Considering Scar Revision

Before considering scar revision, the treating physician must have an understanding of wound healing and how scar tissue forms. Wound healing progresses in 3 phases: an inflammatory phase, a granulation phase, and the final, remodeling phase.

Inflammation is an immediate physiologic response to any injury to the body. In the skin, it serves the additional role of helping to contain and repel any organisms or foreign materials introduced into the tissues by a variety of traumas, including surgical incisions. The various mediators of inflammation are the first materials released in the wound, including activated complement, transforming growth factor-beta, circulating monocytes, tissue macrophages, neutrophils, platelets, clotting factors, and serum proteins, among others. Damaged collagen fibers promote platelet aggregation in the wound. Later, collagen provides the scaffold for wound healing as the major constituent of the extracellular matrix. This primary phase of wound healing typically lasts for 1-2 days.

The granulation or proliferative phase involves fibroblast proliferation within the wound bed. These cells are responsible for the production of the collagen extracellular matrix. Cytokines present in the wound bed at this time also promote the process of angiogenesis and the appearance of granulation tissue, a characteristic of the healing wound. Once collagen is laid down as an extracellular matrix and cells have grown on this scaffold, the wound enters the remodeling phase of wound healing.

The remodeling phase involves the reassortment of collagen fibers laid down in the preceding proliferative phase. Remodeling is the longest period of the wound healing process; it may continue for up to a year. However, 2-3 weeks is a more common interval for this final phase of wound healing. During this time, the net amount of collagen does not increase, but the formation of a more orderly arrangement of fibers helps to greatly increase the wound's tensile strength. When healed properly, the final wound strength reaches 70-80% of prewound strength.

The ideal scar is narrow and fills but does not eclipse the original volume of the wound bed. In fact, the wound often decreases in size upon healing due to contractile forces involved in scar formation. Occasionally, scar formation may be exuberant, as in the cases of hypertrophic scarring or keloid formation. Although discussed in detail in Keloid and Hypertrophic Scar, a brief mention of these unwelcome sequelae of wound healing is warranted.

Hypertrophic scars do not extend beyond the original boundaries of the wound laterally, but scar tissue may rise above the level of the surrounding skin. This commonly results in a very noticeable, irregularly contoured scar. A more extreme example of exuberant growth of scar tissue is the keloid. Keloid scars extend beyond the original borders of the wound, resulting in a raised and expanded scar relative to the original defect. These are often very noticeable, and they occur with increased frequency in persons with dark complexions. In both hypertrophic scars and keloids, components of the extracellular matrix are increased. Thus, while the number of fibroblasts present is normal, the cells present are apparently overactive in their wound healing response.

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.

Scar revision

When damaged skin responds in three phases; inflammation, rebuilding and remodeling. Immune system responds immediately to fight infection. The body produces inflammation to fight infection. Inflammation causes increased local blood flow so that a large number of white blood cells can be brought to the damaged area to fight infection. During the reconstruction phase, the skin began to repair the damage to help heal the wound so it can close. Collagen fibers produced during the repair process. Finally, the remodeling phase, the more collagen fibers are produced and organized to increase the strength of skin.

Often times, the immune system overreacts with more white blood cells and collagen than necessary, causing excessive scarring of red, raised and not attractive. A visible scar differs from normal skin because the fiber is regulated differently than normal skin. Scarring can be worse in certain races, certain regions, certain age (young) or if placed on the lines of skin tension.

A keloid is the overgrowth of scar tissue at the site of skin wounds. Appointed a new network, round, and firm, with irregular and claw-like margins. Keloids occur most commonly in pigmented people and tend to be getting worse. A hypertrophic scar is to heal wounds larger than normal size as a result of aggressive lay down collagen, found in larger cells than normal skin, resulting in raised, smooth, the results of hyperpigmentation. There are several options available for those who want to approve their appearance scar plastic surgery, non surgical treatments include:

Vitamin E: Some surgeons recommend that patients rub vitamin E oil on the incision site once they have been closed. Silicone sheet: the best known products to reduce redness and flatten scars is silicone-based products. Silicone sheets are products you can buy at your surgeon's office or you may be referred to the hospital. Silicone Gel: You can also buy the product in the form of silicone gel, such as Dermatix C Gel. Gel has similar properties as silicon sheets, but dried in a thin layer acts as an extra layer of skin.

If the scar does not respond to treatment over the other there are several procedures plastic surgeons may offer. A scar revision can be done, in which surgeons basically cut away the old scar and restitches cuts. Cortisone injections or laser treatments may also be available. Your plastic surgeon will be able to recommend appropriate actions for you to take.