Is my scar a keloid, or something else?

Posted May 5, 2026 by
Woman with scar on abdomen

Your tummy tuck incision has healed, but the scar looks nothing like you expected. It’s thick, raised, and honestly concerning. Is it a keloid? A hypertrophic scar? Something else entirely?

These are important questions, as the type of scar you have determines how we approach treatment. Here are the characteristics that help us tell them apart.

What Makes Keloids Different

The defining characteristic of a keloid is that it grows beyond the boundaries of the original incision. If you had a facelift incision along your ear that’s now a raised scar extending onto your cheek or neck—skin that was never cut—you’re likely looking at a keloid.

Keloids don’t follow the normal rules of healing. Most surgical scars go through a predictable process: they’re red and slightly raised at first, then gradually flatten and fade over 12-18 months as they mature. 

Keloids don’t do this. They keep producing collagen well past the point where healing should have stopped, and they can continue growing for months or even years after your procedure.

I’ve seen keloids develop from the smallest surgical incisions—an eyelid surgery (blepharoplasty) incision in the eyelid crease, a small excision site, even the tiny entry points from liposuction cannulas. The body’s response is completely disproportionate to the original incision. And once a keloid starts forming, it rarely goes away on its own.

The appearance is distinctive too. Keloids often have a shiny, smooth surface with a firm or rubbery texture when you touch them. They can be darker than your surrounding skin and sometimes take on an irregular, almost tumor-like shape. Some patients describe them as looking like stretched, glossy skin pulled too tight over a bump.

Location matters quite a bit for cosmetic surgery scars. The chest and shoulders are particularly prone to keloid formation, which is something I discuss carefully with patients considering breast augmentation or reduction. Upper back procedures and any surgery near the earlobes also carry higher risk. These areas seem to trigger excessive collagen production more readily than others, which is why surgical technique and the closure method used matter so much in these locations.

Hypertrophic Scars: The More Common Reality

Contained Within the Incision

Here’s what I see far more often in my practice: hypertrophic scars after surgery. These are raised, thick scars that stay within the borders of the original incision. They can look quite dramatic and concerning to patients, but they behave very differently from keloids.

The key difference is containment. A hypertrophic scar from a tummy tuck incision might be raised and red and uncomfortable, but if you look closely, you’ll see it hasn’t spread beyond where the incision was made. It’s confined to exactly where tissue was cut.

Hypertrophic scars also tend to improve with time, even without treatment. I tell patients this might take a year or sometimes longer, but unlike keloids, these scars usually get the message to stop overproducing collagen and begin to soften and flatten.

Timing

Timing is another clue. Hypertrophic scars typically develop within the first few months after surgery. Keloids can show up much later—sometimes six months to a year after your incisions have seemingly healed.

The Role of Tension

Tension plays a significant role in hypertrophic scar formation after cosmetic surgery. Areas where skin is pulled or stretched during healing—tummy tuck incisions across the lower abdomen, breast lift incisions, body lift scars, anywhere the wound edges are under constant tension—are more likely to develop hypertrophic scars. This is why I’m so particular about surgical technique and incision placement. Reducing tension on healing tissue from the start, using layered closure techniques, and placing incisions strategically can prevent these scars from forming in the first place.

Large scar on faceless woman's shoulder

Who Develops Abnormal Scars

Genetic Predisposition

Genetics are powerful here. If your parents or siblings form keloids, your risk increases substantially. This isn’t just a casual family tendency—keloid formation appears to have a strong hereditary component, and knowing your family history helps me predict your risk before any cosmetic surgery procedure.

Skin Type and Ethnicity

Skin type matters tremendously. Keloids occur much more frequently in individuals with darker skin tones. Studies show significantly higher rates in people of African, Hispanic, and Asian descent compared to those with lighter skin. This doesn’t mean lighter-skinned individuals can’t develop keloids, but the risk is considerably lower.

Age Factors

Age is a factor I always consider. Younger patients, particularly those between 10 and 30 years old, have a higher rate of abnormal scarring. We think this relates to increased collagen production and faster cell turnover during these years.

What About Other Scars?

While keloids and hypertrophic scars account for most of the problematic scarring I treat, there are other types worth mentioning.

Atrophic scars sit below the skin surface rather than above it. These are the depressed scars you see after severe acne or chickenpox. The tissue loss creates small pits or indentations rather than raised tissue.

Contracture scars typically develop after burns and can actually restrict movement, particularly when they form over joints. The skin tightens and pulls, sometimes significantly limiting range of motion.

Occasionally, what appears to be a keloid turns out to be something more serious. I’ve had patients come in concerned about a “keloid” that was actually a dermatofibroma or, in rare cases, a type of skin cancer. This is why having an experienced physician evaluate any unusual scar growth is important.

