Explore Plastic Surgery

The creation of a scar is the end result of the wound healing process, specifically the third phase of wound healing when new collagen is laid down. It is commonly believed that the inflammatory component of the wound healing process is essential for not only healing of the wound but the development of a scar as well. As a result, potential scar therapy innovations are looking at inflammatory mediators in the hope that less scar will be formed by controlling the inflammatory process of the wound healing sequence.

Currently available scar reducing therapies include steroids (triamcinolone injections), 5FU (5-fluorouracil, bleomycin, laser therapy, silicone gel sheeting, pressure therapy, radiation, and cryotherapy. All of these have been shown to have some effect and can be part of many contemporary scar treatment strategies.

I like to rank these agents based on their risk of potential side effects. No risk therapies would be silicone gel sheeting, topical silicone gel and pressure therapy. Despite their frequent touting and use in scars, the actual evidence that they really do prevent or improve poor scarring is very weak. But their no risk of side effects makes them popular. Low risk therapies include laser and pulsed light treatments. Their benefits are more theoretical (currently) than proven, but other than the potential for some mild hypopigmentation they have very little risk to their use in experienced hands. Injection therapies, such as steroids, and cryotherapy fall into the moderate risk use category. They do have a proven track record of success which accounts for their intial use in many problematic scars. But they frequently have some side effects as well including subcutaneous fat atrophy, skin thinning, and hypopigmentation. Controlled and limited use is the key to avoid these potential problems. Overdosing or chronic use of injectable steroids will eventually exhibit these adverse cosmetic outcomes. Higher risk strategies include surgical excision and radiation. While both can work well, they are usually at the end-stage of treatment options and are reserved for the most problematic of scars or those that have failed previous less risky treatment options. In the worst of scar problems, a combination of treatments is often done, such as surgical excision and steroids or surgical excision and radiation. This combined approach is almost always reserved for the pathologic true keloid of which recurrence is high no matter what is tried.

Emerging scar-reducing therapies are coming from the TGF-beta family of growth factors. Several such containing products are in clinical trials currently. TGF-beta is a known key agent in the inflammatory wound healing cascade and offers the theoretical hope of controlling inflammation and scar production but perhaps with less side effect than traditional injectable steroids. COX-2 inhibitors, a well known mechanism in many non-steroidal anti-inflammatory drugs, is of interest topically. It works by modulating prostaglandin production which can potentially limit the amount of collagen production and possibly scar formation. Both of these approaches are of great interest currently but are years away from becoming an actual clinical therapy. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana’

Indianapolis

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

Insight on Scar Revision by Dr Eppley in Indianapolis

The occurrence of scars is a frequent fact of life. As a plastic surgeon, I usually see several patients a week who come in just to have a scar evaluation and talk about what can be done to improve the appearance of their scars. Such requests are so common that I created a website dedicated to the topic of scars as a resource for patients called ScarScription. (http://www.scarscription.com) Patients are initially referred to it before their appointment so they can be better educated.

In reality, while scars can occur anywhere and from just about anything, there are only 4 basic scar problems that make them more noticeable than we would like. Treatments for scars are based almost exclusively on this appearance classification. Scars can be too high (raised), too low (depressed), too wide (wide), or with poor color. (red or brown)

While most scars can be cut out and reclosed, otherwise known as re-excision or scar revision, certain types of scars may be successfully treated by other methods. Raised scars can be treated by steroid injections, pulsed light, or mild laser resurfacing in an attempt to flatten them, depressed scars can be treated by injectable fillers although that effect may be only temporary, and scars with red or brown discoloration can be treated by pulsed laser light in an effort to remove the unnatural color. Wide scars can be treated only by….re-excision, as there is no non-surgical method to narrow a scar.

Much ado has been made of scar treatment gels, which have become very popular in the past decade. Certainly using topical gels early after the scar is created can’t hurt (whether they really help or not has not been conclusively proven for most of them), but an established scar rarely gets any significant improvement from the external application of any cream, gel, or salve.

Seeing an experienced plastic surgeon is the best way to get good answers to any scar question that you may have.

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