Surgical Scar Management and Outcomes in Racial/Ethnic Minorities: A Systematic Review

Abstract

Background:

Patients with darker skin tend to experience an increased prevalence of adverse surgical scarring and poorer treatment response in comparison to White patients. Ethnic and racial factors play a role in overall surgical scar outcomes because they predispose darker-skinned individuals to sequelae such as scar hypertrophy, keloid formation, and an overall negative psychosocial impact. This systematic review will summarize existing literature on surgical scar outcomes and management in minority patients and will highlight gaps in the medical literature.

Methods:

The search was conducted using PubMed, Embase, Scopus, and Cochrane Library to identify relevant articles. All articles went through title and abstract screening, followed by full-text review.

Results:

Of 1235 articles, 40 met eligibility criteria. Following the full-text review, 10 articles were included. In 5 of the 10 studies, patients were characterized as having Fitzpatrick skin types II–V. Five studies utilized laser techniques, and the remaining 3 studies utilized silicone sheet, topical silicone, and surgery. The Vancouver Scar Scale was the most utilized assessment tool. The two studies that evaluated fractional CO₂ laser interventions using the Vancouver Scar Scale showed improvement in scar outcomes and overall patient satisfaction.

Conclusions:

Laser interventions were the most utilized and show promise for improving scar management outcomes in ethnic patients, though there is little work highlighting treatment decision-making in scar management. This review emphasizes the need for increased research focused on scar management interventions and comprehensive protocols to address scar management in plastic surgery for patients with darker skin.

Takeaways

Question: What is the current level of knowledge and understanding about scar management and outcomes among minority patients?

Findings: Although there is limited research in minority patients, this systematic review shows that use of laser treatment was the most common intervention, whereas the Vancouver Scar Scale was the most utilized assessment tool. All interventions showed measured improvement of scars from baseline.

Meaning: There is a need for increased research focused on scar management interventions and comprehensive protocols to address scar management in plastic surgery for patients with darker skin.

INTRODUCTION

Disparities in surgical outcomes and scar management are unique challenges often faced by racial and ethnic minorities. Surgical scars in particular can have significant psychosocial and functional impacts on patients, such as negative perceptions and functional impairments associated with minority populations.¹ Despite the growing awareness of these issues, there remains a significant gap in the literature regarding effective and validated scar management strategies tailored to the needs of minority patients. The Agency for Healthcare Research and Quality defines racial and ethnic minorities as American Indian/Alaska Native, Asian, Black, Hispanic, and Native Hawaiian/Pacific Islander individuals.² According to the American Society of Plastic Surgeons, in 2020, 32% of all cosmetic plastic surgery patients were Asian, Black, or Hispanic.³ These statistics underscore the need for a comprehensive understanding of scar management practices and outcomes in racial and ethnic minorities. Existing evidence suggests that minority patients, particularly those with darker skin tones, often experience poorer scar outcomes, such as the development of keloids and hypertrophic scars, compared with their lighter-skinned counterparts.⁴

Health disparities are known to profoundly impact the quality of life for minority patients, and in the context of surgical scarring, factors such as adverse appearance, symptoms, and psychosocial impacts predispose minority patients to worse outcomes. Although some studies have explored minority patients’ perceptions of their scars, there is limited information on the specific management practices used, including considerations of race and ethnicity, approaches to scar management, and rates of scar revision. Notably, there has been a push in recent years to understand the underlying factors contributing to inferior diagnosis, increased prevalence, and clinical severity in minority populations with skin diseases such as the development of keloids.⁵

An in-depth examination of scar management in minority patients is a crucial step for addressing challenges in wound healing, reducing healthcare disparities, and enhancing overall knowledge about effective scar management in this population. This systematic review aimed to fill this gap by critically examining the existing literature on minority patients and scars and to provide a basis for future research in patients with darker skin.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.⁶ This outlines how to methodologically approach the synthesis of knowledge within a given domain.

Search Strategy

The search for this systematic literature review was conducted in December 2023 using PubMed, Embase, Scopus, and Cochrane Library databases without any timeline limitations. To capture the relevant articles that provide data on surgical scar outcomes and management in ethnic and minority populations, the following search terms were used: (((surg*) AND (scar*)) AND ((patient reported outcome) OR (patient assessment) OR (scar assessment) OR (scar scale) OR (scar evaluation) OR (patient reported outcome measure))) AND ((minority patient) OR (dark* skin*) OR (“patient of color”) OR (ethnic skin) OR (“skin of color”)).