How We Approach Treatment

Treatment strategy depends entirely on accurate diagnosis, which is why I examine scars carefully before recommending any intervention.

Options for Hypertrophic Scars

For hypertrophic scars, patience often pays off. Many of these scars improve substantially over time without any treatment. However, several approaches can accelerate improvement:

Silicone has been the standard in scar management since the 1980s, when surgeons caring for burn patients observed that those wearing pressure garments with silicone inserts healed with flatter, softer scars. That observation led to decades of refinement, and today silicone reaches scars in two main forms: sheets and gels.

Both work through the same general mechanism: by maintaining consistent moisture and temperature at the scar’s surface, silicone appears to signal the collagen-producing cells (fibroblasts) to slow down. There’s also evidence that silicone directly influences growth factors and signaling molecules (cytokines) involved in scarring, though researchers haven’t pinpointed the exact mechanism.

When to Use Sheets

Silicone sheets tend to perform better in controlled clinical studies, likely because they deliver more consistent, prolonged contact with the scar. The tradeoffs are real: sheets need to be worn 12 to 24 hours a day to be effective, they can be visible under thin clothing, and they don’t stick well to areas that move a lot, like joints or the face.

When to Use Gel

Silicone gels are more forgiving. They apply like a thin lotion, dry to a nearly invisible film, and work in areas where sheets simply can’t stay put. The tradeoff is that gel requires reliably consistent application, and in some studies it slightly underperforms sheets used optimally.

My Recommendations

For most of my body contouring patients, I recommend sheets on tummy tuck, body lift, and breast surgery scars where they’re easy to wear under clothing. For facial scars, scars near the mouth or eyes, or scars over active joints, gel is almost always the better choice. Either way, silicone needs to be used consistently for at least two to three months before you should expect to see meaningful results.

One suspicion I’ve had for years is that scars perform better with less friction from clothing. Tapes and silicone seem to limit this irritation. Above all, consider what’s touching your scar and put something between your scar and your clothes to reduce friction.

Steroid injections remain one of my most effective tools for both hypertrophic scars and keloids. The steroids reduce inflammation and inhibit excessive collagen production. These injections need to be spaced appropriately—typically four to six weeks apart—and usually require multiple sessions.

5-Fluorouracil has an interesting backstory in scar treatment. Researchers originally developed it in the 1950s as a chemotherapy drug for colorectal and breast cancer, and for decades nobody thought of it as anything else. In the 1990s, dermatologists who were injecting it into skin cancers noticed something unexpected: the scars left behind were flatter and softer than anyone predicted. Richard Fitzpatrick’s 1999 paper established 5-FU as a legitimate option for hypertrophic scars and keloids, and since then it has earned a real place in the scar treatment toolkit—though it remains astonishingly underused.

How 5-FU Works

The mechanism is worth understanding. 5-FU is what scientists call a pyrimidine analog—it mimics a normal building block of DNA and slips into its place during cell replication, effectively stopping the process. In a keloid or hypertrophic scar, the collagen-producing cells (fibroblasts) cranking out all that excessive collagen are among the most rapidly dividing cells in the scar, so the drug hits them harder than the surrounding tissue. The result is less collagen production, fewer overactive fibroblasts, and gradual flattening of the scar.

Why I Often Choose 5-FU Over Steroids Alone

What I appreciate about 5-FU is that it sidesteps some of the problems that can appear with repeated steroid injections, particularly skin thinning (atrophy), broken blood vessels, and color loss around the scar. It’s actually my first choice when I’m concerned about the cosmetic side effects of steroids, because 5-FU gives me another effective option that works through a completely different pathway.

The combination of 5-FU with triamcinolone (a corticosteroid) has become one of the more powerful approaches I use for stubborn keloids and hypertrophic scars. I think of them as complementary agents attacking the same problem from different angles.

Why the Combination Works

Triamcinolone works on the inflammatory side of scarring, calming down the signaling that drives fibroblasts into overdrive. 5-FU works on the fibroblasts themselves, directly inhibiting their ability to replicate and produce collagen. Using them together tends to produce better results than either one alone, and clinical research supports this. Darougheh’s 2009 trial compared triamcinolone by itself against triamcinolone mixed with 5-FU and found the combination produced better scar flattening, less itching and pain, and fewer patients needed to stop treatment because of side effects. Subsequent analyses of the broader research have reached similar conclusions.

How I Use This Combination

The practical reason this combination matters so much is dosing. Adding 5-FU lets me use less steroid overall and still get a better result. The typical mix I use is about 9 parts 5-FU to 1 part triamcinolone, injected every 6 to 8 weeks for several sessions depending on how the scar responds. For scars that have frustrated patients through earlier treatment attempts, this combination has produced some of the most satisfying results I see in my practice.

