Scar Revision

Scars are the body's reaction to healing skin. Unfortunately, when injuries occur, the size, shape, and location of wounds are unpredictable. Wounds heal by laying down scar tissue. Physicians are unable to consistently predict how a patient will heal for a given injury. Ethnic skin, such as Blacks, Hispanics, Asians, and patients of Mediterranean decent have a higher incidence of healing with hyper pigmentation. Caucasian skin tends to heal with hypo pigmentation.  It is important after appropriate cleansing and wound care that a patient understands that a scar will continue to heal and look its best one to two years post injury. Most physicians would not recommend scar revision for a minimum of six months to one year after the injury/surgery. Besides the expertise of the surgeon, to limit scarring, other factors, such as size, location, shape, age of the patient, and healing ability play a role in the final result. Even with scar revision , which can be performed by several techniques, the resulting scar may be better, worse, or the same. Therefore, it is important that the patient and the physician revise scars that are cosmetically unacceptable and have a high probability of improvement. Scars play a role in appearance, but can limit movement of a joint, retard growth of a child, and may be painful, bleed or ulcerate. Scars that cause functional impairment are almost always revised. Non-surgical treatments of scars include sun avoidance, Vitamin E, steroid applications, steroid injections, or the use of silastic gel sheeting. It is the public's misperception that plastic surgeon s operate without producing scars. Plastic surgeons are specialized surgeons that are trained in wound closure as to minimize scarring, and where appropriate will place scars in locations, or in certain directions that will leave the patient with the best possible scar. However, as previously stated, other factors are involved when determining the patient's resultant scar.

Unsightly facial scars and blemishes can very often be improved by well planned and carefully executed surgery. It must be stressed that a cosmetic surgeon cannot make invisible scars. He can only make the scars as inconspicuous as possible. The aim of scar revision is to achieve a scar which is fine, level and even with the surrounding tissue and about the same colour as the adjacent skin. We do not want the scar to pull on the surrounding structures. The old unsightly scar has to be removed first. Any planned surgical incision heals in exactly the same manner as any other deliberate or accidental cut, i.e. it produces scar tissue which is nature's method of healing. Once an incision is made and sutured the surgeon has little control over the healing process, a fact which must be appreciated by the patient. It is often not realised that a period of 6 to 18 months must elapse before the scar is mature; the stage where no further change or improvement will occur. Initially, any scar will be red and raised above the level of the surrounding skin and may often be hard in consistency. Gradually the redness and hardness lessen and resolve leaving a soft scar which is level with and somewhat paler than the adjacent skin. For these reasons scar revision must not be undertaken too soon because adequate time must elapse to allow the original healing tissues to mature. When revising a scar on the face the surgeon attempts to get the best possible result by placing the new scars parallel to or actually in one of the normal crease lines of the face. This usually means that the direction and shape of the original scar has to be changed.  I use operating loupes for accurate alignment of scar edges.

Although scar revision often requires surgical treatment, non-surgical treatment should be considered appropriately and sometimes considered first. Non-surgical options include: silicone sheeting , laser use, steroids, ultra-violet radiation, and permanent cosmetic camouflage. It would not be inappropriate to combine different options. Excision of large scars or blemishes may require several operations over a period of time. It must also be mentioned that some areas of the body always produce noticeable scars, e.g. nose, chin, chest, shoulders, upper back and parts of the arms and legs. The patient is admitted on the morning of surgery. Most facial scars can be revised under local anaesthesia. Extensive scarring in adults and scars in children are best treated under general anaesthetic. Most scar revision procedures can be treated on a day-care basis , but some may require an overnight stay in the hospital. Unfavourable results will occur when a scar becomes stretched, thickened or infected. It is important to follow post op instructions carefully. Be very careful to not abuse the new wound. We want to give the revision every advantage. It is most unlikely that any scars can be removed completely, but the aim of the procedure is to make them less noticeable and perhaps easier to disguise with make-up . The goal in scar revision is improvement and not perfection. Patients who are unable to accept this should not have treatment.

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