Scar Revisions

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. However, there is no harm in an early consultation with a plastic surgeon if you are concerned, as many of the non-surgical treatments are only effective in the first few months of ‘scar maturation’. These treatments include taping, massage, pressure garments, steroid cream, ultrasound, and topical silicone therapy. Effective scar management during the first 3-6 months of healing may prevent the need for surgical revision of some scars in the long term.

For more information about postoperative scar management, please click here. (here is linked to patient resources- postoperative care page).

If you're bothered by a scar, your first step should be to consult a 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 these expectations are 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 health insurance to be sure.

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 colour 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 commonly 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. There is higher incidence of keloids in people with Asian, Indian or African ancestry. Keloid scarring has a strong genetic predisposition and is difficult to prevent.

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 and soften the scar. If steroid treatment is inadequate, the scar tissue can be cut out and then closed with one or more layers of stitches. This is generally an outpatient procedure, performed under local anaesthesia. You should be back at work in a day or two, and the stitches will be removed in a few days. A skin graft is occasionally used, although the site from which the graft was taken may then also 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 surgical scar removal with steroid injections, direct application of steroids during surgery, or a short course of postoperative radiation therapy. Or you may be asked to wear a pressure garment or pressure clip over the area for as long as a year. Even so, the keloid may return, requiring further steroid injection or repeated excision and treatment.

Hypertrophic scars are often confused with keloids, since both tend to be thick, red, and raised. Hypertrophic scars, by definition, and in contrast, 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. They may also respond to conservative management and good preventative scar therapy during the first few months of healing.

If 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 anaesthesia, depending on the scar's location and size. You may receive steroid injections during surgery and at intervals for up to two years afterward to prevent the thick scar from reforming. Often a rigorous postoperative scar management regime is instituted with taping, massage, pressure garment and topical silicone for the first 6 months to minimise recurrence.

Stretched Scar

Sometimes Scars over joints, backs and mobile areas of the limb and torso can become wide, without being raised. These are scars which have stretched due to poor collagen support in the scar tissue and constant movement across the collagen fibres in the scar. These scars do not respond to conventional scar treatment such as pressure, massage, or silicone, as they are not hypertrophic nor keloid.

These scars can only be treated with surgical revision, where the scar is excised and re-sutured in layers to give the skin maximal support. Dissolvable skin sutures buried under the skin are also used to close the skin, instead of horizontal skin sutures on the surface. This will decrease the width of the scar and obliterate the ‘ladder-appearance’ on the vertical scar. Taping is also recommended at all times on the wound to decrease tension across the scar for the first 6-8 weeks. Sometimes immobilisation or minimising activity in that body region may be required to allow the scar to strengthen. The scar takes 8 weeks to regain its maximal collagen strength, by which time any stretch or strain put across it should not widen or distort the scar.

However, there is a significant recurrence rate with widened and stretched scars, particularly if the scar is in a very mobile area of the body or you have a genetic predisposition for this type of scarring. Some people form widened scars due to the different collagen type deposited in their scars; these tend to coincide with people who have the propensity to form stretch marks.

Contour Deficiency from a Scar

Certain injuries can result in a scar with a significant contour deficit or depression. This is particularly common in injuries associated with underlying soft tissue or fatty tissue loss as well as scars caused by extensive underlying inflammation such as skin boils, acne and ruptured skin cysts.

There are several ways of correcting contour depressions, ranging from simple procedures to extensive complex procedures, depending on site, size and extent of scarring.

The usage of a Dermal Filler is a good option for small areas, with small volume soft tissue deficit. This can be done in the office straight away, and does not require any anaesthetic. It is a cosmetic procedure, thus not rebatable from the health insurance. It is especially effective in contour deformities of the face. A semi-permanent filler is often recommended to start with, which will require ‘top-ups’ every 9-12 months. If the correction is not adequate, more filler can be used as required after the initial injection. To find out more about Dermal Fillers please go to our Creare Clinic website on Dermal Fillers. (Creare Clinic website on Dermal Fillers)

Fat Injection is an effective corrective procedure for slightly bigger defects. Fat is harvested from your body (usually from the abdomen or inner knee) and this is injected into the contour defect under the skin. The fat cells injects are essential grafts which pick up blood supply from the surrounding tissue. This procedure is often done in a hospital as special equipment is required, but can be under local or general anaesthetic. Depending on the amount of fat required to fill the deficit, it is not uncommon that repeated surgery may be required before a satisfactory result can be achieved. This is because there is often a maximum volume of fat cells that can be transferred before jeopardising survival of the cells.

Dermofat Grafting is where a piece of the underside of skin with its fat is taken from the groin and placed under the skin to correct a contour defect. This method is suitable only for recipient sites with healthy overlying skin as well as healthy soft tissue underneath. Results can be unpredictable as some partial graft failure is always expected. Repeat procedures may be necessary to obtain a satisfactory result.

For larger and extensive contour deficits, Flap Reconstruction may be required. Local Flaps which can be transposed or distant flaps that need to be transplanted into the defect are often used, depending on the location of the contour deficit. Flaps are the superior reconstructive option if the contour deficit includes an extensive, unsightly, poor quality scar involving the skin. They are also the reconstruction of choice in wide extensive scars close to or directly overlying bone, bony prominences, joints and tendons. (See below for Major Corrective Surgery for Scars)

Scar 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 long term effect is banding of this scar tissue in a set direction, resulting in a contracture. This band may affect the adjacent muscles and tendons, or pull on an underlying joint, 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 to break up the length and orientation of the scar band. 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 under local anaesthesia. 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, these are the scars which do not blend into the ‘wrinkles’ of the skin.

For more extensive and severe contractures, major corrective surgery may be required (see below). If the contracture has existed for some time, you may need intensive physiotherapy and occupational therapy after surgery to restore full function. Rigorous scar therapy after surgery is also very important to prevent recurrence and re-formation of contracture bands.

Major Corrective Surgery for Scars

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 anaesthesia. 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 or heavily scarred 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 divided, moved and reattached to vessels at the new site using microvascular surgery (i.e transplanted from one part of the body to another).

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 colour and texture of the surrounding skin. In general, flap surgery produces better cosmetic and functional results than skin grafts.

Other techniques, such as tissue expansion, can also be used. This is most commonly utilised in revising areas of scar associated with baldness, or specific areas of the body such as the breast.

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.

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, using techniques such as z-plasty, where it will be less conspicuous. 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.

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