Plastic and Reconstructive surgery is a sensitive matter, it is about ensuring the patient is satisfied with themselves, whilst adhering to medical requirements and ensuring clinical negligence is no longer at hand. Consultant Plastic Surgeon and Director, Fortune Iwuagwu, offers his expertise advice on scars, reconstructive surgery and the lengths he goes to make his patients happy.
What is your main interest with respect to scars?
As a Consultant Plastic, Reconstructive and Hand Surgeon for the last 13 years, I have managed various kinds of “obvious” scars following reconstructive, cosmetic and hand surgery. But I have also had the privilege of treating “hidden” scars, which limit the movement of joints in the hand. I have written on scar issues in medical journals and worked as an expert or provided numerous medico-legal reports on scars following personal injury and clinical negligence.
Let’s talk about the obvious scars or the ones we can see on the skin. How do you manage the medicolegal patient with scars?
In the history, though it may be obvious, I try to establish the circumstances of the index incident (injury or surgery) including the offending weapon. It is very useful if the solicitor has provided me with pictures of the injury in the very early period. Most clients or patients now have smartphones and usually take pictures of the injury. They either bring copies of photographs to the consultation or are very happy to send them on. This is useful because it makes me confirm if the scars are consistent with the initial injury. There is an empirical honesty attributed to the patient but it is reasonable for the expert to be aware that a few clients can distort or be very economical with the truth. Obviously, a medical expert is not a solicitor /barrister but a true account enables one to make an informed and right conclusion.
So, what are you looking for in a scar?
In the examination, various parameters are important to me including the length, width of the scar, shape, presence of any cross hatching, colour, pigmented or not, quality of the scar (atrophic or not), contour (depressed or not), tenderness, sensitivity, height of the scar (same level as skin, depressed or raised such as hypertrophic scar or keloid scar, etc.
The parameters of the scar have to be matched with the age of the scar (the time since injury). Each parameter tells a story about the scar, which helps one arrive at an informed opinion.
How do you approach the options of treatment or what treatments are available to get rid of the scar?
It is essential as an Expert to state that scars are permanent. Therefore, the scar is a permanent symptom of the index incident, which is useful for the solicitors. This is to dispel some of the myths in newspapers, magazines etc. that give patients false hopes. For example, if you excise a scar, the new wound will heal with a new scar, which is hoped to be better but the ultimate appearance cannot be guaranteed.
But the good news is that scars can either be improved or can improve on their own with time. Scars ‘cannot be gotten rid of’ but can be ‘swapped with a better appearing or better positioned (hiding the scar) scar’.
Time is also a great friend of scars as many scars improve in appearance with time and become less bother to the patient.
More specific treatment options can be non-surgical and/or surgical depending on what aspect of the scar is most bothersome to the patient and there are a myriad of them.
Non-surgical options include cosmetic camouflage, medical tattoo, laser therapy etc. The surgical treatment options include simple excision and re-suturing (single or multi-stage), tissue expansion and excision, fat transfer for contour deformities, free tissue transfer etc.
What about the ‘over the counter’ scar creams?
Yes, there are also general non-surgical techniques that help scar mature and look better such as creams, silicone gels etc.
Scars especially when new or immature do benefit from massage of the scar with moisturizing creams, which helps remodel the scar. The creams include commonly available scar creams on the high-street supermarket.
Silicone gels also help hydrate and soften the scars and do help.
