Scar revision

SHORT SUMMARY

  • different parts of the same body heal differently and specific areas of the body produce worse scars than others
  • the scar should not be exposed to sunlight preferably up to six months after the operation
  • suturing technique is important but frequently neglected factor in the final appearance of scars
  • because of unique biological characteristics of each individual there is always some uncertainty regarding how much the scar can be improved with surgery

Can scars be prevented?

If the skin is cut or damaged through its full or almost full thickness, it will inevitably heal with a scar. In some people, the scar can mature and fade in time to almost invisible line while in others; they may become stretched, red and raised. One thing that makes the scar more obvious than necessary are the suture marks which are dots or small perpendicular lines beside the scar. The other is increased width of the scar due to increased tension that pulls the scar apart.


What factors influence the appearance of the scar?

Different parts of the same body heal differently and specific areas of the body produce worse scars than others. The thinner and less elastic the skin, the finer the scar usually is. Therefore, the scars on the eyelids are almost invisible, and this region never develops hypertrophic scars or keloids. Fortunately the face and neck make good scars generally. Contrary, the worst scars appear in the middle of the chest and the tip of the shoulder. On rare occasions, these areas produce keloid scars without any known injury.

Scars which lie in the lines of skin tension (Langer’s lines) tend to be better than ones that run across them. To make scar inconspicuous, the incision should be placed in normal skin creases developed by muscle movements and gravity. We always choose the optimal site and direction of the incisions and make them as short as possible.

Due to reduced elasticity of the skin and decreased activity of scar tissue the scar tend to look better in older people.

The suturing technique is often the most important but frequently neglected factor in the final appearance of scars. Absorbable sutures in deeper layers and hidden stitches in the surface leave no suture marks and reduce the risk that the edges of the scar will stretch apart. If a large amount of skin has been removed, or the scar is exposed to a lot of tension during initial healing period, the scar tends to widen. Therefore, movements that put a lot of tension on the scar should be avoided for approximately three months after the procedure.

There is considerable variation between individuals in biological characteristics and the way the scar heals. We cannot accurately predict this, but in general we are aware that patients with fair freckled skin and red hair and at the opposite end of the spectrum patients with a black skin will tend to produce poor scars including hypertrophic scars and keloids.


What is the difference between keloid and a hypertrophic scar?

Hypertrophic scar occurs when the wound heals to become red, raised and itchy for a few months, but will then resolve to some degree and become more or less flat and pale. A keloid is similar, but the scar continues to grow and never regresses spontaneously. Due to hereditary determined hyperactive healing, it grows beyond the edges of original incision or damage and may require specific treatment. Keloids and hypertrophic scars are usually made worse if they are simply excised. They may become larger and even more irritating. Therefore, the surgery must be combined with additional treatment.


How do we treat active scars?

Over the months following surgery the scars mature and tend fade from being red, possibly thick and uncomfortable, to becoming paler and less obvious. However, there are factors that influence the maturation process and reduce hypertrophic scaring. That is why looking after the scar after the procedure is extremely important for a good result. The scar should not be exposed to sunlight preferably up to six months after the operation. Pressure applied to the scar in the form of bandage or compressive garment speeds up the maturation process, and application of silicone sheets keeps moist environment and makes scar softer and less noticeable. Already developed hypertrophic scars and keloids can be softened and reduced to some extent with injections of steroids (triamcinolone), which are usually repeated over 1-2 months periods.


What is scar revision?

The look of some scars can be improved by surgical procedure. When it is felt that a scar can be improved because of particular circumstances or complications of healing in the first instance, or because the procedure is likely to be carried out in a better manner scar revision should be performed. Because of unique biological characteristics of each individual there is always some uncertainty regarding how much the scar can be improved with surgery. Especially indented scars, which are due to the formation of scar tissue joining the skin with underlying muscle fascia, can always be corrected. Before the correction, the scar should be mature and well healed, normally at least a year should be allowed for maturation and spontaneous improvement of the scar. The procedure is usually done under local anesthesia. The old scar is removed by one of several plastic surgery techniques and the skin sutured preferably in two layers. Dermabrasion and laser surgery can also be used to blur the edges of the scar and minimize surface irregularities.Post operatively advice for scar treatment should be followed closely to achieve best possible outcomes.


Is there specific treatment for acne scars, burn scars and keloids?

Acne scars are difficult to treat. Even though, some procedures offer significant improvements, it should be stressed out that scars cannot be removed. Sometimes it is possible to reduce them by cutting them out and lift them to normal skin level. Skin resurfacing procedures are used to reduce the overall depth of scars and to tighten the skin.

Deeper burns tend to heal with scars. Children are particularly affected by hypertrophic scars as a result of scalds. Burn scars should be treated with compression garments, and silicone sheets can also be helpful. Surgery is used to reduce tension and replace severe scars with skin grafts.

Keloids still remain an unresolved problem. The easiest to treat are earlobe keloids, which sometimes appear after piercing and often simple excision is adequate. Elsewhere courses of steroid injections are the main course of treatment. Rarely, excision and some other treatment (steroid injections or irradiation) to reduce recurrence of keloids can be helpful.


What are beneficial effects of skin creams?

It is not felt that skin creams have a direct effect on the scar, but the massaging of a moisturizer into the scar will keep it from becoming dry and help make it supple. Scars are sun sensitive, and sun screen should be used to protect them.