Scar revision

What is scar?

What is scar revision?

How to improve the appearance of scars

Candidates for scar revision surgery

Before Scar revision surgery

Types of scars and treatment

After Scar revision surgery

What is scar?

A scar is the body's natural way of healing and replacing lost or damaged skin. A scar is usually composed of fibrous tissue. Scars may be formed for many different reasons, including as a result of infections, surgery, injuries, or inflammation of tissue. Scars may appear anywhere on the body, and the composition of a scar may vary--appearing flat, lumpy, sunken, or colored. The scar may be painful or itchy. The final look of a scar depends on many factors, including the skin type and location on the body, the direction of the wound, the type of injury, age of the person with the scar, and his or her nutritional status.

Skin cancer

What is scar revision?

Scar revision is surgery to improve or reduce the appearance of scars. It also restores function, and corrects skin changes (disfigurement) caused by an injury, wound, poor healing, or previous surgery.

Scar revision is plastic surgery performed to improve the condition or appearance of a scar anywhere on your body. The different types of scars include:
Discoloration or surface irregularities and other more subtle scars can be cosmetically improved by surgery or other treatments recommended by your plastic surgeon. These types of scars do not impair function or cause physical discomfort and include acne scars as well as scars resulting from minor injury and prior surgical incisions.

Scar tissue forms as skin heals after an injury (such as an accident) or surgery.

How much scarring there is depends on:

• Size, depth, and location of the wound
• Your age
• Skin characteristics, such as color (pigmentation)

Depending on the extent of the surgery, scar revision can be done while you are awake (local anesthesia), sleeping (sedated), or deep asleep and pain-free (general anesthesia).

When to have scar revision done is not always clear. Scars shrink and become less noticeable as they age. You may be able to wait to have surgery until the scar lightens in color. This can be several months or even a year after the wound has healed. For some scars, it is best to have revision surgery 60 to 90 days after the scar matures. Each scar is different.

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There are several ways to improve the appearance of scars:

• The scar may be removed completely and the new wound closed very carefully.
• Dermabrasion involves removing the upper layers of the skin with a special wire brush called a burr or fraise. New skin grows over this area. Dermabrasion can be used to soften the surface of the skin or reduce irregularities.
• A laser may be used to soften the surface of the scar, and stimulate new collagen growth within the scar.
• Very large injuries (such as burns) can cause loss of a large area of skin and may form hypertrophic scars. These types of scars can restrict movement of muscles, joints and tendons (contracture). Surgery removes extra scar tissue. It may involve a series of small cuts (incisions) on both sides of the scar site, which create V-shaped skin flaps (Z-plasty). The result is a thin, less noticeable scar, because a Z-plasty may re-orient the scar so that it more closely follows the natural skin folds and releases tightness in the scar.
• Skin grafting involves taking a thin layer of skin from another part of the body and placing it over the injured area. Skin flap surgery involves moving an entire, full thickness of skin, fat, nerves, blood vessels, and muscle from a healthy part of the body to the injured site. These techniques are used when a large amount of skin has been lost in the original injury, when a thin scar will not heal, and when the main concern is improved function rather than improved appearance.
• Tissue expansion is used for breast reconstruction. It is also used for skin that has been damaged due to birth defects and injuries. A silicone balloon is inserted beneath the skin and gradually filled with salt water. This stretches the skin, which grows over time.

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Candidates for scar revision surgery

Only you and a qualified cosmetic surgeon can determine your individual candidacy for scar revision procedures. Candidates should be healthy and have scarring that is either unsightly, physically uncomfortable, or causes psychological discomfort and self-consciousness. Scar revision is such a custom procedure that it can be difficult to predict the results of each treatment. Patients will need to be realistic and strive for improvement over perfection. Scar revision is not an instantaneous solution, and candidates should be prepared to be patient and give the treatment time to work, which can be a lengthy process. However, good candidates can see significant improvement in scarring, which can have an immensely positive impact on overall quality of life.

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Before scar revision surgery

The various factors which should be considered before doing scar revision are:

1. Patients with unrealistic expectation

It is important to explain to the patient that scar revision will improve and not erase the scar and it may require multiple surgical procedures along with adjunct treatment in order to obtain an optimal result over a period of many months or years.

2. Time of scar revision

Due to continuous collagen remodelling it takes around 12-18 months for the scar to mature and gain tensile strength of 70-80% of uninjured skin. Immature scars are prone to hypertrophy and give poor results after scar revision. Adjunct treatments like use of silicone sheet and intralesional steroid injections can be given during this period. However, if early intervention is needed it is wiser to do it only after 8-12 weeks in adults and 6 months in children smaller than 7 years of age.

3. Nutritional status and medical history of the patient

A well-balanced diet is essential for good protein synthesis. Vitamin A, C, E and zinc help in wound healing. Herbal supplements and medicines which increase bleeding should be stopped 3 days to 2 weeks before scar revision. Medical conditions like diabetes mellitus and immunosuppression negatively effects wound healing.

