Joel R. Studin, MD, FACS
New York City Cosmetic Surgeon
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Great Neck 516-482-8008

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A Blemish on Your Surgeon's Reputation???

The Real Story and How to Improve Your Odds!

By JOEL R STUDIN MD, FACS

New York, N.Y.

After surgery or injury, our body turns on its emergency repair system!  Whether the area that needs repairing is on the surface of the skin or deep inside, the process is similar.  The treatment, is however very different.

In this article, I will explain what happens with skin scarring as well as the internal scar known as "capsular contracture" of breast implants.  I will give you an outline explaining how to help prevent scarring and how to treat it if it has already occurred.

Capsular Contracture
Internal Scarring Around Implants

Or "How Come My Breast Is Hard, Rippled, or Too High?"

Anytime something is implanted, whether it is a knee joint, heart valve or breast implant, our body forms a wall of scar tissue around it.  This wall is usually soft, thin and unable to be felt.  But just like one child falls on the playground and cuts their chin and has a bad scar, and the next child with the same injury and same plastic surgeon has almost no scar to speak of, the scarring inside around an implant is unpredictable.

It would seem logical that scarring inside could be predicted by past scarring from injuries or by their family history.  Unfortunately, none of these help us predict who will form extra scar tissue inside. It is truly a random occurrence.

What happens when a little extra scar tissue forms inside?

 If someone forms a small amount of scar tissue, they feel rippling through the skin of the breast.  Is this rippling because the implant has not been filled enough?  No, I don't think this is true.

After removing implants for rippling, I have found small bands of scar tissue in the wall of scar tissue around the implant. Which came first, the chicken or the egg?  Did rippling of the implant cause the bands of scar tissue or did the bands of scar tissue cause rippling of the implant?

Because there was no visible rippling of the implant itself upon opening the pocket, I believe that this rippling is actually the smallest form of capsular contracture, or over-formation of scar tissue around the pocket. 

In cases where a small amount of rippling occurs (you can feel it but not see it), I recommend only that the patient continue massage and take vitamin E. (I will explain vitamin E a little bit later.)  Sometimes it goes away over time and sometimes it does not, but these breasts look perfect. While it is possible to feel a small amount of rippling if you try, there is nothing that looks abnormal. Risking more scar formation trying to squeeze the last bit of perfection out of a good result is usually unwise.

What happens when a lot of extra scar tissue forms?

If someone really forms a lot of scar tissue, one of two things can happen.  They get either visible rippling or hard breasts.

Solving Visible Rippling

If visible rippling occurs, it is usually seen on the outer part of the breast upon bending over. If the implants are saline, changing them to silicone gel implants usually helps a lot. If they are already silicone and they are over the muscle, then converting to under the muscle may help.

Solving Hard, Round, High-Riding Breasts

If firm high riding breasts occur, then a lot of extra scar tissue has formed and needs to be removed.  Formation of dense scar tissue will result in a pocket that is too small and squeezes the implant.  The breast can appear round, feel firm and may ride too high or hurt. Fortunately, this is uncommon.

To correct this problem the implant is removed, the scar tissue taken out, and the implant replaced.  Years ago, it was common to try and squeeze the breast very hard to break this scar capsule.  Most surgeons today, believe it is better to remove the scar tissue than to try and rupture it.

Can I stop scar tissue from forming in the first place?

As we discussed above, capsular contracture is a random occurrence.  While it is not uncommon to feel a little rippling, especially in thin skinned to patients, it is not common for someone to have enough scar formation that they need to have it fixed. 

There is no way to test for a tendency to form extra scar tissue. There does not appear to be a relation to your outside scar formation. There are two things that I believe may help to prevent it.  Notice that I use the word "may".  There is no good study to prove that the two suggestions I am about to make really work!  It is my belief however, that they do.

 Vitamin E

We have all heard that vitamin E helps scars.  Actually, vitamin E does not melt scars it may make them softer. It also may reduce future scar tissue formation.

If you take vitamin E after having implants, does it make the capsule around the implant softer and more pliable?

While there is no good study showing that this works, I have my patients take relatively high doses of vitamin E for at least one year after having breast implants. (For exact dosages you must ask your own doctor).  I believe that this has made a significant difference in decreasing the number of capsular contractures in my practice.

The No Touch Technique

There are many surgeons that believe that one cause of capsular contracture might be a low-grade infection and that a super sterile technique in putting in these implants might lead to a lower incidence of capsule formation. 

