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5 ways to treat keloid scars

Keloid scars are an abnormal form of scarring that occur in some individuals.

They are more common in certain skin types such as Afro-Caribbean skin and they are also more common in certain areas such as the earlobes, the shoulders or over the breast bone.

They are raised lumpy scars which are often itchy and are darker in colour to the normal skin colour so they can be red or purple in Caucasian skin or darker brown in pigmented skin.

They are difficult to treat because it is an abnormal response by the body and we don’t really know why they occur.

There are five main forms of treatment for keloid scars:

1. Moisturising and Massage

If your scar is only slightly raised and particularly if it is within the first year then you may have a hypertrophic scar rather than a keloid scar and these tend to be less severe and more likely to improve over time.

Moisturising and massaging the scar will help it to soften and may help with the itch.

2. Silicone

The next step would be to use silicone on the scar.

Silicone comes in 2 forms, a gel or a sheet.

Silicone sheets are useful on flat areas particularly underneath clothes because while the silicone sheets are sticky, they do not stay on well on exposed areas.

For keloid scars in exposed places like the face or the ears, silicone gel is more effective.

The silicone needs to stay on for 23 hours of the day and is only taken off to wash.

It can help with the red and raised nature of the scar and also the itch.

3. Pressure

Pressure is known to improve the quality of keloid scars although it is dependent on the area as to whether it can be used as a modality for treatment.

Keloid scars on the earlobes may be amenable to having pressure applied by using a custom-made clip which will press on the scar and can help it to flatten.

Other areas of the body can be more difficult to apply pressure to although it may be possible to have a custom-made garment depending on the size and location of the scar.

For severe scarring of the face, a custom mask can be made to apply pressure, although this is only for extreme cases.

4. Steroid Injections

The next step for troublesome keloid scarring is to use steroid injections.

Steroids are used to dampen down inflammation and it is presumed that the cause of the keloid scarring is an inflammatory reaction within the scar.

The steroid needs to be injected into the scar itself and this can be uncomfortable.

Steroid injection is a procedure that can be performed in the outpatient clinic and may need to be repeated.

5. Excision Of Keloid Scars

One of the last options we consider, but perhaps one of the first options that many people think about, is excision of the scar.

It may seem an obvious choice to excise and give a fresh neat scar. However because keloid scarring is due to your body’s reaction to forming scars, there is a high probability that if a fresh scar was made, it could be keloid again and it could come back worse because the new scar would be longer than the original one.

Excision of a keloid scar is sometimes performed if it is a very large and bulky scar that is unlikely to be significantly reduced with steroid, pressure or silicone.

When excision of a keloid scar is considered, we would usually perform what is known as an intralesional excision of the scar which involves leaving a rim of keloid scar behind so that fresh skin is not cut into.

This leaves a residual lump which can then be treated with one of the other methods above such a steroid injection, pressure clips and silicone dressings or a combination.

 

 

The treatment of keloid scar is challenging and as you go up the ladder of increasingly invasive methods then the potential risks also increase.

This is an outline of what is available for keloid scars but each patient needs to be treated on a bespoke and personal level with a package or combination of treatments which will give the best possible outcome.

If you would like a consultation with one of our Plastic Surgeons for an assessment of your keloid scar then you can call us on 0121-454 3680, alternatively email us a photograph if you would like us to give you an opinion.

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For more information about scar revision, visit our scar revision page.

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Laser excision of a mole versus surgical excision

It is not uncommon for people to enquire about laser excision of a mole here at the Staiano Clinic as I think that sometimes people feel that it is somehow better than surgical excision.
Anything with the term laser in it is deemed to be futuristic and therefore better than the old-fashioned ways, and indeed lasers have been a great advance in the field of plastic surgery and are very useful in many situations.

We do not offer laser excision of moles here at the Staiano Clinic, however we would be happy to talk to you about it.

If you wanted laser excision, it would always be best to talk to a practitioner who does offer laser excision of moles, because they would be best placed to tell you the pros and cons and the reasons why they offer it.
The main point to consider, is that if you want to have your mole removed, then it will need to be destroyed in some way.  The sort of lasers that are used for mole removal are quite destructive and cut the skin in a similar way to a scalpel.

One of the reasons people feel that laser is preferable to surgery is because they do not want the scar.
However, if the mole is going to be destroyed then it will leave a scar or a mark whatever modality is used.
The pattern of scarring might be different and that is true for the different types of mole excision.

