Postoperative scar management

Article information

Kosin Med J. 2025;40(2):96-105

Publication date (electronic) : 2025 June 20

doi : https://doi.org/10.7180/kmj.25.107

Jinyong Shin ¹

, Yoonsoo Kim ²

, Hongil Kim ²

, Jinhyung Park ²

, Hyungsuk Yi^,²

¹Department of Plastic and Reconstructive Surgery, Jeonbuk National University Medical School, Jeonju, Korea

²Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, Busan, Korea

Corresponding Author: Hyungsuk Yi, MD, PhD Department of Plastic and Reconstructive Surgery, Kosin University Gospel Hospital, Kosin University College of Medicine, 262 Gamcheon-ro, Seo-gu, Busan 49267, Korea Tel: +82-51-990-6131 Fax: +82-51-990-6312 E-mail: sencha21@naver.com

Received 2025 March 24; Revised 2025 June 4; Accepted 2025 June 5.

Abstract

Postoperative scars inevitably occur after surgical procedures and can impact both aesthetic and functional aspects of healing. With advancements in medical research, various strategies have been developed to prevent and manage surgical scars. This review explores mechanisms of wound healing, the classification of postoperative scars, and the latest approaches in scar prevention and treatment. The wound healing process consists of the following phases: hemostasis, inflammation, proliferation, and maturation. Understanding this process is essential for effective scar management. Factors such as tension, infection, and individual patient characteristics can influence scar formation. Preventive strategies, including optimal suture techniques, taping methods, silicone therapy, and corticosteroid injections, have demonstrated significant benefits in minimizing scar severity. Additionally, advanced treatments such as laser therapy and surgical scar revision techniques, including Z-plasty and W-plasty, offer effective solutions for improving established scars. Relaxed skin tension lines in surgical planning also play a crucial role in minimizing scar prominence. Evidence suggests that a multidisciplinary approach that integrates prevention and treatment modalities can optimize wound healing and improve patient outcomes. Implementing these evidence-based strategies can significantly improve postoperative scar management, ultimately enhancing both functional and cosmetic results for patients.

Keywords: Cicatrix; Postoperative care; Scar prevention; Surgical wound; Wound healing

Introduction

All surgical wounds make a scar. To fix a fracture or remove a tumor, the skin, our primary defense barrier, must be incised. Both the surgeon and the patient hope that there is no scar after a surgery. However, scars inevitably form to varying degrees. Scars are not only of aesthetic concerns, but also accompanied by pain, pruritus, or tethering in some cases.

With advancements in medicine, the number of fully recovered patients has increased, leading to a growing demand for minimizing postoperative sequelae. As a result, scar is no longer a concern limited to plastic surgeons alone.

Minimally invasive surgery (MIS) leaves smaller scars than traditional surgical methods through small incisions [1]. MIS has been researched since the 19th century to minimize surgical scars and promote faster recovery by reducing the size of incision [2]. To minimize surgical scars, techniques such as laparoscopic and endoscopic surgery have been developed, with robotic surgery being widely used now. However, not all surgeries can be performed using these methods. In addition, even these methods require some degree of incision. Therefore, surgical scars cannot be entirely avoided.

Surgery is an essential procedure performed to save lives or maintain bodily functions when necessary. Incisions are unavoidable in all surgical procedures. As a result, scar formation has traditionally been considered an inevitable sacrifice. However, advancements in medical research have led to the development of various methods to prevent scar formation and reduce existing scars. Scars can result from trauma, burns, surgery, and other causes. Among these, scars caused by surgical procedures are specifically reviewed in this study. Retrospective or prospective studies are appropriate for conducting successful research [3]. In this study, we review existing successful retrospective and prospective studies to discuss postoperative scar management methods. This study aimed to assist in postoperative scar management by reviewing the latest published research on causes, classification, prevention, and treatment of surgical scars.

Wound healing process and scar formation

Understanding the mechanism of wound healing can help us identify causes of postoperative scarring and aid in its prevention. Wound healing is generally divided into four stages (Fig. 1) [4-10].

Fig. 1.

Wound healing process and duration of each phase.

The hemostasis phase marks the beginning of wound healing. During this phase, the body's defense response initiates mechanisms to minimize vascular damage. Vasoconstriction then occurs and platelets along with fibrin appear at the wound site to aid in hemostasis.

The second phase is the inflammatory phase, during which symptoms and signs such as redness, local heating, swelling, and pain appear around the wound. Physiologically, white blood cells aggregate, venules dilate, and lymphatic vessels become blocked. Macrophages secrete cytokines while neutrophils perform chemotaxis and phagocytosis.

