Starting about 2 weeks after skin repair, scar tissue starts to grow and thicken. This is a normal process of healing which can make the surgical area look worse. The thickening of the scar is also known as hypertrophic scarring. Keloid scarring, an extreme case of scar growth, is rare and is characterized by a ballooning scar lump in the repair area.
To fight that scar hypertrophy, patients should start scar massage at two to three weeks after surgery. This should be done less like a massage and more like painful scar crushing. The "massage" should be performed for 2 minutes several times daily. It is a well known fact that compression dressing or objects such as earrings and glasses can soften and even eliminate the thick subcutaneous scar within a few weeks. The massage alternative should be done for up to 2 months after surgery.
Also starting 2-3 weeks after surgical repair, use of silicone sheeting can be helpful. A small adhesive sheet of clear silicone is place on the scar for up to 12-16 hours per day. It suppresses scar inflammation - redness and itching- and can even decrease hypertrophic scar. The silicone is used for 1-3 months. The science behind why silicone sheeting works is lacking. It is theorized that the occlusion of the scar helps trap moisture, heat, and certain wound healing molecules. These would normally diffuse out through the thin epithelium of a new scar. Continuous wear of silicone sheeting can cause skin maceration (whitening and wrinkling) and irritation. Limiting silicone sheeting to 12 -16 hours per day can prevent that. Liquid sealers such as Mederma can also be helpful by drying to a thin covering layer. However, they rub off easily and require frequent reapplication. Perhaps the best combination is liquid sealant during the day and silicone sheeting at night.
Sun protection of the scar in the first several months of healing is critical. UV rays will increase scar inflammation and hypertrophic healing. What is more serious is that fresh scars do not have natural pigment protection from UV rays, making the ultraviolet rays more carcinogenic. Cancers occurring in sun-exposed scars 15 years after surgery is seen too often. Sun screen is important. But complete sunblock with clothing, hat, Band-Aid, or brown surgical tape is even better in the first several months.
Cortisone injection of hypertrophic scars is an option starting as early as 3 weeks after surgery. It can be repeated every 2-4 weeks for up to 2 additional times. Injections can be painful and sometimes can cause unwanted alterations of surrounding skin (fat atrophy and violaceous color). Thus, cortisone injections are used only in very specific cases.
Superficial radiotherapy is a great alternative to keloid treatment and prevention. 1-3 treatments of 1 minute each are required in the first 3 weeks after keloid excision to prevent recurrence.
Most scars, especially of the face, resolve rapidly and without hypertrophy. No scar management is needed in those cases. Other areas such as the chest, back, shoulders, and legs heal with hypertrophic scarring majority of the time.
Ironically, older age is an advantage with scarring - scars are not as thick in older patients. Teenage years and early twenties is the time of most agressive healing and hypertrophic scarring. Other factors of scarring include genetics, overall patient health, and tension of surgical repair (greater tension creates greater scarring).