William Callaghan. MD (Scar-Revision Surgery)
Scar revision is surgery to improve or reduce the appearance of scars. It may also restore function, and correct skin changes (disfigurement) caused by an injury, wound, or prior surgery.
What is it?
A scar is a normal response to injury of any kind, including surgery. This is the body trying to protect itself from exposure to external environment or repair itself following trauma. Many factors influence how a scar forms or how much scar tissue is formed. These factors are influenced by wound size, depth, and location, the person’s age, skin characteristics (such as color of skin). Unfortunately, not all of these factors are completely understood and even their associations, mentioned above, may not even be factors at all!
Scar revision is performed when scars are unsightly, or influence function of a body part, or cause pain and discomfort. Depending on the extent of the revision, the procedure may be performed under local, sedation, or general anesthesia.
Sometimes, surgery may not even be necessary. Steroid injections can improve the appearance of a scar or even function of a body part from the scar.
When to have scar revision done is not always clear. Scars do tend to contract (shrink) with time and thus revision may not be necessary. When to perform a revision depends on the location, size, the amount of time from the injury, or the emotional impact of the scar. Generally, the minimum time is approximately 2-3 months, though it is not uncommon to wait even longer, sometimes one year after the injury.
Types of Revision
There are several ways to improve the appearance of scars: generally, a rule to remember is that it is often times better to “re-create” the original wound and then revise. That is, it is often better to remove the scar completely, and then begin the revision process.
- 1. Steroid injection: This is the simplest approach and it works in certain types of scars, such as hypertrophic or keloid scars. Multiple and serial injections are not uncommon.
- 2. Dermabrasion involves removing the upper layers of the skin with a special wire brush called a burr or fraise. New skin grows over this area. Dermabrasion can be used to soften the surface of the skin or reduce irregularities.
- 3. Massive injuries (such as burns) can cause loss of a large area of skin and may form hypertrophic scars. These types of scars can restrict movement of muscles, joints and tendons. Surgery removes extra scar tissue. The resultant defect may require a skin graft or local skin flaps (Z or W-plasties) to repair.
- 4. Skin grafting involves taking a thin (partial or split thickness) layer of skin from another part of the body and placing it over the injured area. Skin flap surgery involves moving an entire, full thickness of skin, fat, nerves, blood vessels, and muscle from a healthy part of the body to the injured site. These techniques are used when a large amount of skin has been lost in the original injury, when a thin scar will not heal, and when the main concern is improved function (rather than improved appearance).
- 5. Tissue expansion is used when there is not adequate tissue or skin to cover the defect. A silicone balloon is inserted beneath the skin and gradually filled with salt water. This stretches the skin, which grows over time thus allowing enough skin to cover the subsequent defect.
- • A keloid is an abnormal scar that is thicker and of a different color and texture than the rest of the skin. Keloids extend beyond the normal boundries of the wound and are likely to come back. They often create a thick and looks like a tumor. Keloids are removed at the place where they meet normal tissue. These can be very difficult to treat and may recur despite excision. Oftentimes serial steroid injections are required over a long period of time.
- • Hypertrophic scar: these are scars that are much thicker than a normal scar; however, they do not go beyond the normal boundaries of scars like keloids. Interestingly, histologically they are identical to keloids!
- • A scar that is at an angle to the normal tension lines of the skin.
- • A scar that causes distortion of other features or causes problems with normal movement or function.
- • Bleeding
- • Infection
- • Scar recurrence
- • Keloid formation (or recurrence)
- • Separation (dehiscence) of the wound
Care following revision is very important. Wearing protection against sun damage (sun blocks) is critical as is massaging of the scar 2-3 weeks following revision. Another important treatment in the recovery process is the placement of silicone gel or sheet. There is some data to show that scars may improve following placement of silicone directly over the scar for a period of time (3-6 months).
When you return to normal activities and work depends on the type, degree, and location of the surgery. Most people can resume normal activities soon after surgery. If the scar revision.