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Scar Revision

Injuries that penetrate the full thickness of the skin will produce scars. The appearance of scars depends on a number of factors including time from injury, anatomical position, healing process, suture technique, age of patient and genetic predisposition. It is common for people to think that if they have a bad scar, it is due to the fact that the original wound was not sutured properly. Actually, although possible, this is rarely the case. Genetic predisposition is by far the major factor.

Scars are most prominent in the first two months after injury. They normally become red, thickened and raised as the products required for healing are laid down and the local blood supply increases to provide energy for the healing process. Over the next six to eighteen months, remodeling takes place with flattening of the scar, and the tiny blood vessels decrease in number causing its color to become pale. In other words the scar matures.

When the red and raised condition of the scar is prolonged, it is termed a ‘hypertrophic scar.’ In rare instances, and as a result of a genetic predisposition, scars can proliferate, become nodular and invade the surrounding tissue. This is a ‘keloid scar.’ It should be noted that genetic factors play a part in all scarring, not just in the formation of a keloid scar.

Plastic surgeons, including myself, cannot eliminate scars! If a scar is excessively wide due to a healing problem (e.g. infection, or wound breakdown) it may be revised simply by excision and re-suturing. Sometimes the direction or position of a scar may be altered to help conceal it. The skin has a ‘grain’ and scars going against this grain are worse than those going with it. Also, a scar placed in a natural fold is far less conspicuous than one crossing it. Sometimes, scars may be made less obvious by breaking them up using geometric alterations in shape (‘W of Z plasties’).

Hypertrophic scars may be treated with scar reduction products together with massage. A series of cortisone injections into the scar itself can often help. Pressure dressings with silicone inserts are effective in many cases. Surgical revisions, if necessary, should await maturation of the scar so as not to compound the hypertrophy.

Keloid scars are a special case. Some individuals will develop keloid scars wherever they are injured; others will only develop keloid scars with wounds in specific locations – earlobe, central chest and shoulder – while forming normal scars elsewhere. Keloids may be excised and the new wound treated with repeated cortisone injections. Pressure dressings or devices can help prevent their recurrence. In difficult cases, postoperative radiotherapy is occasionally necessary.

During your consultation, I shall assess your scar and let you know what type of scar you have. Some scars, though disturbing to the patient are healing normally and simply kept under review until maturation is complete. Scar reduction creams and gels will be made available to you. Other patients will need non-surgical intervention to minimize the final result. Surgical revision is reserved for those scars that are mature and have a reasonable chance of improvement by employing the techniques outlined above.

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