While scars have a negative connotation due to the imperfect appearance of the skin, they are a normal result of most injuries and surgeries. This is part of the wound healing process and their appearance (or perpetuation) is the expected result of this dynamic process. It is only deviations from normal wound healing, hypertrophic scars and keloids, that should be considered abnormal.
The differences between hypertrophic scars and keloids is a confusing one for most people. One is often thought of as the other, most commonly hypertrophic scars being confused as keloid scarring. But they are in both appearance and biology distinctly different. Hypertrophic scars appear raised but stay within the confines of the original wound. They are more likely to occur in wounds that cross the so-called relaxed skin tension lines or in wounds that have been left open to heal on their own or have become infected.
Conversely, keloids extend beyond the confines of the original wound (mushrooming from the wound edges) and are often associated with ongoing growth. They may stop growing but many do not. It is this progression in size that is the hallmark of their behavior. They often cause pain and other symptoms such as itchiness. This is due to the tight scar tissue and a sign of ongoing growth. They may also be a family history of keloids due to a genetic inheritance. They are often associated with traumatic wounds such as ear piercings, tattoos and burns.
Just like their biology the treatments for hypertrophic scars and keloids is different. While hypertrophic scars may improve with time, significant improvement in their appearance is usually only going to come from excision and closure, with or without some form of geometric rearrangement.(e.g., z-plasty, running w-plasty) This almost always solves this particular scar problem or, at the least, provides significant in its appearance. While the same issue for improvement applies to keloids, careful consideration needs to be given to how recurrence is going to be prevented as the propensity for so occurring is remarkably high.
Combining some recurrence prevention strategy with keloid excision is standard and most commonly is the injection of steroids along the wound edges. This is best done before surgery to get some regression of the keloid and then the excision is performed. At the time of excision the wound edges may be injected with steroid followed by repeat injections every several weeks after surgery for a few intervals. This is far more successful that just excising a keloid alone but is still associated with a near 50% recurrence rate.
For the refractory keloid, radiation therapy is the one known alternative approach that is often better than steroids. It is combined with scar revision and is started immediately, even on the day of surgery. It is known as low dose radiation and, while there is no standard dosing regimen, most patients receive between 1500 and 2000 rads over several sessions done daily for the first week after the surgery. This radiation-induced disruption of collagen synthesis at its inception has the best chance of preventing new keloid formation although it is not foolproof and recurrences have been known to recur .
Any interruption of the skin, whether from a fall on the ground, an accident on the job, or from the surgeon’s knife, prompts the complicated and not yet fully understood process of healing, the end result of which is a scar. However, the word “scar” often invokes the image of an unwanted deviation of the healing process, that which is a physical derangement from the smooth and non-discolored appearance of skin that it replaces.
As do the injuries from which they result, the appearance of scars can vary tremendously. Differing scar appearances are because the scars are different from each other. Different scar types are treated differently! Like all of medicine, successful treatment is based on establishing the diagnosis first. The wrong treatment method on a scar results in not only no beneficial effect but a waste of your time and money.
Hypertrophic scars appear as raised, wide,firm,and red to purple-colored scars that
remain within the physical boundaries of the original skin injury. They are more likely to
occur in wounds that cross natural lines of skin tension or an original open wound that
healed on its own. These can cause some itching and discomfort to the touch but may
improve with time.
Keloids are also raised, reddish-purple, nodular scars that are usually firmer than hypertrophic scars.Keloids are the result of uncontrolled scar healing that the body does not stop once the wound is healed. The difference between keloids and hypertrophic scars is that keloids extend beyond the boundaries of the original injury site, encroaching upon surrounding uninvolved healthy tissue. Keloids can result from seemingly innocuous activities such as ear piercing and tattoos and unlike hypertrophic scars, keloids do not regress over time. While keloids can occur in all skin types, they are generally more common in darker skin.
Stretch Marks are linear bands of wrinkled skin that most frequently result from rapid weight loss or weight gain, for example following pregnancy, and tend to appear in areas like the abdomen, breasts, thighs, and hips. Initially, they tend to be red or purple, but often fade to white over time. They are essentially ‘partial tears’ on the underside of the skin from overextension.
Depressed Scars (atrophy) are due to the irreversible damage of the skin from the injury where the amount of scar formed is less thick than that of the surrounding normal skin. The level of the scar (thickness) is less than that of the surrounding skin. They can occur from a multitude of inciting events such as acne lesions, burns, or skin avulsive injuries from trauma. Trying to apply makeup to conceal depressed scars actually worsens their appearance as makeup enhances the textural variations.
