Why Scars are a Trade-Off You Won’t Regret

Monique Ramsey (00:04):
Welcome everyone to The La Jolla Cosmetic Podcast. I'm your hostess, Monique Ramsey. Today we're talking about something that is often overlooked but plays a huge outcome in the overall procedure and the satisfaction. And I think as patients, it's something that we're very, very critical about, when we're going into a procedure, what are my incisions going to look like? What's my scar going to look like? It's very important, but it's kind of hard to find information out there on what can we do to give ourselves the best chance for a beautiful scar from pre-op planning post-op care, we're going to answer all your birding questions about scars and healing and incisions. So I want to welcome back to the podcast studio Dr. Hector Salazar. Welcome Dr. Salazar.

Dr. Salazar (00:54):
Thank you so much. Thanks, Monique.

Monique Ramsey (00:55):
Okay, so let's talk about the length of incisions for different procedure. What do they look like at first and what they look like as they're fully healed? So let's start with breast procedures. So breast augmentation. What is a scar for that? What's the typical placement? How long is it or how big is it and what's that going to look like as you heal?

Dr. Salazar (01:18):
During a breast augmentation, the classic incisions, the most common places where you can put an implant through is going to be underneath the breast or through the areola, and those incisions are going to be about four centimeters. So literally four, four and a half centimeters. You can see a couple of finger breadths, so that's the length, four centimeters. It's very, very small, plastic surgeons are very good at closing incisions and hiding incisions. It's not that we can do things without incisions. If you hide the incision underneath the breast, of course if you have a full frontal view of the patient, you cannot see that incision because it's hiding underneath the breast or because you're hiding it exactly at the margin of the areola. But yep, four centimeters.

Monique Ramsey (02:09):
Four centimeters. Okay. And then when is that scar, I guess, fully matured or healed in a patient's mind? When are they going to say, oh gosh, I forgot it was even there.

Dr. Salazar (02:21):
Well, I forget it was even there, probably it's going to take some time. It's probably going to be, you're talking about most likely, we consider a scar fully matured, even though it continues to improve, but at about a year. At about a year, it's that point in which pretty much the remodeling of the scar is slowed down enough that you can consider a mature scar. At six months you're going to have a very good idea of how it's going to look and then it'll continue to progress. But to the patient's eye, the scar at about two to three weeks, it's completely healed and then it will continue evolving the next months up to a year.

Monique Ramsey (03:01):
And that's a word I've heard before, remodeling. What does that mean? What's the body doing?

Dr. Salazar (03:07):
I like to create analogies for patients and imagine that you are at a construction site and you're building, let's say a house and you're part of the construction company and then you've already signed some contracts with the people that are going to be bringing the material, all the materials for you to build a house like wood and sand and rocks and all those different materials that you need for the construction. So what happens is even though at three weeks the scar has healed enough that to the human eye it looks like everything's closed, that nothing else is happening internally, there is still a lot of collagen being deposited, meaning a lot of materials are still being delivered. Even if you said like, Hey, the construction's over, and then you get this truck, semi-truck unloading and saying, Hey, I dunno, I already have a contract here.

(04:09):
I'm just going to dump this sand and rocks and everything that you already signed up for. And you're like, but we're done, we don't need it. And that's what the body does. The body continues to deposit some healing materials up to three to four months. So that is the reason why patients see that the scar actually, and that's one of the things that I like to show always patients when we are done with surgery, it's a fine line. It's a very fine line, and that's what we are very good at, plastic surgeons. Then their body takes over and then you'll see that at about three to four months, and I know you know this, Monique, the scar turns a little intense. And that intensity, it's part of the fact that more material than what's needed continues to be deposited. And then patients go like, oh, but my scar used to be a little bit better and now it looks like so purple and it's because there are still those trucks are unloading and unloading. What happens, and I like to tell patients that at about three months is when the cleaning crew comes in. So that is the true scar remodeling phase and when pretty much all that extra material that it's not needed, it's going to be cleaned up and then the scar actually flattens, and then the color, the intensity of the color goes down, and then eventually at six months or a year you have a fine white line that it's pretty inconspicuous and that is the remodeling phase of the scar.

