Surgery, Scarring and Black Skin
When it comes to skin, be it elective or emergency, any type of surgery will require a period of healing. Who you are, where you’re from and how you look after your skin pre and post surgery can make a big difference to both your likelihood of scarring, the healing process of your skin and the appearance of scarring on your body.
A lot of the information available about pre and post-surgery skin care isn’t always written with Black people in mind so if you’re wondering whether Black skin heals differently compared to other skin types, what potential scarring may look like or how it can be reduced, we’ve got you covered. We’ve asked Specialist Maxillofacial and Facial Plastic Surgeon Natasha Berridge and Consultant Plastic Surgeon Sujatha Tadiparthi to share some insights.
Does Black skin heal differently from white skin?
According to Tadiparthi, skin healing follows the same basic biological process, regardless of ethnicity. Research studies have shown differences at a cellular level between Black, Asian and White skin - levels of collagen in the skin, how compact the skin cell layers are and their ability to resist injury or maintain hydration.
Initial healing, however, is more dependent on certain risk factors than ethnicity. “Age, smoking/vaping, underlying medical conditions, poor diet and compliance with treatment can all have an impact on the healing process.” There are variations during the wound healing response - Black skin (when compared to white skin) is more prone to pigmentary changes and hypertrophic or keloid scars. “The appearance of scars during the healing process varies when I see patients long-term - in white skin, the scars become red and fade gradually over a few months, but in Black skin, the scars becomes darker after a few weeks and this hyperpigmentation can take years to fade or may not fade fully.”
Are there any concerns/complications that are specific to Black skin?
“Black skin is more at risk of hyperpigmentation and abnormal scarring such as keloid scarring following surgery which does mean that awareness from surgeons is needed,” Berridge says. While individual healing responses vary greatly, there are specific scar concerns related to Black skin such as keloids. “Keloids are thick, raised scars that are itchy, painful and continue to grow over time beyond the original wound boundary. They can recur at any time, even after surgical removal or other treatment,” Tadiparthi adds. Research suggests that people of African descent are up to 15 times more likely to develop keloids compared to those of Caucasian descent. There is often a family history with 50% of patients and younger patients up to aged 30 more prone to abnormal scarring.
Hypertrophic scars are another complication that can be specific to Black skin. They are thick raised scars that stay within the original wound boundary. While they usually flatten over time, they can leave a stretched scar once mature. “Like keloids, Black people are more prone to developing hypertrophic scars than Caucasians,” Tadiparthi says. Post-inflammatory Hyperpigmentation (PIH) and Post-inflammatory Hypopigmentation can also occur. “PIH manifests as darkened patches or spots in the area where the injury occurred and can persist for months or years whilst the latter leads to lighter skin patches at the surgical or injury site.”
What causes these differences in healing?
The difference in healing outcomes for patients is related to skin colour. Melanin is the pigment that gives us our skin colour and is produced by melanocytes to protect against harmful UV radiation from the sun. According to Berridge, “While there’s no difference in the number of melanocytes in dark skin tones compared with light skin tones, darker skin types will have more visible scars due to the (higher) concentration of melanin in the top layer of the skin, hence a greater propensity to developing abnormal scarring such as keloids.”
Are there particular areas of the body that can have more scarring?
Surgery anywhere on the body will result in a surgical scar, though the ears, shoulders, chest and upper back have a greater risk of hypertrophic or keloid scarring. It’s unusual to get scarring on the face as healing is generally much faster.” In her practice, Tadiparthi says she has seen patients with hypertrophic or keloid scars in pubic/perineal areas and recommends avoiding procedures on high-risk areas of the body. “If hypertrophic or keloid scarring does occur, available treatments include: silicone sheets, gels or creams; steroid injections into raised scars administered every 4-6 weeks; pressure garments; laser and radiotherapy and surgery to remove any scars.”
How can these concerns be managed pre, during and after surgery? How can the potential of scarring be reduced?
There are no 100% preventive or curative treatments for scarring that are effective, meaning that they’ll have to be managed if/when they appear post-surgery. For those at increased risk of developing keloids or have already experienced keloids, it’s important to stick to the pre and post-operative surgical protocols set by your surgeon. “They may also employ additional techniques to further minimise this risk such as steroid injections, silicone gels and compression dressings." While scarring cannot be prevented, Tadiparthi notes that wounds should not be left open to heal or become infected as they will be much more prone to hypertrophic/keloid scarring as well as hyperpigmentation.
Before and after surgery; exercising, maintaining a healthy balanced diet, staying hydrated, avoiding smoking and vaping are recommended. “Smoking constricts blood vessels and restricts blood flow which delays wound healing and increases the risk of complications such as wound injections, wound separation and skin loss. Excessive alcohol consumption can also slow down the healing process. If you have any medical conditions, keeping them well controlled before surgery is essential. Conditions such as diabetes and high blood pressure can impede healing. “Medications may also need to be stopped before surgery, so your surgeon or hospital should advise you.”
Post-surgery, the most important thing you can do is adhere to the care instructions that have been given by your surgeon including wound care, taking prescribed medications, wearing of pressure garments and activity restrictions. “Attend dressing clinic or follow up appointments so that your wounds are monitored regularly. If you notice anything unusual (such as redness, swelling, pus or more pain than usual) or have any concerns, contact your surgeon immediately,” Tadiparthi advises. During recovery, physical activity should be limited to avoid stress to the surgical site. Once your wounds have closed, the scar massage and moisturisation process can begin (as advised by your surgeon).
How do we ensure successful surgery outcomes for Black patients?
While a variety of factors (age, pre-existing medical conditions, patient expectations and skin type) can have an impact on surgery outcomes for Black patients, both Berridge and Tadiparthi highlight the importance of choosing an accredited surgeon to discuss your expectations and the associated risks. “Find a surgeon that has experience with Black skin and has dealt routinely with scarring and view results from their previous Black patients. Assess your risk factors and how they can be minimised if you decide to proceed with surgery,” Tadiparthi says.
Tips/product recommendations for scarring on Black skin?
In addition to being prone to scarring post-surgery, Black skin is also prone to water loss, so maintaining a healthy skin barrier will support the healing process, according to Berridge. “A good post-surgical skin care regime should include SPF50 sunscreen, silicone gel (for any scars), a gentle exfoliating wash and a hyaluronic acid based moisturising lotion,” she says. Similar to above, Tadiparthi’s scar management regime also includes using Skinade before and after surgery to help minimise bruising, swelling and inflammation. “It also promotes hydration, boosts collagen production and reduces scar maturation.”
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