Explore Plastic Surgery

Scar revision is a common request and a frequently performed procedure in plastic surgery. Whether it is scars from an accident from a surgical encounter, many patients have concerns about their scars. As a result, there is much interest in scar improvement whether it is immediately after the scar event has occurred or even years later. The sheer number of over-the-counter scar treatments attest to the public’s interest in eradicating these unsightly and disfiguring marks.
As a general rule, there are no specific scar creams or ointments that will make any significant improvement in an established scar. Topical scar treatments do have a role to play in early scars but not in older scars. Only the concept of some form of scar revision has any hope of improvement at this point. Scar revision can consist of a variety of treatments including excision and rearrangement (cutting out and reclosing), laser therapies, and mechanical methods of dermbrasion or sanding. All are not equal, meaning that each has a specific role to play and can be beneficial if used in the right kind of scar.
There are several extremely important points that one needs to understand about scar revision. First and foremost, no method of scar revision can completely erase a scar’s appearance. The skin were the scar lies is never going to be normal…..ever. Scar revision is about lessening its appearance, not completely eliminating it. As a plastic surgron, I have no magical wand or an eraser at most disposal The critical question before contemplating scar revision then is….how much improvemennt can be had and is it worth the effort. That is where the value of a consultation with a plastic surgeon is…….determining what degree of improvement may be possible.
Secondly, there is no single method of scar revision that will work for all scars. Much ballyhoo goes on about the use of lasers, but quite frankly, lasers are not the most common method of treating scars. They may seem like an ‘eraser’ but their use is restricted to treating early or persistent redness of scars and some light skin resurfacing of scars. Both of these laser effects produce mild degrees of improvement but it is not effective for many types sof scar problems. By far, excision and primary closure (cutting the scar out and reclosing it) or excision and tissue rearrangement (cutting the scar out and realigning it through geometric rearrangements such as z- or w-plasties) is most common. Scar excision is probably the most effective method of scar improvement, if the scar problem permits, as it is removing the scar first and creating a fresh wound. Dermabrasion and deeper laser resurfacing may be helpful for wide scars that are raised that do not lend themselves to excision.
Lastly, scar revision, no matter what method is used, takes time. I tell patients that scar revision is a process that usually involves takes a step back (to allow healing) in the hope that in the long term you have jumped two steps forward and it looks better. It requires a commitment of time and a leap of faith that the ‘effort’ will be worth the result.
Dr. Barry Eppley
http://www.scarscription.com/
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Concern about scars, those one already has or those that might occur from an upcoming surgery, is a frequent patient concern. As a plastic surgeon, I see patients weekly that have existing scars from injury or surgery and would like them improved. While scars come in many varieties (see my scar website, http://www.scarscription.com/) and can be treated by numerous methods, a common treatment method is excisional scar revision. Simply put, the actual cutting out of the bad tissue (scar) and putting it together with fresh unscarred skin. While this creates a ‘new’ scar, the goal is that the new scar is better looking than the old one. The fundamental concept is…..no scar can be completely erased (we are physicians, not magicians) but can be made less noticeable.

Scar excision (revision) is appropriate for scars that are wide, raised, depressed, or are a relatively straight line that crosses the relaxed skin tension lines (RSTL) of the face. (RSTLs are the natural cleavage lines of one’s skin that become quite evident when we get old……as wrinkles and folds….scars that lie parallel to the RSTLs will stay narrower and are less noticeable than those that cross it at angles or run perpendicular to them) No amount of time or any other form of scar treatment will make a scar narrower or make its edges flush with the surrounding skin. When a scar is cut out, it can be put back together in numerous geometric ways….depending upon what scar configuration will look better.

If putting the scar back together allows it to lie in a straight line parallelling a RSTL (for example, a horizontal orientation in the forehead or part of a circular pattern around an arm or leg), then a simple straight line closure would be most favorable. If, however, closing the scar makes a line that runs at angles to the RSTL…then a more geometric scar closure pattern may be used.

Geometric scar revision is based on a simple visual concept…..the eye has a harder time following an irregular line than a straight one. If the cutout of the scar and the way it is put back together creates an irregular pattern, then the scar may ultimately be less noticeable. These geometic scar patterns can be done as running Ws (like the pattern created by pinking shears), intermittent Ms, or a variety of other configurations. This type of scar revision is known as a broken-line closure or pattern. The most well-known geometric scar revision is the Z-plasty. Creating a Z along the line of a scar is the ultimate use of geometry. Z-plasties are most commonly used in scars that cross a moving surface (and have created a tight band or scar contracture) such as a joint or when the scar lies directly perpendicular a RSTL on the face. Skin flaps are cut around the skin crease or RSTL and the limbs of the scar flaps interposed. (criss-crossed) A Z scar is subsequently created but, equally important, the scar is actually lengthened across this area. Mathematically, the angle of the skin flaps that are cut determines how much scar length is actually gained. This technique is particularly valuable in the release of scar bands as reorientation and extra length is usally needed so that they do not recur after scar revision.

Geometric and broken-pattern scar revisions are an essential technique for improving many types of scars. These scar revision techniques require a good dose of time after surgery to see their benefits.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.scarscription.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis