Scar Revision General Information

Whether the skin has been violated by a traumatic injury, a burn, surgery, or acne, it will form a scar. A scar is merely your body's response to healing the damaged tissue. It is formed when collagen produced by your body organizes itself on the wound to repair it and protect it from outside elements and infection. Unfortunately, the way a scar looks depends as much on how your body heals as it does the type of skin it's on, the tension of the wound, the presence of infection, and sometimes the technique and skill of the surgeon.

While no scar can be removed completely, plastic surgeons can often improve the appearance of a scar, making it less obvious. This can be done through the injection or application of certain medications or through surgical correction. Surgical scar revision includes scar excision and approximation of the tissue back together, reconstruction with a flap, or a Z-plasty. These will be described below.

Many scars that appear large and unattractive at first may become less obvious with time. Most plastic surgeons recommend waiting as long as a year or more after a scar causing injury or surgery before you decide to have scar revision. The surgeon will examine you and discuss the possible methods of treating your scar, the risks and benefits involved, and the possible outcomes. Be honest in discussing your expectations with the surgeon, and make sure they're realistic. Don't hesitate to ask any questions or express any concerns you may have.


Facial reconstruction following trauma

Surgery following facial trauma may take as long as four to 14 hours, as the goal is to repair as much as possible in one operation. The surgeon may use bone grafts, taking bone from other parts of the body to repair the facial bones, or fill in smaller areas of missing bone with prosthetic materials and implants. Broken facial bones are held in place with titanium mini-plates and surgical screws. This technique is called rigid fixation. Lacerations (tears) in the face are usually simply closed with stitches. If large areas of skin are missing, the surgeon may use a flap, which is a section of living tissue carrying its own blood supply, from another area of the patient's body and transplant it to the face. Some facial injuries may require the assistance of a neurosurgeon, oral surgeon, or ophthalmologist. More Scar Revision Facts...

Candidates for scar revision

There are many variables that can affect the severity of scarring. This includes the size and depth of the wound, the blood supply to the area, the thickness and color of your skin, the direction of the scar, and the tension of the wound. How much the appearance of a scar bothers you is, of course, a personal matter.

If conservative treatment fails or if your scar cannot be treated with medication alone, you will be considered for surgical revision. First and foremost, an individual must be in good health, not have any active diseases or pre-existing medical conditions which can increase your operative risk. In addition, you must have realistic expectations of the outcome of their surgery. Communication is crucial in reaching your goals. Discuss your goals with your surgeon so that you may reach an understanding of what can realistically be achieved.

If you have the desire to diminish or remove existing scars, you may be a good candidate for scar revision. In your consultation with your surgeon, it is very important to disclose any tendency to develop hypertrophic or keloid scars. Revision of keloids can actually make them worse! More Scar Revision Facts...

Different types of scars

  • Keloids
    Keloids are thick, puckered, reddish scars resulting from excessive growth of fibrous tissue outside the boundaries of the original wound. They usually develop on the chest, back and earlobes. Acne can cause keloids to form in those who are prone - on the face, back and upper chest to sternum area. However, keloids can form anywhere on the body. Keloids are initially treated by injecting a steroid medication directly into the scar tissue to reduce redness, itching, and burning. In some cases, this will also shrink the scar. If steroid treatment doesn't work, surgical treatment may be considered.

    No matter what approach is taken, however, keloids have a stubborn tendency to recur, sometimes even larger than before. The surgeon may combine the scar removal with steroid injections, direct application of steroids during surgery, or radiation therapy. You may even be asked to wear a pressure garment over the area for as long as a year. Even so, the keloid may return, requiring repeated procedures every few years. Radiation therapy is final therapy for stubborn, recurrent keloids that do not respond to steroids or surgery. More Scar Revision Facts...
  • Hypertrophic
    Hypertrophic scars are also thick scars that may look like keloids except they remain within the margins of the original wound and do not form outside of this area like keloids do.

