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.
If you're considering scar revision,
this will give you a basic understanding of the most common types of scars, the
procedures used to treat them, and the results you can expect. It can't answer all
of your questions, since a lot depends on your individual circumstances. Please
be sure to ask your doctor if there is anything about the procedure you don't understand.
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 affect
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. (See Z-plasty)
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
underlocal 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 may be 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 or 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.