Scars are the natural result of the body’s attempt to heal an open wound or tear in the skin surface or body tissues. All people form scars, and scars always result from surgical incisions or trauma which goes to or through the deeper layers of the skin or underlying tissues and structures. In fact, scars occur from any type of procedure, and there is no such thing as a “scarless” operation, regardless what is hyped or advertised.
Unfortunately, sometimes the body’s healing results in scars which are unsightly or cause unwanted symptoms such as tightness or pain.
The process of scar revision involves the removal of the offending scar and its replacement with an improved surrounding skin or soft tissue. This may allow the scar to be minimized and camouflaged in a much functional and aesthetic way.
Healing of Scars
The best candidates for this procedure are in good health and have a realistic expectation of what can and should be achieved. Dr. Granzow believes a conservative approach to this and all other areas of facial surgery is critical, and a goal or expectation of removing every last forehead wrinkle is not realistic or desired.
Scars are one of the few things whose appearance tends to improve with age! What are often thickened, unsightly scars at first can become thinner and almost unnoticeable with time.
Scars commonly undergo several stages of healing. A carefully closed incision or wound will typically have a small amount of swelling and bruising over the first several days after the injury or procedure. Sutures are then removed, if necessary, and wound healing and scar production begins. The body brings in natural building blocks such as collagen to the area of the wound to allow the area of scar to be bridged and sealed.
The scar will appear to become more lumpy and redder at first. This process will take between two and six weeks. Between approximately four and eight weeks the scar will look much wider and redder than it did initially. This is usually the worst the scar will look, and this is a natural part of the healing process. The scar will tend to remain red for 1-6 months afterwards. After that as the collagen, fibers and scar organizes and matures, the scar tends to contract down and flatten out. The color becomes less red and begins to take on the color and appearance of the surrounding tissue. It will then gently fade with time.
Sometimes scars do not heal as expected or described above. In some individuals, the scars can actually overgrow the edges of the wounds and get larger, rather than smaller, with time. Such healing scars are known as keloids. They tend to occur most frequently in individuals with darker and thicker skin.
Fortunately, though, most people do not develop keloids. In fact, the vast majority of people who think they have keloids and have one or more wide scars have a type of scarring called hypertrophic scarring instead (see below). Dr. Granzow will discuss the details of keloids vs. hypertrophic and other sorts of scars with you in detail at your consultation.
Keloids can sometimes become a significant problem and may be very difficult to treat. They can result in cauliflower-like overgrowths of skin and are quite prone and often recur even if removed by the most careful surgeon.
Keloids are most commonly treated with direct excision or removal of the area. Additional treatments such as steroid injections, surface creams and even radiation may be attempted or required as dictated by the lesion. Unfortunately, the recurrence rate of keloids may be greater than 50% in even the most experienced hands.
Hypertrophic scars are used to describe thick and widened scars which can and do occur in some people during the normal healing process. They are often confused with keloids but are differentiated by the fact that the actual scar or healing material usually does not extend past the borders of the scar itself.
Hypertrophic scars may be wide, painful and very unsightly. However, they are often amenable to excision and treatment and are usually more easily treated then keloids.
All scars heal and contract with time. This is the body’s natural method of pulling together a wide wound into as small and compact an area as possible.
However, sometimes the body’s natural contraction of the scar edges result in an over-contraction or tightness in that area. This is called a contracture. Such contractures can be painful and unsightly.
Fortunately, such contractures are often amenable to scar revision with specialized flaps or scar revision techniques.
Z-plasty describes the specialized surgical procedure used to relieve tightened scars or contractures. Small incisions are made along the length of the scar in a pattern similar to the capital letter Z, hence the name. These small incisions then allow the skin next to the scar to be rearranged to relax the tension and provide greater length and movement to the area. The straight-line shape of a scar may also be made more irregular. This irregularity will help hide the appearance of the scar and make it less noticeable.
In the hands of an experienced surgeon, a Z-plasty can be performed safely and effectively as an outpatient procedure under local anesthesia.
Local Skin Flaps
Local skin flaps are described areas of tissue, near the site of a scar or wound that can be moved carefully to cover the wound or fill in an area where a defect has been created or a scar excised. An almost innumerable number of such flaps and their variations exist and Dr. Granzow will go over the specifics of the flaps that are most appropriate and effective for your individual case if they are required.
Local flaps have the advantage that they can usually be performed as an outpatient procedure under local anesthesia. They allow skin with a similar color and texture to the area that must be repaired to be brought in for an overall better final appearance.
A skin graft is a small area of skin taken from another area of the body to cover a wound defect. Skin grafts are easy for an experienced Plastic Surgeon to perform and quite effective in many cases. However, skin from a different area of the body may have different color or texture than the area that must be repaired, leaving a color and texture match that may be permanent.
The decision about whether to use a skin graft flap or a local scar revision technique can often be quite involved and require the expertise of an experienced plastic surgeon.
Risks of Scar Revision
Scar revision is normally quite a safe procedure. Most scar revisions can be performed under local anesthesia in an outpatient setting. Healing tends to be rapid and the procedure and the recovery usually are not painful.
Risks common in a scar revision are low and are similar for all surgeons and centers. These include bleeding, infection, pain, damage to nerves and vessels, small fluid collections and numbness of the skin around the surgical area. There is a chance that a skin graft or flap or a skin edge may lose blood supply and require further revision. Scars that are excised are always, by definition, replaced by other scars, although these tend to heal much more cleanly and leave a significantly better cosmetic result than the original scar. Reactions to anesthesia are rare but have been known to occur and an unsightly scar, especially if it is a keloid or hypertrophic scar, may recur and require further treatment.