Scar Revision and Secondary Procedures
Scars form for many reasons. Unfavorable scars can occur due to problems with surgical technique, post surgical care, the condition of the skin, or the size of the incision. However, the most important factor is genetics. If there is a family history of scarring, then increased care should be taken during surgery to achieve optimal results.
Type of Scars
Several types of scars exist and each can require different treatment.
Depressed scars
This type of scar is most commonly seen as the pitted scarring associated with acne. These are notoriously difficult to treat because of the depth of the scarring. As with any type of scar, the treatment depends on multiple factors, including the size and the location. Lasers and peels can be augmented with the use of fillers for optimal results. In some cases, resection of the depressed area with re-closure gives the best result.
Widened scars
These scars can occur if there is too much tension or pull on the incision. These scars are typically discolored and flat, and are best treated with dermabrasion, lasers, peels or carboxytherapy. Topical medications can also improve the appearance. As with any type of scar, removal and re-closure is an option should other methods of treatment fail.
Hypertrophic scars
These scars are raised above the skin and are somewhat firm. They do not grow beyond the margins of the incision. They appear to respond well to topical treatments with silicone or injection of steroids. They also respond well to dermabrasion, lasers, or carboxytherapy. Excision and re-closure is an option.
Keloids
Keloids are scars that grow beyond the borders of the incision. Unlike hypertrophic scars, keloids can continue to grow, sometimes to enormous sizes. There is usually a genetic predisposition to keloid formation and a history of keloid formation in the family increases the risk of developing keloids. The treatment for keloids varies depending on size and location. Some success has been found with topical silicone and steroid injections. In some cases, excision with re-closure is the only available treatment. However, the new incision can form another keloid. In most cases, partial resection with the use of lasers is done to improve the scar, but a complete removal of keloid may be impossible.
Type of treatments
Non-invasive
Several non-invasive treatment options are available. These have minimal recovery time and can greatly improve the appearance of a scar.
Fillers and Botox
Several classes of fillers exist for use in Facial Plastic and Reconstructive Surgery. They can be used to fill a depressed scar and improve the loss of volume that can be seen with resection of a tumor. They vary from temporary to semi-permanent to permanent. Because of this variability, you and your surgeon can determine the correct treatment for your specific scar.
Hyaluronic acids have revolutionized the field of facial plastic surgery and are now by far the most widely used materials. They are, however, temporary and require re-administration every 4-6 months. Fat, on the other hand, is permanent but requires anesthesia for harvesting and administration.
BOTOX has been used to paralyze the muscles around a scar, resulting in decreased tension on the scar. This decreases the widening of the scar and can improve the final appearance.
Laser scar revision
Certain non-ablative lasers such as IPL, PDL and Nd-Yag lasers have been used to improve the appearance of scars. These lasers work to decrease the discoloration of the scar, improve the healing processes occurring deep in the skin, and flatten a raised scar. They require several applications to achieve optimal results, but there is no downtime associated with their use.
Carboxytherapy
Carboxytherapy involves the injection of Carbon Dioxide (CO2) gas under the scar. It works by separating the skin layer from the deeper dermis and increasing blood flow to the scar. This increased blood flow brings in immune cells that reorganize and improve the appearance of the scar. The application is painless. However, it does require 5-6 weekly treatments. For a published article on Carboxytherapy click here.
Topical Treatments
Silicone
Although the exact mechanism is unknown, the application of silicone to a scar, either in the form of a gel or sheet, has been shown to improve its overall appearance. This process requires twice daily application for up to 3 months. However, the results are noticeable after 1 month of treatment.
Steroids
Topical steroids come as creams and ointments, and can be used to decrease the redness associated with healing. Steroids can also be injected into the scar to improve the appearance of raised, hypertrophic, pigmented and keloid scars. Several injections might be needed for keloids or hypertrophic scars to obtain desired results.
Herbal
Some topical herbal applications have been shown to improve the appearance of the scars. Vitamin E and Vitamin C seem to achieve this by delivering free radicals to the area and removing harmful materials from the healing incision. They can soften a firm scar and improve the overall appearance.
Surgical Touch-ups
Should the scar not be amenable to repair with non-invasive approaches, several surgical touch-ups are available to improve the appearance of a scar. The recovery time for these procedures varies from several days to 1-2 weeks.
Dermabrasion
Dermabrasion involves gently "sanding" the outer layer of the skin away using a dermabrader. This allows fresh healthy skin to replace the removed skin. Dermabrasion can also be used to bring down a raised or hypertrophic scar. Topical anesthesia with some mild sedation is usually required for this treatment.
Lasers & Peels
Ablative lasers and peels work by stripping away the outermost layers of the skin, allowing a new layer to regenerate and thus improving the appearance of the scar. These techniques work best for depressed scars (especially acne scars) as well as scars with varying pigmentation.
Acne Scars
Pitting acne scars continue to be among the hardest scars to treat. The most extensive treatments can still leave some pitting behind. Full resurfacing lasers or a deep chemical peel appears to give the best overall outcome. However, these procedures have a prolonged recovery time. Recently, fractionated laser treatments have been used to decrease the downtime associated with this treatment. However, to achieve the best results they require multiple treatments. If you suffer from acne scarring, please discuss all available options with one of our fellowship-trained surgeons.
Procedures
Certain scars will not respond to any of the previously mentioned treatments. In order to appropriately treat these difficult cases, further surgical care is needed.
Excision
Sometimes a scar simply needs to be removed and the incision closed with proper technique. This could make a widened scar into a thin line and make a raised hypertrophic scar into a flat thin line.
Flaps
In certain areas of the face, it is possible to bring tissue from nearby areas to close a defect. This technique is called a flap. An appropriately selected and well-designed flap can heal with minimal scarring and give a better cosmetic outcome.
Rearrangement
Rearrangement is the process by which a scar is moved to better hide it in one of the skin lines and wrinkles. This will allow for better camouflaging of the scar and thus an improved appearance. Certain types of flaps and techniques can be used to achieve these results.
