All wounds, surgical and otherwise, heal by producing a scar. Over the course of a lifetime we acquire numerous scars but fortunately most of these fade over time to become barely noticeable. Sometimes, however, scars not only don’t fade but may become prominent, painful, and even limit normal bodily function. When this happens, we are often called upon to evaluate these patients and provide suggestions for treatment.
Causes of poor scarring
There are a number of factors that may lead to poor scarring. Among these are:
The location of a scar is important in how well it fades. While certain areas are very forgiving (eyelids, for example) other areas are much more prone to poor scarring (upper chest, shoulders, joints, and others). In fact, we will often discourage patients from having minor benign skin lesions removed from these areas if we feel the potential scar may be worse than the lesion,
As we get older, we don’t heal as quickly but are also much less prone to poor scarring. A skin lesion removed from the cheek of will leave a much more prominent scar on a patient 20 years old than on a patient 80 years old.
Scars that lie parallel to lines of skin tension will fade much better than those that are perpendicular. For example, a horizontal scar on the forehead will fade much better than a vertical scar.
Scars located in areas of skin subject to constant skin tension pulling the skin edges apart will tend to widen over time.
Cause of the wound and healing conditions
The ideal wound for good scarring has cleanly cut skin edges, is repaired promptly, and heals quickly without infection or other complications. A wound that takes a long time to heal is more likely to leave an unattractive, thick, or painful scar.
Some patients because of their genetics and skin type are more prone to poor scarring.
Scars are subject to the influence of hormones, which may explain why we see worse scarring in adolescents, especially during puberty
Ultraviolet radiation during the scar maturation process may darken scars permanently.
Nearly all scars improve with time as the collagen in the scar continues to remodel. A fresh scar is nearly always more visible than one that has been allowed to mature.
When we evaluate your scar we will ask you about the above factors and anything else that might have lead to your scar becoming or remaining prominent. In some cases, especially if the scar is immature, we may simply advise conservative measures to improve scarring (described below) and delay any treatment until further time has passed. If treatment is indicated, we will discuss a plan with you to improve your scar.
Early scars and how to improve them
There are several things that you can do to a newly created scar during the healing process to help improve the appearance and decrease the chance of a problem scar developing. After we have performed an operation or have repaired in injury, these are measures we discuss with our patients to improve their outcome:
Maintain hydration of the collagen during scar formation
People use many over the counter scar creams, vitamin E oil, aloe-based products, and other topical treatments that are applied frequently to the scar for several weeks after healing has occurred to improve appearance. The likely mechanism for the effectiveness of these treatments is increasing the hydration of the collagen during the remodeling phase. Evidence based studies do not strongly favor one topical treatment over another, or even over an inexpensive moisturizing cream, but there does seem to be a benefit to utilizing some type of topical treatment on immature scars during this phase of healing which starts a week or two after the procedure or injury and may last up to 1-2 years.
Another way of increasing the hydration of the collagen in an early scar is by keeping tape or a silicone gel sheet over the scar. We often have our patients fresh scars completely covered with a tape strip for the first several weeks after a procedure and utilizing silicone gel sheeting for scar improvement, particularly on our breast surgery patients. Silicone gel sheeting has been used effectively for scarring for many years on burn patients and is now available over the counter at many pharmacies.
Scar massage is a cheap, low-tech, and simple way to improve a scar. By massaging the scar with your fingers several times a day you stimulate blood flow and lymphatic drainage, as well as break up abnormal collagen formation at the scar surface and in the deeper tissues.
Constant, even pressure applied to a scar will improve the appearance and keep the scar from thickening. However, this may be difficult or impractical for many scar locations, especially on the face.
How we treat problem scars
If a scar develops abnormally we have several approaches we may use either alone or in combination. Once we have evaluated your scar we can suggest a treatment plan that best fits your scar and you.
A small amount of a slow release steroid can be injected directly into the scar to help with thick or painful scars to decrease collagen formation. This is particularly effective for early scar formation but is not as helpful in mature scars. More than one injection may be necessary over time until the scar is more mature.
The Gemini laser is sometimes used to help fade the redness of scars by decreasing vascularity. Again, this is most helpful on immature scars. Some dark, hyperpigmented scars can also be improved by using the laser.
We sometimes utilize the Venus erbium laser to perform resurfacing on more broadly scattered scarring of the face such as with acne scarring. We have seen a modest improvement in several patients, but generally have been unable to completely eradicate the effects of acne scarring.
Surgical scar revision
Scars that have healed abnormally may simply need to surgically removed and the skin and deep tissues resutured. Especially useful in scars that were the result of delayed wound healing or otherwise healed under poor conditions (emergency surgery, traumatized tissues, etc.), this gives us a chance to “start over” with a fresh wound that will heal under more ideal conditions. We can then use many of the conservative measures discussed above to achieve a better long term outcome.
In addition to simply removing the scar and closing it directly, we also may use other techniques to break up tight, linear scars and place the scar in a more favorable location or orientation. This may involve a z-plasty or similar more advanced techniques to make up for lost tissue length.
Depressed scars can sometimes be improved by the injection of a filler material beneath the scar after we have freed up the skin from the underlying tissues (subcision). Hyaluronic acid fillers such as Restylane or Juvederm, have been used in our office in this way with good results.
Small, deep scars that may result from acne or chicken pox (pockmarks or “ice pick” scars) are sometimes best treated by excising the scar completely and suturing the defect, much like removing a mole. This creates a short, linear scar which is less visible and more easily concealed.
Insurance coverage is sometimes available for treatment of problem scars. When significant procedures are planned we can submit information and photographs to your insurance company to determine if they will be covered prior to proceeding.
All wounds, surgical or otherwise, heal by scarring. At Lawrence Plastic Surgery we deal with scars every day. We have multiple tools and techniques available to us to see that your scars end up looking as good as possible. If you have a bad scar, we may be able to help.