Patients ask me about scars constantly. Before surgery, they want to know how visible the scar will be. After surgery, they want to know what to put on it. When the scar does not fade the way they expected, they want to know why.
The honest answer to all three questions is more complicated than most consultations allow time for. Scar outcome is not primarily determined by the cream you apply afterward. It is determined by factors that are partly biological, partly surgical, and only partly within your control.
Here is what actually drives the difference.
Your skin type is the single biggest variable
This is the one most patients do not know going in. People with darker skin tones — Fitzpatrick types IV through VI, which includes most South Asian, African, and Middle Eastern patients — have a significantly higher tendency toward hypertrophic scarring and keloid formation. This is not a flaw. It is a biological characteristic of how melanocyte-rich skin responds to injury.
A keloid scar extends beyond the original wound boundary. A hypertrophic scar stays within it but remains raised, firm, and often red or darkened for longer than a flat scar would. Both are more common in darker skin and in certain anatomical locations regardless of skin tone.
What this means practically is that two patients who have the exact same surgery, performed identically by the same surgeon, can have dramatically different scar outcomes purely based on their individual biology. A patient with a personal or family history of keloid formation needs to know this before surgery, not after.
Location on the body matters as much as technique
Skin behaves differently depending on where it is on the body. The chest and shoulders are high-tension areas where the skin is constantly under pull from movement. Scars in these locations are more likely to widen, thicken, and remain visible regardless of how carefully the wound was closed.
The lower abdomen and inner thigh are relatively low-tension areas. The face heals with exceptional speed and quality because of its dense blood supply. The back is poor healing territory. The scalp, despite its vascularity, heals well but hides scars in hair.
A surgeon placing an incision should be thinking about these factors as part of the surgical plan. The location of an incision relative to skin tension lines, natural creases, and areas of movement is not a cosmetic afterthought. It is a technical decision that directly affects the long-term scar.
What the surgery itself contributes
The quality of wound closure is genuinely important. A wound closed under tension — where the skin edges are pulled together with more force than the tissue naturally accommodates — heals wider and thicker. A wound closed in layers, with the tension distributed across deeper tissue and the skin edges approximated without stress, heals with a finer scar.
This requires time and surgical care. It also requires honest patient selection. Performing surgery in an area without enough tissue laxity to close without tension is a surgical decision that produces a predictably worse scar.
What you can control afterward
Silicone is the most evidence-backed topical treatment for scar management. Silicone gel or sheeting applied consistently over 3 to 6 months reduces the height and redness of hypertrophic scars in a meaningful proportion of patients. It does not eliminate scars. It improves them.
Sun protection over the healing wound is critical and consistently underestimated. UV exposure on a healing scar causes permanent hyperpigmentation. In patients with darker skin, this hyperpigmentation can be more pronounced than the scar itself. Keeping a healing wound out of direct sun — or covering it with SPF 50 when that is not possible — for the first 12 months is one of the most effective things a patient can do.
Massage of the scar from week 4 onward improves pliability and can reduce thickening. Avoiding tension on the wound in the early weeks — no heavy lifting, no activity that pulls at the area — reduces the chance of widening.
What does not work the way marketing claims
Vitamin E oil is perhaps the most widely used scar remedy in the world. The evidence for it is poor. Several studies have shown it makes no difference to scar outcome and causes contact dermatitis in a significant proportion of users. I mention this not to be contrarian but because patients spend months applying it diligently while skipping silicone, which actually has clinical evidence behind it.
Onion extract gels (Contractubex and similar products) have some weak supportive evidence in certain scar types. They are not harmful. But they are not the treatment of choice for significant hypertrophic or keloid scars.
When topical treatment is not enough
Established keloid scars and significant hypertrophic scars that do not respond to silicone and massage have other options. Intralesional steroid injections reduce the bulk and firmness of hypertrophic scars reliably in most patients. They require multiple sessions, typically 4 to 6 at monthly intervals. The injections are uncomfortable but the effect is real.
Surgical excision of keloids with immediate steroid injection and radiation therapy (brachytherapy) is used for large or recurrent keloids where injection alone is insufficient. This is a specialist area of management and not every scar warrants it. But for patients with a keloid that has been present for years and has not responded to conservative treatment, the option exists.
The one thing I tell every patient before any incision
Your scar is a collaboration between what I do in the operating room and how your biology responds to healing. I will close the wound as carefully as it can be closed. I will place the incision where it has the best chance of fading. I will give you clear instructions for the months afterward.
What I cannot do is guarantee a scar of a specific quality, because no surgeon can. Anyone who tells you they can is not being honest with you.
What I can do is make sure you understand your own risk factors going in, so that the outcome — whatever it is — is not a surprise.
If you are in Mumbai and have questions about scar management after surgery, or about a scar you are already dealing with, contact my clinic to arrange a consultation.
Dr. Vicky Jain is a board-certified plastic and reconstructive surgeon with over 17 years of clinical experience across cosmetic and reconstructive surgery in Mumbai. Learn more about Dr. Jain →