Study Criteria and Selection

Inclusion criteria for study design were randomized and non–randomized controlled trials, cohort, case–control, cross-sectional, and case reports. Studies that focused on scar outcomes, and management within minority and ethnic populations were also included. Included settings were medical/academic research hospitals and clinics. Excluded studies were lack of surgical scar outcomes or management, unpublished papers, reviews, nonhuman studies, and nonminority, or solely nonethnic populations (White). Two researchers independently screened all the studies using Covidence. Phase 1 was initial screening based on titles and abstracts. Phase 2 involved the full-text review for eligible studies. Two reviewers (F.I.O. and M.A.S.) screened to verify if the studies met inclusion criteria. In the case of conflict, a third reviewer (A.J.V.) provided resolution. In phase 3, references from included studies were re-reviewed as an additional level of screening to ensure that no relevant articles or studies were missed or erroneously excluded.

Data Extraction

In addition to patient demographics and study characteristics, data for postsurgical scar outcomes and management within minority and ethnic populations were extracted. Data extraction was conducted by each reviewer and conflict was resolved by the third reviewer.

Outcome Measures

The primary outcome of scar outcomes and management included any reported assessment tools, patient satisfaction, descriptive findings, and adverse events.

Risk of Bias

We assessed the risk of bias (RoB) for each study included using the ROBINS-I (Risk Of Bias In Nonrandomized Studies-of Interventions) tool, which was particularly useful for systematic reviews that included nonrandomized studies. The ROBINS-I tool was developed to assist researchers in evaluating RoB in estimates of the comparative effectiveness (harm or benefit) of interventions from studies that did not use randomization.^7,8

RESULTS

A total of 1235 articles were retrieved following our initial search. After screening the titles and abstracts, 40 articles met the eligibility criteria and were selected for full-text review. After full-text screening, 10 articles were identified for data extraction based on inclusion criteria (Fig. 1). The RoB assessment of each study is reported in Figure 2.

Fig. 1.

PRISMA flow diagram.

Fig. 2.

Risks of bias summary.

Fitzpatrick classification was specified in half of the studies, including types II–V, whereas the remaining studies categorized patients by racial or ethnic groups Table 1. Of the studies that reported based on Fitzpatrick classification, only 3 studies included patients with type V skin. Studies range from 2002 to 2022 and present data on patients from various regions, including Asia,^{9–11,13,14,18} Africa,^12,15 and North America.^16,17 Among these, 8 were evaluating a specific treatment, whereas the remaining were observational studies. Sample size and treatment duration varied. Follow-up was greater than 1 month in studies evaluating treatment for scarring. Characteristics of all studies are noted in Table 2.

Table 1.

Patient Demographics

Author	Age, y	Sex	Race/Ethnicity	Fitzpatrick Classification
Maninder et al9	7–28	M = 19	Asian	Type IV and V
		F = 23
Rhee et al10	16–51 (mean 31.7)	M = 15	Asian	Not specified
		F = 25
Yun et al11	20–50 (mean 31.60)	–	Asian	Not specified
Darwish et al12	10–51 (mean SD 22.45 ± 11.46)	M = 12	Other: Egyptian	Types III (3; 15%), IV (15; 75%), V (2; 10%)
		F = 8
Li-Tsang et al13	14–85 (mean SD 57.35 ± 19.74)	M = 68	Asian	Not specified
		F = 86
Long et al14	19–58 (mean SD 32.20 ± 6.39)	M = 242	Asian	Not specified
		F = 203
Ibrahim et al15	15–47	M = 12	Other: Egyptian	Type III (11; 40.74%), IV(13; 48.14%), V (3; 11.11%)
		F = 15
Bowes et al16	15–56	–	Not specified	Types II–IV
Garg et al17	≥18	–	Black/African American	Not specified
Guo et al18	23–65 (median 32)	M = 10	Asian	Type III–IV
		F = 18

–, unavailable; F, female; M, male.

Table 2.

