Patients arrive at my Dubai practice with a scar and a list of treatments they have read about — silicone, laser, steroid injections, massage, surgery. The list is usually accurate. What is almost always missing is the question that determines whether any of it will work: are we trying to stop a scar from forming, or to improve one that has already formed?
Those are different problems, and the evidence treats them differently — a distinction I find myself explaining almost daily in Dubai. When researchers graded scar interventions by the strength of the studies behind them, they graded each one twice — once for prevention and once for treatment — and several treatments moved between the columns. A therapy weakly supported for preventing a scar can be strongly supported for treating one. This article is about that distinction, and about why the scar in front of you decides what should be done to it.
Key takeaways: what the evidence grades
- Prevention and treatment are graded separately, and differ.
- Silicone is the only intervention strongly supported for both.
- Laser and massage: weak for prevention, strong for treatment.
- Keloids extend beyond the wound; excision alone often worsens them.
- Atrophic scars need volume or resurfacing, never steroid.
- A contracture is lengthened by geometry, not cut out.
A note on scope: this article concerns scars that already exist. How a scar is prevented in the operating room — by incision placement, tension-offloading closure, and the aftercare that follows — is the subject of my article on scar placement and closure technique; the daily care of a healing incision in my article on wound care after surgery.
The grading that most articles omit
Scar treatments are usually presented as a single arsenal from which a surgeon selects. That framing is comfortable and it is misleading. An evidence-based review of scar management examined high-level studies and rated each intervention’s effectiveness as none, low, or high — separately for preventing a raised scar and for treating one that has already formed.
For prevention, the interventions with high efficacy were silicone, reduction of tension across the wound, and eversion of the wound edges at closure. Pulsed-dye laser, scar massage, pressure garments, and onion extract were all rated low.
For treatment of an existing raised scar, the picture changes. Silicone remains high. So now do pulsed-dye laser, fractional CO2 laser, corticosteroid injection, 5-fluorouracil, bleomycin — and scar massage. Onion extract stays low, and fat grafting is rated low as well, which is worth knowing before it is offered to you as an advanced solution.
How the evidence grades scar interventions differently for prevention and for treatment, by Dr. Nazmi Baycin, Dubai.
Why the same treatment can move between columns
The reason is biological rather than statistical. Before and immediately after a wound closes, the variables that matter are mechanical and inflammatory: how much tension pulls on the healing edges, how the edges sit against each other, how hydrated the surface is. Silicone and tension reduction act on exactly those variables. A laser aimed at a wound that has not yet built its collagen has little to work on.
Once a raised scar exists, the problem is a mature, over-abundant, over-vascularized collagen deposit. Now a pulsed-dye laser has a target — the microvessels that make the scar red. Now a steroid has something to break down. Now massage has fibrous tissue to remodel. The treatment did not become better; the target came into existence.
The scar in front of you decides the algorithm
The second thing most treatment lists obscure is that scars are not one condition. International practical guidelines developed by a panel of twenty-four specialists set out separate algorithms for linear scars, widespread raised scars, and keloids, with silicone as the first-line measure across them. The distinctions are not academic:
- Hypertrophic: raised and red, but confined within the original wound borders. Often improves with time and silicone.
- Keloid: grows beyond the original wound, has a genetic basis, and recurs. Excision alone frequently produces a larger keloid.
- Atrophic: sunken, from tissue lost beneath. Needs volume or resurfacing — a steroid would deepen it further.
- Contracture: a tight band restricting movement. A functional problem requiring lengthening, not excision.
That keloid point deserves emphasis, because it is where enthusiasm does real harm. Cutting out a keloid without adjuvant treatment — steroid, pressure, sometimes radiotherapy — invites a recurrence larger than the original. I will not excise one on its own, and among the keloid patients referred to me in Dubai I say so at the first consultation rather than the second.
| Intervention | For prevention | For treatment | What this means |
|---|---|---|---|
| Silicone | High efficacy | High efficacy | Useful throughout |
| Pulsed-dye laser | Low efficacy | High efficacy | Wait for a target |
| Scar massage | Low efficacy | High efficacy | Later, not sooner |
| Fat grafting | — | Low efficacy | Be wary of the offer |
When surgery is the answer, and when geometry is
Surgical revision earns its place when the problem is the scar’s geometry rather than its biology: a line that runs across the natural creases of the skin, a wide and stretched scar, a step in the edge where the original repair was misaligned. Here I excise the old scar in a spindle shape oriented along the relaxed tension lines, close the deep dermis with strong absorbable sutures that carry the tension, and approximate the surface without pulling on it.
