Scar revision

The healing of traumatic or surgical wounds is a complex biological process, which progresses in a cascade of physiological events and ends with permanent scarring. The final appearance of a scar is the result of a long process, which can last from a few months to over a year.

In the first weeks after trauma (cuts, lacerations, burns) or surgery, scars appear erythematous (red and inflamed). Over time, scars progressively return to approximate the colour of the surrounding healthy skin. Post-traumatic scars are generally wide and irregular. Conversely, surgical scars are usually linear and strategically positioned, subject to minimum tension and located along grooves, wrinkles and shadow areas.  Deep sutures reduce the initial tension on wound margins, whereas superficial sutures in the skin, do not leave stitch scars.

It is possible to implement preventive measures during the scar formation process, be they post-traumatic or surgical, so as to reduce the risk factors which are responsible for aesthetically unacceptable scars:

  • the continuous application of paper tape on the scar, during the first three months of its formation, helps to reduce skin tension on wound margins, preventing widening;
  • use of silicone gel for a few months prevents excess scar tissue formation;
  • application of sun screen prevents colour alteration.

Correct scarring can be impaired by various factors, which can interfere both at an early phase, and later on at an advanced maturation phase. As a result, pathologic scars can develop:

  • Hypotrophic scars are due to disease (e.g. diabetes, conditions which prevent consolidation of wound margins, or because of protein or vitamin deficiencies). Hypotrophic scarring is soft and indented in comparison to the surrounding healthy skin.
  • Hypertrophic scars are due to personal predisposition; high skin tension associated with certain areas; or following complications (haematoma, infection, wound break-down and secondary spontaneous healing). Hypertrophic scarring is elevated compared to the surrounding healthy skin. It is red, thick, hardened and itchy.
  • Keloids are due to individual predisposition. They are similar to hypertrophic scars, but larger than the original wound, hardened, inelastic and often painful.

The ideal scar is narrow, the same thickness as the neighbouring healthy skin and in an orientation in harmony with the treated area so that it is inconspicuous.

Many plastic surgery techniques can be employed to improve the appearance of a poorly healed scar. Nevertheless, it is important to understand that final results only partially depend on surgical techniques and ability. It is impossible to eliminate scarring; it is only possible to improve it and make it less visible. Any scar revision must be performed once the scar has adequately matured, on average between 6 and 12 months following surgery or trauma.

There is no ideal treatment; in each particular case it is necessary to use the most appropriate technique:

  • Hypotrophic scars It is possible to remove the scar, release underlying connections, and then apply a sub-cutaneous suture to restore continuity in deep layers. Alternatively, fat transfers can be performed, which use processed fat from the patient’s own body to elevate depressed scars. Fat cells are removed by liposuction from the donor area – usually from the abdomen, thighs or buttocks – using a small needle attached to a syringe. The fat cells are cleansed and processed, and then injected into the scar area using a blunt needle and syringe. Because there is a fairly high rate of reabsorption of the fat cells into the body, the surgeon will likely overfill the treated area. Fat, in addition to filling, improves scar elasticity and appearance.
  • Hypertrophic scars In selected cases, treatment can be performed during the initial inflammatory phase through local application of corticosteroids (creams or infiltration). These treatments stop scarring. Usually, enlarged, retracted scars with irregular thickness and colour can be treated by excision of the scar tissue followed by the application of a suture with dissolvable subcutaneous and intracuticular stiches. Fat transfers can be performed, which improve scar elasticity and appearance.

Alternatively, or in combination with, the above-mentioned techniques, another option is “resurfacing” (superficial exfoliation). This is achieved through laser CO2 (beam of light which destroys superficial skin layers); peel (application of exfoliating chemicals); dermabrasion (use of a smoothing mill).

The width of the scar can be partially reduced by stimulating production of collagen in the surrounding healthy skin and made more compact with specific lasers.

  • Keloid The treatment of choice is infiltration with corticosteroids, possibly followed by surgical reduction.

Scar revision is also indicated in case of:

  • Scar areas (post-traumatic, burns, chemicals): Complex reconstructive procedures may be required, such as use of skin expanders, to stretch the neighbouring healthy skin for use in reconstruction, preparation of skin grafts and flaps. Alternatively, serial excisions can be performed: multiple excisions of portions of the scar at different stages.
  • Badly oriented scars or retracting scar bridle: When the scar does not lie along “Langer’s lines” (incisions along these lines reduce tension on wound margins and allow better aesthetic scarring), it may be necessary to use surgical techniques to change the scars’ orientation and make them parallel to Langer’s line, so as to reduce tension. Scar orientation should be corrected especially in case of scar bridles: “cords” of scar tissue which prevent skin stretching during movement.

Scar revision is usually performed under local anaesthesia (the anaesthetic is administered locally proximal to the scar) on an out-patient basis. In case of revision of wide scar areas, it is necessary to give general anaesthesia with a hospital stay.

It is crucial, in order to prevent recurrence of poor scarring, to implement preventive post-operative measures (paper taping, silicone gel, sun screen).