Plastic surgery, whether done for cosmetic enhancement or reconstructive purposes, is designed to improve how you look and feel. The procedures of body contouring and facial surgeries are done to create the most refined result possible, carefully. However, no matter how precise the technique or how experienced the surgeon is, every surgery involves scarring.
As the body repairs the areas, a scar is formed. In most cases, this scar fades with time. But in some patients, especially those who are more prone to raised or thickened scars, the healing process becomes more aggressive. It can lead to hypertrophic scars, which are within the incision’s boundary but remain raised, or keloid scars, which grow beyond the original site. These scars are not cosmetic concerns, but can cause discomfort, itching, and emotional distress.
What is a Hypertrophic scar?
A hypertrophic scar is a thick, raised scar that stays within the exact borders of the original wound. It often appears within a month of the injury, may feel firm or itchy, and importantly, can slowly improve over time. They are common after surgical incisions, acne, and burns, especially in areas under mechanical tension (e.g., chest, shoulders, joints). The main reasons behind these scars are:
- Early, robust inflammation after injury or surgery
- High skin tension at the site (movement, stretching, location)
- Depth of injury (dermal involvement), infection, or delayed healing
What is a Keloid scar?
A keloid is a thick, rubbery, overgrown scar that extends beyond the original wound edges and can continue to enlarge for months to years. Keloids tend not to regress on their own. They’re more likely on the chest, shoulders, jawline, and earlobes, and in people with darker skin tones or a family history of keloids. They may itch or hurt and can be very sensitive.
The main reasons behind a keloid scar include:
- Genetic predisposition and skin type
- Location (high‑tension or high‑movement sites)
- Triggers such as piercings, acne, minor cuts, or surgery
Difference between Hypertrophic and keloid scars
- Boundary of the scar: Hypertrophic scars stay within the original incision or wound. Keloids push past those borders into nearby healthy skin. This makes keloids less predictable and often more concerning functionally and cosmetically. Hypertrophic scars mirror the size and shape of the original wound; keloids can look disproportionate and extend well beyond it.
- Growth timeline and progression: Hypertrophic scars usually appear within weeks and tend to stabilize or slowly flatten. Keloids may appear later, sometimes months after the injury, and can keep growing for years without treatment. While hypertrophic scars often enter a quiet, improving phase; keloids tend to persist.
- Response to treatment: Hypertrophic scars often do well with conservative care such as silicone therapy, corticosteroid injections, and non‑ablative lasers. Keloids are tougher to manage and often need combination therapy, steroids with agents like 5‑fluorouracil, cryotherapy. In selected cases, surgical removal with postoperative measures such as radiation or compression can also be involved. Keloids also have a higher chance of coming back.
- Common locations and risk factors: Hypertrophic scars show up where tension is high, shoulders, chest, joints, or after deeper injuries and burns. Keloids favor certain regions (chest, jawline, earlobes, upper arms) and are more common with darker skin tones or a family history. Keloid formation points more to genetics; hypertrophic scarring is more about local mechanics and healing conditions.
- Surface characteristics and symptoms: Hypertrophic scars are typically linear, firm, and raised, often pink or red early on with occasional itch or mild discomfort. Keloids are thicker, shinier, and can be nodular or irregular. They’re often more symptomatic, with persistent itching, tenderness, or pain, making them more distressing day‑to‑day.
Initial Care for Hypertrophic and Keloid Scars
Successful scar treatment begins with understanding the underlying behavior of the scar and matching it with the appropriate therapeutic response. While both hypertrophic and keloid scars involve overproduction of collagen, they require different strategies due to their biological differences and progression patterns. The goal of treatment is not only to improve appearance, but also to reduce discomfort, flatten the scar, and restore skin flexibility where needed.
To support this process, we follow a structured, phased care system known as the Scar Protocol. This protocol does not rely on a single product or technique, but instead provides a thoughtful, stepwise approach based on the timing of scar development, its type, and how the tissue is responding.
