silicone gel sheeting should begin soon after surgical closure, when the incision has fully epithelialized, and be continued for at least 1 month.”

Linear hypertrophic (surgical/traumatic) scars (red, raised). “Silicone gel sheeting should be used as first-line therapy.”

Widespread burn hypertrophic scars (red/raised). “Widespread burn scars should be treated with first-line therapy of silicone gel sheeting and pressure garments, although there remains limited significant evidence for the efficacy of pressure garments.”

Minor keloids. “The consensus view from the literature and the authors is that first-line therapy for most minor keloids is a combination of silicone gel sheeting and intralesional corticosteroids.”

Source: Plast Reconstr Surg. 2002 Aug;110(2):560-71. International clinical recommendations on scar management, Mustoe TA, Cooter RD, Gold MH, Hobbs FD, Ramelet AA, Shakespeare PG, Stella M, Téot L, Wood FM, Ziegler UE; International Advisory Panel on Scar Management.