Introduction Surgical interventions will always leave scars in each and every case. Scars are defined as the body’s natural healing process, its way of repairing tissue and protecting the body from germs and further injury. Many people considering plastic surgery interventions are worried about the appearance of scars and how it will affect the results of the surgery. The type of scars that occur after surgery is one of the main concerns for plastic surgery patients, especially among women who are afraid that the scars will be highly visible and their skin will never look good again. In other cases, we see the exact opposite: the patients are under the impression that the scars will be completely invisible and then get a rude awakening after surgery. There are no invisible scars after plastic surgery A responsible plastic surgeon will tell you before the intervention that there is no such thing as invisible scars after the surgery. It is only natural to feel concerned and it is completely understandable. Whatever tools we might use when performing the surgery, a lesion is produced at skin level that will heal after going through a recovery process. But, it is also true that the surgical technique and the method chosen by the plastic surgeon have a lot to do with outcome and can spell the difference between having a very visible scar that is hard to conceal and one that is hidden in the natural folds of the body, which is more acceptable and tolerable. To achieve this, the surgeon needs to give special attention to all operative stages: before, during and after the intervention: – Preparing the patient for the surgery; – The procedures performed during the surgical intervention; – Post-operative management; – The post-operative care of the patient on the short and long term. The plastic surgeon needs to make sure that he offers all the best conditions and recommendations so that the healing process is short and uneventful. Careful thought should be given to the type of incisions to be made and its positioning, the handling of tissues that will be impacted by the surgery, and how to minimize damage to the skin during surgery. Just as important is the quality of the suture material and the type of sutures used to leave less visible and fine scars. Generally, subcutaneous sutures are preferred because these are buried sutures concealed by the skin but this is not always possible for certain surgeries. After the surgery, the long-term treatment of the scars is also critical. You should know that it takes about a year for a scar to evolve, and mature until it is completely healed. After 8 months, you will get a better idea of the aspect of the scar you will permanently have. Post-operative recommendations for wound healing It is very important for the patient to strictly follow the instructions of the surgeon during the wound-healing period. The surgeon will usually recommend Steri Strips bands and silicone gel bands. These are thin, transparent and adhere well to the skin. It helps the skin knit together and it promotes smooth and natural healing. The plastic surgeon will prescribe wearing the strips for a month or six weeks after the surgery and then the patient can start using creams designed to reduce the size and visibility of the scars. If the patient follows the doctor’s instructions for the first year after the surgical intervention, the scar will go through the natural healing process and turn thin and white, without going through the reddish and purplish stages that looks very unpleasant. It bears pointing out that aside from the talent and experience of the surgeon and the post-operative care of the patient, the body’s ability to recover and heal is also a primary factor. Each person heals differently. There are people who heal very well with barely visible scars and others that can have prolong and difficult healing, which leaves ugly, thick and reddish scars. There are also cases of extreme compositions like the keloid scars and the hypertrophic scars that are defined as raised formations of scar tissue that doesn’t stop growing like normal scars. It is a healing defect that is dependent on the patient’s genetic predisposition and the body’s particular response to trauma and surgery. Keloid and hypertrophic scars Clinically, the process manifests through congestion, edema and pruritus that are characteristic to the evolution of a new scar. In most cases, it is virtually impossible to prevent hypertrophic scars and especially the keloid ones from occurring even when the surgery is performed by the most experienced and talented plastic surgeon. The hypertrophic scar and its tumor form, the keloid, usually appear in the early stages of scar modeling as opposed to full maturity of the scar following surgical trauma, wounds with excess tension or other skin injury. We can know for sure if a scar is excessively invading the nearby tissues or putting pressure on the healthy tissues with the help of a clinical checkup There are situations when the diagnosis cannot be given if the hypertrophic cicatrization reaction is intense, resulting in the formation of hypertrophic scar even to tissues with minimal damage. Hypertrophic scars are scars with a short evolution and are more numerous and occur only after a wound. The scar becomes red, irritable and it increases in volume rapidly in three months or up to six months. After this period of time, the scar will stay unmodified and even regress. Hypertrophic scars can occur in any part of the body and they won’t show any signs of invading the healthy skin. The elevated voluminous scar might not regress and it can stay in its original shape for years, and even after any activity signs have disappeared because of over abundance of dermal collagen in the wound area. When there is an injury, the body produces collagen, a natural protein, to heal the damage to the skin. Too much of it results in hypertrophic and keloid scars. Keloid scars, are scars with a prolonged evolution that can develop over the course of several years and grow beyond the wound area. The incidence is definitely lower vis-à-vis hypertrophic scars. Keloids specifically appear on the sternal area as a unique lesion and during their evolution they typically look like butterflies. Because the occurrence of keloids is more frequent in women, the shape of the butterfly is due to the tension of the collagen fibers determined by the weight of the mammary glands. It is also possible for the keloid to occur in multiple lesions on other areas such as the abdomen, back, thighs and hips. The keloid is like a healed wound of the skin that stretches beyond the margins of the old wound and is characterized by super abundance of collagen. When trying to diagnose the hypertrophic scar and the keloid, the best way to tell them apart would be to examine the extent of the overgrowth of the scar tissue. Keloids are thick, raised, and reddish clumps of scar tissue that grow not just at the wound site but also beyond, extending into healthy tissues. The hypertrophic scar occurs as an individual raised scar, red during the first stages and almost white during late stages with congestions during inflammatory stages, accompanied by pruritus and/ or pain. The hypertrophic scars evolve for no longer than 18 months after the plastic surgery and after this they are mature and won’t change their size, shape or color again. The keloid presents itself as a red or pink tumor that is warm, hard, always growing, located at wound site and beyond, configuring itself into unsightly shapes. The evolution of the keloid is progressive and continuous; it doesn’t stop evolving. This abnormally abundant and rich vascularization is involved in the development of keloids and responsible for its hot pink color. Conclusion Scars are unavoidable when there is trauma to the skin, which is what happens in any surgery. Scar formation is simply part of the healing process. In some cases, hypertrophic and keloid scars can be avoided but as a rule, this is highly influenced by other factors like genetics and racial predisposition towards keloid formation. It happens despite and in spite of the surgeon’s experience and skills and the patient’s proper care of post-operative wounds. To minimize and stave off development of unwanted scars, avoid sun exposure after plastic surgery. No sunbathing for at least six weeks after the surgery or cover incision sites with bandages while doing so. Still, it is best that you desist. Another factor that is very important to the process of wound healing and scar formation is maintaining a constant weight during scar maturation. You must also avoid putting unnecessary pressure on the wound site during recovery. This is why performing strenuous physical exercises such as weight lifting are strongly discouraged. Of course, the patient should resume regular exercises as soon as the surgeon allows it but first discuss with your plastic surgeon the workout routine you have in mind, so he can determine if it will adversely affect scar formation or not. Specialists who will conduct medical examinations will be able to correctly diagnose if the scars are hypertrophic or keloid. Only after the diagnosis is final will the plastic surgeon recommend available treatment options that are best suited for your particular case.