One of the main benefits of laser is that multiple moles can be targeted at the same time, but one of the big downsides is that laser destroys the tissues and so the mole cannot be sent for histology, and it is good practice certainly for pigmented lesions, that they are sent away for histological analysis to be sure that there is nothing to worry about.

There are no moles that are removed by laser excision that cannot be removed by surgical excision and we are all plastic surgeons here at the Staiano Clinic and we specialise in the surgical excision of moles.

There are clinics that do offer laser excision of moles, but you have to be absolutely sure that they are benign before going down that route.

Ideally you would find a plastic surgeon who does laser excision of moles and surgical excision to get a balanced view.

The fact is that laser is often performed by non-plastic surgeons who may not have the ability to offer surgical excision, so it is sometimes hard to get a balanced view and opinion, and so my advice would be to look at the results of different practitioners and choose someone you can trust, who seems to give results and have happy patients because you will find, like with most things, there are many ways to crack a nut.

We are very comfortable with performing surgical excisions of moles here at the Staiano Clinic and we offer free consultations with one of our plastic surgeons if you would like to come along and have an assessment and a chat.
You can also download our guide with details of when you should worry about your mole here.
We are one of the few clinics to offer a see and treat service where you can come to the clinic and have your mole assessed and removed on the same day, and while we do ask for a deposit, there is no obligation to proceed and the deposit is fully refundable if you do not proceed with the surgery on the day.

If you have any questions and want to get in touch, then contact us on the website or on Facebook where I do a live Q and A on Facebook every Tuesday at 7 p.m.  Please visit our Facebook page if you would like to put a question directly to Jonathan.
Feel free to leave a comment below, or drop us an e-mail.
If you want to come for a free no obligation consultation with one of our plastic surgeons, please call or email us or fill in the on-line contact form.

Scar Revision

Scar Revision At The STAIANO Clinic

You may think that scar revision is bread and butter for a plastic surgeon, but it is important to be aware of what is possible when it comes to considering revision of your scar.
It is not possible to remove scars completely, but plastic surgeons are trained in techniques to alter and improve scars so that they can be hidden or blend in with their surroundings.
If you think that you might be a suitable candidate for scar revision, then watch this video where our director, JJ Staiano, talks about what can be achieved with plastic surgery to help improve and reduce scarring.

What Scars Are Suitable For Scar Revision?

Not all scars are suitable for scar revision and you would be welcome to send us a photograph of your scar so that we can give you an assessment on whether we can help.
Scar revision is particularly suitable for scars that are stretched or indented or scars that are lying in an unfavourable orientation.  This is usually scars that are caused by some sort of trauma or injury rather than scars that have been made following surgery.
If you have a surgical scar, then it could be raised and lumpy and this is known as a keloid or hypertrophic scar.  Keloid scars are best managed by a qualified surgeon or dermatologist as they are difficult to treat and there is a risk of causing more keloid scarring if surgery is performed.
We have a wealth of options to treat problematic scars at The STAIANO Clinic ranging from non-surgical treatments such as silicone gel that can be applied to your scars to steroid injections that we can perform here at the clinic through to surgical revision to improve the look of your scar.

Before - Puckered Scar

Before Scar Revision – Puckered Scar

After Scar Revision - Puckered Scar

After Scar Revision – Puckered Scar

 

Before Scar Revision - Stretched Scar

Before Scar Revision – Stretched Scar

After Scar Revision - Stretched Scar

After Scar Revision – Stretched Scar

When plastic surgeons perform scar revision surgery, they are creating new scars and so the aim is to create a new scar that is better than the old scar.  It is very much a bespoke service that we offer and we will assess your scar and take a full history so that we can offer you the best treatment for your scar and give you the best result possible.

When Is The Best Time To Undertake Scar Revision Surgery?

All scars take 6 to 12 months to mature and so you should not consider scar revision until your scar has fully matured and is going to be as soft and supple as it is going to get.
It may sound counter-intuitive to wait until your scar has fully settled before undergoing revision, but it it is important for it to have softened and settled fully before undergoing further surgery.

Want To Find Out More About Scar Revision?

Find out more about removing your scar on our scar removal page.
All of the surgeons at The Staiano Clinic are fully trained plastic surgeons and have extensive experience in managing scars and obtaining the best outcomes possible.
For more information, call us now on 0121-454 3680 to book a FREE consultation with a Consultant Plastic Surgeon or you can send us a photograph of your scar to info@staianoplasticsurgery.co.uk and we will get back to you with an idea of what can be achieved.

Capsular Contracture After Breast Augmentation.

What is capsular contracture?

Capsular contracture can happen to breast implants over time.