    Both of these entities are reasons for needing scar revision as well as potential complications of surgery. More Scar Revision Facts...
  • Contractures
    Contractures are scars that result of skin edges pulling together as the skin is healing over a large area which has lost its skin. A contracture may affect nearby muscles and tendons as well, therefore, restricting normal movement.

    Correcting a contracture usually involves cutting out the scar and replacing it with a skin graft or a flap. In some cases a procedure known as Z-plasty may be used. And new techniques, such as tissue expansion, are playing an increasingly important role. If the contracture has existed for some time, you may need physical therapy after surgery to restore full function. More Scar Revision Facts...
  • Facial Scars
    Facial scars are frequently considered a cosmetic problem for obvious reasons. There are several ways to make a facial scar less noticeable. Often a surgeon will simply cut out the scar and close it with tiny stitches, leaving a thinner, less noticeable scar.

    If the scar lies across the natural skin creases (or "lines of relaxation") the surgeon may be able to reposition it to run parallel to these lines, where it will be less noticable. (See Z-plasty)

    Some facial scars can be softened using a technique called dermabrasion, a controlled scraping of the top layers of the skin using a hand-held, high-speed rotary wheel. Dermabrasion leaves a smoother surface to the skin, but it won't completely erase the scar. More Scar Revision Facts...

Scar revision surgery

Once you are on the operating room table, you will then be given your choice or your surgeon's preference choice of anesthesia as discussed prior to your surgery date. The nurse anesthetist or anesthesiologist will than insert an IV to keep you hydrated during your surgery and to have a means to give you anesthesia, antibiotics, and other medications.

You will be marked with a magic marker type pen for the incision placement areas and you will then be injected with a local anesthetic that can also prevent bleeding (lidocaine or marcaine with epinephrine). Your scar is then excised; the skin is pulled together and resutured. Areas which cross the natural lines and folds of the body may need methods such as flap rotation to close the area of excised scar. Even Z- plasty may be an issue where the scar has contracted and is limiting movement or covers an area such as the knee or the elbow. Please discuss these techniques with your surgeon as not all surgeons will offer the same treatment.

  • Z-Plasty
    Z-Plasty is a surgical technique used to reposition a scar so that it more closely conforms to the natural lines and creases of the skin, where it will be less noticeable. It can also relieve the tension caused by contracture. Not all scars lend themselves to Z-plasty, however, and it requires an experienced plastic surgeon to make such judgments.

    In this procedure, the old scar is removed and new incisions are made on each side, creating small triangular flaps of skin. These flaps are then rearranged to cover the wound at a different angle, giving the scar a "Z"pattern. The wound is closed with fine stitches, which are removed a few days later. Z-plasty is usually performed as an outpatient procedure underlocal anesthesia.

    While Z-plasty can make some scars less obvious, it won't make them disappear. A portion of the scar will still remain outside the lines of relaxation. More Scar Revision Facts...
  • Skin grafting and Flap Surgery
    Skin grafts and flaps are more serious than other forms of scar surgery and they can greatly improve the function of a scarred area. They are more likely to be performed in a hospital as inpatient procedures, using general anesthesia. The cosmetic results may be less satisfactory, since the transferred skin may not precisely match the color and texture of the surrounding skin. In general, flap surgery produces better cosmetic results than skin grafts.

    Grafting involves the transfer of skin from a healthy part of the body (the donor site) to cover the injured area. The graft is said to "take" when new blood vessels and scar tissue form in the injured area. While most grafts from a person's own skin are successful, sometimes the graft doesn't take. In addition, all grafts leave some scarring at the donor and recipient sites.

    Flap surgery is a complex procedure in which skin, along with the underlying fat, blood vessels, and sometimes the muscle, is moved from a healthy part of the body to the injured site. In some flaps, the blood supply remains attached at one end to the donor site; in others, the blood vessels in the flap are reattached to vessels at the new site using microvascular surgery. More Scar Revision Facts...

Expectations after surgery

With any kind or scar revision, it's very important to follow your surgeon's instructions after surgery to make sure the wound heals properly. Although you may be up and about very quickly, your surgeon will advise you on gradually resuming your normal activities.