The next phase is the proliferative phase. During this phase, fibroblasts play a crucial role in collagen production. As collagen synthesis increases, tensile strength of the skin rapidly improves.

The final phase is the maturation phase. In this phase, immature type III collagen is replaced by mature type I collagen and previously dilated blood vessels return to their normal state.

During these four phases, wounds are stabilized and the skin's protective function is restored. Some factors such as medications, smoking, alcoholism, obesity, diabetes, stress, hormones, age, sex, infection, and oxygenation can influence the wound healing process [11].

Fibroblasts play a crucial role in wound healing by proliferating, migrating into the wound site, producing extracellular matrix (ECM) components, and remodeling the scar tissue. Their actions are regulated by various growth factors and cytokines throughout different stages of wound healing [12].

Hypertrophic scars and keloids both result from excessive fibroblast activity and collagen deposition, with keloids exhibiting uncontrolled growth beyond wound boundaries due to persistent upregulation of transforming growth factor-beta1 and chronic inflammation. However, hypertrophic scars remain confined. They may regress over time [13].

After a surgery, adequate blood supply, proper moisture balance, and effective infection control are three fundamental factors that could be controlled for wound healing. If any of these factors are compromised, wound healing will be delayed, increasing the likelihood of unwanted scarring.

Classification of postoperative scar

Scars develop as a natural part of the wound healing process. Their appearance, texture, and symptoms can vary widely. Based on their clinical characteristics, scars can be categorized into several types, including flat scars, depressed scars, hypertrophic scars, and keloids. Understanding types is essential for predicting scar progression and selecting appropriate management strategies [14].

1. Flat scars

Mature flat scars represent the final stage of the wound healing process. These scars are flat, stable, and free of erythema (redness). Unlike immature scars, mature scars do not cause pain, itching, or other symptoms (Fig. 2A).

Fig. 2.

Types of postoperative scars. (A) Flat scar. (B) Depressed scar. (C) Widened scar. (D) Hypertrophic scar. (E) Keloid. Photos provided by the authors, all images included in this review were obtained with informed consent from the patients for publication.

2. Depressed scars

Depressed scars, also known as atrophic scars, are a type of scar that sits below the surface of the surrounding skin due to a loss of underlying tissue. These scars form when there is insufficient collagen production during the wound healing process, leading to a sunken or pitted appearance (Fig. 2B) [15].

3. Widened scars

A widened scar is a type of atrophic scar that appears broader than the original wound or incision due to inadequate healing, tension on wound edges, or other external factors. Unlike hypertrophic scars or keloids, widened scars are usually flat without excessive collagen deposition. If too much tension is placed on wound edges during suturing, the skin may pull apart as it heals, leading to a widened appearance. When a wound partially reopens due to mechanical stress, infection, or poor healing, it can result in a wider, more visible scar (Fig. 2C).

4. Hypertrophic scars

Hypertrophic scars occur due to excessive collagen deposition during the healing process. They are classified into two types: hypertrophic linear scars and hypertrophic wide scars. Hypertrophic linear scars develop several weeks after an injury, evolving from immature scars. They appear ropy, pink, or red. They may progressively enlarge for several months before gradually becoming less active. Many patients experience mild itching or soreness during this time. Over time, these scars remain elevated but lose their pink coloration as they mature (Fig. 2D).

Hypertrophic wide scars are commonly seen in widespread injuries such as burns. These scars are elevated, pink or red, and often associated with severe itching and tenderness. Unlike linear hypertrophic scars, wide hypertrophic scars are typically very stiff. They may restrict movement when located near joint surfaces.

5. Keloid

Keloid scars form when collagen production continues beyond the wound boundary, leading to excessive scar tissue growth. They are categorized into minor keloids and major keloids based on their size and severity. Minor keloids appear round or elevated, extend beyond the original wound margin, and frequently occur at sites such as pierced earlobes or surgical incisions. Keloids have a strong genetic component, making them different from hypertrophic scars. Surgical excision of minor keloids often results in a high recurrence rate unless additional treatments such as corticosteroid injections or laser therapy are used. Major keloids are large, irregularly shaped, and significantly elevated. They often develop in multiple locations on the body, sometimes forming a butterfly-shaped pattern. Unlike minor keloids, even minor injuries can trigger the formation of major keloids. These scars frequently cause severe pain and intense itching, which can significantly impact a patient’s quality of life. Treatment options for major keloids are limited as recurrence is common even after surgical removal or medical interventions (Fig. 2E).