All implants have a capsule that forms around them.

A capsule is made up of scar tissue and it is the body’s reaction to the implant.

It is a normal reaction and it happens to all implants, no matter where they are in the body – in your hip, or your heart, in your chin or your eye.

The capsule is normal scar tissue and is nothing to worry about.

Over time the capsule (like all scar tissue) tends to contract and it is the capsular contracture that is the problem.

The problem is not with the implant, the problem is with the scar tissue that forms around the implant.

If an implant is solid like a hip implant or a chin implant, the contracture of the scar tissue does not have much of an effect on the implant.
However if the implant is soft, like a breast implant, then the contracture does have a constricting effect on the implant and this is what causes the problem.

 

Breast implant having been removed from its surrounding capsule, seen side by side.

Capsular contracture is a progressive condition and over time, the implant can start to feel hard, then it can start to look ’rounded’ and then it becomes uncomfortable.
That is the natural history of capsular contracture.
Capsular contracture is graded according to the following scale (Baker classification):

  1. Grade I capsular contracture: you cannot see or feel your breast implants (i.e. everybody has at least a Grade I capsule)
  2. Grade II capsular contracture: you can feel but you cannot see your breast implants
  3. Grade III capsular contracture: you can feel and see your breast implants
  4. Grade IV capsular contracture: your breast implants feel painful

No matter what the shape or profile of your implant, when the scar tissue contracts around it, it becomes spherical, like a ball.

This can make your breast look unsightly and feel uncomfortable.

For whatever reason, capsular contracture often only happens on one side which can lead to your breasts looking asymmetrical.

 

Capsular contracture is a progressive condition but it is usually very slow to progress.
Capsular contracture does not need to be treated and it is your choice whether you have your implants replaced.

Prevention of capsular contracture

There are a number of potential causes for capsular contracture that we work hard to avoid in order to minimise the risk of capsular contracture.

Small amounts of infection around the breast implant or a collection of blood around the implant (haematoma) can predispose to capsular contracture.

We do everything we can to minimise the risk of infection with breast implants and are very careful to control any bleeding at the time of surgery.

Fortunately the risk of infection and haematoma are very low after breast implant surgery.

Using textured rather than smooth breast implants and placing the implants under the muscle has also been shown to reduce the risk of capsular contracture, but probably the most significant thing that you can do to reduce the risk of developing capsular contracture is to use polyurethane foam coated breast implants.

These implants have not been widely adopted in the U.K. but have a been used in hundreds of thousands of women worldwide.

They are controversial and like most things, they have pros and cons and you can read my blog post about them here.

I think they are good implants and I use them a lot because I do not want my patients to have problems with capsular contracture in the future, but I discuss the risks and the benefits with everyone because ultimately it is your decision as to what type of implant that you have in your body and you need to be comfortable with the choice.

Treatment of capsular contracture

The good news is that capsular contracture is not a harmful condition and it is perfectly acceptable to leave it alone.

It does tend to be a progressive condition and so will probably get worse, but progression is usually slow and it can take many years for it to develop.

The bad news is that the only effective treatment of capsular contracture is surgery.

There are no tablets or creams or any other cures that have been shown to be effective in the treatment of capsular contracture.

Surgery involves removing the capsule (capsulectomy) and replacement of the breast implants.

This surgery is more extensive than the original surgery to insert the breast implants and so it is more expensive and because it is more extensive, it is more traumatic and creates more scar tissue.

Because capsular contracture happens in the first place because of scar tissue forming around the implant, another capsular contracture happens quicker after a capsulectomy and implant replacement than it does after the initial breast implant operation.

For this reason, my advice to patients is always to wait as long as possible before undergoing a capsulectomy in order to minimise the number of operations to your breast in your lifetime.

The type of surgery that can be performed on the capsule could be:

 

Capsulectomy

this is removal of the capsular tissue and can be partial or complete.  This can be quite an extensive operation and there is a risk of bleeding that can form a haematoma and cause the breast to swell up. This would require another visit to the operating theatre to evacuate and wash out the haematoma.

Capsulotomy

this is scoring of the capsule to release it and allow it to expand if a new implant is being placed (note, if you are changing from a silicone to a polyurethane implant, then a total capsulectomy should be performed to allow virgin tissue around the polyurethane implant to grow in to it).  This is usually performed in cases where there is only a mild form of capsular contracture otherwise capsulectomy would be needed.

Capsulorrhaphy

this involves using the thick tissue of the capsule to suture together areas of the breast pocket to manipulate the shape and appearance of the breast.