Laser therapy has evolved significantly over the years. Different lasers target different aspects of scar tissue: some reduce redness by targeting blood vessels, others soften and flatten the scar by creating microscopic channels that trigger remodeling. I often use fractional lasers for scars that restrict movement or haven’t responded well to other treatments.

Close up of large scar keloid on man's hand

Treating Keloids Requires a Different Strategy

Keloids require a more aggressive, multi-modal approach because they’re notoriously resistant to single treatments. Surgical excision alone rarely works—keloids tend to grow back, often larger than before. When I do remove keloids surgically, I always combine the procedure with additional treatments like steroid injections or, in select cases, radiation therapy to prevent recurrence.

Cryotherapy uses extreme cold to reduce keloid size, and while it can be effective, results vary significantly from patient to patient.

In my experience, combining treatments typically produces better outcomes than relying on any single approach. The right combination depends on the scar’s location, size, symptoms, and how long it’s been present.

Prevention Strategies

If you know you’re prone to keloid formation, this becomes an important part of our surgical planning conversation. I need to know about any previous keloids or problematic scarring you’ve experienced, as this significantly influences which procedures might be appropriate and how I approach incision placement and closure.

Surgical Technique

Proper surgical technique matters immensely. When I perform surgery, meticulous closure technique—placing incisions in areas of minimal tension, using fine sutures, creating layered closures, avoiding excess tightness—makes a real difference in how scars heal. For patients at higher risk, I’m even more particular about these details.

Post-Operative Care

Following recovery instructions carefully, keeping incisions protected from UV exposure (which can darken scars), avoiding activities that put tension on healing incisions, and using any recommended scar care products all contribute to better healing.

Choosing the Right Sunscreen for Healing Scars

Sun protection on a healing scar isn’t optional. Ultraviolet exposure on immature scar tissue can cause permanent darkening (hyperpigmentation) that’s extremely difficult to reverse, so which sunscreen you choose actually matters.

The two main categories—physical (also called mineral) and chemical sunscreens—work in fundamentally different ways.

Physical sunscreens use zinc oxide and titanium dioxide to sit on top of the skin and physically reflect and scatter UV radiation. They start working the moment you apply them, they aren’t absorbed into the body in any significant amount, and they’re currently the only two sunscreen active ingredients the FDA recognizes as Generally Recognized As Safe and Effective (GRASE).

Chemical sunscreens—including avobenzone, oxybenzone, octinoxate, and octisalate—absorb UV radiation and release it as heat. That process can produce cell-damaging molecules (reactive oxygen species) as a byproduct, and Hanson and colleagues demonstrated in 2006 that once several common chemical filters penetrate past the skin’s outermost layer (the stratum corneum), they actually increase free radical generation in the deeper skin compared to untreated skin.

On intact, mature skin the barrier keeps most of the filter on the surface where it’s doing its job, and the net benefit of using any sunscreen consistently vastly outweighs this concern for the general population—though I conceptually disagree and prefer reflecting UV rays to allowing them to interact with the skin.

Healing scar tissue is a different environment. Inflammation is already driving the remodeling we’re trying to calm down, and free radicals feed directly into some of the same pathways that fuel abnormal scarring. Chemical filters also cause contact irritation (dermatitis) and sun-triggered allergic reactions (photoallergic reactions) more often than mineral ones, and researchers have recently shown that several active ingredients reach measurable blood levels that the FDA has asked manufacturers to study further.

For those reasons, I always recommend physical sunscreen on healing surgical scars. Zinc oxide has the added benefit of mild anti-inflammatory properties, which can help a scar that’s still maturing. I always tell patients that year-round sun protection over any scar—or for that matter any skin they care about—remains a lifelong habit worth keeping.

Early Intervention

If you notice a surgical scar becoming unusually thick or spreading beyond the incision line, contacting me sooner rather than later often leads to better outcomes.

When to Seek Evaluation

You should contact me about a surgical scar if it’s growing beyond the original incision line, continuing to expand months after your procedure, causing significant pain or itching, restricting your movement (particularly with body contouring scars), or simply bothering you cosmetically.

Accurate diagnosis makes all the difference. While you can find plenty of scar images online, nothing replaces an in-person examination where I can assess the scar’s texture, review your surgical history and healing process, and discuss treatment options specific to your situation.

At my Bellevue cosmetic surgery practice, I personally evaluate every patient with problematic scarring. We can discuss whether you’re dealing with a keloid, hypertrophic scar, or something else entirely, and develop a treatment approach that makes sense for your specific circumstances.

Give us a call at (425) 453-9060 or contact us online to schedule your complimentary consultation.

References »

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