As you heal, keep in mind that no scar can be removed completely. Any time an incision is made, a scar will result. Unfortunately, the thickness and the texture of the scar is only partially related to the skill of the surgeon and the procedure itself. In no case will scar revision surgery eliminate a scar completely. In nearly all cases, it will minimize the scar. In very rare cases, the scar could be made worse. Although very uncommon, it is a risk that must be accepted by the patient.

The degree of improvement depends on the size and direction of your scar, the nature and quality of your skin, and how well you care for the wound after the operation. This is an operation that requires patience and stability in dealing with the healing period. There is sometimes a lull or depression after surgery and if there is already a pre-existing emotional problem, this low period can develop into a more serious issue. Please consider this before committing to a procedure. More Scar Revision Facts...

Other ways to treat scars besides with surgery

This depends entirely on your condition and needed treatment but it is important to remember that sometimes conservative treatment is the best form of therapy. For simple scars that are not too problematic, your physician may have you try less invasive means such as lotions, gels, medications, dermabrasion, laser resurfacing, and collagen implanation.

  • Pressure and Massage: Repeated massage using cocoa butter or vitamin E can greatly improve the appearance of scars. In some cases, special pressure dressing may also be of use. More Scar Revision Facts...
  • Cortisone Drugs: Various types of cortisone drugs may be used either as injections, topical preparations, or in the form of special tapes. These may well improve the scar to a point where surgery is not required. More Scar Revision Facts...
  • Dermabrasion or Laser resurfacing: Dermabrasion is a technique which can be used to smooth down raised or uneven scars. Most commonly used for acne scarring, it is frequently helpful in the treatment of other injury scars. More recently, the surgical laser has been found to be a superior resurfacing tool. Dermabrasion or laser resurfacing is frequently used as a planned component of the initial repair. Approximately five weeks after the initial wound is sutured, the repaired area is dermabraided. This often results in a scar less noticeable than it would have been without the combined dermabrasion. More Scar Revision Facts...
  • Collagen Implantation: Collagen implantation involves the injection of a collagen material into the scar. It can be helpful in the treatment of depressed scars. In some cases, it can flatten the scars and make them almost completely unnoticable. Collagen does not result in permanent correction and treatment must be repeated after several months. More Scar Revision Facts...
  • Silicone Pressure Therapy: A silicone dressing can be applied to a raised scar and help to soften or thin out the scar. The mechanism of this effect is unknown at the present time, but it has proven useful in many cases. It is very safe and simple to use. The special silicone sheet is cut to size and applied to the scar. It should be kept in place for 12 to 24 hours a day, depending on tolerance. Effects are not immediate, but results are usually seen within several weeks. More Scar Revision Facts...
  • For problematic scars (keloids): Some problematic scars may be somewhat remedied by injections of Kenalog (a corticosteroid) which seems to break up collagen such as scar tissue. In very problematic cases, surgical revision will not even be attempted for fear of worsening the current condition of the scar. More Scar Revision Facts...
  • For hypopigmented scars: Scar tissue lacks melanin, melanin gives your skin its color or skin tone and darkens with sun exposure or hormones. If your scars are lighter than the skin around it, you could try Micropigmentation. Micropigmentation is the art of implanting ink subdermally (such as a tattoo) into the lightened areas to match the skin around it. Just be sure that your micropigmentation technician is skilled in scar revision tattooing and has photo of his or her work to show you. Scar tissue tattoos differently than unaltered (normal) skin and may appear darker than the intended pigment. Be sure that you choose a natural color that you are able to upkeep (such as not being tanned) so that your result looks normal. More Scar Revision Facts...

Scar Revision Frequently Asked Questions ?

What is Scar Revision Surgery?

Am I a candidate for scar revision?

A keloid; what is it, who gets it, and what causes it?

Are there other ways to treat scars besides surgery?

What kind of procedures are used during scar revision surgery?

This information is intended only as an introduction to this procedure. This information should not be used to determine whether you will have the procedure performed nor does it guarantee results of your elective surgery. Further details regarding surgical standards and procedures should be discussed with your physician.

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