Study Characteristics

Author	Year	Sample Size	Procedure	Duration	Follow-up	Evaluators
Maninder et al9	2021	42	Ablative fractional CO2 laser	4–8 wk	2–8 mo	2 independent observers
Rhee et al10	2010	40	Silicone sheet	3 mo	2 wk, 1 mo, 3 mo	3 plastic surgeons
Yun et al11	2013	80	Dermatix Ultra	6 mo	stitch removal, 2 mo, 6 mo	3 plastic surgeons
Darwish et al12	2016	20	Fractional CO2 laser	Sessions vary, beginning postoperative	3 mo after the last laser session	2 independent dermatologists
Li-Tsang et al13	2005	101	None	None	30 d postsurgical procedure	Occupational therapist
Long et al14	2016	445	Protocol 1: keloid resection and direct closure technique	Varies depending on the protocol	6–18 mo (mean 13 mo)	Plastic surgeon
			Protocol 2: keloid resection with flap
			Protocol 3: perilesion incision + first session of radiotherapy + skin graft + second session of radiotherapy
			Protocol 4: keloid core resection and radiotherapy
Ibrahim et al15	2019	27	Fractional CO2 10,600 nm laser	1mo interval after 4–6 wk postoperative	3 mo after the final treatment	Dermatologists
Bowes et al16	2002	6	Q–switched 532 nm Nd:YAG laser, variable pulse 532 nm Nd:YAG laser, 585 nm FLPDL	Mean 3.3, intervals of 4–6 wk	22 wk	Blind observer
Garg et al17	2022	675	None	None	None	–
Guo et al18	2022	28	Nonablative fractional laser	5 mo	3 mo	2 physicians at the treatment center

–, unavailable; CO₂, carbon dioxide.

Eight of the 10 studies specified interventions for postsurgical scar management, highlighting a range of techniques used to address scarring in minority populations. The (modified)Vancouver Scar Scale (VSS/mVSS) was the most utilized scar assessment tool used (6 of 10) to evaluate scar pigmentation, height, vascularity, and pliability. Laser therapy was the most common treatment method (5 of 10). A few studies focused on other treatments such as silicone sheeting (1), silicone gel product (1), and surgery (1). The remaining 2 studies focused on scar outcomes over time with no specific intervention.

All studies found that treatments resulted in significant improvements in scarring from pre- to postintervention. Notably, 2 studies using fractional CO₂ laser interventions demonstrated significant improvement in decreasing pigmentation, height, vascularity, and total VSS. More specifically, Darwish et al¹² found that patients who underwent specific laser treatment demonstrated lower mean total scores on the VSS from 6.1 ± 2.6 to 3 ± 1.2 posttreatment (P < 0.001). (See table, Supplemental Digital Content 1, which displays summary of findings, http://links.lww.com/PRSGO/D950.) Similarly, Ibrahim et al¹⁵ found that CO₂ laser therapy resulted in scar improvement from 5.33 ± 1.33 compared with 2.55 ± 1.06 posttreatment (P ≤ 0.001) (Supplemental Digital Content 1, http://links.lww.com/PRSGO/D950).

Four studies reported on patient satisfaction, with three studies focusing on patient satisfaction and one study focusing on both patient and provider satisfaction. Finally, adverse events were reported in 4 studies. Adverse events included hyperpigmentation and hypopigmentation (2); pain and itchiness (1); and delayed wound healing, partial flap loss, and surgical intervention for scar management (1) (Supplemental Digital Content 1, http://links.lww.com/PRSGO/D950).

DISCUSSION

This systematic review highlights scar outcome and management approaches for ethnic/racial minority patients. Given the limited research focusing on this population with regard to scar management and sequelae, only 10 studies met eligibility criteria and were included in this review. The Fitzpatrick scale is a long-standing guide used to classify skin type, and the majority of the studies in this systematic review focused on Fitzpatrick types II–IV. Type II skin may be considered “White” and not “skin of color” although some minority patients may have type II skin despite demographic status as minority. This article reports common interventions and scar assessment scales for scar management while highlighting the need for more appropriate assessments and protocols in patients with darker skin (Fitzpatrick types V–VI).

Interventions

Laser treatments were found to be the most common scar management tool utilized for ethnic/racial minority patients, supporting its benefit in scar management. African American patients with conditions such as pseudofolliculitis have responded positively to certain types of laser treatment.¹⁹ However, the risk and duration of adverse effects associated with laser skin resurfacing are significantly higher in patients with dark skin, with transient hyperpigmentation being about 70% in patients with darker skin.¹⁸ The anticipated benefits from laser treatments for other skin conditions highlight the potential for developing standardized studies to assess its efficacy and safety for surgical scars in diverse skin types. Although less common within the published literature, other interventions (silicone sheeting, topical silicone gel, and surgery) were also effective in improving scar appearance.

The variety of management options underscores the importance of scar management protocols for tiers of scarring in ethnic/racial minorities. Considering adverse events and treatment effects within this group may be useful factors for targeted therapies. Two studies reported on scar outcomes using VSS in addition to patient satisfaction and adverse effects,^12,18 with another 2 studies using scar assessment scales that rely on patient perceptions (Patient and Observer Scar Assessment Scale [PSOAS], SCAR-Q).^14,17 Garg et al¹⁷ determined African American patient perceptions of their scars resulted in significantly lower median SCAR-Q and Career/Sexual Well-Being scores compared with their White counterparts. These studies highlight the importance of incorporating patient perspectives in evaluating scar outcomes. More importantly, they emphasize the necessity of using assessment scales that can capture characteristics unique to individuals with darker skin tones, as well as the utility of these scales in informing and improving scar treatment strategies.

