Scar (also knows as cicatrix) is an area of fibrous tissue that replaces normal skin after injury.  Scar tissue is not identical to the tissue that it replaces and is usually of inferior functional quality. For example, scars in the skin are less resistant to ultraviolet (UV) radiation, and are devoid of sweat glands and hair follicles.

Scars, whether following skin surgery or trauma, are unpredictable. Many variables affect the final appearance of the scar.  These include the size and depth of the wound, the blood supply to the area, the thickness and color of your skin, the direction and the tension of the scar.

While no scar can be removed completely, the appearance of a scar can be improved and less noticeable through techniques described below.

SCAR & INJURY TREATMENT OPTIONS

• • Dermabrasion involves mechanical removal of the superficial layer of the skin (epidermis) and is most useful for the treatment of raised scars.   Dermabrasion is performed under local anesthesia.
  • Filler (hyaluronic acid, calcium hydroxyappetite) injections can be used to raise depressed scars to the level of surrounding skin. The effects are however temporary lasting on average 6-18 months.
  • Laser surgery and resurfacing – The use of lasers and light sources is the newest method of scar treatment. Over the past several years cosmetic resurfacing lasers have gained FDA approval for the treatment of scars. By removing superficial layers of skin resurfacing lasers may also help flatten scars.
  • Other cosmetic lasers including vascular lasers (pulsed dye laser, PDL) have been proven to greatly reduce the redness of most scars 6–10 weeks after the initial treatment.
  • Surgical scar revision – While no scar can be removed completely, the scar revision surgery may improve appearance of a scar. If you’re considering scar revision, the information below will give you a basic understanding of the most common types of scars and the procedures used to treat them.

Making the Decision

Many scars that appear large and unsightly at first may become less noticeable with time.  Scars mature and remodel becoming more conspicuous over the period of a year. For this reason, we tend to recommend waiting as long as a year or more after an injury or surgery before you decide to have scar revision.

Facial Scars

Because of its location and high visibility, a facial scar is frequently considered a cosmetic problem.  There are several ways to make a facial scar less noticeable. Often it is simply cut out and closed with small plastic surgery stitches, leaving a thinner, less noticeable scar.

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

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 scar contracture.

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 a different angle, 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.

Contracted Scars

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 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 Z-plasty may be used.  In larger and complex cases newer techniques, such as tissue expansion, are playing an increasingly important role. If the contracture has existed for some time, physical therapy after surgery may be necessary to restore full function.

Skin Grafting and Flap Surgery

Skin grafts and flaps are more involved than other forms of scar surgery. Grafting involves the transfer of skin from a healthy part of the body to cover the injured area. The graft is said to “take “when new blood vessels and scar tissue form in the injured area.

After Scar Revision

With any kind or scar revision, it’s very important to follow your post-op instructions to ensure that the wound heals properly. As you heal, keep in mind that no scar can be removed completely; the degree of improvement depends on 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.

Radiotherapy

Radiotherapy is a reserved for the treatment of severe keloids and hypertrophic scars.  Low-dose, superficial radiation therapy, is used to prevent re-occurrence of severe keloids and hypertrophic scarring. It is usually effective, but only used in extreme cases due to the risk of long-term side effects.

Vitamins

Vitamin C normalizes collagen production and encourages the production of an organized, healthy collagen framework which improves scar appearance of the scar.  Vitamin C and some of its esters also fade the dark pigment associated with some scars.

Research shows the use of vitamin E and onion extract as a treatment for scars is ineffective. Vitamin E causes contact dermatitis in up to 33% of users and in some cases it may worsen scar appearance.

Abnormal Scars

Two types of scars are the result of the body overproducing collagen, which causes the scar to be raised above the surrounding skin.

A HYPERTROPHIC SCAR is an overgrown scar that remains within the confines of the initial injury or cut.  Hypertrophic scars often improve in appearance after a few years.  Hypertrophic scars are usually present without symptoms, although they might be itchy, red and relatively firm.They often improve on their own-though it may take a year or more-or with the help of steroid applications or injections.

If a conservative approach doesn’t appear to be effective, hypertrophic scars can often be improved surgically. Excess scar tissue is then removed and incision lines are repositioned in a less visible pattern. This surgery may be done under local or general anesthesia, depending on the scar’s location. You may receive steroid injections during surgery and at intervals for up to two years afterward to prevent the thick scar from reforming.

Keloid

A Keloid is a large, irregular scar that outgrows the site of initial skin injury. The tendency toward the development of hypertrophic scars may be inherited. Keloid scars can occur on anyone, but they are most common in dark-skinned people. Keloids can appear anywhere on the body, but they’re most common over the breastbone, on the earlobes, and on the shoulders. The tendency to develop keloids lessens with age. Keloids are often treated by injecting a steroid medication directly into the scar tissue to reduce redness, itching, and burning. In some cases, this will also shrink the scar.

If steroid treatment is inadequate, the scar tissue can be cut out and the wound closed.   This is generally an outpatient procedure, performed under local anesthesia. A skin graft is occasionally used, although the site from which the graft was taken may then develop a keloid.

No matter what approach is taken, keloids have a tendency to recur, sometimes even larger than before. To discourage this, we may combine the scar removal with steroid injections, direct application of steroids during surgery, or radiation therapy. Or 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 repeated procedures every few years.

Surgical excision of hypertrophic or keloid scars is often associated to other methods such as presso-therapy or silicone gel sheeting. Excision of keloid scars without any adjuvant therapy shows a high recurrence rate close to 45%.  

Clinical Features of Hypertrophic Scars and Keloids

Hypertrophic Scars                                                                        Keloids

Develop soon after skin trauma/surgery                                   May develop months after the trauma

Usually improve with time                                                           Rarely improve with time

Remain within the confines of the wound                                Spread outside the wound

May improve with appropriate surgery                                     May worsen by surgery

Have no association with skin color                                           Are associated with darker skin color