 Scar Revision
If you're considering scar revision
...
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.
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.
Questions?
If you have any questions about this procedure, please feel free to call our
office at (703) 742-8004. We'd be more than happy to help.
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