Considerations during surgery

1. Why is RSTLs important for surgical scar prevention?

Understanding the relationship between relaxed skin tension lines (RSTLs) and scar formation is crucial for optimizing surgical outcomes and minimizing visible scarring. RSTLs are natural lines with minimal skin tension when the skin is in a relaxed state. Aligning surgical incisions with these lines can significantly influence the quality and appearance of scars.

RSTLs represent the natural orientation of collagen fibers and the direction of minimal skin tension. They can be identified by gently pinching the skin. Resulting furrows indicate the direction of these lines. This method is particularly useful for evaluating living subjects because RSTLs reflect the skin's relaxed state and guide optimal incision placement [16].

Aligning surgical incisions with RSTLs offers several benefits. Incisions parallel to RSTLs are subjected to less tension during healing, leading to narrower and less noticeable scars. Minimized tension can facilitate better approximation of wound edges, thus promoting efficient healing. Scars that align with natural skin lines are less conspicuous, especially on visible areas like the face [17].

2. Which materials are better for aesthetic results in surgical wound closure?

The traditional method of skin closure after surgery is suturing. Sutures can be broadly classified into absorbable and nonabsorbable sutures. Absorbable sutures are naturally degraded within the body without requiring removal [18,19]. Nonabsorbable sutures are made from either natural mammalian collagen, synthetic polymers or natural silk. Compared to absorbable sutures, nonabsorbable sutures are easier to handle with greater elasticity, which could be used for managing wound swelling [18,19]. A meta-analysis of multiple studies has found no significant difference in terms of wound infection rates, scar formation, or wound dehiscence between absorbable and nonabsorbable sutures [20-22].

Sutures can also be classified based on their structures into monofilament (single-strand) and multifilament (multi-strand) sutures. It has been shown that a suture can affect scar formation. Monofilament sutures are associated with reduced inflammation and a lower risk of hypertrophic scar formation, whereas multifilament sutures tend to induce greater inflammatory responses and result in more prominent scarring [23].

The timing of suture removal can also influence scar formation. The appropriate removal time varies depending on the location of the sutured area. For example, sutures on the face are typically removed within 7 days, whereas sutures in high-tension areas such as joint flexion areas may be kept in place for up to 14 days [24,25]. A recent study investigating the effect of suture removal timing on scar formation has compared 7-day versus 10-day removal. Its results showed that the group with sutures removed at 7 days had significantly better cosmetic outcomes than the 10-day group [26].

If traditional suturing materials are considered standards for wound closure, various alternative closure materials developed recently are now widely used. Suture alternatives that prioritize convenience and stability include skin staplers and adhesive agents. Skin staplers allow for rapid wound closure. They are particularly useful in high-tension areas [27,28]. However, compared to traditional sutures, they have a higher likelihood of leaving more noticeable scars [29]. Adhesive agents such as cyanoacrylate-based adhesives provide a noninvasive wound closure method that can eliminate the need for suture removal while achieving cosmetic results comparable to sutures [30,31]. These adhesives are especially beneficial for pediatric patients or individuals who experience anxiety about suture removal [30].

Preventive methods for surgical scars

1. Taping technique

Taping techniques often used to close open wounds are also utilized as a method to prevent scar formation by providing mechanical support after suture removal. The function of taping technique is by approximating wound edges, thereby reducing tension across the incision site. This is crucial for optimal healing and scar prevention. The taping technique contributes to wound healing through the following three mechanisms: (1) wound edge approximation; (2) tension reduction; (3) barrier protection.

Among these, tension reduction plays a key role in preventing scar formation. Applying skin tape helps evenly distribute mechanical forces across the wound, minimizing stress that can lead to hypertrophic scarring or wound dehiscence. This tension reduction is particularly beneficial for areas prone to movement or stretching.

Taping techniques are generally applied immediately after suture removal. Studies have reported the use of taping techniques following procedures such as caesarean section, breast augmentation, lesion removal, and traumatic facial laceration [32-36].

When the taping technique is used alone, most studies have applied it continuously for 12 weeks [32-36]. Studies using paper tape have reported no occurence of hypertrophic scarring if the tape is in place [32,35]. However, five cases of scarring were observed after the tape was removed at 12 weeks. The replacement cycle of the tape was generally once per week, as long as the tape remained intact. One advantage of the taping technique is that patients can apply the tape themselves, eliminating the need for hospital visits and additional costs. However, adverse reactions such as itchy rash, superficial rash, contact dermatitis, and tape allergies can occur. Multiple studies have reported a very low incidence (0.12%) of these complications [32-36].

