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.
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.
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. 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
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 af-
fect 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. 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.
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 under local 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 maybe 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 of 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.