Overview of Scar Revision
When your skin gets injured, it starts working to fix itself by improving blood flow and functionality. This is a well-organized process called wound healing that happens in three stages: inflammation, proliferation, and maturation. A study by Dunkin and colleagues discovered that permanent scars will form if the deeper layer of the skin, called the reticular dermis, is damaged.
Scarring is a natural and expected part of recovery after a skin injury. The best-case scenario is for scars to be flat, thin, and the same color as the surrounding skin. However, several factors can interfere with wound healing and may lead to poor results. These factors include infection, poor blood flow (known as ischemia), and further trauma to the area.
Some scars can become thick (proliferative), darker (hyperpigmented), or shrunk (contracted). Such changes can cause severe issues, impacting a person’s ability to move normally and causing emotional distress.
Anatomy and Physiology of Scar Revision
The skin is an important organ with many jobs, such as protecting us from germs and helping to regulate our body temperature. It has three layers: the epidermis (the outer layer), the dermis (the middle layer), and a layer of fat underneath. Most of our skin is made up of the dermis, and it’s where you’ll find blood vessels, nerve endings, hair follicles, and sweat glands.
When you get a skin injury, your body starts healing it right away. The first step, called the inflammatory phase, lasts about 2 to 5 days. After this, your body starts the proliferative phase. This is when new tissues start to grow to repair the damage. This phase can last for weeks. The last step in the healing process is called maturation. It is during this time that myofibroblasts, a type of cell, help the wound to contract and become smaller.
Doctors usually check the progress of scars by looking at their color, flexibility, size, and height. Immature scars, which are still healing, are usually red to pink and might itch or hurt a little. Mature scars have finished healing and are usually flat and light in color. Sometimes, scars become thick and raised, a condition known as keloids or hypertrophic scars. These types of scars are thought to be due to prolonged inflammation in the deeper layer of the skin. The tissue makes more fibroblasts, specialized cells that produce the collagen protein that helps to connect tissues and heal wounds.
Why do People Need Scar Revision
People can decide to have their scars treated for many reasons, both physical and emotional. Sometimes, scars might limit the movement of certain body parts, making simple tasks harder to perform. If a scar affects how well a person can move, the main goal of treatment would be to restore their mobility.
Scars can also be painful, particularly if there’s a neuroma, which is a painful condition usually associated with nerve damage. Moreover, a scar can be a constant, visible reminder of past trauma, which can make a person want to get rid of it. Lastly, some people may feel embarrassed or awkward in social situations because of their scars.
All of these are valid reasons for considering scar treatment. Doctors should be understanding and considerate of the physical discomfort and emotional distress these patients might be going through. However, it’s crucial to mention that scars typically take around 12 to 18 months to fully heal. Premature treatment, or treatment before the scar has fully healed, may lead to less satisfactory results.
When a Person Should Avoid Scar Revision
Before opting for a scar revision treatment, it’s important for patients to have a clear understanding of the process and its results. This procedure aims to make the scar less noticeable, not to remove it completely. There are certain situations where the treatment might not be recommended, such as when the new scar could look worse or affect bodily functions.
Patients taking blood thinners, also known as anticoagulants, must stop using these before the procedure. If a patient can’t stop taking these drugs, then a scar revision treatment is not advisable.
There are also certain factors that can negatively affect the healing process. For example, a balanced diet is very important because proteins help with wound healing. Also, certain vitamins and minerals, especially vitamins A, C, and E, and zinc, play a key role in wound healing. There are some health conditions, like diabetes, and certain medications, such as those suppressing the immune system, that increase the risk of slower healing. Smoking is another factor that may delay the healing process.
Equipment used for Scar Revision
The necessary equipment for this procedure can be found in a fully-operational surgery room that’s equipped with fundamental tools used for general surgery and staffed by skilled medical professionals.
Who is needed to perform Scar Revision?
To have a successful scar revision surgery, it’s important to have a team of healthcare professionals in the operating room. The most important member of that team is a surgeon who is well-trained and experienced in scar revision procedures. This ensures that the doctor performing your surgery is highly knowledgeable and skilled in this particular area of medicine, which can lead to better results for you.
Preparing for Scar Revision
Smoking can increase the risk of infection and slow down wound healing after surgery. Therefore, all patients are recommended to quit smoking and ideally remain smoke-free for at least 30 days before having a scar revision operation. It’s also important for patients to keep their blood sugar levels under control because high glucose levels can slow wound healing too. The ideal blood sugar level is less than 180 mg/dL.
