Demystifying Scars

Demystifying Scars
Every plastic surgeon is faced with this query. The answers are different, but the truth is the same. Scars can never be removed. They can only be reduced and not always. Let us start by understanding scars. Scars are the outcome of our bodies natural tendency to close all gaps in tissues. Our body is programmed to do this. Depending on the amount of movement and stress in the area, the amount of scar varies. If there is a lot of stress on the scar- for example a wound on the knee where the scar is pulled every time we fold the knee- the body produces more scar. Thus the scar becomes thick. At other times the edges of the skin instead of getting pulled together will spread wide- a stretched scar. For example on the forearm after a bone surgery. If there is an 'ideal' set of combinations, the scar can be so thin that it is almost invisible! Scars and skin are different. Scars are a repairing tissue. They look different, do not have hair growth, have little sensation and have no sweat glands. No wonder they look different.
What is a good scar?
When the scar is thin, flat ( at the level of the surrounding skin) , the color is somewhat similar to the surrounding skin and does not have itching or pain- it is called a good scar. Occasionally scars are difficult to spot, but that is not the rule.
What is a bad scar?
When the scar is thick, raised , discoloured, causes pain, restricts movement. This can happen when wounds heal slowly, there was infection, some 'foreign body' may be trapped, the injury was over a joint or in 'red zones' or occasionally for no reason.
Which areas tend to have poor scar?
The middle of the chest and shoulders are notorious for thick scars. Scars across joints, back of the forearm and foot tend to have bad scars. The junction between different tissues can have bad scars ( skin graft and normal skin).
When does a scar necessitate treatment?
This can be a medical or cosmetic reason
MEDICAL REASONS
A thick scar which restricts movement, a scar which has a wound or develops wound frequently, scar which harbours infection, itching or one that is growing in size.
NON MEDICAL REASONS
Scar that is wide, color match is poor, extends in a linear direction ( resembling a sharp weapon assault) Methods available Surgical : Scar removal- No such term exists. Scar reduction: The size of the scar (mainly width) can be reduced. The scar is removed and stitched with greater support to reduce the forces that widen the scar. Z plasty: The scar is interrupted and parts of it are re aligned so as to avoid a long line. The scar length is increased which is an additional benefit if the scar was tight initially. On healing, the scar is less noticeable to the eye W plasty: less often used, it also makes the scar wavy and reduces the visibility of scars. Skin graft: This is an infrequent option and used when the area is wide and large. Split skin graft are thin skin layers that can cover large areas as in burns wounds . Full thickness skin grafts, give better appearance but use is limited by the limited donor area available Fillers: This is used for depressed scars. These can be synthetic filler of fat from other areas of the body. Non surgical: Massage: Many scars , especially when they are young are amenable to improvement by massage. The massage has to be in the general direction of the scar or on a circular fashion. Duration of massage has to be significant and consistent. Scar creams: Many scar creams exist. They have one or more ingredients which can have an influence on scar formation. No scar can remove scars but they can reduce scars , especially when used on young scars. Lasers: By delivering low doses of energy to the scars, the collagen formation can be minimized and thus the scar. But this is a repetitive treatment, also useful for younger scars. Scar care is a challenge for the surgeon as well as patient. It is a battle against 'natural' mechanisms and while the battle can be fought it is not always won.

The Operation

Is it safe to get operated?
Anesthesia is a way we make operations to be pain free. The progress made in anesthesia has been phenomenal. The drugs are safer and more effective, monitoring is more vigilant and the result is a significant increase in safety levels… Anesthesia and surgery have made great strides in this area. Anesthesiologists have a wonderful range of safe drugs and are aided by multiple monitors. All through the surgery the heart rate , the oxygen level, the carbon dioxide level, the blood pressure, ECG, breathing cycles are all measured almost routinely..and each has set alarm limits. The only part with a little pain is the insertion of a needle in the hand. After this most people only become aware when they are woken up in the presence of their near and dear ones! The chance of something going wrong is very low. To ensure this, we ask for some basic tests before surgery. You will also be meeting the anesthesiologist before the date is finalized. Additional opinions are taken if required by your health condition. Diabetes, Blood pressure, previous heart problems, breathing problems are all reasons to be careful. But they are not reasons to avoid an essential surgery today. This is a joint decision where you will be made fully aware of all issues. When advised an operation, many questions come up. Here are a few answers… All people who are advised surgery have some fears
If it is General Anesthesia the fear is of death...
I no longer ponder over whether General anesthesia is necessary. Of course we need to do some basic tests. Those under 40 years are subject to basic tests. The tests will enlarge if the age is over 40. The tests will include checks for diabetes, tests of the kidney function and check of the heart function. The person is evaluated by an Anesthesiologist beforehand. If needed further opinions are taken. SAFETY is always the first criteria. I tell most people 'The possibility of death is lower than the chance of being run over while crossing a road..'
Pain
Most people are frightened of pain during the operation. This is unnecessary.
What to expect in the O T?
After changing into a different dress, the patient can expect a canula (plastic tube) to be placed into a vein to inject drugs. Inside, the patient will have a pulse oximeter (like a large clip) placed on finger for checking oxygen levels. Some stickers will be placed around the chest to monitor the heart. A blood pressure cuff will be tied. This automatically checks pressure every few minutes, your arm will feel tight! The anesthesiologist will place a 'mask' on the face and ask you to take deep breaths. Usually you will remember nothing after this... If it is a long surgery, a tube to drain urine may be placed later.
When the surgery is over, as you recover...
You will wake up with a feeling of floating and light headedness with people asking you to open the eyes or show the tongue. This is how we assess that you are out of the effect of drugs. If there is a collection of saliva in throat, it will be sucked out. A tube will be felt in your mouth and throat. This will be removed, do not try to cough or struggle For the first few hours, the throat will feel sore. You will not be given anything to drink for a few hours. Later you will be allowed liquids and later solids. Pain medications are usually given, but if you have pain additional drugs can be given. Every effort is made to make the surgery a pleasant experience. In surgeries where general

