Most scars fade quietly over time, a subtle reminder of the body’s healing power.
But when the process goes into overdrive, it can result in hypertrophic scars: raised, firm, and often itchy marks that linger well beyond the initial injury. For patients in Singapore, these scars are more than a cosmetic concern, they can cause discomfort and emotional distress.
Why do some wounds heal cleanly while others scar excessively? The answer lies in a complex mix of biological, mechanical, and environmental factors. In Singapore’s humid climate, with its prevalence of darker skin phototypes and growing demand for aesthetic procedures, hypertrophic scarring is a common and often preventable issue.
Whether caused by accidents, surgery, or cosmetic treatments, understanding what triggers hypertrophic scars is the first step toward better healing.
In this article, we examine the most common contributors, from wound mechanics to genetics, offering insights that can guide both practitioners and patients toward more effective prevention and care for hypertrophic scar healing process.
To understand hypertrophic scarring, it is essential to examine how the body responds to injury.
Wound healing is not a single event but a multi-phase biological process involving:
Haemostasis – Blood vessels constrict, and clotting begins almost immediately after injury.
Inflammation – White blood cells flood the site to remove bacteria, debris, and damaged tissue.
Proliferation – Fibroblasts produce collagen and extracellular matrix to rebuild the skin.
Remodelling (Maturation) – Collagen reorganizes and the wound gradually strengthens over weeks or months.
Hypertrophic scars typically form when something disrupts this tightly regulated sequence, especially the proliferation and remodeling phases.
One key trigger is excess collagen production. In normal healing, collagen fibers are laid down and then remodeled in an orderly fashion. However, in hypertrophic scarring, fibroblasts become hyperactive, depositing excessive amounts of collagen, particularly type III collagen, resulting in a raised and rigid scar.
Another factor is prolonged inflammation. When the inflammatory phase drags on, due to infection, repeated trauma, or poor wound care, it sends misleading signals to the body that the wound isn’t healing properly.
In response, the body continues to produce collagen and inflammatory mediators, fueling excessive scar tissue formation.
Quick Comparison Table: Normal vs Hypertrophic Healing
Source: Depositphotos.
Healing Phase
Normal Healing
Hypertrophic Scarring
Inflammation
Resolves within days
May persist for weeks
Collagen Production
Balanced (Type I > Type III)
Excessive (Type III > Type I)
Appearance
Flat, soft, blends with skin
Raised, firm, may appear red or dark
Timeline
Matures over 6–12 months
May remain raised for years
It’s important to note that not all wounds are created equal. The depth, size, and location of an injury heavily influence its healing outcome.
For example, deeper dermal injuries tend to scar more than superficial ones, and areas of high mobility (like the chest or shoulders) are more prone to hypertrophic response.
In short, hypertrophic scarring often begins in the earliest moments of healing, when the body either misjudges the wound’s severity or overreacts in its attempt to repair it.
Surgical Scars and Healing Complications
Surgical incisions, by design, are clean, controlled wounds, yet they are not immune to problematic healing.
Post-surgical wounds are more likely to develop into hypertrophic scars when healing is disrupted. Even under sterile, professional conditions, several factors can compromise recovery and lead to excessive scar tissue formation.
The key issue lies in mechanical stress, poor wound closure, or suboptimal post-operative care.
For instance, when sutures are placed under tension or a wound reopens slightly due to patient movement or inadequate support, the body registers this as ongoing injury. This prompts the healing system to stay “switched on,” producing excess collagen and inflammatory mediators.
Source: Depositphotos.
According to studies published in the Journal of Cutaneous and Aesthetic Surgery, surgical scars on areas like the chest, shoulders, and back are more prone to hypertrophy due to higher skin tension and movement, compounding the risk of abnormal scarring.
Moreover, delayed wound healing is another key contributor. This may be caused by:
Infection at the incision site
Poor circulation (common in older adults or smokers)
Underlying conditions like diabetes
Inappropriate dressing changes or wound exposure
Each of these prolongs the inflammatory phase, increasing the likelihood that fibroblasts will remain overactive and generate a raised, fibrous scar.
Clinically, one of the most challenging aspects of post-surgical care is patient compliance. Even with perfect surgical technique, failure to follow post-op instructions, such as avoiding strenuous activity, protecting the wound from sun exposure, or using prescribed scar creams, can significantly impact healing quality.
It’s also worth noting that some types of surgery carry inherently higher scar risks. Cosmetic procedures, where incisions are made on visible areas (such as the face, jawline, and chest), often come with higher patient expectations — and therefore, more attention to scarring outcomes.
However, ironically, procedures like mole removal, keloid excision, or jaw contouring may create fresh opportunities forHypertrophic scars to form if aftercare is not diligently followed.
Skin Tension and Scar Development
Source: Depositphotos.
