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By Michelle M.
Zormeier, MD of Chernoff Plastic Surgery and Laser Center
The purpose of
scar revision is to optimize scar camouflage. A person considering
facial scar revision must understand that there is no way to remove
scars completely. The goal is to improve the appearance of the scar
either by disguising it, relocating it, or minimizing its prominence.
The ultimate appearance of a scar is dependent on many factors including
the orientation of the scar, amount of tissue loss or injury, scar
position, age of the patient, patient’s underlying health, genetic
predisposition to abnormal scar formation, and technique of wound
closure all contribute to the final result.
Understanding the
mechanism of scar formation can be helpful in deciding on the method of
scar revision. Blunt trauma, gun shot wounds, and burn scars tend to
involve a larger surrounding area of injury than surgical incision
scars. Scars resulting from these types of injuries my be less amenable
to a satisfactory result or require staged revisions. Also, there are
some guidelines for optimizing initial scar formation, which may
facilitate later scar revision or even circumvent the need for a
secondary procedure. All scars tend to improve spontaneously after a
period of maturation of one year.
Different scars
require different treatments. For example, severe burns that destroy
large sections of skin cause the skin to heal in a puckered way. As the
skin heals, muscles and tendons may be affected in this “contracting”
movement. Keloid scars are a result of the skin’s overproduction of
collagen after a wound has healed. These scars generally appear as
growths in the scar site. Hypertrophic scars, unlike keloids, do not
grow out of the boundaries of the scar area, but because of their thick,
raised texture, can be unsightly and may also restrict the natural
movement of muscles and tendons.
When a scar is of
the contracture type, surgery generally involves removing the scar
tissue entirely. Skin flaps, composed of adjacent healthy, unscarred
skin, are then lifted and moved to form a new incision line. Where a
flap is not possible, a skin graft may be used. A graft involves taking
a section of skin tissue from one area and attaching it to another, and
time must be allowed following surgery for new blood vessels and soft
tissue to form. Z-plasty is a method to move a scar from one area to
another, usually into a natural fold or crease in the skin to minimize
its visibility. While Z-plasty does not remove all signs of a scar, it
does make it less noticeable.
Dermabrasion and
laser resurfacing are methods to make “rough or elevated” scars less
prominent by removing the superficial skin layers. Clearly, the scar
will remain, but it will be smoother and less visible. Keloid or
hypertrophic scars are often treated first with injections of steroids
to reduce size. If this is not satisfactory, the scars can be removed
surgically and the incisions closed with fine stitches, often resulting
in less prominent scars.
Both old and new
scars can respond well to laser therapy. The Versapulse laser is an
excellent treatment for scars when they are in the vascular phase, or
red or pinkish in color. The scar will become smoother, less red, and
less visible. The CoolTouch laser can soften and minimize the
appearance of the scar by stimulating collagen production. This is the
treatment for depressed scars or acne scarring. The laser therapy may
require multiple treatments, but requires no down time, minimal
discomfort, and can be performed easily in the office setting without
anesthesia. Epigel sheeting is a simple, topical silicon sheeting
which can be used in the management of old and new hypertrophic or
keloid scars and can be used to aid in the prevention of scarring.
Insurance does not
generally cover surgery that is purely for cosmetic reasons. Surgery to
correct or improve scars caused by injury may be reimbursable in whole
or in part. However, changing how a scar looks can help improve a
patient’s self esteem.
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