CHOOSE A SURGEON

How to choose a surgeon?
Sitting on the other side of the chair, I have often wondered how and why patients choose to get operated by me. Not once or twice but 14000 times over the last 17 years. From my patients I have gleaned these thoughts on decision making and added some of my own. First impression: Many patients expect a certain look from their surgeon. The well-dressed surgeon is making a statement of being careful and organized, while the scrub suited surgeon is advertising his packed schedule. Try to disregard these aspects. You are there to get a professional opinion on a complaint. The surgeons brain and his skills are what matters.
The waiting period:
This is forever a bugbear. Please do understand that most of the time, doctors are struggling to cope with demands of time. Everyone of the relatives we meet on the staircase want all the details again. Refusal to talk is arrogance and agreeing leads to delays. These days , you can either be ready to deal with this ( a tablet or a book you wanted to read) or you can ask to be called on your phone when the doctor is ready. It doesnt solve the problem, but makes it tolerable. If you feel offended, it may be prudent to go somewhere else. You can always inform the reception or email the surgeon, your opinion.
Did the surgeon allow you to express your problems properly?
Your problem may be common and the surgeon may want to save time on this. You can make this out by his/her behaviour. But sometimes this can also lead to a misdiagnosis. While it is difficult for you to talk, listen to him for logic and reasoning. Then ask for a second appointment. Many places dont charge for a reappointment within a specific period . Use that.
What is your impression of the reply?
Was there a lot of medical terms thrown in? Was the surgeon keen on making you understand? All these are signs that this is a person who is concerned about your problem and wants to be part of the answer. What is the body language? You dont require medical knowledge to answer these questions.
How to find out if this surgeon is competent?
First check on the doctors degrees. Surgeons generally have an M S degree and Physicians have an M D. Some subjects also offer diploma courses which are of a shorter duration. A DNB is a degree offered by the Union government and this follows an exam at a national level. The same degree (DNB) is awarded for all specialities and superspecialities. MCh is a surgical and DM is a medical superspeciality degree. Degrees in brackets or other symbols mean that it has not been attained! Abbreviations which start with F mean a fellowship at a particular place.
Is a good degree proof of competence?
Yes and no. It is evidence of formal training . It obviously depends on the place of training and the surgeons willingness to invest time and money in being updated. Look for evidences of these being displayed in the consultation. Most patients recognize competence from the body language. Asking other doctors gives you a good idea of past records. It is not unusual to ask if you could meet/ talk to other past patients. Not all patients, however, are willing to be called up and disturbed!
Should I take a second opinion?
It is always a choice. Not because of competence being questioned, but there may be a genuinely good option that your surgeon may not have told you or may not be aware of. If the two opinions match, your confidence levels will go. If they dont, you can go back to one of the two or both for more questions.
What do I need to know apart from the surgery?
The surgeons will generally also tell you about the planned anaesthesia. This is an equally important part. Please be aware that you need a competent anaesthesiologist as well. You can opt to meet the anesthesiologist if possible earlier rather than a few hours before surgery..
Did the surgeon talk about pain management?
In todays world, pain management is an important part of the treatment plan. You need to ask about this, if information is not volunteered.
What about cost?
Each surgeon has decided the value of his/ her services. There is no industry standard! It is linked to the infrastructure, the specialization, the experience and the complexity of the surgery. If you are uncomfortable, please express it. Sometimes, costs can be decreased by altering the plan without endangering safety and outcome. It is wise in bigger hospitals to budget for 20 % mark up in the final bill.
What other information do I need?
The estimated period of recovery ( always unpredictable) will help you plan ahead. What else would be required for a recovery splints, physiotherapy etc. Is there a second stage of surgery later- an implant removal for example. In case of emergencies, what are the means of communication available.
What can go wrong?
Surgery is never 100% safe. But each year safety gets enhanced. Each surgery has a set of general complications and specific complications. By general , it means- Wound healing delay, infection, scar issues, a blood clot etc. There also specific problems for the particular surgery. While death is unlikely as a outcome, all operations do have complications I got operated and something went wrong. Should I see a new doctor or go back to the same surgeon? Things can go wrong in the best of hands. It is never intentional. You will have to decide based on how the doctor dealt with it and explained it to you. Remember, the surgeon is also stressed by the episode. He/she may already have a packed schedule and this episode puts tremendous pressure on time and adds stress to the surgeon too. Most doctors place the patient first and foremost in priority, but at the cost of their personal lives. So ask your questions, but don't add to the pressure. Only if you feel that you are not getting the care you deserve, or strongly doubt the doctors competence or there is a breakdown of relationship- you should think of a second opinion.

COSMETIC SURGERY

How to choose a cosmetic Surgery
A cosmetic Surgery involves changing the appearance of a part of the body in order to improve the appearance. Plastic Surgeons have many techniques of doing this. Shifting skin ( partial or full thickness), moving skin as flaps, reducing scarring, skin expansion, injection of fat, insertion of implants etc are among the techniques used. However, the person who undergoes surgery must understand the proposed procedure well before accepting it. Here are some basic issues I normally ask of people who see me for their concerns. - What do you think is not right about that part - Is the problem increasing or is it the same - Does this bother you somewhat or a lot - What do you feel will make you happier There is no tailor made solution and it is only individual discussion that can help. Sometimes i use the ALTERIMAGE (R) software to try to give an idea of the changes.