Monique Ramsey (05:42):
Oh, I'm so glad you told me this because I've heard that word thrown around and I'm like, okay, I think I know what that means, but I didn't really, so thank you. Really, I feel like a breast augmentation scar four centimeters, it seems small, you're trying to put the implant in, but in other procedures, let's talk about a breast lift or a breast lift with an augmentation. It's more almost like an engineering kind of scar you're trying to lift. You're not just putting something in, you're lifting and these scars have to sort of help create that new look. And so tell us a little bit about other kinds of breast scars other than an augmentation.

Dr. Salazar (06:21):
If you're trying to reduce the size of the areola, right, I mean we had a podcast that we were talking about the areola and the nipple and we dedicated a good amount of time to that. But since we were talking about scars, if you're trying to reduce the size of the areola, so it's a no brainer. I mean people can see the fact that you need a scar around the areola and if you're going to combine that with placing an implant, you can use the same gateway to put an implant in as you're reducing that areola or gets a little bit more complex. If you want to protect a little bit from encapsulation of the implant capsular contracture, you can opt, even though you're reducing the size of the areola to still put the implant underneath the breast with another small incision. Then if you're doing a lift, as you're saying, think about this, patients often when we have those big mirrors in our consultation rooms and patients look at the mirror and then they do this right, it's like if I would like my breast to be lifted. So then they pull and the engineering part of a breast lift we're limited. I mean we said plastic surgeons we're very good at hiding scars. So the worst thing that we could do is make an incision from here to here and lift up the breast and then have a patient with incisions on both breasts up here.

Monique Ramsey (07:42):
At the top for the people, the top just for the people listening only if you were lifting from your chest, I guess above, right?

Dr. Salazar (07:50):
Above.

Monique Ramsey (07:50):
Yeah, you wouldn't want scars up there.

Dr. Salazar (07:52):
You wouldn't want scars up there. So then what happens is that since we, I tell patients since we cannot pull, we have to be able to push and we hide those scars then underneath the breast. So those incisions, when we're planning for someone's surgery, either we tell them they're going to have an incision around the areola and then from the areola down to the inframammary fold, or the crease of the breast, and or adding an incision under the crease, the breast, the inframammary fold, and all that, of course they're trading those scars, trading that incision for a perkier breast for a tighter breast. And that's where the pushing part, sometimes when patients develop ptotic breast, a droopy breast, also, they have extra skin and that extra skin has to be removed at the same time that we are lifting up the breast. So the more extra skin, the more excess skin, the longer the incision needs to be because we need to capture all that skin and remove it. And there's no trick other than making an incision to extending it a little bit.

Monique Ramsey (09:13):
Let's move into the body procedures and like tummy tucks or body lift, thigh lift, I guess sometimes, or even let's talk arms too, because arms are part of a brachioplasty, an arm lift those incisions, how do you determine the length of those incisions?

Dr. Salazar (09:32):
So for the arms there is something that's called a short scar brachioplasty or a short scar arm lift. And for patients to qualify for that, they have to have a very minimal amount of excess skin and it's basically an incision that you can hide completely in the axillary fold, the armpit, in the axilla, you can hide a very short incision. You're talking about five, six centimeters in length or a little bit longer, maybe eight at the most, but it's an incision that's hidden underneath the armpit, but that captures, remember the shorter the incision, the less power it has. So mainly patients that come in looking for, get rid of my bat wings or get rid of all this, and then they're like floppy arms, then those patients need a brachioplasty, an arm lift incision that goes from starts at the level of the elbow and then goes into the axilla.

(10:42):
And sometimes, or most of the time, we extend that into the side of their chest, into the lateral chest wall to be able to capture the saggy skin of the arm next to the axilla. Why? Because if you would stop right there, your power stops where you needed the most. So that's the reason why we faded into the side of the chest wall and what we do, there's two ways when you're working in the arm, either you put that incision in the mid part of the inner aspect of the arm, which is called the bicipital groove. When you look at your arm in front of a mirror, you see that there's a little shadow in the mid part of that inner aspect of your arm, and that's called the bicipital groove. So either you can hide it there or you can put it right on, you touch the most prominent part of your elbow, and you want to draw a line from your elbow in the back of your arm all the way into the axilla. That's another spot where we can hide them. Brachioplasty incisions, they are going to be visible either when you're standing at a supermarket in a line and you're wearing a short sleeve, the person who's behind you is going to see that you have a couple of long lines in the back of your arm. Or if you opt for the first one, then when you're waving, you can see that line in the inner aspect. Then is when you pretty much evaluate the patient, make sure that the patient's a good candidate, that they don't have this keloidal healing previously, once you've seen several pictures and then they say, that scar, I don't mind it, but all this I do mind. So it's a good trade off.