When you look at a beam of sunlight entering your bedroom window in the morning, you can see dust particles floating in the air.  The air in an operating room has dust particles in it as well. Theoretically, these dust particles could settle on the implant and contaminate it slightly.  After all, there are bacteria in dust particles.

It was theorized that these dust particles might lead to very low-grade infections later on and cause capsular contracture.

The No Touch Technique is designed to avoid even the air from touching the implant. Implants are packed in a sealed plastic container.  As soon as the package is opened the implant is covered with an antibiotic liquid.  After the pocket is made for both implants, the pocket is washed out with antibiotics solution.  The surgeon then puts the implant into the pocket inside a sterile sleeve called a Keller Funnel, that prevents any skin bacteria from touching it.  Every effort is made to prevent air and skin bacteria from touching the implants. 

Does this technique work? 

Nobody has been able to prove statistically that the No Touch Technique actually works.  My feeling is, though, that my rate of capsules dropped significantly since adding this technique to my practice.  All of my implant surgery is done following these recommendations.

Scarring of the skin

-Or-

“Did the doctor do a bad job stitching me up?”

What is a Scar?

After a surgical incision, we make collagen to repair the gap. Collagen is just like cement filling the space between two bricks. 

Too much collagen is always made, but then we also make an enzyme called collagenase that melts the extra collagen.

This molding process goes on for months. Collagen is made and the extra removed in a process designed to mold the original shape of the skin.  If extra collagen is left, a thick scar is formed.

A perfect balance between collagen and collagenase will leave the least noticeable scar.

Often, our healing process works too well! After the skin has re-formed, we keep on healing. If we could “turn up” the collagenase in our cells, we could melt the extra scar tissue.

Plastic Surgeons and Dermatologists have known for decades that there are ways to reduce scars. Until now though, none have been very convenient.

Pressure bandages were found to help increase production of collagenase, our natural scar-melting enzyme, and have been used on burn scars for over a century.

Cortisone Creams not only soothe irritated skin but also stimulate natural collagenase production. In extreme cases, doctors may use cortisone injections.

Doctors have prescribed Silicone Sheets for decades. Silicone sheeting taped over a scar will help reduce it. This was discovered in the early 80’s, when a doctor tried to apply pressure to a scar more evenly with a silicone gel sheet. The scars treated with silicone seemed to decrease much more rapidly.

Vitamin E helps by working on the collagen fibers and makes a scar softer and more pliable.

Closing the Skin

The first step in getting the best scar we can is the skin closure. Fortunately,for a Board-Certified Plastic Surgeon, closing the skin is like breathing. You have so much practice and training, it is second nature and there is truly very little difference from one experienced Plastic Surgeon to another. I have had many patients come to me over the years to fix scars left by other surgeons. They are sometimes surprised when I explain to them that it looks like the incision was closed properly, but formed a bad scar anyway. This can happen.

 After the skin is closed properly, what else can I do to lessen my scar?

For years, after the bandage or sterile strips were removed all you could do was cross your fingers.

In 1938, Vitamin E was discovered. Over the past 20 years painting it on scars has been popular, but as I explain above, it probably doesn’t shrink them.

There have been cortisones tapes and silicone gels and creams, all of which were helpful, but difficult to use because they were either messy or fell off.

I recommend a product called ScarGuard. This product combines all of the treatments that I described above into one liquid.  It is a clear liquid that forms a fine flexible film within a few seconds after painting it onto the scar.  This film helps to protect the scar from irritation while delivering silicone cortisone and vitamin E throughout the day.  I have my patients start using ScarGuard right after the steri-strips or bandages come off, but each case is different, so you need to ask your surgon when to start. Treatment is continued twice a day for three to six months or until the scar has almost disappeared.

Nothing will completely remove a scar, and a few will heal badly no matter what we do, but I believe that using a product such as ScarGuard makes a very big difference in the end result. 

What if I already have a bad scar?

The first step is to see your doctor for an evaluation.  Sometimes, a second minor surgery to revise the scar is advisable.  If scar revision is not indicated then ScarGuard will often help tremendously. ScarGuard works on old scars as well as new ones as long as the scar is not sunken already. 

If you undergo a scar revision, talk to your doctor about starting ScarGuard as soon as the bandages are removed.

 

In Closing

I hope this has helped to clear up the myths about scarring.  While this will sometimes happen no matter how careful we are, fortunately there are some very positive things that we can do to improve our chances.

Dr. Joel Studin 

 

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Joel R. Studin, MD, FACS