Scars are a natural result of the healing process after an injury. Every skin incision or laceration results in some type of scar. Some may blend in with the surrounding skin, some may be sunken in and others may be raised. In addition scars will vary in color including light, dark, and pink.
The goal of scar revision is to remove an existing scar and replace it with a smaller and more aesthetic scar. If the scar had somehow decreased function in the area, restoring function would be a priority. Some may call their scars a mark of pride; however, more often than not, many people find that they want to get rid of their scars. Scars affect one’s appearance and may make some people feel self-conscious. So let us understand what a scar is, how it is formed, and how to get rid of it.
What is a scar?
Scars are formed as part of the wound healing process by the body. Skin is a seamless structure covering our body. Wound healing is the process by which our body naturally replaces missing cells of our skin. It is a complex and dynamic process during which the body produces cells called collagen to fill a wound or incision in the skin. The scar tissue is made rapidly by the body to fill the wound and seal off the outer world preventing infection.
Because of the rapid process, scars are not as organized as our natural skin. Therefore, this new tissue, which is strong and serves its functional purpose is different in appearance and texture from the normal skin. Generally, if a wound is small or sharp like a surgical incision, there is only minimal scarring. The larger and wider the wound, the more the likely an unaesthetic scar will result. The formation of a scar depends on the size, depth, and location of the injury.
Types of Scars
These are scars formed after the loss of tissue either from trauma, inflammation, infection, surgery, or healing issues. They will have a “sunken in” or concave appearance and may have darker pigmentation than the rest of your skin. A common example of atrophic scars are Acne scars which appear concave and darker than surrounding skin. Atrophic scars result when the body is not able to fill in the wound all the way.
These are the opposite of atrophic scars. Hypertrophic scars are raised higher than the surrounding skin and may be red. They are formed due to an overactive scarring process by the body. They can be tall, but typically do not extend beyond the boundary of the injury.
Keloid scars are thick, raised, red or dark, scars that usually extend beyond the boundary of the injury. Keloids are known as those scars that “don’t know when to stop.” They form due to an abnormal aggressive healing process involving an excessive production of collagen. They typically have darker pigmentation than their surrounding skin, usually a smooth top with pink or purple color. Keloid scars may enlarge progressively and, unlike other kinds of scars, DO NOT regress over time. Keloids may also cause itching and irritation due to excessive stretching and rubbing on clothing.
The chance of developing keloids can be decreased by following proper wound care and avoiding unnecessary skin injury such as piercings if you are prone to getting keloids. Treatment of keloids is a complex process that should be handled by an experienced soft tissue surgeon such as a plastic surgeon. Treatment may require pressure dressings, surgery, steroid injection, radiation, etc. Although there seems to be a genetic component to Keloid scarring, they can occur in a person without a family history.
A contracture scar occurs when a large area of missing skin is not treated at the time of injury. The tissue edges stretch across the wound in an attempt to heal the area. However, because the area is so large, the resulting scars are thick bands of collagen pulling the tissue edges together and contracting the skin and tissues in the area. Contractures can cause significant functional issues such as limitation of motion around a joint. These types of scars are common in individuals who have had significant burn injuries.
Stretch marks result when skin is expanded faster than it can adapt to the changes. This is commonly seen in pregnancy, growth spurts, and body building. When the skin is stretched too fast the collagen and elastin fibers in the dermis rupture resulting is a tear of the dermis. Stretch marks, like other scars, are permanent. However, topical creams and resurfacing procedures may help to improve the appearance
Danger areas for scars
Scars can cause aesthetic or functional issues in danger areas. Scars on the face are of particular aesthetic concern. However, scars in facial areas near the eyes, ears, nose, or around the mouth can cause significant functional issues as well.
Repair of these areas may require advanced plastic surgery techniques to restore form and function. When present around joints like the hand, elbow, knee, ankle, neck, etc. scars may restrict the range of motion in these body parts. Injuries in such danger areas should be treated initially be experts such as plastic surgeons.