2. Silicone treatments

Silicone sheets are composed of silicone polymers, including polysiloxane and polydimethylsiloxane. These polymers can cross-link with silicon dioxide, forming long chains that give them a flexible, rubber-like property.

Silicone is manufactured in gel or sheet forms for application on scar sites, with both types functioning as semi-occlusive barriers. This semi-occlusive effect can act on scars and contribute to scar prevention through the following three mechanisms [37]: (1) occlusion and hydration; (2) temperature modulation; (3) protection from external forces.

Occlusive properties of silicone gel sheets can help maintain skin hydration, which in turn can modulate collagen production and fibroblast activity, contributing to improved scar appearance and texture. This barrier can significantly reduce trans epidermal water loss, thereby maintaining adequate hydration of the stratum corneum (the outermost layer of the skin). Proper hydration is essential as it can regulate fibroblast activity and collagen production, leading to the formation of softer and flatter scars. This mechanism has been supported by clinical studies demonstrating the efficacy of silicone gel sheets in scar management. The application of silicone gel sheets can slightly increase the temperature of the scar tissue. This rise in temperature may enhance activity of collagenase enzymes, which break down excess collagen, thereby aiding in scar maturation and reduction [38]. Silicone gel sheets can act as a protective barrier, shielding the scar from external mechanical forces such as friction and tension. This protection can help prevent additional trauma to the scar tissue, which can exacerbate hypertrophic scar formation [37].

Initiation timing is usually after the wound has fully healed and all stitches have been removed. A 12-hour application per day was well tolerated, while 24-hour application led to maceration and poor tolerance. Maximum scar improvement was observed after 2 months, with only minor additional benefits at 3 months [39]. In 2002, an international group developed an evidence-based analysis to develop guidelines for treatment [40] and found that there was strong evidence for the use of silicone gel both for treating and preventing hypertrophic scars. To maximize their benefits, proper application and adherence to specific precautions are essential. Removing hair from the application site can improve sheet adhesion and effectiveness. Silicone sheets should be cleaned daily using mild soap and lukewarm water to remove oils, dirt, and dead skin cells. Proper cleaning can maintain the adhesiveness and hygiene of those sheets, reducing the risk of skin irritation and infection. Some patients may experience itching, redness, or mild irritation when using silicone sheets. If irritation occurs, wearing time can be reduced. The wearing time can then be gradually increased as tolerated. If persistent allergic reactions occur, discontinuation may be necessary.

There has been no study comparing the effectiveness of silicone sheets and silicone gel to determine which one is more effective. Both forms have shown highly positive effects in patients at high risk of hypertrophic scars or keloids. Even when including all patients, the analysis yielded statistically significant results (p<0.02), confirming that the use of silicone products is an effective method for scar prevention [41].

3. Corticosteroid injections

Multiple mechanisms of action of corticosteroids in scar prevention and treatment have been reported. Including anti-inflammatory effect [42-44], immunomodulatory effect on T cells [45,46], anti-fibroblast proliferation effect [47,48], inhibitory effect on angiogenesis [49,50], and ECM remodeling-promoting effect [50,51].

By various actions on scars, corticosteroids can be used for preventing scar formation and treating existing scars. Intralesional injection of corticosteroids is the most widely used clinical treatment for pathological scars [52]. Triamcinolone acetonide and compound betamethasone are the most commonly used corticosteroids in clinical practice [53,54]. This method can deliver medication precisely where needed, enhancing its effectiveness in scar modulation. For effective use, the following application methods are recommended. Volume per injection site is generally, about 0.1 to 0.2 mL of the corticosteroid solution is injected per square centimeter of the affected skin. Total dose per session is 1 to 2 mL. Injections are usually administered every 4 to 6 weeks, with the total number of sessions depending on the scar's response to treatment. Some studies have reported that injections are performed at monthly intervals. Significant improvements in scar appearance and symptoms over multiple sessions have been reported [55].

While corticosteroid injections are effective, they might be associated with side effects such as skin atrophy, pigmentation changes, and telangiectasia. Therefore, their use should be carefully considered and monitored by healthcare professionals [52].

Treatment of postoperative scar

Despite applying various scar prevention methods mentioned earlier, scars may still form in some cases. Among preventive measures, intralesional corticosteroid injection can be used for therapeutic purposes. Silicone products have been reported to be effective in improving existing scars. There are many therapeutic options for surgical scars, including surgery, radiation, corticosteroids, 5-fluorouracil, cryotherapy, laser therapy, anti-allergy agents, and anti-inflammatory agents. The two primary treatment methods commonly used are scar revision surgery and scar laser treatment.

