SCAR MANAGEMENT

If you’re considering scar management…

Scars, whether they’re caused by accidents or by surgery, are permanent and there is no way to totally remove a scar.  The way a scar develops depends upon how your body heals, the mechanism of the original injury and on the surgeon’s skills.

Many variables can affect the severity of scarring, including the size and depth of the wound, the blood supply to the area, the thickness and color of your skin, and the direction of the scar.  How much the appearance of a scar bothers you is, of course, a personal matter.

While no scar can be removed completely, plastic surgeons can often improve the appearance of the scar, making it less obvious through the injection or application of certain steroid medications or through surgical procedures known as scar revisions.

If you’re considering scar revision, this section will give you a basic understanding of the most common types of scars, the procedures used to treat them, and the results you can expect.  It can’t answer all of your questions, since a lot depends on your individual circumstances, so please be sure to ask if there is anything about the procedure that you don’t understand.

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MAKING THE DECISION

Many scars that appear large and unattractive at first may become less noticeable with time.  Some can be treated with steroids to relieve symptoms such as tenderness and itching.  For these reasons, many plastic surgeons recommend waiting as long as a year after an injury before you decide to have scar revision.  It is important to keep the sun off any pink scars.

If you’re bothered by a scar, your first step should be to consult a board certified plastic surgeon.  The surgeon will examine you and discuss the possible methods of treating your scar, the risks and benefits involved and the possible outcomes.  Be frank in discussing your expectations with the surgeon, and make sure they’re realistic.  Don’t hesitate to ask any questions or express any concerns you may have.  Insurance doesn’t usually cover cosmetic procedures such as scar revision.

ALL SURGERY CARRIES SOME UNCERTAINTY AND RISK

While scar revision is normally safe, there is always the possibility of complications.  These may include infection, bleeding, a reaction to the anesthesia, or the recurrence of an unsightly scar.

You can reduce your risks by choosing a qualified plastic surgeon and closely follow his or her advice, both before surgery and, most importantly, the follow-up care.

KELOID (Hypertrophic) SCARS

These scars are thick, puckered, itchy clusters of overgrown scar tissue that grow beyond the edges of the wound or incision.  These scars are an overgrowth of your normal scar to heal a wound.  They are often red or darker in color than the surrounding skin.  These hypertrophic scars occur when the body continues to produce the tough, fibrous tissue known as collagen after a wound has healed.

These scars can appear anywhere on the body, but they’re most common over the breastbone, on the earlobes, and on the shoulders.  They occur more often in dark skinned people than in those who are fair.  The tendency to develop these keloids lessens with age.

Hypertrophic scars are often treated by injecting a steroid medication directly into the scar tissue, especially if the scar is new, to reduce redness, itching and burning.  In most cases, this will also shrink the scar.  Sometimes, a steroid injection is required on a monthly basis to finally control the collagen overgrowth.

If steroid treatment is ineffective, the hypertrophic scar tissue can be cut out and the wound closed to try to initiate a more controlled healing process.

No matter what approach is taken, keloids have a stubborn tendency to recur, sometime even larger than before.  To discourage this, the surgeon may combine the scar removal with steroid injections, direct application of steroids during surgery, or radiation therapy.  You may be asked to wear a pressure garment over the area for as long as a year.  Even so, the keloid may return, requiring a different treatment plan.

If a conservative approach doesn’t appear to be effective, these scars can often be improved surgically.  The plastic surgeon will remove excess scar tissue, and may reposition the incision so that it heals is a less visible pattern.  This surgery may be done under local or general anesthesia, depending on the scar’s location and what you and your surgeon decide.  You may receive steroid injections during surgery and at monthly intervals for up to two years afterward to try to prevent the thick scar from reforming.

CONTRACTURES

All scars have the tendency to contract as they mature.  Burns or other injuries resulting in the loss of a large area of skin may form a scar that pulls the edges of the skin together, a process called contraction.  The resulting contracture may affect the adjacent skin, muscles and tendons, restricting normal movement.

