So how can hypertrophic and keloid scars be improved? What options are available to treat unsatisfactory scars? Here are some of the different scar treatments utilized.
Excision and Primary Closure
This is probably the most common scar revision technique. It often involves making a lens-shaped excision, to remove the scar and a small amount of the surrounding normal skin, then careful re-closure of this new wound. Wide undermining is sometimes employed, to reduce the tension across the repair.
Z-Plasty or W-Plasty
These are techniques for rearranging the scar. Their names are derived from the pattern of the resultant scar. Z-plasty may be used to lengthen a scar if it is pulling too tightly, or to change the direction of a scar, to make it less conspicuous. Both can be used to align scars with an existing wrinkle or landmark and make the scars less noticeable.
Deep, dissolvable sutures (stitches) are used to bring the edges of the skin together. These do not need to be removed. Thinner sutures are used for the fine tailoring, to line-up the two edges of the wound. The superficial sutures are sometimes not dissolvable. Non-dissolvable sutures decrease the amount of inflammation at the surface. Non-dissolvable sutures need to be removed. How long before removal depends on the location and nature of the scar. For example, sutures on the face often can be removed in less than a week, while those on the sole of the foot may need to stay for two weeks.
Buried Dermal Flap
Sometimes the scar is indented (concave). If this is the case, something is needed to fill in the missing volume beneath scar. Several options are available including: a portion of the original scar, deeper layers of the surrounding normal skin or occasionally an artificial filler can be used. The filler brings the level of the revised scar up to that of the surrounding skin.
Occasionally a discrepancy in the length or positioning of the sides of a wound result in a raised portion at the ends of the scar. These are referred to as “dog ears”, as they stand up and are often found in pairs (one at each end of the incision). Revision requires lengthening or changing the direction of the original scar in order to smooth out the ends.
Skin Graft and Flaps
Skin grafts and flaps are not needed for most scar revisions. They are reserved for scars, such as burn scars, that cover a large area. Sometimes scars are too large to simply excise and close. More complicated techniques like tissue expansion, composite flaps and microvascular transplantation (free flaps), have evolved to move “normal” skin into the proper position.
This is the same technique use for treating wrinkles, and is useful for surface irregularities, or scars with obvious shadows or highlights. Dermabrasion can be performed shortly after a scar revision, or after the scar has matured. Dermabrasion appears to work better if used at 4 months rather than 8 months after the revision. This has led some plastic surgeons to use dermabrasion at the time of the revision.
There are many types of lasers. The CO2 and Erbium lasers work very similarly to dermabrasion. They remove the outer layers of the skin, and can be used to take down high points.
The blue-green Argon and flashlamp pumped dye lasers, are more selectively absorbed by blood vessels and skin pigments, and can be used to treat red, purple or pigmented scars.
Pressure and Massage
These modalities can be used alone or in conjunction with the methods listed above. Pressure and massage cause realignment of the fibers in the scar and surrounding skin, and can dramatically flatten and smooth raised scars. This may be why Vitamin E works – the continuing replication ensures adequate scar massage is performed.
Both Mineral Oil and Silicone Gel impregnated sheeting seem to decrease the time needed for a scar to soften and mature, and as a result may lead to the accelerated formation of smoother scars. Sheeting can also be used alone or with other treatments. The drawbacks include the possibility of dermatitis (irritation of the skin), foliculitis (irritation or infection of the hairs) or scar ulceration. The sheets must be worn 12 hours a day and treatment may be needed for as long as 18 months.
Occasionally injectable steroids are used to slow scar formation. Drawbacks include the possibility of lightening the color of the surrounding normal skin. If steroids are used at the time of repair/revision, the wound will require extra support. Frequently this means sutures must be left in longer.
Topical skin bleaches, such as hydroquinone, can sometimes fade a darker scar, or even prevent its occurrence. It takes several months for its effects to be seen and longer to reach optimal results. This can be used separately or with a surgical scar revision.
Local anesthesia is usually all that is necessary to perform scar revision. Occasionally for larger scars, or younger patients, regional or general anesthetic is needed. If so, this will be discussed prior to surgery. Many times epinephrine (adrenaline) is added to the local anesthetic, to minimize any bleeding.
For scar revision, as with any surgical procedure, there are potential risks that accompany the potential benefits. Here are some of the more common risks:
Fluid tends to collect in the operative site. A small amount is normal. If a large collection of fluid accumulates, then it must be removed. Usually this is easily treated in the office by aspiration; occasionally the wound may need to opened temporarily. It is important to remove large fluid collections as these may become infected or put too much tension on the wound.
As with any scrape or cut, an operative site can become infected. A dose of antibiotics can be given just before surgery to minimize this risk. Occasionally antibiotics may be continued for several days after surgery. Even with these precautions, an infection can occur.
Dehiscence (Reopening) of the Wound
This can occur if too much tension is placed on the wound, before it has fully healed. If dehiscence occurs the wound must be cleansed, and if appropriate, sutured again.
Milia frequently occur around scars. These represent blocked glands, or trapped surface skin cells. They can be treated in the office, by gently unroofing them. Once adequately treated, they tend not to recur.
The resultant scar can become darker (hyperpigmented) or lighter (hypopigmented) compared to the surrounding skin. Too much pigmentation can occur as a direct result of exposure to the sun. A sunblock, no less than SPF 15, is recommended until the new scar is fully matured (approximately one year). If the scar is under clothing, this is less of a problem. If the scar is on the patient’s face or neck, a hat is recommended. Skin bleaches are also available to lighten a darkening scar. A light scar on a dark skinned person is more difficult to treat, but options such as make-up and tattooing can be utilized.
Despite the most meticulous, careful repair, there is always the possibility that another unsatisfactory scar may result. This is why a careful dialogue between you and your plastic surgeon is critical. You need to know the chances for improvement, and which aspects of the scar are likely to improve. Knowing where we are going can be as important as getting there.
Next time: another example of a scar revision.