1. Scar laser

Laser therapy has become a cornerstone in the management of various scar types, offering targeted treatments that can address specific scar characteristics. Laser treatment can improve scars through two primary mechanisms: (1) selective photothermolysis; (2) collagen remodeling.

Lasers can emit specific wavelengths absorbed by chromophores such as hemoglobin, melanin, and water, causing localized thermal damage. This triggers a healing response and collagen remodeling, leading to improved scar texture. Additionally, thermal energy from lasers can stimulate fibroblast activity, promoting the synthesis of new collagen and elastin fibers, which can enhance scar texture and elasticity [56]. Lasers are categorized based on wavelength and tissue interaction type: (1) ablative lasers; (2) nonablative lasers; (3) fractional lasers.

Ablative lasers such as CO₂ and Er:YAG can remove the epidermis and part of the dermis, thereby inducing collagen remodeling. These lasers are effectively used for atrophic scars and acne scars. However, a long recovery period is required after treatment. Representative nonablative lasers include Nd:YAG and pulsed dye lasers. Nd:YAG laser does not affect the epidermis. Instead, it generates heat in the dermis, leading to suppression of neovascularization and dilation of blood vessels. As a result, it can improve scar thickness and texture [57,58]. Fractional laser works through a mechanism called fractional photothermolysis. The laser energy is delivered in a pixelated pattern, creating multiple microscopic treatment zones (MTZs). These MTZs can apply controlled thermal energy to stimulate the body’s natural healing processes, promote collagen remodeling, and replace damaged skin with healthier tissues [59]. Ablative fractional CO₂ lasers can significantly improve atrophic surgical scars [60].

2. Scar revision surgery

The most proactive and definitive method for reducing scars is scar revision surgery. To achieve optimal results, the appropriate surgical technique must be selected based on the type of scar. In general, simple excision and re-suturing are most effective for long, narrow scars. However, if the scar surface is irregular or raised, techniques such as dermabrasion can be employed to smooth the skin by removing outer layers (Fig. 3A) [61].

Fig. 3.

Scar revision methods. (A) Simple excision. (B) Z-plasty. (C) W-plasty. (D) Geometric scar revision. RSTL, relaxed skin tension lines [61].

Scar revision follows the following fundamental principle. If the scar aligns with the RSTLs, an elliptical excision with adequate suturing is recommended. However, if the existing scar does not follow the RSTLs, Z-plasty or W-plasty can be performed to reposition the scar, making it less noticeable and improving functional outcomes [62].

Z-plasty is an effective technique for redistributing contracture forces. It can improve both mobility and scar aesthetics. However, if not properly designed, Z-plasty may lead to elongation and irregularities in the scar, making it essential to carefully plan the procedure while considering RSTLs (Fig. 3B) [61].

W-plasty is a more effective method than Z-plasty for modifying linear or curved scars that do not align with RSTLs, as it creates multiple triangular skin flaps that help break up the scar. The amount of tissue excised in W-plasty is comparable to elliptical excision, ensuring minimal tissue loss while improving scar aesthetics (Fig. 3C) [61].

A modification of W-plasty, known as broken line scar revision, can be used when a scar has irregular borders. Geometric scar revision techniques allow for minimal normal tissue loss while blending the scar into the surrounding skin, making it particularly useful for keloid scars or nonlinear scars (Fig. 3D) [61].

Scar revision surgery initiates the wound healing process from the beginning, requiring proper postoperative scar management to prevent recurrence and optimize healing. Therefore, combining scar revision with additional scar prevention strategies, such as silicone therapy, pressure therapy, or laser treatment, is recommended to achieve better long-term results.

Conclusions

Postoperative scar management remains a critical aspect of surgical outcomes, influencing both aesthetic and functional results. While surgical techniques have advanced to minimize scar formation, complete prevention is not always possible. Understanding the wound healing process, proper surgical planning, and early intervention with scar prevention strategies such as taping, silicone therapy, and corticosteroid injections can significantly reduce scar severity. Moreover, advanced treatment options such as laser therapy and surgical scar revision provide effective solutions for managing persistent scars. By integrating evidence-based prevention and treatment strategies, clinicians can optimize healing and improve patient satisfaction following surgery.

Notes

Conflicts of interest

No potential conflict of interest relevant to this article was reported.

Funding

None.

Author contributions

Conceptualization: HY. Data curation: HY. Formal analysis: JS. Investigation: JP. Methodology: YK. Project administration: HY. Resources: HK. Software: HK. Supervision: JP. Validation: YK. Visualization: HY. Writing-original draft: JS, YK, JP. Writing-review & editing: HK, HY. All authors read and approved the final manuscript.

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