Monique Ramsey (12:31):
And I think that is, that's the number one word, right? Trade off, which is more important to you, less of a scar, but less of a result, sometimes.

Dr. Salazar (12:42):
Exactly.

Monique Ramsey (12:42):
At the consultation, you're able to, I would assume, assess between the patient's goals and then show them where that scar would be.

Dr. Salazar (12:51):
Definitely. And sometimes even I ask them, are you heading to somewhere like you have a social commitment or something? And then I asked for their permission to even draw on them where the scar would be and even showing them the length, and for them it's not going to be some sort of a mystery or a surprise. They can actually see that length of that scar and see where it's going to go and then see how comfortable they are with it.

Monique Ramsey (13:18):
Yeah, that's really helpful I think for people. And they can also see pictures at a consultation, whether you're talking about a breast procedure, a body procedure, a face procedure, you can see pictures of patients, how far their scar, the length of it, where it was placed, how it healed, and I think that's really helpful for people too. Now let's talk about men. Are all these procedures that we've, not maybe the breast procedure is slightly different. We have a whole session on gynecomastia, which is a male breast reduction, but if we're talking about tummy tucks or body contouring for men, is that going to be about the same kind of scars for a tummy tuck?

Dr. Salazar (13:58):
It's going to be about the same kind of scars for a tummy tuck in men, the same thing for the arms. And I know that we're also going to touch base quickly on the thighs, which is pretty much the same concept of the arms that you can hide that scar along the groin. That's for a short, limited thigh lift. Or if you need a real thigh lift, which you have some extra skin that, the classic is patients hold their inner thigh and give a big pinch and a big pull up and they say, I want this pretty much that is an incision that it starts in your groin and goes all the way in the inner surface and the inner part of your thigh and stops right above the knee. And when patients are standing with both feet together and facing a mirror, you can't see it. But if you're sitting down and then you cross your leg, you're going to be able to see it. So again, it's a trade off. We're going to be covering tips and tricks and things about how to improve scarring, and we always do with our patients and we follow them very closely to catch any deviation from a nice good healing. Again, it's a trade off. It's a trade off. So scars end up healing really well.

Monique Ramsey (15:11):
I feel like this episode could be called the power of the scar, right?

Dr. Salazar (15:14):
The power of the scar. Yes, yes, yes, absolutely.

Monique Ramsey (15:19):
We want a strong scar. We want a good scar. And before we go into kind of what patients can do on their own and managing scars, let's just touch on another part of the body, the face, and even because you have an expertise in hair restoration, I want you to also, we can talk about eyelid lifts and face lifts and neck, and we could even talk about lipo, but also hair. So where are those, if we're talking about brow lift or where are all these different scars on the face?

Dr. Salazar (15:51):
Again, face is, I mean it's pretty much our business card for everybody. What you want to do is you're going to try to hide those scars as much as you can. So for instance, if you talk about eyelids, you make your incision and your upper eyelid, you're going to make the incision right along the crease that you already have, which is called the supratarsal crease. So literally if you close one eye and then you're facing a mirror and you look at the other eye, the eye that's closed, then you see that there is a small line right there, and that's exactly where we place that incision and then we continue that incision along that line and then we curve it up out a little bit. And then what we use to continue beyond the margin of the eyelid in order for us to be able to capture all that extra skin is we use a, when you smile, when you have a big smile, you can see that what people call crows feet, you can see those lines.

