Why do scars form?
When the skin is injured through its full thickness it does not renew itself as it was; it closes the gap with repair tissue made of collagen fibres. That tissue is different from what was there before: its colour, its elasticity and its surface all differ. This is why every injury leaves a mark, and why a scar cannot be removed altogether.
The aim of scar revision is not to erase the mark but to turn it into a scar that is less conspicuous, more supple and does not stand in the way of function.
The same injury may leave a different scar in two different people. What determines this: the depth and site of the injury, the direction of skin tension, age, inherited predisposition, infection, and tension during the period of healing.
Types of scar
| Type | Appearance | Approach |
|---|---|---|
| Mature (normal) scar | Pale, thin, level with the skin | Usually needs no procedure |
| Atrophic / depressed scar | Below the level of the skin, hollowed | Filler, rearrangement of tissue, excision and re-closure |
| Hypertrophic scar | Raised, but does not extend beyond the margin of the wound; regresses in part with time | Silicone, pressure, corticosteroid injection, laser |
| Keloid | Grows out beyond the margin of the wound; does not regress on its own and tends to recur | Combined treatment; surgery alone is not enough |
| Contracture scar | Tight, restricts movement; important around joints and the eyelid | Surgery takes priority; planned early |
When is treatment carried out?
Once formed, a scar passes through a period known as maturation: in the first months it may be red, raised and firm, after which it fades and softens. This process usually takes 6-12 months.
Waiting is therefore the rule for surgical corrections directed at appearance; a procedure carried out before maturation may make the result worse.
There are, on the other hand, situations in which waiting is not the right course:
- Contractures that restrict joint movement, mouth opening or closure of the eyelid
- Sites that affect vision or breathing
- Repeated breakdown of the wound, discharge or infection
- Supportive treatments begun early in hypertrophic scars and keloids (silicone, pressure)
Non-surgical methods
- Silicone gel and sheeting. The most widely used support during the period of maturation; it calls for regular and prolonged use.
- Pressure therapy. Effective particularly in burn scars and in regions prone to keloid.
- Corticosteroid injection. Reduces the raised component in raised, itchy scars; given as a series of sessions.
- Laser. Used to reduce redness, to even out irregularity of the surface and to improve suppleness.
- Massage and moisturising. Simple, but applied regularly they contribute to the quality of healing.
- Protection from the sun. A new scar darkens permanently in the sun; protection matters throughout the first year.
Surgical methods
- Excision and repair (cutting the scar out and closing it again). A wide, irregular or badly placed mark is removed and closed again in keeping with the natural direction of skin tension.
- Z-plasty and W-plasty. The line of the scar is broken up so that tension is redistributed; instead of a straight, tight line, a supple line that catches the eye less is obtained. In contractures it gains length at the same time.
- Skin graft and flap. Where the amount of tissue lost is large, tissue is brought from a neighbouring region or from a distance.
- Tissue expansion. Healthy neighbouring skin is increased step by step with an expander that is placed there; this allows wide scars to be covered with skin of similar colour and texture.
- Fat transfer. Adds volume in depressed, firm scars and helps the tissue to soften.
In most cases more than one method is used in sequence; the revision, too, passes through a period of maturation of its own.
What to expect
The realistic goal in scar revision is to reduce the visibility of the mark and to restore function. Since the result also depends on the way the skin heals, the same technique may give a different result in different people. In types prone to recurrence, such as keloid, supportive measures need to be continued after treatment.
Assessment
Right timing and the right method are half the outcome in scar revision. The age, type and site of the scar are assessed together when the plan is drawn up; sometimes the soundest advice is to wait a while.
If you would like an existing scar assessed, you are welcome to book an appointment; it helps to bring the date on which the scar was formed, and any photographs from the period of healing.