The evaluation of a scar encompasses the following ten points, the first and last may be the most important.
1 – Time Since Injury
Scar revision is usually performed on mature scars. Depending on your age, this normally requires one to two years of healing. In general, the younger you are, the longer it takes for a scar to mature.
A mature scar has entered the “resting” phase of healing, and can be recognized as a soft, pliable scar in which the redness has faded. Sometimes the maturation process can be accelerated with the use of pressure, massage, steroids or silicone gel sheeting.
There are times when waiting will not help; however, this is the exception rather than the rule. Examples include cases of gross misalignment, i.e. a step-off at the border of a lip, or an injury causing severe distortion, i.e. exposure of an eye or inability to straighten a joint.
2 – Nature of the Injury
The type of injury and the mechanism of injury can influence the treatment. Whether an injury is from a surgical scar or an animal bite is important in planning a revision. A carefully planed operative incision is more likely to heal in an optimal fashion, and as a result, is less likely to require a scar revision. A injury which is not planned, such as an animal bite, or a wound which was infected, tends to give a worse scar and will be more likely to require from revision.
3 – Location of the Injury
Scars of the head and face, in general, respond more favorably to revisions. Areas below the clavicle can often still be improved; however, they are less likely to improve. A triangle on the chest, formed by the shoulders and the lowest portion of the sternum, is a “danger zone”. The thicker skin in this area, and the pull of the underlying muscles, can produce a widespread and darkened scar, even under otherwise ideal conditions.
The orientation (direction) of the scar can also be important. When possible, the scar revision is positioned perpendicular to the underlying muscle to provide a narrower scar and improve its appearance. Wrinkles tend to run in the same direction, and this may also disguise the scar.
4 – Age of the Patient
Older people tend to require scar revisions, less often than younger ones. Younger people heal more exuberantly, and over a longer period of time. This leads to a higher incidence of hypertrophic (excess) scars in the young. Because of this exuberant wound healing, it is also necessary to delay scar revision longer if you are younger.
5 – Ethnicity
The darker the hair, skin, and eyes, the more likely a noticeable scar is to form. Wounds in darker skin tend to be darker, wider, lumpier and more problematic than wounds in lighter skin. The biochemical reasons for this are still largely unknown. It is due in part to innate differences in the healing, and in part to how the scar appears as light reflects off of it. This is outlined below.
6 – Skin Tone and Light Effects
For someone with fair skin, light reflecting off a scar may go unnoticed, but the same scar in darker pigmented skin will be easily spotted. What catches the eye is the difference in brightness between the reflected light, and the surrounding skin’s color.
7 – Healing of Previous Injuries
Healing varies from area to area. A previous injury can be an indicator of what type of scar to expect. If nearby scars are all widespread, raised and darkly pigmented, then chances are higher that a revision will also be widespread, raised and darkly pigmented.
8 – The Nature of the Scar
As a simplification, scars can be separated into four groups: a fine line scar (the desired result, flat and thin); a widespread scar (flat but wide); a hypertrophic scar (raised and wide); and a keloid scar (raised and extending outside the original zone of injury). The more the original scar is like a keloid scar, the less likely a revision of this scar will result in a fine line scar.
9 – Loss of Skin
If a significant amount of skin is lost at the time of the original injury, then closure of that wound may result in increased tension at the site of repair. Tension is the enemy of fine line scars. The greater the tension, the higher the risk of a wide scar.
10 – Perceptions and Expectations
This may be the most important part of the evaluation. If your expectation is that your scar will become completely invisible, you will be disappointed, no matter how much improvement is achieved. However, if you understand what makes their scar more obvious, and understand which of these features can be expected to improve (and conversely which will not improve) then an informed decision can be made. If your decision to proceed with the revision is based on realistic goals, then we all achieve greater satisfaction with the results. A scar will always remain a scar. If we improve its appearance, we can make it less noticeable.