(16:54):
So we use take advantage of that line that's already there, and then we place that incision so it can be hiding. Patients, and then underneath for your lower blepharoplasty, there's two approach. One, you can actually go in the inside of the eyelid and if you have to remove extra skin, remember, I mean if you have to remove extra skin, there has to be an incision. So that incision comes right below the margin of the eyelashes. So also that is hiding pretty well. Then if you talk about the eyebrow, if you're lifting your eyebrow, it could either be a coronal lift, so meaning an incision all the way in the top within your hair. So that's, it's really, really hard to see. Then if you're talking about a temporal brow lift, then your incision is just right at the hairline. If it's done correctly, you can hide those incisions pretty well. Continuing down for your nose for rhinoplasties, so some of those incisions go inside the nose, if it's a closed rhinoplasty, so you're not going to be able to see a single incision because it's in the mucosa, it's inside. Or if it's an open rhinoplasty, the incision is going to be right here at the base because again, it's all taken into consideration like your regular social interaction, I mean, nobody looks at the bottom of your nose, I mean when you're talking.

(18:20):
So it's hard for you to catch that. For instance, for a lip lift, the gullwing lift or the long horn lip lift, so that incision is hiding right at the base of the nose. It's really hard to see it if it's well done and heals correctly. If you're talking about a face lift, a face and neck lift incision goes along the hairline, right? It could be a little bit behind the hairline or at the hairline depending on the preference of the surgeon, and then goes into inside the ear and it goes all the way around and behind your ear lobe, and then it's going to go into the hairline in the back. When we open the neck for a facelift on where we are doing some work in the neck, we use an incision that we call submental, and that is if we pretty much retract our head, we all have a little crease underneath, yes, underneath our neck.

Monique Ramsey (19:21):
I'm doing it for people.

Dr. Salazar (19:22):
We use that crease to place an incision, yes, and we use that crease to place an incision. Then continuing on the neck, I mean when we do, for instance, liposuction to the neck, we put a very, very tiny neck incision right there in that same line and then two incisions behind the ear lobe. So it's really, really, those are hard to see. For the buccal fat pad removal. If patients want to have a little bit of a slimmer size of, I mean less cheeky appearance, we make those incisions inside of the mouth and those heal pretty well. And you can't, of course, see it. When you want to have a chin implant, you can either do this, make that incision inside of the mouth, or you can do it exactly at the level of that crease that we've been talking about in the neck. For an operation called the TZ plasty, which is removing, like patients that have a lot of extra skin, that they have a turkey gobbler deformity. That's how it's called, the turkey gobbler deformity, a lot of extra skin. Everybody knows what I'm talking about. You can make an incision directly on top of it, but again, the way we do it and the way we limit that incision allows it to heal pretty well and to be almost non-visible and even though it's directly placed on the neck. Monique, did you want to talk about the fact that when you make incision, for instance for facelift, sometimes you lose a little bit of hair.

(20:54):
For a facelift in front of right here on the temporal area on the side of your forehead and down, sometimes those incisions cause a little bit of hair loss. And with hair restoration, we can actually graft some hair over those incisions and make them even less visible. So you can graft some hair and cover those facelift incisions.

Monique Ramsey (21:20):
And I think for a lot of patients, I mean I know myself, as you age, you kind of thin out right there anyway. Right?

Dr. Salazar (21:28):
Exactly.

Monique Ramsey (21:28):
So it's a nice to know. Now, if you're having a hair transplant, where is that incision? Where are those little grafts coming from?

Dr. Salazar (21:36):
There's several techniques. The one we use is called FUE, which is follicular unit extraction. So we extract the hair follicle one by one without an incision. And then we have to make a nick incision where the follicle is going to go, but then that's covered by the follicle, so it's just like you're seeding the follicle, so you create that little nick that's done with a needle, actually it's not even a scalpel, and then the hair follicle goes in. There are some patients that have undergone the previous technique, which was the line or the linear technique in which they used to remove a good wedge of the posterior of the back of your head. They would remove a whole wedge of scalp, so they would remove all that skin and then they would close that with a baseball stitch. And then sometimes patients, you can see when you put your fingers through the back of their head, you can see that linear incision healed. And that can also be grafted if that bothers the patients.

Monique Ramsey (22:52):
Now, in terms of incision care, what you're recommending, and maybe it would vary slightly depending on what part of the body we're talking about, but in general, are you recommending specific care for them prior to surgery and then postsurgery, what is their best chance to get that good scar?