Correcting a contracture usually involves cutting out the scar and replacing it with a skin graft or a flap.  In some cases a surgical procedure known as Z-plasty may be used to change the direction of the scar.  Techniques, such as tissue expansion, are playing an increasingly important role.  If the contracture has existed for some time, you may need physical therapy after surgery to restore full function.

FACIAL SCARS

Because of its location, a facial scar is frequently considered a cosmetic problem, whether or not it is hypertrophic.  There are several ways to make facial scars less noticeable.  Often the scar is simply cut out and closed with different stitches, leaving a thinner, less noticeable scar.

If the scar lies across the natural skin creases (lines of relaxation) the surgeon may be able to reposition the scar to run parallel to these lines, where it will be less conspicuous.

(See Dermabrasion)

The appearance of some facial scars can be softened using a technique called dermabrasion, a controlled sanding of the top layers of the skin using a hand held, high speed rotary wheel.  Dermabrasion leaves a smoother surfaced scar, but it won’t completely remove the scar.

Z-PLASTY

Z-plasty is a surgical technique used to reposition a scar so that it more closely conforms to the natural lines and creases of the skin, where it will be less noticeable.  It can also relieve the tension caused by a scar contracture.  Not all scars lend themselves to Z-plasty, however, and it requires an experienced plastic surgeon to make such judgments.

In this procedure, the old scar is removed and new incisions are made on each side, creating small triangular flaps of skin.  These flaps are then rearranged to cover the wound at different angles, giving the scar a Z pattern.  The wound is closed with fine stitches, which are removed a few days later.  Z-plasty is usually performed as an outpatient procedure under local anesthesia.

While Z-plasty can make scars less obvious, it won’t make them disappear.

SKIN GRAFTING AND FLAP SURGERY

Skin grafts and flaps are more extensive than other forms of scar surgery and are more likely to be performed in a hospital as a inpatient procedure, using general anesthesia.  The treated area may take several weeks or months to heal, and a support garment or bandage may be necessary for up to a year to keep constant pressure on the new maturing scar tissue.

Grafting involves the transfer of skin from a healthy part of the body (the donor site) to cover the injured area.  The graft is said to “take” when new blood vessels form in the injured area.  While most grafts from a person’s own skin are successful, sometimes the graft doesn’t take.  In addition, all skin grafts will leave some scarring at the donor and recipient sites

Flap surgery is a complex procedure in which skin, along with the underlying fat, blood vessels, and sometimes the muscle, is moved from a healthy part of the body to the recipient site.

Skin grafting and flap surgery can greatly improve the function of a scarred area.  The cosmetic results may be less satisfactory, since the transferred skin or flap may not precisely match the color and texture of the surrounding skin.  In general, flap surgery produces better cosmetic results than skin grafts.

AFTER SCAR REVISION

With any kind of scar revision, it’s very important to follow your surgeon’s instructions after surgery to make sure the wound heals properly.  Although you may be up and about very quickly, your surgeon will advise you on gradually resuming your normal activities.

As you heal, keep in mind that no scar can be removed completely, the degree of improvement depends on how you heal, the size and direction of your scar, the nature and quality of your skin, and how well you care for the wound after the operation.  If your scar looks worse at first, don’t panic – the final results of your surgery may not be apparent for a year or more.

This thick, over-grown cluster of scar tissue on the earlobe is a keloid. Here it has been removed and the incision closed with stitches, leaving a thin scar.
This hypertrophic scar has formed a contracture, restricting finger motion.
Using Z-plasty, the scar is removed and several incisions are made on each side, creating small triangular flaps of skin. Then the flaps are rearranged and interlocked to cover the affected area.
The incision is closed with a Z-shaped line of sutures. The new scar is thinner and less visable, and allows the finger to be extended.
The scar crossing the natural line, or crease, between the nose and mouth is removed and repositioned using Z-plasty. The forehead scar, located in the natural lines, is excised with tapered ends. The skin is then loosened and brought together with stitches.
The repaired scars now lie partly within the natural skin crease, where they are less visible.