Plastic surgeons are frequently sought out to address the appearance of scars, but the goal is not total erasure, but rather scar revision. Revision means making a scar less noticeable and improving its texture, color, and contour. This specialized field utilizes a range of surgical and non-surgical techniques, which are carefully selected based on the scar’s characteristics and location. The ultimate success of a revision procedure depends on proper initial assessment and managing patient expectations about what can be realistically achieved.
How Scar Type Dictates Treatment
The approach to scar revision is fundamentally guided by the specific type of scar present, as different scars result from distinct healing processes. Scars are broadly categorized by whether they are raised, depressed, or cause restriction of movement.
Hypertrophic scars are raised, red, and thick, but they remain confined within the boundaries of the original wound or incision site. These scars are a result of excessive collagen production during healing and often become noticeable within the first few weeks after the injury.
Keloid scars are similar in appearance but aggressively grow beyond the original wound margins, invading healthy surrounding skin, and tend not to regress spontaneously.
Depressed, or atrophic, scars, such as those often caused by acne or chickenpox, appear as sunken areas or pits due to a loss of underlying tissue. These often include ice pick, boxcar, and rolling scars. Contracture scars typically form after large amounts of skin loss, like from a burn, and cause the skin to tighten, which can restrict movement across a joint.
Primary Surgical Revision Methods
When a scar is mature, wide, or causing functional issues, surgical revision is often the most direct approach to improve its appearance. Simple scar excision and closure involves removing the entire scar and meticulously closing the wound in layers to create a new, less conspicuous line. This technique is most effective for scars that were poorly closed initially and those running parallel to the natural skin tension lines.
For scars that are long, linear, or under tension, plastic surgeons employ geometric break-up techniques like W-plasty and Z-plasty. W-plasty involves excising the scar in a series of small, interlocking, triangular points, creating a jagged line that is less visible because it reflects light less uniformly than a straight line. Z-plasty is a versatile technique that uses two triangular flaps of tissue to change the direction of a scar, which helps align it with the relaxed skin tension lines and can also lengthen a contracted scar to improve movement.
In cases of very large or complex scars, particularly contractures, the surgeon may need to use skin grafts or tissue expansion. A skin graft involves transplanting healthy skin from another area of the body to cover the excised scar site. Tissue expanders are balloon-like devices placed under healthy skin near the scar, which are gradually inflated with saline over weeks or months to stretch the skin, providing a larger flap of local tissue that closely matches the area being repaired.
Non-Surgical and Minimally Invasive Options
Minimally invasive treatments are frequently used alongside or instead of surgery, especially for scars that are not significantly raised or depressed. Injectable treatments are a common method, where corticosteroids are delivered directly into the scar tissue to reduce inflammation and flatten raised hypertrophic or keloid scars. For depressed scars, dermal fillers, or even nanofat injections, can be used to raise the sunken area to the level of the surrounding skin, improving the contour.
Laser therapy offers a range of options to address specific scar characteristics, such as color and texture. Pulsed-dye lasers target blood vessels to reduce the redness in new or active scars, while fractional lasers create micro-injuries in the skin to stimulate new collagen production, smoothing the scar’s texture. Surface treatments like dermabrasion or chemical peels work by removing the top layers of skin, which helps to blend the edges of depressed or irregular scars with the surrounding healthy tissue.
Understanding Outcomes and Recovery
It is important to maintain realistic expectations, as scar revision aims for improvement, not complete disappearance. The treated scar will always be replaced by a new, less noticeable one. A treated scar undergoes a lengthy process of maturation, which can take 12 to 18 months before the final result is apparent. The scar will initially be red and firm before gradually fading to a paler color and softening in texture.
Post-procedure care is a significant factor in achieving the best possible outcome. Patients are typically instructed to use silicone gel sheeting or topical silicone products, which can help flatten and soften the newly revised scar when worn consistently for several months.
Protecting the incision from sun exposure is necessary, as ultraviolet light can cause permanent darkening, or hyperpigmentation, of the healing tissue. Follow-up appointments are scheduled to monitor the maturation process and determine if any additional treatments, such as further injections or laser sessions, are needed.