Dr. Salazar (23:14):
In terms of, for instance, nutrition, nutrition is going to be very important for patients to heal that incision and for them to have, like eat good folic acid, to have all their vitamin supplements, to have their good amount of protein. Because they're going to need a lot of protein to, they need blocks to be able to repair that wall that we're going to be repairing. So that's really important. Habits, as you can imagine, smoking it affects wound healing or nicotine use in general affects that. In terms of, there are other things that we cannot control, but the fairer the skin, the better the healing, the darker the skin, the healing tends to be a little bit more aggressive. Another thing that we cannot control is the younger the person, the healing is going to be a little bit more vigorous, and the older the person, the healing is going to be a little bit more mellow.

(24:11):
We have a comprehensive scar therapy that we provide for patients. We use products from Alastin depending on the surgeon, but I know that there's quite an advantage of starting the care of the area with the Alastin products before the fact that you go and undergo surgery. And then it's very important for an incision to have for the first 24, 48 hours an environment with a good amount of moisture that promotes healing of the epithelium, meaning of the top layer. So that's for the first days, and you'll see that all of us, all the surgeons uniformly say we put some dressings and we leave those dressings on. We see patients either the next day after surgery and a couple of days after, and then we tell them we're going to be leaving this on top. We want that incision to be pampered. Then at a week, we always want to make sure that there's no infection.

(25:14):
We take a look at that and those incisions, and most likely we're going to be either replacing or leaving some of those tapes on or the dressings or the derma bond or all these different paraphernalia that we use to cover those incisions. Then at about two to three weeks, and again, this depends a lot on the specific surgeon, we start with that scar therapy, scar massage, actively telling patients how to do it when often, and depending on the different procedures you're saying how they're going to be doing it. And then you start to see that scar at about six weeks, at about three months and catching and seeing if the scar tries to heal more than what it's the right amount. So meaning if the scar starts to become a little raised, a little too exuberant, and then you can start intervening at those points. But I mean that's as you can see as part of a process and you want to go through that process in a close weight and together with your patient.

Monique Ramsey (26:18):
Right, with the one-to-one with your doctor. Because you might be healing differently than somebody else. So that there's that partnership,

Dr. Salazar (26:29):
There is a partnership.

Monique Ramsey (26:31):
At the end of the surgery on the table before they go to recovery, that scar is looking the most perfect it can look.

Dr. Salazar (26:40):
Exactly.

Monique Ramsey (26:40):
And then your body takes over and you as the patient also take over. Because if you decide to go skydiving or you decide to go sunbath topless with your new fabulous looking curves at 10 days, you're risking, you're doing something that could really undo what the surgeon did in some ways or to compromise it in some ways. So that partnership I think is so critical that the doctor's going to do as much as they can do and the patient needs to be there to do as much as they can do as well.

Dr. Salazar (27:16):
Yeah, there's a lot of active care and I mean one of the things that you're mentioning is really important. Since we hide those scars pretty well, normally where we make those incisions, when we locate those incisions, for instance, it's rare that you're going to be putting, let's say sunscreen. You go to the beach, let's say a patient had a breast augmentation, you always apply your sunscreen at the front. I mean, it's rare that someone's going to say, oh, yes, let me not forget about my inframammary fold right underneath the crease. I'm going to put a lot of sunscreen right there. Or at a facelift, oh, let me make sure that behind my ears I'm going to put all the sunscreen. So we normally, in some of those places, because of the fact that we normally hide those incisions quite well, we forget about applying some sunscreen and it's something that we always remind our patients, or if they have facial surgery and they're at least within those first three months, always wear a big hat or wear sunglasses or wear something that will be protecting those areas and take extra care. Because remember when the semi trucks are delivering that extra material, also the melanocytes, the cells that are in charge of pigment or color of the skin, they can be hypersensitive.

(28:37):
So if you have lighter skin, you can heal and you can stimulate those melanocytes and then heal with a black line. It can happen the opposite. If you have darker skin and you stimulate those melanocytes, then you can heal with a very wide line. It's something that we have to remind patients as they're healing, like always wear your sunscreen, always do this, always do that.

Monique Ramsey (29:03):
Right. Now, let's talk about sutures because there's a whole bunch of different kinds of sutures, which I didn't realize, but there's probably, I don't know, hundreds. But there's different sutures for different things, and going back to maybe the engineering analogy, or if you were hanging pictures on a wall and you have a very tiny, delicate picture, you only need a little tiny nail cuz it's not heavy and it's going to go up there, but if you have a big huge poster that's framed in glass, you're going to need some really stronger nails. And so tell us a little bit about sutures when they're inside the body, when they're not inside the body, and tell us how to think about that for scarring.