Treatment options for Scars
When an injury heals, it eventually turns into a scar that regresses with time. Being a part of natural healing, scars do not ordinarily require treatment. But some facial scars, keloids, or scars in the exposed areas of our body may become cosmetically undesirable and other scars may present functional issues. In such cases, various treatment options are available.
Massage and Pressure application
Some scars may respond to regular massage and chronic pressure, which reduces the blood flow to the area.
Silicone sheets are one of the most widely used scar remedies and one of the only treatments that have been proven to aid in shrinking some scars and keloids. Silicone sheets are inexpensive, have minimal side effects, and are easy to use. It is believed that the warm and humid environment created by the sheet leads to the scar reduction.
Over-the-counter or prescription creams, ointments, or gels
There are numerous over-the-counter creams, like steroids or antihistamines, that may be prescribed by your doctor. These creams may help lessen irritation or reduce the size of the scar. However, there are also many expensive unproven treatments for sale, so understand what product you are purchasing and if it is proven to work. Don’t waste money on unproved treatments.
Steroids injections are commonly employed to flatten out thick scars and keloids when injected directly into the fibrous scar tissue. Plastic surgeons commonly use triamcinolone acetonide suspension (Kenalog) intralesionally to flatten keloids. The results depend on the size, age, location and type of scar. Smaller and more recent scars may have better outcomes.
The hardness and size of the keloid can be reduced by freezing the scars using cryotherapy. This generally works best on small keloids. This process is not as accurate as other available techniques and may result in incomplete removal or collateral damage to adjacent normal tissues.
Thick scars or keloids, which are not regressing by other means, can be flattened out or refined using dermabrasion. This approach involves the elimination of the surface of the scar with special abrasive equipment. The scar can be flattened to the level of the adjacent skin. It is helpful to blend in the irregularities of a scar, however it does not remove the scar.
Laser surgery can be used to resurface scars as well. The process is similar to dermabrasion but more accurate. Modern lasers have been shown to achieve more subtle results by working on the dermis without removing the upper layers of skin. This results in less downtime, unlike traditional laser resurfacing and dermabrasion, which requires a longer recovery time. However resurfacing will not remove the scar, it will just flatten it.
Surgical excision with primary closure
An experienced surgeon can excise the entire scar and suture the unscarred tissue edges together. Unlike dermabrasion or laser resurfacing, scar excision will remove the entire scar and replace it with a smaller thin scar. Simple scar excision can be performed when the scar is narrow enough to allow the normal tissue edges to be re-approximated without tension..
Serial scar excision
In the case of large scars, your surgeon can choose to carry out multiple surgeries removing a portion of the scar each time. The scar will become progressively smaller and eventually totally removed. The last excision of scar tissue will be similar to a simple scar excision.
Scar excision with skin grafting technique
This surgery is generally used for scars present in locations that are not cosmetically critical or for patients who do not care or are not healthy enough to undergo larger procedures to avoid a skin graft. When skin grafting, a layer of healthy skin from one area of the body is removed and transplanted to cover the area where the scar was surgically removed. This is not an ideal aesthetic procedure and has the added downside of creating a second surgical site and scar when the skin graft is harvested.
Scar excision requiring adjacent tissue transfer to close
This technique is required for large wounds left after removal of a scar. In this technique, the surgeon repositions a flap of healthy skin from an adjacent site and sutures it into the area of wound. This is a more complex procedure typically performed by plastic surgeons or facial plastic surgeons
Surgical excision requiring tissue expansion
Tissue expansion is a technique used to grow extra skin near the site of a scar that will be used to cover the area once the scar is surgically removed. This technique is employed to enable the scar to heal with primary closure for large defects. Tissue expanders are similar to balloons which are placed under the skin and injected with saline on a regular basis to slowly expand the skin over time. In the subsequent surgery, when the scar is excised, the expanders are removed and the extra tissue is used to close the wound with a primary closure.
Although most scars lessen and dissolve with time, larger scars or keloids may often be unsightly and undesirable or may present functional issues if located on the face or over joints. Although it is reasonable to attempt non-surgical methods first, if these are not successful, you should contact an experienced surgeon for a consultation with minimal delay. At the Vanish Center we will provide a full evaluation and treatment for any scars or wounds you may have.