Is Scar Surgery Right for Me? A New Tool Guides Decisions Around Reconstructive Scar Surgery for Burn Survivors
Written by Clifford Sheckter, MD, MS, FACS on September 30, 2025
"I can't believe I did this. This is not better. I don't know why I did this to myself."
I was taken aback by her words.
As a plastic surgery resident working on a burn unit, I had just completed a scar release and reconstruction for a patient with a neck contracture. Objectively, the procedure had been successful. She had an increased range of motion in her neck, and she even acknowledged it. But emotionally, she was deeply dissatisfied.
Unfortunately, I did not have the opportunity to understand her dissatisfaction. Before I could get closure, the schedule of residency whisked me off to my next rotation. Still, her case stuck with me.
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In the midst of an existential crisis, I asked myself a very basic question:
Does reconstructive scar surgery actually help burn survivors?
I was able to answer with a resounding yes, because I had witnessed successful outcomes with other patients. One, in particular, stood out: I had seen a patient back in the clinic who’d had a scar release on his hand. He was overjoyed to regain the ability to hold a can of beer, something impossible before because his thumb was scarred into his palm prior.
What explains this discrepancy? How could some patients receive these operations and be so happy, and yet other patients be so dissatisfied?
I wanted to understand, in aggregate, how burn survivors actually fare after scar-related surgery.
This was not an easy question to answer. In an ideal world, I'd ask every burn survivor who underwent reconstructive surgery how the operation went and how it impacted their function and quality of life—both objectively (through range-of-motion tests) and subjectively (through personal reflection and surveys). But that kind of study is rarely feasible.
Like many things in science, we can't do the exact experiment we want. So, I turned to the next best thing: the Burn Model Systems (BMS) program—a federally funded, long-term database tracking burn survivors across the United States (though it recently has come on the chopping block as part of the large-scale movement to shrink the federal government). I analyzed this dataset, looking specifically at individuals who had undergone scar operations.
In 2020, I published a study demonstrating exactly what I had seen in the clinic with my patients. Some patients had improved quality of life after their scar operations. Others saw no significant change, especially when undergoing procedures for contracture release. More interestingly, I found patients were more likely to have improved quality of life if they waited at least 6 to 12 months to undergo their scar surgery, compared to embarking on these procedures in the immediate period after discharge. We later replicated a study using slightly different outcomes data and found similar results.
This left me wondering: why the disconnect?
Objectively, I knew there was an opportunity for improved quality of life and satisfaction when regaining the use of a hand, the neck, and the axilla. But there was clearly something going wrong in the process for many burn survivors to feel underwhelmed and dissatisfied with the outcome of their operation.
Every time I take someone to the operating room, I ask myself a fundamental question:
Am I operating to save someone's life, or am I operating to improve their quality of life?
When the operation is lifesaving, the decisions are easy. When a patient arrives with 70% full-thickness burns, the path is clear: get the burn off, operate fast, close the wounds. But when a survivor walks into your clinic six months post-injury, unable to use their hand because of scarring, the decision becomes more challenging.
Rushing to surgery, especially for a patient struggling with depression or unable to complete hand therapy, can yield minimal benefit. Worse, it may lead to setbacks. Surgery itself is traumatic. This, I realized, was the real issue. The question wasn't just what operation is right. It was a much greater conversation about everything occurring in that person's life, for which the hand scar may be only 1% of their actual problems. Most importantly, we weren't talking enough about expectations.
Decision Aid for Reconstructive Scar Surgery
I looked for tools to guide these complex decisions and align patient expectations with likely outcomes. I found decision aids for other quality-of-life surgeries, like breast reconstruction. But for burn scar surgery? Nothing.
With the support of the American Association of Plastic Surgery, the Plastic Surgery Foundation, and Phoenix Society, I set out to create a tool grounded in scientific methods, and importantly, that included the voices of burn survivors, family members, and the clinicians who care for them.
We interviewed 40 participants and used qualitative research methods to identify core themes. We included a burn survivor as part of the research team to maintain a perspective fundamentally grounded in the voices of those it was designed to serve.
The decision aid includes six sections:
Get the Facts: Covers the basics of scar surgery—objective info, recovery timelines, risks, and quotes from survivors and clinicians.
Compare Options: Defines the often-confusing jargon (Z-plasty, flaps, lasers, tissue expanders) so survivors can better understand their choices.
Your Feelings: After reviewing the first two sections, survivors read seven thematic statements and rate their agreement with the statements to assess readiness for surgery.
Your Decision: Survivors are then asked four simple questions based upon the SURE Framework to give them a self-reported sense of readiness for the procedure.
Quiz Yourself: Burn survivors answer five true/false questions to measure their understanding of the information presented.
Your Summary: The aid calculates three numbers which collectively measure a survivor's 1) feelings towards scar surgery, 2) self-described attitude towards scar surgery, and 3) comprehension of the facts around reconstructive burn scar surgery.
In the pilot phase, patients have reported near universal satisfaction with using the decision aid. We’re now in the process of conducting larger studies to measure the greater impact of this tool for burn survivors across North America.
Our ultimate goal is that all burn survivors undergoing reconstructive scar surgery will be satisfied with their results and gain quality of life in the process. For some, this will mean waiting. For others, it might mean choosing not to have surgery at all. And for many, it will mean addressing trauma, building resilience, and setting clear, realistic expectations before stepping into the operating room.
Dr. Cliff Sheckter is the Burn Center Director at Santa Clara Valley Medical Center, which serves the San Francisco Bay Area in burn and trauma care. He is double board certified in plastic/reconstructive surgery and surgical critical care and dedicates his practice to burn patients and survivors. He completed his medical/surgical training at USC, Stanford, and the University of Washington. Dr. Sheckter is an Assistant Professor of Surgery at Stanford University and teaches medical students and residents comprehensive burn care. He is also a health policy researcher and has published multiple articles related to burn survivor quality-of-life and health economics in burn care.
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