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Scar Revision

Whenever a wound is made in the skin; a scar forms. This may happen accidentally or after a surgical operation. It is not possible to make any sort of wound without producing a scar. This is because the tissue which repairs the deeper part of any wound is always much more coarse (and less organized) than normal tissue. Sometimes a scar is so fine, whereas other scars may be extremely disfiguring. Scars of the same type may even produce more disfigurement on one area of the body than another. Scars may be wide, thick, and sometimes raised, red, irritating and disfiguring for years. This latter type of healing is known as “hypertrophic scarring“.

One common factor which is still not well understood is the fact that wounds in people of certain races produce more persistent and troublesome scarring than in people of other races. This usually occurs in people with darker skin – Chinese, Indian, Black Africans or Black Americans and even people of Mediterranean extraction. All these groups are more likely to develop hypertrophic scars than people of Northern European descent. No one knows why this is, but it may be partly attributable to the organization and tension of pigmented skin. Also, the behavior of wound healing cells is probably different in people with darker skin. Until more is known about the causes of these differences in scarring, surgeons have to be cautious in recommending surgery to people with darker skin and must always warn them of the possibility of post-operative scarring. There is also a risk of developing either increased or decreased skin pigmentation around the wound or in the areas of skin that are injured or grazed, either accidentally or surgically.

People occasionally produce quite large masses of raised, red scarring called keloids. These may develop from small wounds or even from skin blemishes, such as acne. These scars are different from the raised hypertrophic scars which seem to occur because of the effects of cross-tensional pull on wounds and which, in many cases, tend to improve with time. Keloids do not resolve spontaneously and seem to behave like slow-growing tumors, gradually encroaching onto the surrounding skin, often with irregular claw-like extensions. They are usually resistant to treatment, particularly surgical intervention. Various surgical treatments have been devised to try to control keloids, but none has been very successful. There seems to be a strong genetic influence in the production of keloid scarring from parents or grandparents who have produced similar scars. There are many factors affecting wound healing and scar formation; including age, race, genetic factors or tension. The most likely cause is the differences in the physical properties of the skin, particularly its elasticity or tension.

Steroid Treatment: The irritation and tenderness from thickened hypertrophic scars can be reduced by injections of a strong steroid. Steroids appear to decrease the metabolic activity of the cells, which causes the thickened scar process. By overcoming the increased activity of these cells, the scar will quickly soften and flatten and become less irritating. A second injection can be given after six weeks but the activity of these injections lasts for about three months, so time must be allowed for the injection to work completely before further treatment. It is important that the injections are not given too frequently because they may cause skin thinning, ulceration and the development of newer, superficial blood vessels. Steroid injections will not remove the scar completely.

Why is scar revision performed?

It is best to leave wounds to settle for as long as possible before trying to correct them surgically. While scar revision can’t make a scar vanish completely, scar revision can diminish the appearance of the scar. Surgical correction is extremely effective for treating some resistant scarring.

What is involved in the operation?

Scar revision is usually performed under general anesthesia and can take 30 minutes up to several hours depending on the size and if more than one is being corrected. The procedure is performed by the surgeon excising the existing scar and suturing the skin to either side of the excision together.

What are the complications?

There are general risks associated with a general anesthetic such as aspiration of stomach content into the lungs which can cause serious illness or death. Therefore, to help prevent this it is mandatory that you do not eat or drink anything (usually 8 hours) preceding your surgery. Other risks include DVTs, (clots in the veins of the legs) which can break off and travel to the lungs, this is known as an embolus and although very rare, can be life threatening; especially in smokers. You will be encouraged to get up and walk around as soon as possible to reduce these risks. There are always of possibilities of infection, bleeding, numbness and little improvement of the scar. You may also experience discomfort, swelling, bruising and redness.

What happens after the operation?

You will need someone to drive you home and stay with you for the first 24 hours after surgery. You may experience some discomfort which should be alleviated by the pain medications. Any protective dressings, bandages or garments should be worn until advised by your surgeon. Sutures are usually removed in a few days and you can return to work within 1 week and resume strenuous activities in 2 weeks. Final results may not show for up to 1 year.

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