A contracture asks for something different. It cannot be cut out, because cutting it out shortens it further. Instead I rearrange the tissue geometrically — a Z-plasty interposes triangular flaps to lengthen the scar and reorient it into a natural crease. That is not excision; it is redistribution. For very large defects, healthy adjacent skin can be grown before the scar is removed, which I describe in my article on how tissue expansion grows new skin.
Timing, skin tone, and honest expectation
Two further variables shape what I advise. A scar continues to remodel for a year or more, and an immature red scar may settle without any intervention at all; operating early on an unsettled scar frequently produces a worse one. So I wait, and I ask my patients in Dubai to wait with me, which is often the hardest part of the treatment.
Skin tone matters too. Deeper Fitzpatrick skin types carry a higher risk of both keloid formation and post-inflammatory hyperpigmentation, which changes the choice of laser and the threshold for excision. Sun protection is not cosmetic advice here; ultraviolet exposure on an immature scar drives lasting pigmentation. And no scar is ever erased. The honest promise is a scar that is finer, flatter, paler, and better oriented — not one that has gone.
Ask which problem is being solved
If you take one thing from this, let it be a question to put to whoever proposes to treat your scar: which problem is this solving? Is it preventing a scar, or improving one? Is this scar hypertrophic or keloid, atrophic or contracted? Is the difficulty its biology or its geometry?
A surgeon who can answer those precisely is drawing on the evidence rather than on a menu. That is the standard of reasoning I bring to scar work as a cosmetic surgery in Dubai specialist — and the reason I would rather tell you a treatment is weakly supported than sell it to you.
FAQs about scar revision in Dubai
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Can a scar be removed completely?
No, and I would distrust anyone who told you otherwise. Once the dermis has been injured, a scar exists permanently in some form. What revision achieves is a scar that is finer, flatter, paler, and better oriented within the natural creases of your skin, so that it draws far less attention. So the honest promise is improvement rather than erasure. Setting that expectation at the first consultation is, I think, part of the treatment.
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Why does the evidence rate laser differently for prevention and treatment?
Because the treatment did not change; the target came into existence. A graded review of high-level studies rated pulsed-dye laser as low efficacy for preventing a raised scar and high efficacy for treating one. Before the collagen has been laid down, a laser aimed at the wound has little to act upon. Once a raised, red, over-vascularized scar exists, the laser has microvessels to target. So timing is not a detail. The same intervention can be poorly supported early and well supported later, which is precisely why I ask which problem we are solving.
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What is the difference between a hypertrophic scar and a keloid?
A hypertrophic scar is raised and red but stays within the borders of the original wound. It often improves over time, particularly with silicone. A keloid grows beyond the original wound entirely. It has a genetic basis, it recurs, and it behaves quite differently. So they are not degrees of the same thing. Confusing them leads directly to the single most damaging mistake in scar surgery, which is excising a keloid on its own.
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Can you just cut out my keloid?
Not on its own, and I will say so at the first consultation rather than the second. Excising a keloid without adjuvant treatment frequently produces a recurrence larger than the original. If I operate at all, excision must be combined with adjuvant measures such as corticosteroid injection, pressure therapy, and in selected cases radiotherapy. So a keloid is a condition to be managed rather than a lump to be removed. Anyone offering you straightforward excision has not understood what they are looking at.
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What treats a sunken, pitted scar?
An atrophic scar is the opposite problem to a raised one. Tissue has been lost beneath the surface, so the skin sits depressed. It needs volume restored or the surface resurfaced. A corticosteroid injection, which thins tissue, would deepen it further, which is why the distinction matters so much. So the treatment follows from the direction of the deformity. Raised and sunken scars are not the same condition treated with different intensity; they are different conditions.
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Why can’t a tight scar simply be excised?
Because cutting out a contracture and closing the gap shortens the scar further, which is the opposite of what is needed. A contracture is a functional problem, not merely an appearance one. Instead the tissue is rearranged geometrically. A Z-plasty interposes triangular flaps to lengthen the scar and reorient it into a natural crease. So this is redistribution rather than excision. Geometry solves what removal makes worse, and recognizing which is required is most of the skill.
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How long should I wait before treating a scar?
Usually longer than you want to. A scar continues to remodel for a year or more, and an immature red scar may settle considerably without any intervention. Operating early on an unsettled scar frequently produces a worse one. So I wait, and I ask patients to wait alongside me. So patience is genuinely part of the treatment, and often the hardest part. Meanwhile silicone and sun protection are both well supported and can begin straight away.
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Does my skin tone change the plan?
Considerably. Deeper Fitzpatrick skin types carry a higher risk of both keloid formation and post-inflammatory hyperpigmentation after any inflammatory insult, including laser. That changes which laser I would use, at what settings, and how cautious I am about excision in the first place. So sun protection is not cosmetic advice in this context. Ultraviolet exposure on an immature scar drives lasting pigmentation, and it is one of the few things entirely within your control.
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