Scar Revision
Surgical treatments for scarsIf 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
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.
 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 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
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.
 This
hypertrophic scar has formed a
contracture, restricting finger
motion.
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.
 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.
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.Contractures
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/H6>
 The
repaired scars now lie partly within
the natural skin crease, where they are
less visible.
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
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.
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