Scar improvement

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Introduction 

Scars are how the body repairs itself. Once formed they can not be made to disappear. However where scars have formed badly surgery may help to improve the scar. One of the most important factors in how scars form is the person’s genetic make up and scarring tendency that they have inherited from their parents.

If an attempt is going to be made to improve a scar with surgery then it will involve making a wound again. If the result of healing on this second time round is going to better, then there needs to be a reason to expect it to be different and better. If there is no obvious difference then there can be little reasonable expectation that the scar will be different. There are a number of situations or types of scar for which surgery may be helpful.

 

Scars that may be helped with surgery

Tethered scars

When the skin is scarred down to deeper tissues the scar may be pulled in giving a puckered appearance. This may be because a wound healed this way or because the deep layers were not repaired. This is often seen with abdominal scars such as caesarian section scars.

Surgery may improve the scar by repairing the deep layer so the skin does not become scarred down to the deeper structures.

 

Scars following poor wound healing

Infection or wounds healing slowly may result in excess scar tissue forming

Surgery may help by removing the excess scar tissue and then the wound healing well without infection and slow healing.

 

Miss aligned scars

Where a wound involves a structure such as the edge of the lip there is the possibility that it is repaired or heals without correct alignment.

Surgery may help by re-opening the wound and then repairing the wound with correct alignment.

 

Stretched or wide scars

Scars that heal slowly may heal with a scar that is widened or stretched.

Surgery may help by cutting out the wide scar and re-repairing the wound. If the scar healed well the first time but then stretched afterwards there is a high likelihood that it will stretch again second time round. Attempts to counter act this include using long acting stitches and taping the wound to support it afterwards.

 

Tight scars (contractures)

Scars contract after they have healed which leads to them tightening. This  may look unpleasant or can restrict movements such as being able to straighten a joint.

Surgery may help by lengthening the scar. This can be achieved by re-arrangement of the scar tissue with techniques such as the Z-plasty. Larger lengthenings may require skin grafts.

 

Tattooed scars

A tattooed scar is where foreign material e.g. grit from the road ends up trapped in the scar tissue which is visible.

Where this is extensive it can be very difficult to remove with surgery or other means. With sometimes laser treatment may be helpful.

 

Acne scars

Acne can leave scars usually following areas of slow healing. Ice-pick scars are deep pitted scars.

 

Small depressed scars – chicken pox

Chicken pox may leave small but visible pits or ‘pockmarks’ in the skin. Surgical removal of these converts these to flat straight scars which may be less visible.

 

Poorly orientated scars

Occasionally a scar is poorly orientated and can be re-orientated with surgery.

 

Hypertrophic scars

Hypertrophic scars are thickened red itchy scars. Some people are predisposed to this type of scarring. It is more common when wounds are slow to heal particularly if the wound opens up and then takes more than two weeks to heal. Typically the wound heals then after 6-8 weeks the scar becomes red and starts to thicken. The scar is often itchy and can be painful. The scars typically continue to thicken for several months. Usually after 12 to 18 months the scars enters a phase of maturation in which the scar pales, softens and flattens. This may take a 1 to 2 years although sometimes may take significantly longer. Hypertrophic scars are often confused with keloid scars.

Surgery may have role in improving hypertrophic scars. If the scar healed well the first time then simply cutting the scar out and closing the wound is likely to result in a similar scar. If the wound healed slowly the first time then cutting out the scar and closing the wound carefully may result in a better result. If the wound healed well the first time then something different or extra needs to be done second time round. Options include the use of silicone gel on the scar and steroid injections into the scar.

 

Keloid scars

Keloid scars are ones that start to grow after the wound has healed. These differ from hypertrophic scars in that the scars grow beyond the limits of the original wound. Keloid scars can start growing well after the wound has healed and can go on growing for many years.

Surgery for keloid scars is similar as for hypertrophic scars above. Keloid scars are more stubborn and difficult to treat. Sometimes radiotherapy is added to surgery to suppress the scarring reaction.

 

Straight line scars

A very straight scar may catch the eye because it is un natural to have a straight line at this site for example on the face.

Surgery may help by breaking up the straight line using techniques such as the W-plasty. The scar is changed from a straight line to an irregular line which does not catch the eye so readily.

 

Risks of surgery

 Bleeding

Bleeding is a possibility with any operation.

 

Infection

Infection is a risk following any operative procedure. Most scar operations on the skin are clean operations and the risk of serious infection is low.

 

Poor healing

Following infection or if the skin has been damaged previously then wounds may open up and heal slowly.

 

Worse scarring

Any operation which attempts to improve a scar carries the risk of making it worse.