Scar Management And Revisions
Scars are a body’s normal and inevitable response to injury and tissue repair. For the first couple of weeks, the scar(s) may look excellent, but with time become more noticeable, or red and lumpy. This is a normal response to intricate cellular processes associated with wounding, healing and scar maturation.
Scar appearance is influenced by several factors: inherent, individual healing tendencies, wound care, operating technique etc. Many patients do not understand that healing process extends well beyond the first two weeks when the wound ends have reconnected so that sutures can be removed. At that point immature scar has glued two sides of the wound together, but important, secondary healing processes only then begin. And they take weeks, even months! With time, scar collagen becomes softer, thinner and paler. Initially red or pink, firm scar line will gradually fade and eventually become white and/or almost regain the colour of the surrounding, normal skin. Scar will also become much more pliable. Patience is essential as this might take between 6-9 months and for bigger scars up to 24 months.
As plastic surgeon, we make particular efforts to leave behind fine scars: use very fine instruments and sutures and handle tissues and wounds in a way likely to result in as favorable scarring as possible.
Adverse scarring most commonly include 3 main groups: unsightly, hypertrophic and keloid scars.
The commonest unsightly scars are those with stretched, widened appearance and surrounding stitch marks from previous surgery (Picture 1). This group also involves scars which developed after spontaneous, prolonged healing whereby the wound has not been treated surgically. Usually a lot of scar tissue is deposited after such healing therefore scars are likely to be thick and unsightly.
Hypertrophic scars are red (pink) lumpy scars that continue to grow, after the original wound has healed (Picture 2).
We do not completely understand why hypertrophic scars form, but there is a lot of globe-wide research looking into this. It seems as if the body does not switch off the scar forming mechanism after a wound has healed, and scar tissue continues to be produced, forming a lumpy nodules. This is more likely to happen if there has been a delay in the wound healing, infection, or when the wound has pulled apart and has been left to heal naturally. Some areas of the body are more prone to them such as the chest and the shoulders. They are commonly seen in people with pale, fair skin and red hair.
Keloid scars (Pictures 3a and 3b) are even more unsightly and annoying then hypertrophic ones. Scars that continue to grow, long after the original wound has healed and expand outside the original area of surgery/injury are defined as keloid. They can be quite large and often itchy.
Keloid scars are particularly common in people with Afro-Caribbean descent and people from the Far East. Unfortunately, keloids are difficult to treat and cannot be cured.
Treatment for Adverse Scars
Hypertrophic and keloid scars can be difficult to treat. The commonest treatment options are listed below:
Silicone gel – sticky gel sheet applied to the scar or alternatively as a liquid from a tube (e.g. Dermatix or Kelo-cote)
Steroid injections – a regular course of injections into the scar itself, repeated every 6-8 weeks induces scar flattening and alleviation of itchiness. This may also be performed in combination with surgery.
Surgery in considered in certain circumstances – usually if the original wound had healing problems due to an infection or prolonged healing, scar is very wide and has stitch marks around it.
Operation allows excision of the scar and fine re-suturing. If the wound can be restitched and made to heal again, without adverse effects of acute injury, infection or prolonged healing, it is less likely that it will become hypertrophic, keloid or unsightly again. Personally, I always use a suturing technique whereby the stitch is hidden under the skin surface (interwoven) in order to avoid any subsequent stitch marks (Picture 4)
Rarely surgery may be performed in conjunction with radiotherapy applied within 24-48 hours after surgery. This method is the most radical, with lowest recurrence rate, but should be reserved for particular scars because of side effects of irradiation
The success rate of different treatments is variable and depends on individual circumstances as well possible triggering cause. Once the hypertrophic or keloid scar has improved in terms of size and texture it may not be a trouble again. However, in some cases, the hypertrophic scar recur and further treatment may be necessary.
Sometimes scars are not lumpy and/or thickened, just wide, irregular and/or big. Such scars can be improved by various means depending on what exactly needs to be addressed.
Surgical revision – removes unsightly scar and re-sutures skin edges delicately using strong, yet non-irritating suturing techniques and sutures. This method is the best for the scars which resulted from original suboptimal healing, which are broad and can be physically reduced and converted into a linear scars. When scars are quite wide, several operations might be required in order to remove or just reduce the scar patch. This is known as serial (staged) excision
Chemical Peels – thinning of the scars by chemical means (trichloroacetic acid, phenol, etc.).
Dermoabrasion – thinning of the scar by mechanical means (fast rotating diamond burr/wheel)
Derma rollers – thinning of the scar by mechanical means – a newer device consisting of a roller with huge number of micro needles which induce micro trauma and stimulate collagen production and healing.