Scars

When a wound heals it lays down scar tissue to join the sides of the wound together. This is then visible as a scar.

Most scars start off red and then after a few months fade so the result is the scar is often paler than the surrounding normal skin. Scars may shorten or tighten after they have formed. Scars will usually go through a period of maturation in which they soften, fade and flatten that lasts months before they reach their final appearance.

Scar appearance is very variable between individuals and from part to the body to another in the same person. Some scars can be almost invisible where others are very visible and unsightly.

When a wound has healed normally and produced a poor scar, surgery to improve the scar is less likely to be successful. If the scar is old then it may be worth attempting surgical improvement but there is a risk the end result may be no better.

When abnormal healing has resulted in a poor scar then there is a better chance that surgery may produce a better scar. For example if the original wound was infected and opened up it may have resulted in a wide and depressed scar. If the scar tissue is surgically removed and the wound heals well then the resulting scar may be better.

Wide scars may result from poor healing in which case surgical revision of the scar may produce a worthwhile result.

Some wide scars are simply due to stretching of the original scar after normal healing. These scars are less likely to be improved with surgery as the second scar may well simply stretch again.

Hypertrophic scars are scars that become red, widened and raised in the weeks and months after healing. Sometimes they are called keloid although this is not correct. The hypertrophic scar will then mature. It pales, softens and becomes flat. The resulting scar is usually relatively wide. Further surgery is likely to result similar scar if the new scar becomes hypertrophic again.  There are measures that can be taken to reduce hypertrophic scarring but their effectiveness is usually quite limited. As people get older they are less likely to make hypertrophic scars.

Lumpy scars may be the result of an irregular wound, a poor repair or complications such as infection during healing. Surgical revision of the scar may improve the appearance. However, if the original wound was clean and healed well then the lumpiness may be due to abnormal scarring like hypertrophic scarring or keloid scarring. This type of scarring is usually something that a person is predisposed to so it is likely to happen a second time round if the scar is revised.

Skin scars can become attached to the deeper muscle layer. Normally there is a layer of fat between the skin and the muscle layer however, sometimes this is missing under the scar. The result is the scar is pulled and this makes the scar very obvious. This tethering of the skin scar to the muscle can happen with normal healing. However, it is more likely if the fat layer under the skin is not repaired when the wound is closed. These indrawn or tethered scars can often be improved considerably with surgery. The old scar is opened up and the fat either side of the wound brought together between the skin and the muscle.

Scars shorten and tighten during healing. This can cause a problem with the scar becomes too short. It can prevent a joint extending properly or it can pull down on a part of the body such as an eyelid. These are usually called scar contractures. There are surgical techniques for lengthening a scar such as a Z-plasty. These types of scars need assessment on a one to one basis.

A wound can be incorrectly aligned when it is closed. A good example is where the vermillion of the lip is not correctly aligned when a cut through the vermillion is repaired. The incorrect alignment can usually be corrected by surgically opening up the original scar and closing it correctly.

Hypertrophic scars is the name given to a particular pattern of healing and maturing of a scar. Most wounds heal to leave a narrow red line which then fades over several months to leave a narrow pale line. Hypertrophic scar heal but then the scar thickens, widens, remains red and is usually itchy. They can be painful. The thickening process will usually start 4 to 8 weeks after the wound has healed and continue for between 6 months and 2 years. The hypertrophic scar then goes into a maturation phase when it fades, softens and flattens. As it matures it stops being itchy. The final result is usually a soft, flat relatively wide scar.

Hypertrophic scars are more common in some people who appear to have a predisposition to this type of scarring. Certain areas of the body such as the shoulders and upper chest are more prone to it. Younger people are more prone to hypertrophic scarring.

The use of topical silicone gel on the early healing wound may help to reduce hypertrophic scarring.

Keloid scars have features in common with hypertrophic scarring (see above). A keloid scar is one where the scar tissue of a healed wound forms a lump and the lump grows out from the site of the original wound. Keloid scars can behave like a tumour. They may start to grow soon after the wound has healed but can also start months or even years after a wound appears to have healed normally. Keloids can mature and resolve but often they persist and go on growing for years. They are often quite difficult to treat effectively as they have a tendency to recur. Certain racial groups, especially with dark skin, appear to be predisposed to keloid scarring. However, keloid scarring can affect anyone. Certain sites on the body appear to have a greater tendency to develop keloid scarring. These are the central chest, around the shoulders and the earlobes.

Please see the page on keloid scarring.