Scar Treatment, Correction and Revision
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When considering scarring revision procedures a person needs to gain an appreciation of the fact that scars are long term and cannot be erased or fully removed-they may, however, be improved in appearance. The goal of scar revision is to create a skin surface that is flat and blends better into the surroundings. A flat surface reflects light more evenly without shadowing, is less noticeable and may be further covered-up by application of camouflage makeup. Scars are analyzed with respect to color, contour, width, location and adherence to deeper layers of underlying tissue. Combinations of techniques may be used with the ultimate improvement achieved in serial, incremental steps. Long term sunscreen protection against UVA and UVB light using a barrier sunscreen containing substances such as zinc oxide is strongly advised following scar revision treatment. Scar revision or scar correction requires personalized, tailored therapies often involving several modalities, multiple treatments, with gradual improvement over time to achieve a pleasing result.
Tenderness, itching and contour of a hypertrophic or keloid scar may be improved with serial injections of dilute steroids along with fluorouracil to control inflammation. Mulitple injection sessions are usually necessary for correction. Topical, occlusive silicone gel or sheeting may be tried for improvement of scar color and to flatten scars. At Bel-Red Center for Aesthetic surgery in Bellevue, we sometimes use a compounded ointment that improves scar color and texture over time.
23 year old male underwent surgical reconstruction of keloid scar followed by steroid injections
Excision of scars along with fine, plastic closure techniques should be considered for wide scars and contour deforming scars. Multiple Z-plasties or a geometric closure pattern is useful for longer scars. Follow-up with additional light dermabrasion, laser resufacing or micro-needling may be desirable.
Subcision for Acne Scars and Indented Scars
Depressed scars with adherence to deeper layers of the underlying tissue may be released with subcision. This is particularly useful for deeper, depressed acne scars which usually do not respond to augmentation with dermal fillers alone. At our cosmetic surgery center in the Seattle area we use special needle micro-instruments for this purpose while for longer scars our SMART-lipo Triplex 1440nm fiber can be useful in releasing the scar. A similar technique may be used for cellulite. Filler substances such as fat, Bellafill® or shorter duration fillers (Radiesse, Restylane, Perlane, Juvederm, Voluma) may then be very effective in filling and plumping the newly created space thus achieving a desirable flat surface.
Prolonged redness of a scar may respond to repetitive treatments with pulse-dye lasers or intense pulsed light (IPL). Brown discoloration due to post-inflammatory hyper-pigmentaion (PIH) responds to applications of bleaching creams for several months as well as light to moderate depth chemical peels.
Texture of the scar surface may be improved with techniques that stimulate new synthesis and turn-over of the collagen. These include long-term use of retin-A derived compounds, serial laser resurfacing, micro-dermabrasion, (dermaplaning), and serial micro-needling for delivery of growth factors. In our Seattle area aesthetic practice we use fractionated CO2 laser as a well as a micro-needling pen along with topical or injected platelet-rich plasma (PRP) gel to induce healthy new collagen formation. Some scars do not need surgical excision but may benefit from sequential resurfacing of skin with lasers and/or serial micro-needling (about three treatments each), steroid injections and scar ointments.
- What are the risks of scar revision?
- Depending on the procedure, there can be need for repeat treatment, bleeding, infection, and unfavorable healing.
- What is the cost of scar revision?
- The cost of scar revision depends on the technique, location and number of stages. The process and cost will be discussed during the consultation.
- What is the recovery and care after scar reconstruction?
- After surgical scar revision surgery there may be swelling and discoloration which will gradually decrease over several weeks. The new scar will fade and reconfigure as healing continues over months. Dermabrasion, laser resurfacing, chemical peels make the skin sensitive requiring moisturizing and lubrication. Post-operative care instructions are given after each procedure. Sun screen and shielding newly treated skin from the sun is essential for successful healing.
- What kind of anesthesia is used for scar reconstruction?
- The type of anesthesia used depends on the extent of the procedure and patient wishes. Topical treatments generally do not require any anesthetic whereas extensive reconstruction will require local, IV sedation or even general anesthesia.
- What does scar revision or reconstruction surgery consist of?
- • Topical treatments: silicone gel or gel sheeting can be used to promote healing. Serums and creams can be effective in camouflaging scars.
• Minimally invasive treatment: steroid injections can flatten hypertrophic or keloid scars. Dermabrasion, laser resurfacing, chemical peels can even out texture or depth irregularities. Bleaching creams can diminish color differences.
• Subcision: scars that adhere to the underlying layers of the skin can be released by cutting the connections between the scar and deeper layers. A technique of subcision and suction can be used to cut and lift the scar to prevent the connection between the scar and deeper layers from reforming. Dermal fillers or one’s own fat with fat transfer can be used to plump up and fill depressed tissues.
• Surgical reconstruction: extensive or deeper scars may require more complex reconstructive plastic procedure. Excision, undermining, skin grafts, pharmaceutical tissue substitutes, tissue expanders, or complex tissue closures may be required to conceal scars.
A combination of two or more of the above techniques may be necessary to maximize scar camouflage. Although scar revision can provide a more pleasing cosmetic result or improve a scar that has healed poorly, a scar cannot be completely erased.
- What is scar revision surgery?
- The aim of scar revision is to make a scar less visible, to enable it to blend into the surrounding tissue. Whether the scar is raised or depressed, discolored, of a different texture from healthy tissue, various treatments can be done to even out and make the differences less noticeable.
- Who is a candidate for scar revision?
- Scar revision can be considered by anyone who is bothered by a scar anywhere on their body. For best results you should not smoke. There should be no infection or active inflammatory process at the site.
- What is a scar?
- Scars are irregularities in the skin surface which form when the deeper layer of skin, the dermis, is damaged. As it heals, the body produces new collagen (a protein) to repair the wound. This new collagen is, however, woven differently than the original collagen in the skin it replaces, resulting in a different appearance. Scars can be thickened above the skin surface, as in keloid scars or below the adjacent skin level, as in acne pitting. Healing after burns can cause skin and tissue contracture which may limit movement. Scars can be hyper- or hypopigmented, in contrast to undamaged, surrounding skin. The kind of scar you have will determine the appropriate treatment.