Talking to Your Patients' Families about Scars and Plastic Surgery

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Most scars can be treated by a patient's physician. But if they're painful or disfiguring — or if their appearance bothers the patient, then a consultation with a plastic surgeon may be appropriate. Here we share information about scar care and management, and when you might consider referring your patient to a plastic surgeon.

Understanding your patient's expectations

A commonly-held belief among parents is that scars in children will vanish over time. To prevent potential disappointment, have a candid conversation with your patient and his or her family about their expectations —what is realistic and what's not. While scars often can improve over time, they will not vanish. A plastic surgeon frequently can improve a scar's appearance by applying or injecting a corticosteroid, or performing scar revision. While treatment might improve the appearance of a scar by changing the depth, size or color, it won't erase the scar.

Topical therapies for treating hypertrophic scars

Topical agents are being used more frequently to treat problematic scars because they're easier to use, generally more comfortable for the patient and less expensive. There are several topical treatments available for hypertrophic scars, including pressure therapy, silicone gel sheeting and ointment, polyurethane dressing, onion extract, imiquimod 5% cream, and vitamins A and E. Many of the topical treatments can have some benefit, but some can have undesirable effects as well:

• There isn't one, optimal treatment that eliminates or prevents hypertrophic scars.
• The most widely-accepted treatment for hypertrophic scars — both old and new — is silicone gel sheeting. Silicone ointment or gel alone, however, is not as effective as silicone sheeting.
• Polyurethane dressing may also improve the appearance of scars.
• Pressure therapy has shown some efficacy, but patient compliance may be an issue and there is no standardization for pressure measurements.

Recommendations for scar management

Evidence-based guidelines for managing keloids and hypertrophic scars — published in Plastic and Reconstructive Surgery and addressed in the American Academy of Pediatrics' AAP Grand Rounds — include the following:

• Immature or linear hypertrophic scars: Silicone gel sheeting for one month is first-line therapy. If the lesion is resistant to therapy or accompanied by severe itching, corticosteroid injections may be given.
• Widespread hypertrophic scars: Silicone gel sheeting is recommended in combination with pressure sheeting. Burn-related scars often require massage, corticosteroids, Z-plasty or grafting.
• Minor keloids: Silicone sheeting with intralesional corticosteroids is first-line therapy.
• Major keloids: Symptomatic use of histamines and good hygiene may be helpful. Many are resistant to treatment and recurrence is high. For treatment failures, radiation should be considered.

New research in treating problematic scars

Intralesional 5-fluorouracil is emerging as a new option for treating keloids and hypertrophic scars. A study published in the January 2009 issue of Plastic and Reconstructive Surgery demonstrated that intralesional 5-FU is safe and effective in managing these problematic scars in terms of recurrence and symptom control. Benefits were maintained at least one year after patients completed therapy with 5-FU.

Referring your patient to a plastic surgeon

Consider referring your patient to a plastic surgeon if a patient's scar is tender, itchy, painful, growing, impairing movement, or affecting a patient's self-esteem or confidence. In addition, if there is any evidence of a retained foreign material present from the time of injury, then this should also be referred for evaluation and possible removal.

References

Mustoe TA, Cooter RD, Gold MH, et al. International Clinical Recommendations on Scar Management. Plastic and Reconstructive Surgery. 2002; 110:560–571.

Havlik RJ: Vitamin E and Wound Healing. Plastic and Reconstructive Surgery. 1997; 100:1901-2.

Robert Havlik, MD
Chief, Riley Hospital Plastic Surgery
317-274-2430
rhavlik@iupui.edu