Second Quarter 2009, Volume 23, Number 2

Scar management: What types of scars respond best to varying treatments


Don’t stress the small stuff, it can lead to premature aging

Scar management: What types of scars respond best to varying treatments

Ask the Surgeon / Health Tip / What’s New

How plump do you want them?

When the skin is recovering from an injury—from an accident, a burn, surgery, or acne—scarring will occur wherever there is surface loss or penetration extended through the basement membrane. The size, depth, thickness, and color vary depending on the cause of the scar. Once a scar forms, it is permanent; however, you have options to make it smaller and less obvious. Talk to your facial plastic surgeon about what technique would work best to improve the look of your scar.

Different types of scars respond to different minimizing techniques. The timing of surgery is an important choice; some surgeons advise against revision in cases of injury for a period that might extend up to a year after the injury. This interval allows the body enough time to heal fully. Skin color, skin type, and age are additional factors that must be part of the discussion prior to surgery.

Types and treatments
There are hypertrophic scars, keloids, and contractures. Hypertrophic scars are thick, red, and raised due to the overproduction of collagen after a wound has healed. The scar remains within the boundaries of the original incision or wound. Treatments may include topical applications or steroid injections. The steroid stops collagen production, which may allow the scar to flatten and fade over time. For more extensive revision, the scar can be improved surgically by repositioning the incision so it heals in a less visible pattern. Keloids are thick, protrusive mounds of scar tissue that may be the same color as the surrounding skin or red in color.

Like hypertrophic scars, this type of scar results from an overproduction of collagen; however, unlike hypertrophic scars, it grows beyond the margins of the original wound. Injecting steroid medication directly into the scar tissue will reduce redness, itching, burning, and collagen production. The scar tissue can also be excised and closed with one or more layers of stitches if more extensive revision is necessary.

If you have suffered severe burns that have destroyed a larger area, the skin has probably healed in a puckered way. Other major injuries may also form this type of scar that pulls the edges of the skin together; this process is 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. Skin flaps, composed of adjacent healthy, unscarred skin, are lifted and moved to form a new incision line.

Where a flap is not possible, a skin graft may be used. A graft involves taking a section of skin tissue from one area and attaching it to another; time must be allowed following surgery for new blood vessels and soft tissue to form. In some cases, a Z-plasty or Wplasty may be used. These two techniques depict the different ways to release a contracted scar—cuts that resemble a z shape or a w shape—depending on the severity of the scar. While these techniques do not remove all signs of a scar, they do make it less noticeable.

Scars that are raised or bumpy may respond to a resurfacing technique. In laser resurfacing, the laser emits powerful bursts of high-intensity light that vaporize the scar tissue with little or no damage to surrounding areas of the skin. Another option is dermabrasion (a facial sanding technique). Alternatively, if the scar is depressed, your physician may inject dermal fillers, such as collagen, to raise the scar for a smoother appearance. Talk to your facial plastic surgeon about the many methods and combinations of techniques to attain the best results.

Good candidate
A good candidate for scar revision is someone in good overall health. Expectations of the surgery and of the surgeon must be realistic. There is no way to remove scars completely; the goal is to improve the appearance by disguising it, relocating it, or minimizing its prominence.

Deciding on a treatment
You are not alone if you feel self-conscious about your scars. Some people also experience diminished functioning of the eyes, mouth, or nose due to scarring. If you have wondered how scar revision could improve your appearance, your self-confidence, or your level of facial functioning, you need to know how scar revision works and what you can expect from it. Your first step is to make an appointment with your facial plastic surgeon. Come prepared to discuss your expectations and to ask questions about your options. Once you agree on a treatment plan, your surgeon will inform you about the anesthesia, the surgical facility, any supportive surgery options, and costs. Most scar revision surgeries will require some down time. There may be some swelling, bruising, and redness following surgery. Although sutures will be removed within days after the surgery, your skin will need time to heal. Your surgeon will give detailed instructions regarding what you can and cannot do (activity level), along with the recommendation to keep your head elevated when lying down, use cold compresses to reduce swelling, and avoid activity that places undue stress on the area of the incision. Scar tissues require a year or more to fully heal and achieve maximum improved appearance, so you will have to be prepared to be patient for the final results. Whether the surgery is desired for functional or cosmetic reasons, your choice of a facial plastic surgeon is of paramount importance. Your surgeon will decide upon the proper treatment and inform you of outcomes that can be expected from facial scar revision surgery.