Scars are most obvious because of their poor quality or location. Their appearance is improved by non-operative techniques with or without a surgery. Scar revision surgery or surgical scar removal or surgical scar revision are frequently sought after by many to help them enhance their image and self-confidence.
In principle, a scar can never be fully neutralized and the attempt is always to minimize it so that it is less conspicuous and blends in with the surrounding tone and texture.
Scars are the unavoidable results of injury or surgery, and their development can be unpredictable. Poor healing may contribute to scars that are obvious, unsightly or disfiguring. Even a wound that heals well can result in a scar that affects your appearance. Scars are noticeable due to their size, shape or location. They can also be raised or depressed and may differ in color or texture from the surrounding healthy tissue.
Many factors will influence the quality of a scar and include the nature of the injury or surgery causing the scar, the location of the scar, the person’s innate wound healing properties, racial background, disease states, smoking, the technique of wound repair and the presence of any complications during the wound healing phase.
Although cosmetic surgery for scars can provide a more pleasing aesthetic result or improve a scar that has healed poorly, a scar cannot be completely erased.
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Scars may become a problem for a patient when they cause:
TYPES OF PROBLEM SCARS
Hypertrophic scars take the form of a red raised lump on the . They usually occur within 4 to 8 weeks following wound infection or wound closure with excess tension and/or other traumatic injuries. These scars may improve with time but a stretched or wide scar may remain. The back, chest and shoulders are areas prone to hypertrophic scarring.
Keloid scars are a more serious form of excessive scarring because they can grow indefinitely into large, tumorous (although benign) neoplasms. These are extreme forms of hypertrophic scars where the thickened scar ‘mushrooms’ and extends beyond the boundaries of the original wound.
These scars become thick, puckered, firm, itchy and occasionally painful. Darker ned races, burn injuries, younger patients with wounds on the chest and ears are all more prone to keloid scars. They are usually caused by surgery, accident, acne or, sometimes, body piercings and tend to be most common on the shoulders and chest. Surgical removal of keloid is risky and may exacerbate the condition and worsening of the keloid.
Stretch marks (technically called striae) are also a form of scarring. These are caused when the is stretched rapidly (for instance during pregnancy, significant weight gain, or adolescent growth spurts), or when is put under tension during the healing process, (usually near joints). If the wound has been repaired with inappropriate suture material (the stitch itself), or if there is a problem with wound healing, stretched scars may result in these areas.
The face has an excellent blood supply and consequently heals quickly. However, the location of facial scars (e.g. acne scars and traumatic scars) may make them cosmetically unacceptable.
Scars always shorten or contract as they mature. Extensive scars may lead to restricted mobility when they contract. This is especially true of burns scars and scars in the creases of the armpit, groin, neck and around joints.
It is impossible to remove a scar to its pre-injury state. The medical and surgical treatments aim to improve not eradicate the scar. This may produce a more comfortable, more mobile and less noticeable scar. Usually, a combination of techniques is employed.
Risks versus benefits of scar revision
Scar revision is usually not urgent and should be delayed until the scar is mature (provided no earlier complications have occurred).
You are in charge of making that decision. You should discuss the options fully with your surgeon before proceeding and only make the decision once you feel you have been fully informed.
These may be used in isolation or as an adjunct to surgical methods. These techniques can be used initially to prevent problem scars from forming.
Adhesive tape e.g. micropore tape can be placed over a wound for 6 weeks to stop a thick scar from forming. This paper tape also helps to ‘stent’ a wound to prevent it from stretching. Steroids can be used as a topical cream or injected directly into a scar to reduce a thickened scar. Injections are more effective than creams, and several injections may be required.
Silicone gel is used as a dressing to help prevent or to treat hypertrophic scars. Silicone scar treatments are commonly used in preventing scar formation and improving existing scar appearance.
Compression garments are routinely employed over large scars, to apply a constant pressure. This has been shown to flatten raised scars or to prevent their formation. Pressure dressings are commonly used in managing burn and hypertrophic scars, although supporting evidence is lacking.