Validation of Scar Scale

The majority of the studies evaluated their specific scar intervention using the most validated scar scale (VSS/mVSS) in addition to other known scar assessment scales, such as the Investigator Global Assessment, Patient Global Assessment, Vancouver General Hospital, POSAS, SCAR-Q, and the Career/Sexual Well-Being scale. When evaluating the racial diversity of patients included in scar assessment validation, VSS, POSAS and SCAR-Q were shown to have included darker-skinned or non-White patients.²⁰ However, for mVSS specifically, only 7% and 13% were Fitzpatrick scale type V/VI.²⁰ This again emphasizes the fundamental underrepresentation of darker skin types in the development of scar scales, with a small number of darker-skinned/ethnic patients included and absence of type VI patients. Further validation of these scar scales in individuals with darker skin tones can enhance their reliability, enabling more targeted and consistent research. This structured approach can improve the management of scarring in racial and ethnic minority patients.

Protocol Development

As aforementioned, only 1 study reported an individualized treatment protocol based on patient demographics. Long et al¹⁴ reported an individualized chest wall keloid treatment protocol specifically for Chinese patients. In this study, each protocol implemented for this patient demographic resulted in a decrease in POSAS score with mutual patient and doctor satisfaction. Although this highlights the benefits of individualized treatment protocols based on patient demographic characteristics, there remains equity concerns, as Chinese patients tend to have II–IV type skin or lighter skin tones.²¹ This highlights the potential benefits and opportunities for individualized scar management protocols for patients of V–VI type skins or darker skin tones. Gill et al²² developed an individualized postoperative scar management protocol for scar management in Asian patients, which can be beneficial when expanded to patients with even darker skin tones.

Measuring Scar Outcomes

Most included studies relied on physician-assessed scar outcomes such as the VSS. Although clinical expertise is essential in scar outcome assessment, it is equally important to consider the patient’s perception. Racial and ethnic minorities may have differing perspectives on satisfaction with scar outcomes, which can become even more pronounced with marginal racial concordance of care. This review highlights both the opportunity and the need to prioritize patient-reported outcomes when evaluating scar outcomes and developing management strategies. This approach does not diminish the importance of clinical expertise but encourages a more patient-centered framework. Developing an effective scar management protocol for diverse populations will require a collaborative approach between patients and physicians, improvement of validated scar scales with darker-skinned individuals, and further well-designed interventional studies. By ensuring that patient-reported outcomes, informed by clinical assessment, guide decision-making toward the appropriate management, we can achieve higher-quality and more inclusive care.

Limitations

This study provides valuable recommendations and insights for future directions; however, it is not without limitations. Although we approached the study with a systematic lens, the screening process yielded a limited number of studies. This may be attributed to the varying definitions of ethnic and racial minorities across studies. Additionally, although we took a global approach to this review, the conceptualization of race differs by region, which may have further limited the types of studies identified. Of the studies identified, only one was a comparative intervention study. Most studies offered a longitudinal understanding of the specified interventions however, they lacked robust comparative evaluations. Future research should focus on interventional trials that offer stronger and more comprehensive assessments of these interventions, particularly in the treatment of hypertrophic scarring and keloids, where the evidence remains insufficient.

Future research should examine the universality of the Fitzpatrick scale in scar evaluation and outcomes, exploring its applicability across diverse populations. Moreover, most of the studies that met the inclusion criteria involved Asian patients, which may restrict the generalizability of the recommended scale measures to other groups. Further research is needed to address underrepresented populations, including Black/African American, Hispanic, and other marginalized groups, to ensure a more comprehensive understanding of scar outcomes and management across diverse racial and ethnic backgrounds.

CONCLUSIONS

This systematic review highlights scar outcomes and various approaches to scar management in racial and ethnic minorities. The limited literature in patients with darker skin type underscores the need for more research focused on these populations to develop effective protocols for scar management strategies. Further modification of scar assessment tools and scar treatment studies should actively include individuals with darker skin tones. Additionally, well-designed comparative interventional studies are crucial to better understand and modify current scar management approaches. Future research that prioritizes a patient-centered approach has the potential to lead to significantly better outcomes and improve the quality of life for minority patients and individuals with darker skin.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.