How Scars Form
Surgical scars form through the wound healing cascade: haemostasis (clotting), inflammation, proliferation (collagen deposition), and remodelling. Collagen is deposited initially as type III (thin, disordered) before being replaced and organised as type I collagen over 12–24 months. The remodelling phase determines the final scar quality. Scars initially appear pink or red due to increased vascularity; they typically fade to white or skin-tone over 1–2 years in most patients.
Factors Affecting Scar Quality
Genetic factors (individual variation in healing response), skin type, location (tension across a scar worsens it), infection history, wound closure technique, and post-operative care all influence scar quality. Incisions placed in natural skin folds (inframammary crease) typically heal most discreetly. Periareolar incisions benefit from the natural colour transition between areola and surrounding skin. Axillary incisions are hidden in the armpit fold.
Evidence-Based Management
Silicone sheeting/gel has the strongest evidence base for scar improvement — applied continuously to a healed incision (from week 4–6 post-surgery) for at least 3 months. The mechanism involves hydration and occlusion effects on the scar surface. Sun protection prevents pigmentation changes in healing scars. Massage of mature scars (from 6–8 weeks) can improve texture and softening. Steroid injections are used for hypertrophic or keloidal scars to reduce inflammation and flatten raised tissue.
Hypertrophic Scars and Keloids
Hypertrophic scars are raised, red, and confined to the wound margins — they often improve significantly with time and treatment. Keloids extend beyond the original wound and are more common in darker skin tones; they rarely improve spontaneously and require active treatment. Patients with a history of keloid formation should discuss this with their surgeon before breast surgery, as it affects incision placement decisions.
