Options for Scar Therapy After Plastic SurgeryMay 1, 2017
Among the most visible health trends of the last few decades has been the rising rate of obesity within the American population; one-third of Americans are considered obese. As a result, there has been an increase in bariatric surgery with approximately 196,000 gastric bypass, gastric banding, and gastric sleeve procedures performed in the United States in 2015.
Post bariatric surgery, patients often present with significant skin and soft tissue excess and desire body-contouring surgery to remove the additional skin. To address these skin issues that can occur after massive weight loss, there are many options for scar therapy after plastic surgery.
Bariatric surgery post-op patients have complex issues and require a multi-disciplinary, institutional approach to optimize safety, nutritional status, quality of skin, recurrent laxity, surgical steps, and post-surgical care.
I believe in the integration of nutrition, fitness, and surgery for our plastic surgery patients. I recommend when patients consult with a plastic surgeon that they look for a center that integrates nutrition, fitness, and surgery to provide a center of excellence for achieving dramatic and natural body contouring changes in the massive weight loss patient.
Nutrition & Plastic Surgery
Body contouring surgery for massive weight loss patients is primarily focused on reducing skin redundancies and improving contour; however, many times patients have poor tissue quality, particularly elastin and collagen, which leads to higher rates of complications and poorer aesthetic results.
Bariatric patients are at risk for nutritional deficiencies that can affect healing and thus put you at risk for wound healing complications (with the potential of wound separation after plastic surgery). Nutritional deficiencies and inadequacies can result from anatomical changes in the gastrointestinal tract or an alteration in the diet of those seeking weight loss.
Protein-calorie malnutrition has been associated with significantly lower healing rates among the massive weight loss population, and studies have indicated that a minimum of 70 g/day of protein is necessary to balance this protein-calorie malnutrition in post-bariatric patients.
With these nutritional deficiencies in mind, make sure to have a complete vitamin assessment and supplementation prior to any surgical intervention. We check labs early in the surgical planning process so that any inadequacies can be corrected prior to the future surgery date.
Patients must achieve weight stability and nutritional balance prior to proceeding with body contouring procedures. Ideally, patients should be weight stable for a minimum of 12 months. Weight fluctuations, both gain or loss, can strain the body and affect the outcomes of body contouring procedures.
Scar Therapy After Plastic Surgery
The primary goal of body contouring surgery is to reduce skin and improve contour; however, scar visibility and quality still remain an important consideration for surgeons and their patients.
Given the quality of post-op patients’ tissues, predictability in scar quality and location can be particularly challenging but we take the following steps to maximize outcomes.
Properly managing your scar is essential to optimizing its final appearance. By following wound care guidelines, you are enhancing the healing process and increasing chances on a less prominent scar.
Most importantly, nicotine impairs tissue perfusion and significantly impacts scarring and wound healing. You should be nicotine free for a minimum of four weeks prior to and after any elective procedures.
A fresh surgical scar is usually pink and has a higher risk of sunburn with sun exposure. If a scar gets sunburned, the hyperpigmentation may never fade and may always be darker than the rest of your skin. The best treatment for sunburn is sun protection.
We recommend using sunscreen with zinc or titanium dioxide; these blocking agents protect against UVA and UVB rays. Look for a sunscreen with sun protection factor (SPF) of 30 or higher. Of note, higher SPF may block pores and irritate your skin; always listen to your body and monitor your skin for any reactions.
Finally, remember to hydrate! Water is the primary way that oxygen and nutrients are delivered directly to the wound bed; sun exposure and subsequent dehydration is one of the most common reasons why cell function becomes disrupted and wound healing is impaired.
Silicone therapy can be used to treat hypertrophic scarring with minimal side effects. Silicone therapy increases hydration of the wound, which regulates fibroblast production and reduces excessive collagen production. Regulated collagen production may lead to a softer and flatter scar.
For optimal results, silicone therapy should be applied to a wound for at least twelve hours per day for a minimum of three months. We recommend using Biocorneum ®, the FDA approved silicone gel that creates an invisible silicone sheet over the scar. In addition, Biocorneum ® has SPF 30 which protects a maturing scar from the darkening effects of sun exposure.
Intralesional steroid injections may reduce the size of a hypertrophic or keloid scar. Steroids break the bonds between collagen fibers, which reduce the amount of scar tissue beneath the skin.
In addition, steroids have powerful anti-inflammatory properties, which may help reduce swelling, redness, itching or tenderness. These injections can be administered as soon as a problem scar is identified. Injections can be administered every four to six weeks.
Side effects of steroid therapy should be monitored including atrophy, telangiectasia, and hypopigmentation. Steroid therapy can be used concurrently with other treatment modalities including silicone therapy, compression therapy, and sun protection.
Compression therapy is another useful adjunct for scar management and prevention; compression therapy decreases tissue metabolism and increases collagen breakdown within the wound.