Dr. Salazar (29:43):
Those are critical, and we imagine that we have this huge large menu of sutures, and those are the material that we use to stitch patients back up. So once you make an incision, as I was saying, you know, have to close it. So the closure that you're always going to find, especially again, plastic surgeons, well, you know what, let me talk, classic question. Sometimes patients, where I would say for patients is extremely important, something that it's not very relevant to surgeons, and that is when patients say, how many stitches did you put in there? Right? That's a classic. It's a classic, Dr. Salazar, so how many sutures, how many stitches? Because we are for some reason, I mean we remember since we were kids that someone gets a cut, get a laceration, take them to the er, and little Johnny got eight stitches. And funny enough, the reason why it's completely irrelevant for surgeons and specifically plastic surgeons, the number of stitches is because a stitch is not a fixed measurement. It's not that you always put a stitch every centimeter in a centimeter, you can put 20 stitches, you can put one, one stitch every five centimeters.

(31:09):
So of course the more sutures you use and, up to a certain limit, but the more sutures you place in those, let's say four centimeter, the less tension you're going to have. So in a very, very tiny spot, such as four centimeters, what we normally do is we put deep sutures, then we put intermediate sutures and then superficial sutures. So then in four centimeters, all of a sudden maybe a patient has 30, 30 stitches in a very small space. Because what we want to do is we want to decrease the amount of tension. So we put deep sutures that are going to be dissolving, the body is going to take sometimes three to six months to dissolve those. Then you put in the intermediate plane, you're going to put another good number of sutures that are also going to be dissolving, and then you come to the most superficial part, and then depending on the body part, that varies a lot. In some parts we like dissolving sutures. In some other parts, we like non dissolving sutures that you have to remove. Then again, as civilians, what's the classic? You want the dissolving. That's what everybody wants.

Monique Ramsey (32:28):
That's what we think, right?

Dr. Salazar (32:29):
That's what we all,

Monique Ramsey (32:30):
We want the mini and we want the dissolving.

Dr. Salazar (32:34):
Exactly. You want the mini and you want the dissolving. And in reality, you know that nothing in this world really disappears. When you talk about sutures that are dissolving, what that means is that your body is digesting them. So meaning your defense cells are coming in and they're throwing all their weapons at that stitch for it to get dissolved and disappear. So basically what you're doing is you're mounting an inflammatory reaction and inflammation in that area to dissolve those stitches. So in certain parts, we would rather not have that reaction, and we would rather put in the non dissolving meaning sutures that we have to remove. So your body does not need to mount that aggressive reaction that could be detrimental to the end aspect of that scar.

Monique Ramsey (33:31):
Now I want to talk about revisions, the scars that need revising. So let's say the patient just doesn't heal, right. Maybe the color's wrong, maybe it's raised a little bit. What are the interventions that at the point that the doctor and patient together determine? Like you talked about hair transplants, if you lose a little hair, that's how we would fix that spot. But let's talk about other places where if it's an intervention that's needed, what kinds of interventions can they be?

Dr. Salazar (34:02):
Things that we can do to intervene would be, as we are observing how the scar is healing, and then it's getting a little thicker on this little spot right there. So patients are going to be intensifying their massage, the scar massage that they do. And then we continue to observe it, and if it starts to raise, we can inject steroids, we can inject 5-FU, certain substances that will kind hammer that scar, say like, Hey, stop right there. Do not continue healing so exuberantly, and it's not an exact science. So once we inject, then what happens is we want to follow them in about three weeks for us to see the result. What happened with that scar? What's the scar doing? Because we can potentially inject it again and we want to continue following them up very, very closely. One of the worst things that you could do is try to wedge it out or revise it while the scar is healing exuberant. Well, if Dr. Salazar, I'm two months out, out and my scar, look, it's getting really thick over here, why don't you just revise it now, take it out, wedge it out and do it. Make it freshly. You've got to allow the scar to continue healing. Remember, at two months, those trucks are still bringing the material so it's not the right time because you're going to redo it, and guess what? There's going to be more trucks coming in, delivering more material. So you need to allow the scar to heal, and then it depends on your surgeon and the procedure you had done. You're going to be determining if doing it at about six months, maybe intervening at about nine months, maybe intervening like at around a year would give you better chances to heal, meaning wedging that scar out, making an incision around the scar and refreshing it. Some patients, when you tell them that you're going to revise it, you're going to wedge it out, the natural question would be, and why is it going to heal better this time? Because it didn't heal like a flat line originally. Why is this going to be better? It's really easy because then your body is only concentrated on healing that small portion.

