Scar, cicatriz, narbe, blicna, simadi—call it what you will in any language. It is almost universally the common catalyst to dissatisfaction in surgical outcomes. Whether the surgery was elective, necessary, or posttraumatic, scarring is often the trigger that sends the patient to the plaintiff’s attorney’s office.
Many of us, whose specialty inevitably calls for creating scar as a byproduct of our daily job, can’t understand how common logic can fail to explain that the human body obviously repairs itself by creating a scar as part of the healing process. It’s that simple! We also know that how the patient heals and what kind of scar he or she produces is the inevitable result of several factors. The most important factors are the patient’s genetically acquired predisposition and the possible influence of his or her ethnic background.
In other civilizations, scars may be considered beautiful—the more the better. In fact, some African tribes go to great lengths to create elaborate decorative scars that they display with pride. Most societies in the Western world look upon scarring as, at best, inevitable sequelae of postoperative healing or trauma and, at worst, as the result of bumbling by an incompetent doctor. When the scar is a result of elective surgery, for reasons of health or vanity, it takes on a wholly different dimension.
Physicians who take scar making for granted must educate themselves to carry the layman’s viewpoint on scarring in the foreground of their consciousness. The need to discuss scarring as an important part of the preoperative disclosure process cannot be overemphasized. You have an affirmative duty to discuss the information with the patient. This simply means that, rather than waiting to be asked, you should volunteer information about scarring.
The simple mechanics of describing anticipated scar in terms of location, dimensions, maturation, change, etc., is not a difficult task. It is far more important, however, to make sure the patient understands that no matter how brilliant the doctor’s brain and how deft the hands performing the operation, there is no way the physician can control the eventual appearance of the scar.
Regardless of the circumstances, it is the physician’s responsibility to make each patient understand that the quality of the scar will depend mostly on his or her genetic package and whether the wound was created by incision or trauma. Understandably, there are variations on this score: smoker or not, anemia, diabetes, connective tissue disease, type of trauma, infection, etc. There are also factors that are (or should be) in the surgeon’s control, i.e., suture type, techniques of closure (stitches versus staples versus glue/Steri-strips), and timing of the stitch or staple removal. Obviously, too, there are various forms of contributory negligence by the patient. By and large, however, innate patient healing characteristics and ethnic background are the most important considerations.
Obviously to the surgeon performing elective procedures, any resulting scar plays an inordinately important role in the success or failure of treatment outcome. To the surgeon in any specialty, full disclosure is not only highly recommended, but it is also virtually mandatory. In all scar-based claims, disclosure emerges as an important issue and is often the issue. Certainly, before undertaking elective aesthetic surgery, a thorough exploration of the topic with the candidate patient is a sine qua non.
In surgery requiring incisions on parts of the body that are apt to be exposed (such as the face, trunk, breasts, abdomen, etc.) or in any other operation requiring long incisions, the resulting scar can easily become a contentious issue. To avoid this outcome, it is recommended that the surgeon draw on the patient’s skin with a heavy colored marker exactly where those scars are expected to be, stand him or her in front of a mirror before surgery, and record this disclosure in the chart or even take photographs.
The growing popularity of bariatric surgery is bringing with it massive reductions of weight that result in unsightly excess lax skin. In mature people with diminished elasticity, this condition often requires a plastic surgery consultation. The surgical removal of such “aprons” cannot avoid leaving major, extensive scars. The prospect of extensive scarring must be drilled into the prospective patient and justified as a tradeoff, with graphic descriptions of the location, extent, and probable appearance of the scarring. Failing to document this in the medical record almost certainly invites “If only he or she had told me…” repercussions.
Why all this fuss over what appears to be a relatively minor issue? When faced with the responsibility of reviewing an unending stream of cases in which scarring plays the decisive role in the disposition of the claim, it becomes clear that documentation carries a major weight in winning or losing the case. The irony is that in most situations it is seldom an issue of competence or standard of care. Rather, it is a simple issue of appropriate, well-documented disclosure a priori—a responsibility that every physician must take seriously.
Do not wait to be asked questions about scarring—volunteer information. Always involve the “significant other” in the discussion, particularly in situations involving female breast surgery.
Explain to the patient that scar formation is a natural biological process that is an absolutely inevitable by product of surgery. Firmly disavow the “invisible scar” concept: no scar = no healing.
A number of factors control scar formation. One of the dominant factors is the set of genetically “built-in” healing characteristics. Give examples that include eye color, hair quality, height, and weight.
Ethnic descent may play a significant role in the ultimate appearance of a scar. Cite very frequent keloid formation as natural in individuals of certain ethnic origins. (Use examples, such as the decorative keloids of African, Pacific Islander, or Australasian people.) Always emphasize this information, and document it in the medical record when consulting with patients whose ethnic origins suggest the possibility of bad scar formation.
The variability of the ultimate scar is influenced by whether it was caused by incision or trauma. If repairing primary trauma, always warn the patient and family about the possible outcome that may require revision. Emphasize the influence that smoking has on scar formation. Always document these conversations in the medical record.
Healing characteristics vary with wound location. A scar that is barely visible on the face may have a different appearance on the breast or abdomen. Beware, most particularly of substernal incisions on women or post auricular incisions on deeply pigmented skin.
As part of your consultation, draw the likely scar with a heavy marker. Have the patient (with his or her significant other watching) look in the mirror. Photograph this exercise and document it in the medical record to guard against possible complaints of failure to inform.
In post bariatric contouring consultations or any other surgery likely to require long scars in various body locations, explain the need for the patient to accept the resulting scarring—regardless of the appearance. It must be considered a straight trade off: acceptable contour with major psychological benefits in exchange for an inevitable scar. Include a detailed record of this conversation in the patient’s medical record. Informed consent is mandatory.
Do not communicate criticism—either by word or action—when consulting with a patient about a bad scar that was ostensibly caused by a colleague. (“There but for the grace of God...”) Be sure that you know the causative circumstances before offering an opinion.
Always emphasize that time (a minimum of one year) is the patient’s best friend. Describe—but do not guarantee—existing avenues for scar improvement: post one-year revision, steroids, silicone sheeting, pressure, etc.
Mark Gorney, M.D., F.A.C.S., clinical professor emeritus of plastic surgery at Stanford University, is a founding member of The Doctors Company. Dr. Gorney, the company's medical director for 18 years, is now governor emeritus and senior consultant in plastic surgery.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.