We recommend patients to contact Design Veronique® to order custom-fitted compression garments before surgical intervention. Compression garments not only provides continuous pressure to a maturing scar but also provides optimal contouring of the surgical site. Elastic bandages or stockings may be a useful alternative for compression of the extremities.
For optimal results, these devices must be used continuously for 6-12 months during the maturation of the wound. Of note, pressure garments may need to be replaced every 2-3 months as they lose elasticity.
Bleaching therapy (hydroquinone cream) may be an alternative treatment for persistent hyperpigmentation. Hydroquinone inhibits tyrosinase, an enzyme essential in melanin production. With less melanin, a scar typically has less pigment.
If used regularly, the effects of bleaching therapy usually become visible after four weeks. Of note, hydroquinone therapy may have some adverse side effects including erythema, discoloration, and irritation; this intervention should be prescribed and monitored by your physician. Additionally, bleaching agents increase the skin’s sensitivity to sunlight so sunscreen must be used with any bleaching therapy.
Various laser treatments are available to reduce scar erythema, pliability, and bulk. Pulsed dye laser (PDL) therapy treats a hypertrophic scar with highly focused beams of light, which cause the blood vessels in scar tissue to shrink and eventually dissolve. As blood vessels dissolve, the redness and discoloration of the scars subsequently dissipate. Additionally, the body replaces older, damaged tissue with fresh, new collagen and elastin – the crucial building blocks of normal-looking skin.
Pulsed dye laser therapy is a fast and simple procedure that’s easy to tolerate and requires little downtime. With PDL, the patient experiences a snapping sensation similar to that of a rubber band. Post-treatment, a mild sunburn-like sensation is produced for 15-30 minutes that is generally well-tolerated; however, some patients may require the application of an ice pack.
The most common side-effect of PDL therapy is post-procedure bruising, which can persist for several days. Swelling of treated skin may occur immediately after laser therapy but will generally subside within 48 hours.
Strict sun precautions should be practiced between treatment sessions in order to avoid stimulating pigment production in the treated areas. Subsequent laser sessions should be postponed until any excess pigment has resolved so that the presence of epidermal melanin does not compromise the effectiveness of the laser. Topical bleaching agents may be used to hasten pigment resolution. Treatments are typically delivered at 6-8 week intervals.
Dermabrasion mechanically removes the top layer of skin. This process injures or wounds the skin and causes it to bleed. As the wound heals, new skin grows to replace the damaged skin. An antiseptic ointment may need to be applied as the skin re-epithelializes. The treated skin may have a pink appearance for several weeks while new skin replaces the layers that were removed.
Again, sun protection needs to be strictly followed as the wounds heal. Most people see smoother skin after several months. Dermabrasion softens the skin and helps the color and texture of the scar blend with the surrounding skin.
Autologous Cell Therapy
Recently, scientists have recommended stem cell therapy for scar management. Once stem cells are introduced into a hypertrophic scar, these cells can differentiate into multiple skin cell types and contribute to wound repair. Autologous fat (fat harvested after liposuction) may be an excellent source of stem cells for scar rejuvenation.
Additionally, platelet rich plasma (concentrated platelets from the patient’s own blood) may recruit stem cells to the area and play an important role in the regenerative process.
Further investigations are needed for stem cell therapy; however, these advances may revolutionize the treatment of hypertrophic scars.
Body contouring surgery for the massive weight loss population is primarily focused on tailoring the body to match the underlying framework but keep in mind that you have a high risk for wound healing complications and require a strict wound care protocol.
Preventative measures including smoking cessation, nutrition evaluation, and sun protection will maximize outcomes; however, there are various options for scar management to improve results.
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Small KH, Constantine R, Eaves FF 3rd, Kenkel JM. Lessons Learned After 15 Years of Circumferential Bodylift Surgery. Aesthet Surg J. 2016 Jun;36(6):681-92. doi: 10.1093/asj/sjv265. Epub 2016 Jan 28. PubMed PMID: 26821642.
Constantine RS, Davis KE, Kenkel JM. The effect of massive weight loss status, amount of weight loss, and method of weight loss on body contouring outcomes. Aesthet Surg J. 2014 May 1;34(4):578-83. doi: 10.1177/1090820X14528208. Epub 2014 Mar 27. PubMed PMID: 24676143.
American Society for Metabolic and Bariatric Surgery 2015 Statistics Report
Shelly M. Xie, BS; Kevin Small, MD; Ran Stark MD; Ryan S. Constantine, BA; Jordan P. Farkas, MD; Jeffrey M. Kenkel, MD. A Novel Thighplasty Technique for Patients after Massive Weight Loss. Aesthetic Surgery Journal. Accepted.
ABOUT THE AUTHORDr. Kevin Small is a plastic surgeon at New York Bariatric Group. He is a well-known innovator and an educator in the fields of plastic and reconstructive surgery. He has received many honors and awards citing his excellence in academics, teaching, and research from prestigious organizations such as the American Society of Plastic Surgery, the American Society of Aesthetic Plastic Surgery, and the Plastic Surgery Educational Foundation.