4. Tobacco

Tobacco use causes hypoxia, thrombogenesis, vasoconstriction, aberrant cell function and delays wound healing. It is preferable to abstain the patients from smoking from 4 weeks before to 4 weeks after scar revision.

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Types of scars and treatment

There are many different types of scars, including the following:

1. Keloid scars and scar tissue removal

These are thick, rounded, irregular clusters of scar tissue that grow at the site of a wound on the skin, but beyond the edges of the borders of the wound. They often appear red or darker in color, as compared to the surrounding normal skin. Keloids are formed from skin cells and connective tissue (fibroblasts) that begin multiplying to repair the damage. These scars may appear anywhere on the body, but more commonly on the face, neck, ears, chest, or shoulders. They occur more often in darker-skinned people. Keloid scars may occur up to one year after the original trauma to the skin.

Treatment for keloid scars varies. There is no one simple cure for keloid scar removal. Recurrence after treatment is common. Treatment may include the following:

• Steroid injections. Steroids are injected directly into the  keloid scar tissue to help decrease the itching, redness, and burning sensations that these scars may produce. Sometimes, the injections help to actually decrease the size of the scar.
• Cryotherapy. Cryotherapy involves the scar being "frozen" off by a medication. This treatment is often effective in conjunction with steroid injections for keloid scars.
• Pressure therapy. Pressure therapy involves a type of pressure appliance worn over the area of the keloid scar. These may be worn day and night for up to 4 to 6 months.
• Surgery. If the keloid scar is not responsive to nonsurgical management options, surgery may be done. One type of surgery directly removes the scar formation with an incision, and stitches are placed to help close the wound. Sometimes, skin grafts are used to help close the wound. This involves replacing or attaching skin to an area that is missing skin. Skin grafts are done by taking a piece of healthy skin from another area of the body (called the donor site) and attaching it to the needed area.
• Another option for keloid scar treatment is laser surgery. Scars may be treated with a variety of different lasers, depending on the underlying cause of the scar. Lasers may be used to smooth a scar, remove the abnormal color of a scar, or flatten a scar. Most laser therapy for keloid scars is done in conjunction with other treatments, including injections of steroids, use of special dressings, and the use of bandages. Multiple treatments may be required, regardless of the initial type of therapy.

2. Radiation therapy

Radiation treatment is often used in conjunction with surgery to decrease the risk of recurrence of a keloid scar.

3. Hypertrophic scars

Hypertrophic scars are similar to keloid scars; however, their growth is confined within the boundaries of the original skin defect. These scars may also appear red, and are usually thick and elevated. Hypertrophic scars usually start to develop within weeks after the injury to the skin. Hypertrophic scars may improve naturally, although this process may take up to a year or more.

In treating hypertrophic scars, steroids may be the first line of therapy with this type of scar, although there is not one simple cure. Steroids may be given as an injection or by direct application. These scars may also be removed surgically. Often, steroid injections are used along with the surgery and may continue up to 2 years after the surgery to help maximize healing and decrease the chance of the scar returning.

4. Contractures

Contractures are an abnormal occurrence that happens when a large area of skin is damaged and lost, resulting in a scar. The scar formation pulls the edges of the skin together, causing a tight area of skin. This can also occur as scars heal. The decrease in the size of the skin can then affect the muscles, joints, and tendons, causing a decrease in movement. There are many different surgical treatment options for contractures. Some of which may include the following:

• Skin graft or skin flap for contractures. Skin grafts or skin flaps are done after the scar tissue is removed. Skin grafts involve replacing or attaching skin to a part of the body that is missing skin. Skin grafts are performed by taking a piece of healthy skin from another area of the body (called the donor site) and attaching it to the needed area. Skin flaps are similar to skin grafts, where a part of the skin is taken from another area, but with the skin flaps, the skin that is retrieved has its own blood supply. The section of skin used includes the underlying blood vessels, fat, and muscles. Flaps may be used when that area that is missing the skin does not have a good supply of blood because of the location or because of damage to the vessels.
• Tissue expansion for contractures. Tissue expansion is a newer technique being used for scar treatment, and involves a process that increases the amount of existing tissue available for reconstructive purposes. This procedure is often used in addition to the flap surgery.

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After scar revision surgery

The initial healing phase of a surgical scar revision may include localized swelling, discoloration or discomfort and may take 1 to 2 weeks. Healing will continue for several weeks and as the new scar heals it will slowly refine and fade. With dermabrasion, chemical peel or laser resurfacing, you will experience similar conditions at the treated area, in addition to overall sensitivity.

The final results of your scar revision surgery will be long-lasting, however it may take several months for your final results to become apparent and in some cases it may take a year for the new scar to fully heal and fade.

The practice of medicine and surgery is not an exact science. Although good results are expected, there are no guarantees; and in some situations, it may not be possible to achieve optimal results with a single surgical procedure and another surgery may be necessary.

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Scar revision risks

There are risks with any surgical or laser treatment, though these can be minimized by choosing the right surgeon. Potential risks of surgical revision include:

• Hyper- or hypopigmentation
• Poor aesthetic outcome
• Bleeding
• Infection
• Changes in sensation
• Contour irregularities
• Worse scarring

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