Acne scars are a variety of depressed scars that have occurred due to loss of skin thickness from the body’s inflammatory response to a plugged sebaceous follicle. The inflammatory reaction (infection) results in thinning of the skin even though scar tissue has formed. Acne scars appear in a variety of shapes, which are important to distinguish, as they are often treated differently.
Icepick scars are usually narrow, sharply demarcated tracts that are wider at the surface and taper as they extend through the skin. Rolling scars are more superficial, wider, and produce an uneven appearance in the skin. Boxcar scars are round- to oval-shaped skin dimples with sharp margins and are wider than icepick scars.Most tend to have diameters from 2.0 – 4.0 mm.
Burn Scars are unique in that they have a very thin and atrophic underlying dermis. They are quite stiff and inflexible and do not heal well when cut and sutured. The fat layer underneath them is frequently gone or thinned due to the initial heat of the original injury. The burn scar can appear smooth and almost ‘glass-like’.
Scar diagnosis is critical to selecting the proper scar revision approach. These simple descriptions may help one better describe and identify their scar problem.
Background:Scars are a common patient concern, whether they be slight or significantly disfiguring. While scar treatments and therapies abound, significant scarring requires some form of surgical scar revision. Lacerations and traumatic wounds are particularly prone to hypertrophic scar formation, the most common type of raised and disfiguring scars. While less commonly seen on the face, hypertrophic scars can develop under two healing situations. One is when a laceration crosses a facial transition zone, such as the jaw line. The other is when an open facial wound is allowed to or can only heal by secondary intention. Abrasions, burns and other partial thickness wounds are particularly prone to abnormal scar formation
This is a 22 year-old female who was originally involved in a motor vehicle accident in which she was thrown from the car. She sustained multiple long facial lacerations including a deep abrasion from the left side of her face down into the neck. Her original care was unclear although she may have received suturing of some of her facial wounds. She went on to heal and came in for scar revision 18 months after the accident. Besides the numerous persistent red and prominent scars, she had a large scar contracture across the left jaw line. It was painful and tight and limited her from turning her head to the right.
She underwent revision of all of her scars in a single operation. Some basic plastic surgery scar principles were used. Scar revision of most facial scars is best done by changing the line or orientation of the scars. While you can’t change the direction of scars, you can make them more narrow and not a perfectly straight line. This is the principle of the running w-plasty, it changes a straight line into more of a pinking shears pattern. This is useful if the scar runs obliquely or perpendicular to the natural lines of skin tension. This is known as geometric scar rearrangement. Z-plasties are done when the scar is contracted and needs lengthening. This is of particular need in many scars that cross the jaw line, a transition zone between the face and the neck which differs in both skin thickness and exposure to stretching.
Over 500 skin sutures were placed in doing these comprehensive facial scar revisions. They were removed one week later and replaced with topical glue to allow further healing. She was lost to follow-upbut reappeared nearly two years later. Her scars had adequately faded and the final results of the initial scar efforts could be seen. While I thought some further scar improvements could be obtained, she declined any further scar work.
1)Traumatic facial lacerations and wounds are prone to develop hypertrophic scars. Such scars can only be improved by surgical treatment.
2)The use of a combination of straight line closure and geometric rearrangement for facial scar revision is used based on scar orientation to the relaxed skin tension lines.
3)Most facial scar revisions will require some form of touch-up which can include laser resurfacing and/or treatment of persistent redness. Such considerations should wait at least six months after the initial scar revision.
1.I recently had a car accident and have a very ugly scar on my forehead. Will scar revision help me? The revision of scarsis rarely done prior to 6 months following an injury. This is simply becauseit is too early to intervene as the tissues have not sufficiently softened to handle being surgically manipulated. Another reason is that scar revision prior to nine to twelve months following your injury can also be too early is because scars change in appearance over time.. A scar that initially looked terrible can almost completely fade as it matures and settles down.
In some scars that appear to be healing poorly (wide, irregular, misaligned skin edges), scar revision before six months may be done. It is the progress of a scar over time that determines whether early or delayed scar revision may be beneficial.
Today’s plastic surgery techniques also allow for scar manipulation to be done as it progressively heals. It is wise, therefore, to see a plastic surgeon and have your scra followed as it heals. Certain methods may help a scar heal better along the way. For example, if the scar thickens, it can be treated with injectable steroids to reduce any unwanted hardness or fullness. If the scar stays red for too long, it can be treated with pulsed light therapy to lessen the undesirable redness. If the scar becomes darker due to sun exposure or your natural darker skin color,topical bleaching products may help the darker color fade.
