Clinical Recommendations for Linear Scars: A Comprehensive Guide
Linear scars, which commonly result from surgical incisions or trauma, require precise management to optimize healing and minimize the risk of abnormal scar formation. The treatment of linear scars is a structured, time-sensitive process that should begin immediately post-injury or surgery. This blog will discuss the recommended strategies for managing linear scars over time, divided into different phases: Prevention (first 6 weeks or in some cases even before elective surgery), Early Scar Management (6 weeks to 3 months), Intermediate Scar Management (3 to 6 months), and Late Scar Management (6 to >12 months).
These phases will be explored in-depth, providing insight into how to manage scars, reduce hypertrophic tendencies, and ensure the best possible outcomes.
Prevention Phase (First 6 Weeks)
Objective: Minimize scar formation and encourage proper healing
The first six weeks after an injury or surgery is critical in determining the outcome of scar formation. During this time, the skin is in its early healing phase, and care must be taken to ensure the scar does not become hypertrophic or stretched. Following these steps can help reduce the likelihood of abnormal scarring:
1. Sun Protection
It is crucial to avoid direct sun exposure for fresh scars, as they are more susceptible to sunburn. UV rays can induce or exacerbate hyperpigmentation in new scars, making them more pronounced. For optimal protection, patients should be advised to shield their scars from the sun using physical barriers such as clothing and by applying sunscreen with a high SPF (50+) on the scar area (once epithelialised), consistently for at least 6 to 12 months.
2. Moisturisation
Moisturisation plays a vital role in scar healing. Using a moisturizing lotion/balm in the morning and an oil-based product in the evening can keep the scar hydrated. Hydration reduces itching and tension in the scar, preventing the skin from drying out, which can lead to more pronounced scars.
3. Taping
Applying paper tape or medical-grade silicone tape directly over the scar helps minimize tension on the wound, which is crucial for reducing the risk of hypertrophic scarring. This approach is particularly beneficial for linear scars, as it prevents excessive stretching during the healing process. Maintaining direct pressure and moisture at the scar site are also key factors in preventing hypertrophic scars, supporting a more favorable healing environment.
4. Silicone Products
Silicone gels, tapes, and sheets are among the most evidence-based treatments for scar prevention. Silicone hydrates the skin and regulates collagen production, making it a gold standard for preventing hypertrophic or keloid scars. Sheets also provide pressure, which is beneficial in preventing raised scars.
5. Pressure Application for High-Risk Scars
For areas susceptible to abnormal scar formation, such as the chest or shoulders where hypertrophic scarring is common, applying pressure can be beneficial. This can be achieved through the use of silicone products or compression garments. While using compression garments on the chest may be challenging, they are suitable for areas that can effectively accommodate pressure therapy.
6. Early laser intervention
Recent evidence suggests that initiating laser treatment shortly after surgery can positively influence scar formation and maturation. This approach helps to reduce the likelihood of problematic scarring by promoting more favorable healing conditions and improving the overall appearance of the scar as it matures. It's essential that the laser modality be carefully selected by a specialised provider to ensure optimal outcomes for the specific scar and skin type.
7. Follow-Up Care
It's important for patients to have a follow-up appointment six weeks after surgery or injury to assess the scar and determine if further intervention is needed.
Early Scar Management (6 Weeks to 3 Months)
Objective: Monitor scar maturation and intervene early if hypertrophy is detected
Once the wound has healed, the focus shifts to monitoring the scar for signs of hypertrophy or other abnormalities. This phase is critical because early intervention can prevent the worsening of raised or wide scars.
1. Continue Preventive Measures
- Continue sun protection, moisturizing, silicone application, and taping until the scar has fully matured post-injury or surgery, as scars remain sensitive during this period.
2. Address Early Hypertrophy
Some patients may exhibit early signs of hypertrophic scarring as soon as six weeks post-injury, with the scars generally worsening and potentially peaking around three months or sometimes even later. This phase can include symptoms such as raised, red, or thickened scars. In such instances, it is advisable to apply additional pressure using silicone sheets or compression garments to mitigate the scarring. If hypertrophy is detected, early intervention with corticosteroids (topically, laser-facilitated or injected) and laser intervention can be initiated to prevent further deterioration of the scar, improve and accelerate scar maturation.
3. Follow-Up at 3 Months
Patients should have another follow-up appointment at the 3-month mark. At this stage, the surgeon can assess the scar’s progression and recommend additional treatments if necessary.
