Scars are the result of damage to skin from injury, burns, and infections.
They can be small, large or extensive, located anywhere in the body
The disfigurement caused by scars is because of a combination of multiple factors-
- Level discrepancy
- Colour discrepancy
- Texture discrepancy
- Deviation of landmarks e.g. angle of mouth, corner of eye
- Suture marks in operative scars
In addition, some scars need attention because they are painful, itchy and unstable i.e. they keep on breaking down.
Principles of scar revision
The scars may or may not be amenable to improvement but following principles apply.
- The human skin is not a black board; it remembers and records every insult it bears. scars are forever. Scars cannot be made to disappear altogether; they can only be improved.
- Generally scars are considered for revision when they mature. Maturation is a process which occurs gradually over many months and may take up to one year. Although scars may improve marginally after one year but as a rule, it is believed that what you have at the end of one year is what you have. The benefits of waiting are many- surgery may not be required at all as the scar may show significant improvement or the extent of the procedure may be reduced, the procedure is less bloody and the results are generally better. But sometimes the scar revision may be planned early if there is a serious functional impairment like scars on eyelids and around the mouth which interfere with their opening and closure.
- Scars are only taken up for surgery if they can be improved. The surgeon analyses the scar and the history to find out any factor which led to an adverse outcome in the first place. If that factor in the patient is correctable, the patient is advised surgery.
- The final result is achieved only after 6-12 months over which the scar matures. So, the patient should have enough time for the result to show. Often patients have long standing scars from injuries sustained in childhood and report for surgery only days before marriage or engagement and get disappointed when told about the facts. Remember-a plastic surgeon is not a beautician!
They are generally reserved for hot immature scars. Treatments consist of
- pressure garments
- cold creams
- scar gels
- Steroids as creams or injections are sometimes used judiciously to prevent hypertrophy.
- Lasers can help to improve some scars but the length, width and direction are not altered, only the colour, texture, depth or elevation of the scar can be improved; also, multiple sittings will be required.
If the scars do not improve up to expectation, then they are candidates for revision by Plastic Surgical means. If surgery is not possible or refused, alternate palliative treatments are available.
Alternative treatments – They include
- Camouflage with makeup – Water proof makeups are available which can hide visible scars
Common Scar revision procedures
- Elliptical Excision- Scar is removed along margins and healthy skin is stitched from sides in layers. It is applicable for scars with limited width in favorable lines.
- Z- plasty- Common procedure to reorient scar lines more favourably & to increase the length of tight scars. Z plasties can be single or multiple and the procedure may be combined with other procedures.
- W-Plasty – It also orients the scar more favourably. No increase in length. Generally multiple.
- Grafts – They have limited role in scar revision. The grafts can be full thickness or partial thickness grafts.
- Flaps – can provide excellent quality skin to cover large scars. Generally, flaps from nearby areas are preferred because they offer excellent colour match.
- Expanded flaps- An expander [balloon] is inserted under the neighboring skin and gradually filled up with liquid to expand the soft tissues under which it sits. The expanded skin then is moved into scar area after expansion is complete after several weeks.
- Serial Excision- The scar is removed in two or more stages when one stage may not be enough to remove the entire scar.
General, Local or regional anaesthesia is used as necessary.
Post op care
It varies according to the procedure.
Once sutures are removed, the patient may be advised –
- Strapping for 3-6 weeks to prevent stretching of scar.
- Sunscreens to prevent darkening of exposed scars.
- One of many scar improvement gels to soften the scar.
- Pressure garments to prevent hypertrophy.
- Silicone gel sheets to soften the scar.
These treatments are given for about 3 months postoperatively.
Final results are generally assessed at about one year after surgery.
Immediate – Infections, Blood or seroma collections, necrosis of flap tips
Later – Hypertrophy, Stretching of scar, Hyper/Hypopigmentation, Poor aesthetic result