Plastic Surgery for Scars

What can be done to improve scars? Can problem scars be erased using modern plastic surgery technology? The answer to the first question is complicated enough to warrant a lengthy response. And the answer to the second question above is a simple “no”, but such scars can usually be improved.

First, there are several reasons that a scar may be visible. The color and/or the width of the scar may be the primary problem. The scar may be raised above the surrounding tissue, or it may be depressed below the tissue. A curved scar can cause the tissue inside its concavity to form a lump. Some scars, on the cheeks for example, are most evident when the area is animated.

In addition to the above, different areas on our bodies form scars differently. And, of course, each person forms scars in an individual manner. Some scars are in areas that are relatively inconspicuous. Even patient compliance with treatment and follow-up care can enter into the equation. Finally, timing of scar treatment can be very important. During normal healing, a sutured wound results in a narrow line after about two or three weeks. The scar then becomes pinker, and thus more visible; this process normally increases for approximately the next four weeks. The scar could be widening, but more often it only appears more widened due to dilation of small blood vessels in the adjacent skin. Certain topical treatments may ameliorate the reddened appearance and perhaps decrease the amount of surface scar formation. Certain lasers have been used to intensively heat the blood vessels in the healing area, which lessens the redness that is normal in the first months after healing, but this author is conservative regarding such laser treatment. Approximately six to eight weeks after injury, the scar normally reaches its worst appearance. Over a period of a year or more, depending on the patient, the scar gradually fades, and the redness goes away. Many people have not noted the above natural process, but after plastic surgery, people observe the healing process more closely. Because scars normally improve with time, the “party line” in plastic surgery is to wait a year before revising a scar. Naturally, in many cases it is clear that earlier surgical intervention would be helpful.

A scar that is significantly more raised, red and firm than normal, especially if this process is worsening more than eight weeks after wound repair, may warrant treatment. The range of undesirable healing can vary from scars that are very slightly hypertrophic to true keloids. Scars that become abnormally raised and thick are termed hypertrophic scars. Scars near the middle of the chest exhibit a tendency for growth. Exaggerated scarring may be familial, and it is more common in people of color, but each person and each family must be considered individually. Certain materials, such as silicone sheeting or gel, can help to flatten such scars and slow or arrest the scar growth process. It appears that the negative surface charge on such materials alters cellular signaling favorably. At times, injection of triamcinolone (a type of steroid) into the scar is helpful. The potential benefits of this steroid treatment must be weighed against possible side-effects. (There is a low risk of atrophy of adjacent subcutaneous fat.)

A keloid is a type of scar that continues to grow almost indefinitely (i.e. like a neoplasm). Keloids are probably most common on the earlobe and behind the ear. Treatment consists of silicone (or similar) surface application, repeated triamcinolone injections, and pressure, such as with specially made earrings. Surgical revision must be approached cautiously, as the keloid is expected to recur. After years of research, much is known about keloids, but truly effective prevention and treatment remains elusive.

If the primary problem is the scar width, then scar revision may be a very viable option. Scar revision consists of excision of the scar along its borders, and careful suture repair of the resulting defect. A wide scar resulting from a crush injury, wound infection, wound dehiscence, less than ideal initial suturing, or suboptimal subsequent care can usually be improved by scar revision. Scars on certain areas, such as the shoulders, back or over extension surfaces of joints tend to widen significantly with time. When a wound is repaired under tension, the resultant scar may widen over a period of months. Tension may result when skin is missing or excised, or if the scar is perpendicular to normal skin tension lines. Elective incisions are made parallel to skin tension lines (Langer’s lines) whenever feasible.

The “depressed scar” is a common problem. In the process of normal healing, several weeks after injury, the scar undergoes remodeling and contraction. This scar shrinkage, which is different in each individual, pulls the surface of the scar inward, in the direction of the depth of the wound. The resulting linear depression can be quite obvious, especially if it is across a curved surface such as the cheek. Both indoor and outdoor lighting is usually from above, which results in a shadowing effect. This shadowing makes the scar much more obvious. Such a scar is even more noticeable if it is tethered to underlying musculature; muscle contraction in this case pulls the scar inward. Several techniques are available to improve depressed scars, depending on the configuration and location of the scar. Success depends upon the exact situation, location, and the individual.

Lengthwise scar contraction can result in a troublesome web-like deformity. This can result from a scar across a concave surface. An example of this would be a scar, which crosses the flexion surface of a joint, preventing full joint extension. Techniques that lengthen the scar, such as Z-plasty, W-plasty, or V-to-Y-plasty are often helpful with such contractures. Sometimes, a skin graft is necessary.

When the initial injury or surgery created a flap of skin, the resulting C-shaped scar often results in another deformity as the scar contracts. As the scarred undersurface of the flap contracts, the skin within the curved scar tends to form a lump. Methods are available to improve this problem, but the “lump” can recur after treatment.

The principles behind scar revision involve: (1) retaining (or even building up) tissue beneath the scar to prevent a depressed scar; (2) minimizing tension on the skin surface closure (by closing the deeper tissues and especially dermis); (3) very careful skin approximation; (4) appropriate follow-up care.

Follow-up care is very important. An antibiotic ointment is often applied to the sutures to prevent scab formation. My patients avoid neosporin, as some patients have an unfavorable reaction to products which contain this ingredient. Vitamin E is an irritant, and it can slightly increase scar formation. Avoidance of ultraviolet (sun) exposure is also important, as this causes wound discoloration. Brownish discoloration can usually be improved with hydroquinone products, but it is best to prevent this. Sunlight can also sometimes cause a whitish discoloration, and this is more resistant to treatment. A tobacco product, or nicotine in any form, narrows blood vessels. This is especially important if the wound is compromised in any other way. For example, the risk of skin and tissue necrosis is twelve times more likely if the patient has had exposure to a cigarette within the three weeks prior to, or the three weeks following a facelift. A plastic surgeon can often recognize early signs of abnormal scarring, and institute appropriate treatment.

If an area of scarring is generally flat but significantly discolored it is sometimes possible to tattoo the area with pigment that has nearly the color of the adjacent skin. A local burn treatment center may be able to recommend a person who possesses this specialized training.

“Stretch marks” deserve a brief comment. There is no laser or other modality that improves these areas. In some situations, these marks are best surgically excised. Lower abdominal stretch marks, for example, can often be removed in the process of abdominoplasty (tummy tuck). This type of treatment does not usually remove all of the stretch marks, and the trade-off is a single scar.

There are circumstances which require that additional tissue be placed in or beneath an area of scarring in order to improve contours. In other cases, a troublesome scar can be disguised by hair transplantation into the scar. It is beyond the scope of this article to present more detail regarding management of these situations.

At this point, however, we cannot predictably “remove” scars. Continuing research into the many factors that affect scar formation will someday further improve our armamentarium.