2. Does Cocoa Butter or Vitamin E really work to improve scars?
There is no doubt that these two topical creams or oils have a historic belief that they are helpful for scar reduction. I have seen many patients over the years in my Indianapolis plastic surgery practice that have recounted stories of their relatives or even themselves that have seen the benefits of using them on scars and stretch marks. Despite these long-held beliefs, scientific studies have shown that they are largely urban myths. While good scientific studies in scar revision are largelylacking, a few scientific studies that have been done have shown that these treatments provide no improvement at all in an incision or scar. In fact, Vitamin E oil has been shown that it may actually slow wound healing. (this doesn’t mean that it makes scars worse, just that it does not make them better) Therefore, the use of these topical creams is mainly psychotherapeutic, not clinically effective.
3. What causes scarring and why is it noticeable? A scar is the result of the natural process of wound healing. The body does not always heal a wound with exactly the tissue that was cut or lost. Rather it mends and replaces injured tissue with on-specific collagen tissue to bind it back together. Whether the amount of scar tissue that is formed is a little or a lot depends on a lot of factors, such as the size of wound, how close the skin edges where as it heals, and the mechanism of injury. (e.g., incision, burn etc.) How much and what type of scar tissue that forms will have a significant impact on how much the scar is seen. There are other factors, beyond how the wound has healed, that also influences how a scar looks. A scar can be noticeable because it is a straight line that your eye can easily follow. Another reason a scar is visible is that the scar is darker or lighter than the surrounding skin color. Dark color may fade over time. A white scar, however, will not change color and is a permanent visible contrast to your surrounding pigmented skin. A scar may be visible because it is at a different level to that of the surrounding, It may be raised or indented, causing a visible contour deformity. Lastly, a scar may be adhered (scarred to) a nearby structure which causes it to move abnormally or be tethered as it tries to move. This causes visible distortion of both the scar and the normal structure during movement.
Scar revision is a surgical approach to scar improvement. Fundamentally, it is about cutting out the scar and putting it back together. How it is put back together is different based on the type of scar and its location on the body.
Straight Line Repair. For some scars, it is as simple as cutting it out and putting it back together in the line or orientation that it lays. This can be very effective for scars that already lie along the relaxed skin tension lines of their locations. Some scars are simply too wide or depressed and need to be made thinner and more even with the surrounding skin. This is often how scars on the body (below the neck) are done.
Geometric Broken Line Repair. (GBLR) The concept of GBLR is to cut out a scar and put it back together in an irregular pattern, not a straight line. By doing so, it makes it harder for the eye to follow the scar line thus making it less noticeable. Using precise and randomly alternating squares, rectangles, triangles, and trapezoids that measure between 3 to 5 mm and that interlock with one another, the scar is transformed from a straight line into a very difficult to follow zig-zag appearance. In some cases, a superficial skin resurfacing treatment (laser or mechanical dermabrasion) is done several months later.Z-plasty Repair A z-plasty involves changing the scar from a straight line into a z-pattern. This accomplishes several scar benefits. It redirects the forces of tension and also lengthens a contracted or shortened scar. By irregularizing a straight line, it also serves to make it more difficult to see the scar and thereby camouflage it. W-plasty Repair. The w-plasty serves to irregularize a straight line and creates a ‘pinking shears’ effect. It breaks up the entire straight line of a scar.
5. s there any way to make scars look better without cutting them out? For scars that have some minor contour deformities, ‘sanding’ is one approach. This can be done using mechanical dermabrasion or laser resurfacing. For scars that have some minor amounts of depression or indentation, injectable fillers can be used to raise the scar. Unfortunately, no currently available filler is permanent.
6.What is the difference between a keloid and a hypertrophic scar?
These two types of scars are commonly confused. I have seen lots of scar patients who thought they had a keloid when they did not. A keloid is a scar that grows beyond the boundaries of the original margins of the scar. A hypertrophic scar, on the other hand, is a very thick or widened scar but it stays within the edges of the scar. As a general rule, keloids rarely form on the face. The face is defined as the area in front of the ears and not involving the scalp and the neck. The areas where keloids are often distributed include the earlobes after ear piercing, the neck after shaving, and the back of the head after hair trimming and most often are found in African-Americans or darker complected races. Keloids manifest and may continue to grow after a very minor insult like an ingrown hair or after shaving. Hypertrophic scars usually arise from a real injury of some kind and tend not to continue to grow. This distinction is very important as the treatment for these two scar types can be quite different. Keloids are well known to be difficult to treat and often require multiple treatments and surgeries for improvement.
Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.