Physical therapy such as massage, stretching and physiotherapy may help relieve the discomfort of contracted scars. Cryotherapy is the application of liquid nitrogen. The freeze-thaw cycle causes blistering which then heals as a more shrunken and less noticeable scar.
Chemical peels are chemicals which destroy the epidermis in a controlled manner, leading to exfoliation and the alleviation of certain conditions, including superficial acne scars. Professional chemical peels cause the surface to be shed and produce an effect similar to dermabrasion (see later). Chemical peel for acne scars is a good modality for it.
Soft tissue fillers may either be from the patient (fat) or artificial (Restylane, collagen, implants). Filler injections of collagen can be used to raise atrophic scars to the level of surrounding .
Two or three sessions of radiotherapy immediately after surgery may be used. This is generally reserved for extreme cases of keloid scars that have failed other forms of treatment.
Smaller scars can be revised under a local anesthetic and be performed as a day case or out-patient procedure. Scar revision is a process of cutting the scar tissue out. After the excision, the new wound is usually closed up to heal by primary intention, instead of secondary intention. Deeper cuts need a multi-layered closure to heal optimally; otherwise depressed or dented scars can result.
It is a process used to treat deep rolling scars left behind by acne or other diseases. It is also used to lessen the appearance of severe glabella lines, though its effectiveness in this application is debatable. Essentially the process involves separating the tissue in the affected area from the deeper scar tissue.
Dermabrasion refers to a precise electronic ‘sanding’ machine which removes the top layers of . When the surface re-heals, the scars become less obvious. This is used for ice pick or pockmarks which can follow acne and chicken pox.
Numerous types of laser can be used, and are selected according to the scar. Laser light is a high energy light which is delivered to a selected area, at a precise depth, to remove scar tissue.
Non-ablative lasers, such as the 585 nm pulsed dye laser, 1064 nm and 1320 nm Nd:YAG, or the 1540 nm Er:Glass are used as laser therapy for hypertrophic scars and keloids. Ablative lasersan such as the carbon dioxide laser treatment (CO2) or Er:YAG are the lasers for acne scars.
Simply removing the scar and closing the new wound accurately, with approximation of all the layers of the , can produce a thinner, less noticeable scar.
‘Z’ or ‘W’ Plasty ‘Z’ or ‘W’shaped incisions are made across a scar. The Limbs of the Z/W are then swapped around. This has numerous effects including lengthening a short scar and increasing mobility of the contracted by a scar, bringing fresh, non-scarred tissue into the wound and re-aligns anatomical features. It also helps by changing the orientation of a scar so that it is less noticeable and breaking a long scar into multiple shorter ones that are less noticeable.
grafting may be required where extensive scars need to be excised and the resultant raw surface needs to be resurfaced.
Flap surgery involves the transfer of healthy , fat and muscle along with its blood supply. The importation of new tissues leads to improved function and mobility. The cosmetic appearance may not be dramatically improved as subtle differences in colour and texture may occur.
We will give you specific post-operative instructions relating to the care of your wound after scar revision. Most people will have to wear a paper tape (micropore) for 6 weeks after the operation. The initial scar will be red for up to a period of 4 months.
It is important to protect the scar from sun exposure for a couple of years after the revision. Excessive sun exposure will increase the duration of the red phase of scar maturation, as well as causing excessive pigmentation to the ultimate scar. Further adjuvant treatments may also be required such as compression garments, physiotherapy and use of steroids.
Possible complications of scar revision
The risks will be discussed with you in detail before you consent to the operation. The risks can be broken down into general risks associated with any operation, and those specific to scar revision surgery.
Specific risks include delayed wound healing, excessive pain, allergies to the dressing used, a worse scar after the revision than before, abnormal scarring with a recurrence or worsening of hypertrophic, keloid or stretched scars, and loss of the graft or flap used to resurface the scar.
General operative risks include anesthetic complications, bruising, bleeding, infection and wound breakdown. All of these risks are increased in smokers and furthermore smokers cannot expect good results from scar revision surgery.