This is usually required in situations where the implants are being replaced because they are not sitting well in the breast pocket.
They could be:

  • Too high
  • Too low
  • Too far out to the side
  • Too close together in the middle (synmastia)

It may also be required if the implants are being replaced for smaller implants because the breast pocket may be too big.

The other situation where capsulorrhapy is useful is where there is a poor definition of the inframammary fold.  The inframammary fold is a very important feature of the breast as any surgeon who performs breast reconstruction after mastectomy will tell you.

A very important part of breast reconstruction is to recreate the inframammary fold and these techniques used in breast reconstruction can be transferred to cosmetic breast surgery if needed.

The inframammary fold is the part of the breast where a wire of a wired bra would sit.  If you look at the shape of a breast, it is not simply a dome on the chest wall.  In the upper part, there is a smooth transition from the upper chest to the upper pole of the breast, but it is important to avoid this shape in the lower pole.

The lower part of the breast has a defined and crisp fold which gives a natural shape to the breast as it sits on the chest wall.

This is important, not only so that the wire of a wired bra sits comfortably, but also to give a normal and natural look to the breast. If there is blunting of the sharp angle at the inframammary fold, then the breast lacks aesthetic appeal.

It can be difficult to recreate the inframammary fold in situations where it is not well defined, either following breast enlargement surgery or as a result of your natural breast shape.  This can involve a combination of internal sutures and capsulorrhaphy.

Want to know more about Capsular Contracture?

If you have any questions about capsular contracture or if you are worried about your breast implants, then you can get in touch with us here.

If you would like a free copy of our Breast Implants Guide, then you can request one here.

You can also see Mr Staiano, our director, on Facebook Live every Tuesday evening at 7pm, so you can ask questions there or post your questions to laura@staianoplasticsurgery.estaging.co.uk beforehand using the hashtag #AskJJ.

Less is Not More

Less is not More. In Fact, Less is Usually Less.

We live in an age where everyone wants the best, the fastest, the tallest and the most expensive.

We want it now and we do not want to wait and we want it at the cheapest price. Of course this is natural. It is human nature to want to get the best deal. However, it is important to realise that often compromises will have to be made. This is very true in cosmetic surgery.

Everybody wants the least invasive procedure.

Of course they want the one stitch facelift or the scarless breast reduction or the mini tummy tuck. Less scarring, less downtime, less cost. This is fine, but it is important to realise that as with anything, there is a compromise.
A lot of plastic surgery involves removing skin in order to tighten the tissues and to combat the effects of gravity and weight fluctuations, whether it be in the face, the breasts or the tummy. If we are going to remove skin, then inevitably there will be scarring. Much of the art of plastic surgery revolves around placing the scars so that they are difficult to see and handling the tissues carefully so that when the skin has healed the scarring is just a faint line and blends in with the normal skin.

There is a big difference

between the scar you get from a cosmetic blepharoplasty compared to that when having an emergency appendicectomy, partly because as plastic surgeons we are fortunate to operate on the face a lot and the face tends to scar very well but also because the priorities of surgery are different. The whole aim of a blepharoplasty is to improve the appearance, so taking care over the scar is crucial, whereas an emergency appendicectomy can be a lifesaving procedure and quite rightly the quality of the scar will not be of paramount importance to the surgeon.
Despite our efforts to leave the best quality scars hidden in natural skin creases and shadows, it is important to realise that all scars are permanent and if you look hard enough you will be able to see them. For this reason, if it is possible to perform a procedure with less scarring then we will be all for it.
However, the problem with all of the minimal scar procedures is that if you leave less scarring then you can remove less skin and if you remove less skin, then you cannot tighten the tissues as much and if you do not tighten the tissues as much then you cannot give as dramatic a result as you might want to.
I saw a quote the other day:

Our service is cheap, fast and good quality but you can only have two of the three

By all means you can have a short scar facelift or a mini tummy tuck, but you would have to accept that the result would not be as dramatic as if you had a full facelift or a full tummy tuck. Now for many people this might be an appropriate compromise and they would be quite happy to have a slightly less dramatic result, particularly if the skin laxity preoperatively is not significant; in favour of the reduced complications and scarring. However, this is a conversation that you have to have and you cannot expect to get as impressive a result as you might have done if the surgeon is limited to the amount of scarring that he can leave.
Unfortunately advertising and marketing plays a major role in cosmetic surgery and there will always be those who will seek to use headline benefits like minimal scarring and minimal downtime to attract and seduce customers. However, I would caution you to be careful, to look behind the advertising and make sure that you see before and after photographs and even talk to previous patients to ensure that the headlines deliver on the expectations.