If you’re going to have an operation that involves sedation or general anesthesia, you should not eat or drink anything after midnight before the day of the procedure, which is what NPO (“nothing by mouth”) means. However, you can usually continue to take most, if not all, of your regular medications on the morning of the surgery. Also, it’s important for the surgical team to follow sterile practices to prevent infection.
Before the operation, it’s important for your surgeon to meticulously plan where to make the incision. The surgeon will look for relaxed skin lines or decide the best direction for the scar. Markings will be made on your skin before the operation to line up with these relaxed skin lines. This careful planning helps to ensure the skin can be closed properly without tension after surgery, which is important for successful healing and a good cosmetic result.
How is Scar Revision performed
For treating scars, there are both non-surgical and surgical options. The best approach usually involves starting with the simplest treatments and moving onto more complex options if necessary.
Non-surgical treatments include steroid injections, ablative laser resurfacing, soft tissue fillers, and dermabrasion. Steroid injections are commonly used for keloids and hypertrophic scars, which are types of raised scars. The steroid is injected into the scar every 4 weeks. It’s important to avoid injecting too much, as this can cause side effects like thinning skin or dimpling.
Ablative laser resurfacing can help improve the look of scars. This involves using a laser to remove the top layers of the scar, causing the body to produce new, more evenly textured skin. However, this treatment can sometimes cause hyperpigmentation, or darkening of the skin.
Soft tissue fillers can help with scars that are depressed, or lower than the surrounding skin. These fillers are substances such as collagen or hyaluronic acid that are injected under the scar to raise it to the level of the rest of the skin.
Dermabrasion involves using a device to sand down the scar, making it smoother and more even. This treatment is often used for acne scars and is most effective when performed 6 to 8 weeks after the scar forms.
Surgical options are also available. These include elliptical excisions, Z-plasty, W-plasty, and using flaps or skin grafts. Elliptical excisions involve cutting out the scar and sewing the skin back together in a natural line of tension, which helps prevent the scar from being too noticeable. The length of the incision should be three times its width to prevent puckering of the skin.
Z-plasty and W-plasty involve rearranging the skin around the scar to make it less obvious. In Z-plasty, the surgeon makes two cuts on each side of the scar to create a Z shape, then switches the position of the flaps of skin. In W-plasty, the surgeon cuts out the scar in a zigzag pattern and sews the skin back together. Both of these techniques can make the scar align with natural skin lines and make it harder to see.
If the scar is in a tough area or can’t be easily fixed with tissue rearrangement, flaps or skin grafts might be used. Grafts involve taking a piece of healthy skin from one part of your body and using it to replace the scarred skin. This treatment can work well but it’s important to match the colour and texture of the grafted skin with the surrounding skin.
Possible Complications of Scar Revision
Generally, there are not many problems with scar repair surgery. However, early complications can occur such as bleeding from the surgery spot, pain, reaction to the stitching material, infection at the surgery spot, or death of skin tissue. The cause of infection is usually a bacteria called methicillin-resistant coagulase-positive Staphylococcus (MRSA).
Other problems that may happen later include new or recurring tightness in the skin, overgrown scar, changes in skin color, nerve damage, skin thinning, or a “trap-door” deformity, which is when the scar appears puckered because the tissue under the scar doesn’t move well.
It’s important for people to understand that these complications could result in a less attractive scar.
What Else Should I Know About Scar Revision?
Scars can create various issues, both physical and emotional. Fortunately, one doesn’t have to live with noticeable scars forever, as there are numerous methods to reduce their appearance. You’re a candidate for this treatment if you have a noticeable scar, maintaining a balanced diet, don’t smoke, and have any other health conditions under control.
If the scar is due to a past surgical procedure and is causing functional problems or misalignment in the body, then surgery can help minimize the scar. However, if the scar is still immature – characterized by being red, itchy, raised, and sometimes painful – then surgical correction is not advised. The maturity level of a scar can be assessed by regular medical exams every few months. Treatment for immature scars is best done with additional therapies or lasers. If a scar is less than six weeks old, therapies using injections into the scar can be beneficial.
Mature scars are suited for surgical treatment. The type of treatment will depend on the nature of the scar. ‘Sunken’ or ‘depressed’ scars are best treated with fillers, especially those using your own body fat. If the scar has minimal tissue loss, it can be treated with certain surgical techniques like elliptical excisions, z-plasty, and w-plasty. For scars with larger tissue loss, the options include skin grafting, using skin flaps, or doing serial excision (multiple surgeries over time) under the procedures mentioned above.