(36:23):
I mean, it's rare that we have to revise, so imagine a tummy tuck, you have a long scar right from side to side. It's really rare that the entire scar healed, so in such a thick way or in such a non cosmetically good looking way that you have to revise that entire thing. I mean, normally what we face is a very small area, a very limited that we can sometimes revise it even under local anesthesia in the clinic, they don't have to go back to the operating room, and then we just revise that part. So now your body is only concentrated on that micro part of your scar to heal it better. The second thing is that there is not a lot of tension, so tension is not good for scars, but remember, the only thing that we're looking is for tension. So if you have a neck, that's it lax, what you want is a neck that has good tension and that is bad for scars. If you have your breast can benefit from some volume, volume during a breast augmentation is going to create some tension and you're going to close that incision under tension. The same thing with a tummy tuck. You're going to pull down as much as you can, eliminate as much as skin as you can, and you close under a lot of tension. So then when you revise a scar, when you go and redo it again, that small portion then 99% of the time heals so much better because now you're not dealing with the entire construction. You're just kind of painting a small aspect of a small part of a wall, and then that's it, voila, it looks perfect then.

Monique Ramsey (38:10):
So it's really all about patience, right?

Dr. Salazar (38:14):
It's a process.

Monique Ramsey (38:14):
The patient has to be patient because they're not going to look perfect overnight. None of us are completely, you have your own part in making sure that you're keeping them covered and putting sunscreen where you need and doing all the things your doctor asked for, but at some point it's also just your body and what your body's doing, and I liked your tip about what you're feeding yourself in terms of nutrition and what are the things that you're putting in your body to give your body the best chance to go make those pretty scars. And being healthy and having healthy habits, it's not insignificant. It's a real thing. And I think having patients be thinking about the skincare or I know Alastin is a company right up in Carlsbad, and I love the fact that they're local, but they were developed for post-procedure after laser, after surgery, pre-surgery, and they have a nectar that's really great that you use before, surgeries that helps get that skin ready, right?

Dr. Salazar (39:19):
There is a lot of science behind those products. And it's all about regeneration of the tissue. And you know that, for instance, we also have available nano fat, which in which we remove a little bit of fat from patients. We process that fat in order to break it down, and what we use is we use just a regenerative factors that are around the fat cells and we inject those, and then we have seen, and studies have shown that injecting nano fatt to scars help improving the scarring. It can start from right off the bat, as a primary healer, or it can be done for scars that are old. Let's say I have this bad scar that has been there for five years or six years. You can also inject nano fat and that would regenerate and allow that scar to heal better.

Monique Ramsey (40:15):
Well, I think this has been a really exciting episode because we went from top of the head down to the practically to the feet and everywhere in between, and because I think it is something that patients are concerned about and we all want to do what we can to give ourselves the best chance for that beautiful scar, or that handsome scar, depending on where the scar is going and who it's going on. But understanding sort of where surgeons are coming from in terms of the sutures, and the placement of the scar, and how to take care of it afterwards. All of that's so important, and I thank you for that today. For everybody listening today, if you have questions, check the show notes. We've now got more than three and a half years of episodes. So you can go on our website, go under the podcast, you can search by topic, or you can go to thelajollacosmeticpodcast.com and you can search for all our past episodes. But we'll put some things in the show notes that we did talk about today. And then if you have questions about scheduling or financing or reviews or the photo gallery, check our show notes for links. Thanks again, Dr. Salazar, for your expertise. This was a fun topic today.

Dr. Salazar (41:27):
Thank you so much. I mean, I know that we're talking incisions and scars and those are the bad boys of surgery, but they are actually what are going to give you that result that the patient's looking for. So very happy to be here as usual, let's stay in touch and you know that you invite me, Monique, and I come.

Monique Ramsey (41:46):
Yeah, thank you. Thank you.

Announcer (41:47):
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