Scar Revisions

The treatment of aesthetically displeasing scars of the head and neck is challenging at times, although not without options. While removing one scar without leaving another is not possible, replacing an unfavorable scar with a more camouflaged one, or rendering an existing scar less noticeable, is possible.

By the time scar revision patients present to a physician, they have exhausted every means at their disposal to disguise the scar. These attempts at concealing the scar typically involve the use of cosmetics, clothing, and hairstyle modifications. While various treatments exist, none is perfect, and the cornerstone of any scar revision is a thorough understanding of the patients' dissatisfaction with their appearance and their expectations following treatment. Patients must understand that the best result may require multiple treatments and that initially, little improvement may be noticeable relative to the preexisting deformity.

Other considerations of paramount importance when considering scar revision include whether the scar is in a position that compromises function and if any revision might result in decreased function. As with any skin defect, the quality and availability of surrounding tissue must be assessed.

In general, scar revision techniques are either operative or nonoperative in nature. More aesthetically pleasing scars are those that are less noticeable. Intuitively, this includes matching the surrounding skin in color, texture, distensibility, and elevation. The characteristics of scars are important relative to their surroundings. For example, scars often have fewer dermal appendages or lack them altogether. In areas of hair-bearing skin, a scar's lack of hair follicles is particularly noticeable. In other areas with sparse hair follicles, this is a desirable attribute of scars.

Patient characteristics also play a large factor in scarring, as does the quality of closure and the cleanliness of the wound. Patients at the extremes of age often scar to a greater degree. Young patients are more prone to excessive scar formation, while elderly persons are more prone to poor healing, owing to diminished fibroblast activity. Individuals with connective-tissue disease, diabetes mellitus, or vitamin deficiencies or those who return to activity too early may experience healing complications that result in greater scarring upon final closure.

Wounds that are poorly closed, undergo dehiscence, have necrosis of the skin edges, or have edges that are poorly approximated are more likely to heal with unsightly scarring. Likewise, wounds that become infected or undergo foreign body reactions to sutures more frequently yield poor cosmetic results. Proper screening of patients prior to surgery, proper nutrition, good technique, and conscientious wound care dramatically favor faster wound healing and more aesthetic results.