One of the most overlooked, yet clinically significant contributors to hypertrophic scarring is skin tension.
The human skin isn't just a passive barrier; it’s under constant mechanical stress from the underlying muscles, gravity, and movement.
When a wound or surgical incision runs perpendicular to natural skin tension lines (also known as Langer’s lines), the surrounding tissue pulls at the healing site, increasing the risk of abnormal scar formation.
Here’s the rule of thumb used by many surgeons and dermatologists:
“High tension equals high risk.”
This principle applies especially to regions such as:
Chest and shoulders – broad, mobile areas with poor resting tension
Jawline and neck – highly expressive zones with continuous movement
Upper back – where skin is thick and movement is frequent
Why does tension matter so much? It interrupts the collagen remodeling process.
Under normal circumstances, fibroblasts lay down a scaffold of collagen and then trim and reorganize it over time. But when the wound is constantly pulled or stretched, the skin reinforces the area with thicker, disorganized collagen bundles, which results in a firm, raised hypertrophic scar.
In aesthetic practice, practitioners often counter this by:
Planning incisions along relaxed skin tension lines where possible
Using subcuticular sutures to reduce surface tension
Applying silicone sheets or pressure garments to modulate mechanical stress post-procedure
Recommending tape support or scar massages during the remodeling phase
Some aesthetic clinics in Singapore also use botulinum toxin injections off-label to temporarily paralyze the underlying muscles near a high-tension wound, especially in facial surgery, allowing the skin to heal under more stable conditions.
It’s a subtle but powerful insight: even with perfect technique and no infection, a wound under constant tension may still develop a hypertrophic scar. Recognizing this helps both clinicians and patients take preventative steps that go beyond the surface.
Other Risk Factors (Infection, Genetics)
While wound type and mechanical tension are significant, they aren’t the whole story.
Two other categories of risk, infection and genetics, often determine whether a patient heals with minimal scarring or develops a visible hypertrophic scar.
Source: Depositphotos.
Infection: A Biological Disruption
Infections don’t just delay healing; they prolong inflammation, which directly increases the likelihood of abnormal scarring.
When bacteria invade a healing wound, the immune system responds aggressively, and that often means keeping fibroblasts active longer than necessary.
What makes this particularly concerning in post-surgical or aesthetic procedures is that:
Infected wounds may partially reopen, causing uneven healing.
Localized swelling can stretch healing skin, compounding mechanical tension.
The body lays down excess collagen as part of an emergency response to reinforce the compromised tissue.
In aesthetic clinics, even minor lapses in sterility protocols or improper home wound care can introduce infection.
Patients with acne-prone or oily skin types are at a slightly higher risk due to their higher bacterial load. To mitigate this, practitioners often prescribe topical antibiotics or antiseptic dressings in the early post-operative period.
Genetics: The Inherited Predisposition
Genetics plays a quieter, but no less influential, role in scar formation.
Several studies have demonstrated that individuals with darker skin phototypes (Fitzpatrick IV–VI), which comprise a large portion of the Singaporean population, are more prone to hypertrophic and keloid scarring.
This appears to be due to genetic variations in:
Fibroblast sensitivity
Collagen turnover rates
Melanin production, which may contribute to persistent post-inflammatory hyperpigmentation around scars
There's also a familial link: if a patient’s parents or siblings tend to form raised scars, they are more likely to follow suit. While not deterministic, it raises a flag for clinicians to take more aggressive preventive measures.
Quick Snapshot: Relative Risk Factors
Risk Factor
Influence on Hypertrophic Scarring
Modifiable?
Infection
High — prolongs inflammation
With care
Genetics
Moderate to High — predisposition
Not modifiable
Skin Type (Fitzpatrick)
Moderate — darker types at higher risk
Not modifiable, but manageable
Previous Scar History
High — predictive of future scarring
Not modifiable, but informative
Understanding these hidden contributors is key in a clinical setting. Infections can be managed proactively, allowing for better aesthetic outcomes and lower rates of hypertrophic scarring.
Conclusion
Source: Depositphotos.
Hypertrophic scars aren’t just cosmetic, they reflect a healing process thrown off balance.
In Singapore’s aesthetic landscape, where diverse skin types and humid conditions intersect with increasing surgical demand, understanding what triggers these scars is crucial.
As we’ve explored, factors like wound depth, skin tension, infection, and genetics rarely act alone. Even a clean incision can scar if the healing environment isn’t well managed. That’s why scarring is less about the injury itself and more about how the body is allowed to heal.
Clinicians can reduce risk through mindful surgical planning, tension control, and proactive aftercare. For patients, recognizing personal risk factors and committing to good wound care can make all the difference.
Every scar tells a story, but the ones we prevent speak even louder, reflecting informed care, shared responsibility, and a better path to recovery.
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