Early Intervention with Surface Management
In both scar types, initial intervention focuses on protecting the scar surface and supporting healthy remodeling. This begins as soon as the wound is fully closed.
- Medical-grade silicone (either in gel or sheet form) is widely used to hydrate and gently compress the area. This helps regulate collagen production and supports a smoother healing trajectory.
- UV protection is essential to prevent pigmentation changes, especially in early-stage scars. Broad-spectrum SPF and physical barriers like clothing or tape are recommended during the first 6–12 months post-surgery.
- Moisturizing and approved scar massage (once cleared by the provider) help improve pliability and reduce surface dryness or tightness.
Tension Off-Loading and Mechanical Control
Tension on the healing wound is a known contributor to hypertrophic scar formation. In high-mobility or high-tension areas (shoulders, sternum, joints), we incorporate:
- Microporous tape or postoperative tension-reduction devices to support the incision and minimize mechanical pull during critical healing phases.
- For existing raised scars, stretching, friction, and skin motion are minimized to prevent further aggravation.
This step is particularly useful in preventing hypertrophic scars and reducing the likelihood of worsening in keloid-prone patients.
Intralesional Therapies for Raised Scars
When scars become raised, thickened, or symptomatic, in-office treatments may be required. These are introduced under clinical guidance based on the scar’s maturity and severity.
- Corticosteroid injections (typically triamcinolone) are used to reduce inflammation and shrink hypertrophic and keloid scars. These are delivered at regular intervals depending on response.
- In more aggressive cases, particularly with keloids, 5-fluorouracil (5-FU) or other agents may be combined with steroids to improve treatment outcomes and reduce recurrence risk.
This therapeutic step is central to managing established keloids and hypertrophic scars that have worsened despite conservative care.
Laser and Light-Based Modalities
Laser therapy offers valuable adjunctive treatment, especially for scars that are red, itchy, or firm.
- Vascular lasers, such as pulsed dye lasers (PDL), can reduce redness and early symptoms in both hypertrophic and keloid scars.
- Fractional non-ablative lasers may be introduced later to improve scar texture and flexibility after the scar has matured.
These treatments are introduced selectively under the Scar Protocol, based on the phase of healing and patient-specific goals.
Cryotherapy and Compression (Targeted Use)
- Cryotherapy (typically for smaller keloids or nodular lesions) helps reduce volume by freezing scar tissue.
- Compression therapy, such as pressure earrings or garments, may be used post-excision or to reduce recurrence risk in keloid-prone sites like earlobes and shoulders.
These approaches are case-specific and often paired with other interventions.
Surgical Revision with Adjuvant Support
Surgery is a last resort, and the approach differs significantly between scar types:
- Hypertrophic scars that are mature and stable may be revised surgically, using tension-reducing closure techniques. Post-revision care includes immediate re-implementation of early protocol steps (silicone, tape, protection).
- Keloid scars, however, are rarely treated with excision alone due to high recurrence risk. If surgery is performed, it is always accompanied by adjuvant treatments—such as postoperative steroid injections, radiation therapy, or compression—to reduce regrowth.
In all surgical cases, the Scar Protocol guides both preoperative planning and postoperative maintenance.
How the Scar Protocol Works
The Scar Protocol is not a single product, treatment, or guarantee. It is a structured framework that guides each patient’s healing process through:
- Early-phase protection and mechanical off-loading
- Symptom-specific in-office treatments
- Progressive therapeutic escalation based on scar behavior
- Individualized timelines tailored to location, skin type, and healing response
Its goal is to bring clinical oversight and consistency to what is often an overlooked part of surgery: how the body heals after the incision is closed.
Conclusion
While hypertrophic and keloid scars may appear similar, their causes, behaviors, and treatment approaches are distinctly different. Early recognition and the right strategy are key. The Scar Protocol provides a structured, step-by-step approach to help manage both types of scars, supporting your recovery beyond surgery and helping guide the healing process with purpose and precision.