Intermediate Scar Management (3 to 6 Months)
Objective: Encourage scar maturation and treat hypertrophic tendencies
At the 3 to 6 month mark, most scars are still maturing. However, this is the stage when hypertrophic scars or abnormal scar formations tend to stabilise or worsen without intervention.
1. Continue Maintenance Treatments
- Sun protection, moisturizing, and silicone products should continue to be part of the daily routine until the scar has fully matured.
2. Treat Hypertrophic Scarring
If hypertrophic scarring persists, this is the ideal time to considermore aggressive treatment strategies including :
- Multimodal Laser Therapy: Utilising various types of lasers, non-ablative and fractional lasers can more aggressively remodel the scar tissue. This approach enhances the scar’s texture, color, and overall appearance.
- Laser-Facilitated Drug Delivery: Combining laser treatments with drug delivery, such as corticosteroids, enhances the therapeutic effects. This method allows for deeper penetration and more effective delivery of medication to reduce collagen production and flatten the scar.
3. Address Functional Concerns
In this critical period post-surgery, surgical scar revision is generally reserved for cases where the scar severely impairs function or threatens an organ. For scars that cross joints or are situated in high-tension areas, which may restrict movement, a more conservative approach is typically favored initially:
- Laser Therapy: Utilising treatments such as ablative fractional CO2 laser or fractionated cold laser therapies can effectively minimize scar tension. These methods are known to enhance scar pliability and reduce thickness, thereby improving function. They may be employed with or without laser-facilitated drug delivery to optimize outcomes.
- Surgical Interventions: Surgical options such as Z-plasties are considered for relieving tension and improving functional outcomes but are not typically recommended in this early stage during scar maturation unless an organ (e.g., eyelid ectropion) or a joint is at risk. These techniques are designed to redistribute the tension and prevent the scar from contracting further, prioritising non-surgical methods initially.
4. Follow-Up at 6 Months
Another follow-up at 6 months is essential to differentiate between normal scar maturation and the persistence of abnormal scarring. Based on this assessment, adjustments in treatment can be made.
Late Scar Management (6 to >12 Months)
Objective: Finalize scar maturation and treat abnormal scarring
By the 6 to 12-month mark, most linear scars will have matured. However, abnormal scarring may still persist, requiring further intervention to improve the appearance and function of the scar.
1. Continue Monitoring Scar Maturation
For scars that have matured normally, continued use of silicone products, and pressure therapy may no longer be necessary. However, abnormal scars require ongoing care.
2. Further Interventions for Abnormal Scarring
- Corticosteroids or Antimitotic Drugs: Corticosteroids remain a first-line treatment for hypertrophic and keloidal scars, administered via intralesional injections or preferably via laser-facilitated drug delivery to reduce collagen overproduction, soften the scar, and minimise redness (inflammation). In cases of severe pathological scarring, antimitotic drugs such as 5-fluorouracil (5-FU) may be considered, either alone or in combination with corticosteroids, for enhanced effectiveness. These treatments are typically repeated every 6 to 8 weeks based on clinical response.
- Laser Therapy: Laser treatments, including non-ablative, ablative fractional, and fractional cold fibre lasers are integral for improving scar texture, pigmentation, and pliability. When combined with laser facilitated drug deliveries, laser therapy can significantly enhance outcomes. Even mature scars may benefit, though improvements can take time and multiple sessions.
- Surgical Interventions: For scars that remain significantly thick, painful, and restrictive, surgical options such as scar revision, Z-plasties, or local tissue rearrangement may be necessary, although it is recommended to await scar maturation (>12months). Surgical intervention is generally reserved for cases where severe functional impairment persists, or non-surgical approaches have been insufficient.
3. Final Follow-Up
A final follow-up at 12 months allows the clinician to evaluate the scar's full maturation. By this stage, most scars are considered mature, and no further interventions may be needed unless there is persistent hypertrophy, functional impairment, or aesthetic concerns. For keloids, long-term follow-up is essential to monitor for recurrence, provide ongoing management, and intervene early if signs of recurrence are detected, ensuring better long-term outcomes.
It is important to note that the treatment of scars, beyond 12 months, is evidence-based and can be effective, including in very old, mature scars.
Conclusion: The Importance of a Personalised Treatment Approach
Treating linear scars requires a multifaceted, time-sensitive approach that includes preventive measures, ongoing monitoring, and targeted interventions. Since each patient’s skin type, scar location, and healing process vary, scar management plans must be individualised. Regular follow-up appointments and early intervention for hypertrophic scars can prevent complications and ensure the best aesthetic and functional outcomes.
By following the clinical recommendations outlined in this blog, patients can take proactive steps to ensure their linear scars heal optimally, with minimal long-term effects.