Managing expectations is crucial to our ultimate goal which is to deliver a happy patient.

We all know that these techniques exist.

You will often find that many surgeons do not perform these limited procedures as often as you might think given their stated and highlighted benefits. This is because if they do not deliver a happy patient, it does not matter how short the scar is, the operation will not be deemed a success.
You have to question why you are seeking surgery in the first place because the least scarring and the least downtime comes with no surgery at all, which of course is always an option. However, if you have significant skin laxity or a cosmetic problem, you need to find the best and most effective way to treat that and be guided by your surgeon rather than focus on headlines that promise scarless surgery or a lunchtime facelift.

Many plastic surgeons are against the concept of advertising in cosmetic surgery

and I can understand why but I do think that there are benefits in advertising when it is used to educate and inform the public about what is available. The problem comes when advertising is used to target vulnerable people, is insincere or inaccurate with its claims.
There will always be those who want to chase the sale and worry less about delivering the best service possible. I cannot help but think these people will have very shaky and short term businesses. Any individual surgeon in private practice is in it for the long haul and will put great emphasis on building a good reputation. There is no place for unscrupulous advertising.
It comes back to what I will always advise which is do your research and by all means look at and read advertising material but at the end of the day, ask your surgeon questions, look at the results and talk to previous patients to ensure that you are choosing the right procedure for you, not just the one with the shortest scar.

The Secret of A Good Scar

All surgery will leave a mark or scar of some sorts whether it be having a mole cut out or shaved or having a lesion scraped or having something removed by laser.  All of these things will damage the skin and cause some form of scarring.  The scarring is usually quite red and obvious to start off with and it is how the scarring is managed that can often make the difference between a good scar and a bad scar.

Qualities of a good scar

The first step in obtaining a good scar is to plan where the scar is going to lie and this is something we as plastic surgeons spend a lot of time studying in order to hide scars as much as possible.  There are natural lines, skin creases and shadows all over the body and plastic surgeons will exploit these in order to leave as little a trace as possibly that anything has been done.  The next step is to use meticulous surgical technique and we are trained to minimise the handling of the tissues and to use fine instruments so that this normal skin is damaged as little as possible to improve the healing.  The technique of suturing a wound is an art in itself and it takes many years to learn the techniques to bring the edges together to maximise the contact and the quality of the resulting scar.  It is important that the wound is not closed under any tension and so we use techniques to support the wound using deep sutures or occasionally by moving tissue around to move the tension from one area to another in order to maximise the chances of good wound healing and resulting scars.

Postoperative management of scars

It is important that scars are supported in the initial phases which is why we often use deeper layers of sutures to reinforce the wound.  Tapes and dressings can help although these can often be kept light and the wound is to be kept clean.  Scars on the face are often left exposed and we will often dress these simply with antibiotic ointment.  We try to use waterproof dressings when possible, which means that you can wash and shower immediately.

Timing of suture removal

The classic hatched appearance of a scar with a straight line and dots on the other side as seen in Popeye is something we try and avoid and the dots are caused by sutures being left in long enough to cause a scar of their own.  For this reason we will avoid leaving sutures in too long and so on the trunk will often use dissolvable sutures which are buried and you cannot see and on the face we will remove sutures early, around five to seven days.  In some cases the wound healing is more important than the quality of the resulting scar and so there may be incidences where it will be reasonable to leave the stitches in for longer to make sure the wound stays together.  It is important to avoid too much activity around the scar to allow the wound to heal and to avoid stretching of the scar.

Long term management of scars

All scars will be red and quite obvious to start off with and can take some months before they start to fade.  Moisturise and massage of the scar will help them to fade and there are lots of products available such as Bio Oil, Vitamin E and Aloe Vera which can be used to massage the scars once they have had a chance to heal.  The scar will be red and obvious for the first three to six months and while it is red and obvious it is important to avoid the sun because if you get a suntan on a red scar while it is still active then when you lose the suntan the scar will stay pigmented and you will end up with a brown scar.  This does not mean that you cannot go into sunny climates but it does mean that you should keep your scar covered while you are out in the sun and this can mean high protection sun block, tape or simply wearing a wide-brimmed hat or clothes over the scar to avoid getting a tan on that area.  Most scars will settle by a year although it can take longer.
For more advice feel free to get in touch.  You can call us on 0121-454 3680 or contact us through the website.  I do a live Q&A on Facebook every Tuesday at 7pm.  It would be great to see you there and I would be happy to answer any queries.

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