If
you're considering scar revision...
Scars — whether they're caused by
accidents or by surgery — are unpredictable. The way a scar
develops depends as much on how your body heals as it does on
the original injury or 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 a 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 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. Please
be sure to ask your doctor if there is anything about the
procedure you don't understand.
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 or more after an
injury or surgery before you decide to have scar revision.
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 usually doesn't cover
cosmetic procedures. However, if scar revision is performed to
minimize scarring from an injury or to improve your ability to
function, it may be at least partially covered. Check your
policy or call your carrier to be sure.
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 following his or her
advice, both before surgery and in follow-up care.
Keloid scars
 |
| 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. |
Keloids are thick, puckered, itchy
clusters of scar tissue that grow beyond the edges of the
wound or incision. They are often red or darker in color than
the surrounding skin. Keloids occur when the body continues to
produce the tough, fibrous protein known as collagen
after a wound has healed.
Keloids 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 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 with one
or more layers of stitches. This is generally an outpatient
procedure, performed under local anesthesia. You should be
back at work in a day or two, and the stitches will be removed
in a few days. A skin graft (see the section on skin
grafting) 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 stubborn tendency to recur, sometimes 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.
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.
Hypertrophic scars
 |
| This
hypertrophic scar has formed a contracture,
restricting finger motion. |
Hypertrophic scars are often confused
with keloids, since both tend to be thick, red, and raised.
Hypertrophic scars, however, remain within the boundaries of
the original incision or wound. They often improve on their
own-though it may take a year or more-or with the help of
steroid applications or injections.
 |
| 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. |
If a conservative approach doesn't
appear to be effective, hypertrophic scars can often be
improved surgically. The plastic surgeon will remove excess
scar tissue, and may reposition the incision so that it heals
in 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 intervals for up to two years
afterward to prevent the thick scar from reforming.
Contractures
 |
| 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. |
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 a procedure known as
Z-plasty may be used. And new 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 a
facial scar less noticeable. Often it is simply cut out and
closed with tiny stitches, leaving a thinner, less noticeable
scar.
 |
| 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. |
If the scar lies across the natural
skin creases (or "lines of relaxation") the surgeon
may be able to reposition it to run parallel to these lines,
where it will be less conspicuous. (See Z-plasty)
Some facial scars can be softened
using a technique called dermabrasion, a controlled
scraping of the top layers of the skin using a hand-held,
high-speed rotary wheel. Dermabrasion leaves a smoother
surface to the skin, but it won't completely erase the scar.
Z-plasty
 |
| The
repaired scars now lie partly within the natural skin
crease, where they are less visible. |
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
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 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 underlocal
anesthesia.
While Z-plasty can make some scars
less obvious, it won't make them disappear. A portion of the
scar will still remain outside the lines of relaxation.
Skin grafting and flap surgery
Skin grafts and flaps are more
serious than other forms of scar surgery. They're more likely
to be performed in a hospital as inpatient procedures, 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.
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 and scar tissue 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 grafts
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 injured site. In some flaps, the blood supply
remains attached at one end to the donor site; in others, the
blood vessels in the flap are reattached to vessels at the new
site using microvascular surgery.
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
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 or 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 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.
