When the short-term effects of surgery – such as oozing wounds and incision pain – have long faded, an unseen complication may be lurking beneath the skin. Excess scar tissue, layers deep, can significantly reduce function and movement months after surgery. And on the skin’s surface, visible, lingering scars might be noticeable enough to really bother patients. Before you undergo surgery, here’s what to know about reducing scarring as you heal.
Layers of Scarring
Bend and straighten your elbow. The folds that form in your skin, known as Langer’s lines, represent the direction and orientation of the collagen fibers, similar to the grain of wood, says Dr. Robert Klapper, director of the Joint Replacement Program in Orthopaedic Surgery at Cedars-Sinai Medical Centerin Los Angeles. During surgery, it’s not always possible for surgeons to cut parallel to the grain with their scalpels.
“If you are not able, because of heart surgery for example, to get down to the sternum, we as surgeons have to violate the Langer’s line,” Klapper says. “This can often lead to keloids and bumps and poor healing, and extra scar tissue can take place.”
Performing joint surgery, Klapper says, involves cutting into multiple layers of anatomy: the epidermis or skin surface; subcutaneous fat; fascia or connective tissue; muscles, tendons and ligaments; and the lining around the bone called the ostium. “It’s kind of like a seven-layer cake, if you will,” he says. “As a surgeon, you must respect in your repair of the surgery all layers of the seven-layer cake. All should get closed properly.” The initial length of an incision after surgery could be deceptive. “You can’t tell a book by its cover – you can’t tell a surgeon by the skin incision,”
Klapper says. “Oftentimes, if the surgeon can extend the length of the incision a little bit more, then your retractors are traumatizing the tissues less and you may end up with more of a disappearing scar than someone with a tiny incision.” While surgery of the knees, wrists or ankles is meant to improve movement and function, excessive scar tissue around the joints can do just the opposite. Frozen shoulder, which sometimes follows surgery, involves a buildup of scar tissue around the shoulder joint, caused by irritation and inflammation.
The result is pain and reduced range of motion. For unknown reasons, Klapper says, people with diabetes are much more prone to postoperative frozen shoulder. Surgery anywhere in the body can lead to scarring. If your appendix is removed, for example, the small surgical scar on your belly is usually no big deal. But if you develop adhesions during abdominal surgery, that’s different. Adhesions are bands of tissue that form between organs and abdominal tissues, sometimes making them stick together. That can lead to bowel obstruction or chronic pain in the abdomen. Pelvic adhesions that form after gynecological surgery lead to pain and infertilityin some women.
Surgical techniques, including using certain types of suture or creating adhesion barriers, can reduce pelvic adhesions. It’s worthwhile to ask surgeons how they plan to minimize adhesion risk. Scarring Solutions Surgery is a form of trauma. “Any type of trauma ends up causing inflammation – swelling – of the tissues,” says Dr. Janet Yueh, who specializes in hand surgery with Cohen/Winters Aesthetic and Reconstructive Surgeons, based in Maywood, New Jersey. “Over time, that inflammation ends up being converted into scar.
That scar can demonstrate itself in many different ways.” Healthy young people tend to form more surgical scar tissue than older patients, she says, because they have a bigger scar response to surgery. At the skin level, a thickened, whitened, elevated scar, called a hypertrophic scar, can develop. Keloids occur when collagen buildup creates a larger, puffy-looking scar that grows beyond the boundaries of the surgical wound. Gels, silicone scar sheets and related products might be enough to even out skin color and improve the texture of a superficial surgical scar. Injections, such as steroid compounds, can change the appearance, texture and size of elevated scar tissues. Other injectable treatments fill in caved-in scars.
Surface treatments such as dermabrasion, laser or light therapy or chemical peels may also improve the appearance of scars. A dermatologist can guide you through cosmetic scar-revision choices. With deeper scar tissue, Yueh says, patients complain about a sense of tightness rather than sharp pain. “That tightness can translate to soreness, to pain and to difficulty making a tight fist,” she says. If there’s no improvement after several months, surgical removal might be the next step. Although that comes with a risk of more scar tissue, it’s relatively small. “I always counsel patients that with revision surgery, in the majority of cases it gets better,” Yueh says. “The numbers I usually quote are 70 percent that get better, 20 percent stay the same and about 10 percent get worse.
It really depends on the surgeon and what the issue is.” Moving Beats Scarring Before surgery, ask your doctor about how much scarring to expect and what preventive treatment you’ll receive. Also, ask whether minimally invasive surgery is an option. According to Cleveland Clinic’s Health Essentials webpage, minimally invasive surgery is the No. 1 method for reducing the risk of abdominal adhesions. And whether it’s knee surgery or cataract removal, Klapper says, the concept of minimally invasive surgery is so successful because it minimizes the scar.
Moving your joints the right way after surgery not only improves function, it helps prevent excess scar tissue from forming. “The earlier you get the patient moving – and I don’t care what the surgery is – the better the outcome,” Klapper says. After surgery, Yueh recommends that her patients work with hand therapists – occupational or physical therapists with specialized training in conditions occurring anywhere from the shoulder to the fingertips.
Targeted exercises and spring-loaded splints help stretch the skin and guide joints back into proper position. Massage and ultrasound therapy help soften scars. “With the combination of different therapies, over time the scar will soften and the patient is able regain motion of their fingers,” she says. At home, dedication to treatment plays a big role. By sticking with therapy and doing prescribed exercises at home, patients can do a lot to manage and minimize scarring.
“The main thing is working with a doctor who can diagnose why they’re having the scarring and at what levels they’re having the scarring to figure out a good plan for them afterwards,” Yueh says. “Because often what’s going on underneath is much more than they see on the skin.”