The unavoidable operation: a prevention plan to hand your surgeon

The conversation happens in a pre-admission clinic, usually about ten minutes long, mostly about anaesthetic history and whether you have eaten. Nobody asks about scarring. If you volunteer that you form keloids, the response is often sympathetic and vague. Something about it being noted, and about the surgeon doing their best with the closure.

That is a wasted opportunity, and it is wasted on both sides. The surgeon is not being dismissive. They simply have no reason to have a plan, because keloid prone patients are a small minority of their list and the specific measures that reduce scar risk after a planned incision are not part of routine general surgical practice.

The original element in this piece is a one page prevention plan, written to be handed to a surgeon who is not a scar specialist, sequenced by when each measure has to happen, and separated explicitly into the parts the evidence supports and the parts that are extrapolation. The individual measures come from published scar management guidelines. What does not exist is the version organised around a keloid former walking into an operation for something else entirely, which is the situation almost every keloid former eventually finds themselves in.

Why the plan has to be timed rather than listed. Most scar advice is delivered as a list of products. The reason it fails is that each measure has a window, and several of the windows close before the patient thinks scar management has begun. Two of the most important decisions are made in the operating room, before you wake up.

Before the operation. The first item is the one that has to be said out loud in the pre-admission appointment, and it is not a request for a product. It is a request about closure technique. Tension across a healing wound is the single most consistently identified driver of excessive scarring, and closure that minimises tension across the skin surface, by taking the load in the deep dermal layer, is the intervention that costs nothing and cannot be added later. Updated scar management guidelines put tension relief at the centre of prevention rather than at the periphery (J Plast Reconstr Aesthet Surg 2014, Plast Reconstr Surg 2016).

The second item is incision placement and orientation where any choice exists. Sometimes there is none, because the anatomy dictates it. Where there is a choice, an incision running along the natural resting tension lines of the skin sits under less repeated load for the rest of its life than one running across them.

The third item is a named plan for what happens at three weeks, agreed in advance, with who is responsible for it written down. This is the item that most often evaporates, because the surgical team discharges you and the follow up is about the operation rather than the scar.

The first two to three weeks. The instruction here is genuinely counterintuitive: mostly do nothing to the scar itself. The wound needs to close and epithelialise before occlusive products go on it, and applying silicone to a wound that has not sealed is not helpful. What matters in this period is avoiding tension, meaning restricting the movements that repeatedly stretch the incision, and avoiding infection or wound breakdown, both of which prolong inflammation and make the eventual scar worse.

Steroid injection also does not usually belong here. It belongs in the plan, but early injection into a wound that is still gaining strength is not the standard approach.

From roughly week three, once the wound is closed. This is where silicone starts. Silicone gel sheeting or gel is the most consistently recommended first line preventive measure in the scar guidelines, and the recommendation is specifically for high risk patients and high risk sites, which is exactly the population this plan is for (Eur J Dermatol 2014). The critical detail is duration and adherence. The regimens described in the guidelines involve wearing it for a large fraction of the day and continuing for months, not weeks, and this is where almost all real world failure happens.

Pressure is the second measure, where the site allows it. It is standard practice for earlobes after keloid excision and is used over larger sites where a garment can be worn. It is not applicable everywhere, and pretending it is helps nobody, which is covered in more depth in how pressure therapy actually works.

The review point at six to eight weeks. The plan should contain a date, not a vague intention, at which someone who understands keloids looks at the scar. The purpose is early detection of a scar that is becoming raised, because intralesional corticosteroid works far better on an early raised scar than on an established keloid, and the whole logic of intervening early is the same logic behind deciding whether to treat a new keloid now or watch it.

This is also the point where the difference between a hypertrophic scar and a keloid becomes visible, and the two have different trajectories even though they are treated similarly at this stage.

The separation nobody makes. Here is the part of the plan that should be written in a different colour, because handing a surgeon a document that overstates its own evidence is worse than handing them nothing.

Well supported: tension reducing closure, silicone from around three weeks in high risk patients, pressure where anatomically feasible, early intralesional corticosteroid for a scar that starts to raise, and avoidance of wound infection. These appear consistently across the major scar management guideline papers.

Weakly supported or extrapolated: onion extract preparations, vitamin E, massage regimens, and most over the counter scar creams, which is why whether scar creams work on keloids has a shorter answer than the shelf in the pharmacy suggests. Also extrapolated is prophylactic radiotherapy after an unrelated elective operation, which has a real evidence base after keloid excision but is a very different proposition as prevention for a first incision, and is not something to request routinely.

Genuinely unknown: whether any of the prevention measures work as well after a general surgical incision in a keloid former as they do after deliberate keloid excision. The trials were mostly done in the latter population. Practice surveys have found wide variation in what clinicians actually do about prevention, which is itself evidence that the answer is not settled (Wound Repair Regen 2014).

How to deliver it. Print one page. Put your name and the operation date at the top. Write three headings: at operation, from week three, review at week six. Under each, three lines maximum. State at the end, in one sentence, that you form keloids and which sites they have formed at. Give it to the surgeon at the pre-admission appointment and email a copy to the department, because the person operating may not be the person you met.

Surgeons respond well to a short, specific, correctly hedged document and badly to a printout of an article. The difference between the two is that one asks for a technique decision that they can make, and the other asks them to become a scar specialist between now and Thursday.