How are scars revised?
Depending on the scar and your type of skin, your doctor may use any one of the following techniques to revise, reduce or correct your scar. If the scar lies across natural skin creases, also known as "lines of relaxation", your surgeon may be able to make it less conspicuous by repositioning it so that it runs parallel to these lines,
The 99% Rule of Scar Revision
Many dermatologists and plastic surgeons use the 99% rule when discussing scar revision: a 90% chance of improvement, a 9% chance that the scar will be about the same and a 1% chance that the scar will worsen.
Excision and Closure
When there is minimal skin loss, atrophic or hypertrophic scars may be treated by excising or removing the scar and re-closing the wound with fine stitches. While a scar will still remain, it may be thinner and less noticeable.
Steroid Applications and Injections
Hypertrophic or keloid scars may be treated with steroid applications or injections to help minimize the appearance, as well as any redness, itching and burning. Steroids work by increasing the activity of an enzyme called collagenase, which breaks down the collagen so that scars become less red and thick. If this approach doesn't appear to be effective, your doctor may remove excess scar tissue and/or reposition the incision so it heals in a less visible pattern. You may receive steroid injections during surgery and at intervals for up to two years to prevent the scar from reforming.
Silicone Gel
A more recent development in hypertrophic and keloid scar treatment is the application of a silicone gel preparation. The gel usually comes in clear sheets and is placed on the scar and secured with an ace bandage, cloth wrap or tape for 12-24 hours each day. With daily use, the keloid may become smoother and flatter within 2-12 months. Because keloids have a tendency to recur, sometimes even larger than before, this procedure may need to be repeated every few years.
Mineral Oil
Mineral oil gel sheets are another alternative to silicone gel. These sheets slowly dissolve onto the skin providing protection from friction and pressure. They may also moisturize the skin. Mineral oil gel sheets should not be used on open wounds and are only recommended for scars after the wound has healed.
Lasers
Acne scars and many other kinds of scars can be reduced with lasers including the CO2 laser or the erbium YAG laser. Depending on your scars and the condition of your skin, your doctor may use a combination of surgical excision, dermabrasion, and laser reducing and resurfacing to minimize your scar(s).
Dermabrasion
Dermabrasion and laser skin resurfacing can be used to make acne scars and other rough or elevated scars less prominent by removing the top layers of scar tissue with a hand held high speed abrading tool or laser light. While the scar will remain, it will be smoother and less visible.
Z-plasty
Z-Plasty is a technique that repositions a scar so that it more closely conforms to the natural lines and creases of the skin. After removing the old scar, new incisions are made on either side, creating small triangular flaps of skin. After the flaps are rearranged to cover the wound at a different angle or "Z" pattern, the wound is closed with fine stitches. While Z-plasty cannot remove all signs of a scar, it does make it less noticeable. Z-Plasty is often able to restore movement and a more normal appearance to a contracture or deformed area. This technique is usually performed as an outpatient procedure under local anesthesia. Not all scars lend themselves to Z-Plasty and it takes an experienced surgeon to make such judgments.
Skin Flaps
Burns or other injuries that result in the loss of a large area of skin may form a contracture, or a scar that pulls the edges of the skin together. If Z-Plasty is not recommended, the surgeon may cut out the scar entirely and replace it with a skin flap. Flap surgery is a complex procedure in which skin, along with the underlying fat, blood vessels and sometimes muscle, is moved from a healthy part of the body to the injured site. With flap surgery, the transferred skin may not precisely match the color and texture of the surrounding skin.
Skin Grafts
Where a skin flap is not possible, a skin graft may be used. This technique involves taking a section of skin tissue from one area and attaching it to another. A skin graft is said to "take" when new blood vessels and scar tissue form in the injured area. While most skin grafts are successful, some skin grafts don't take. All grafts leave some scarring at the donor and recipient sites. Skin grafts are occasionally used to revise keloids, although the site from which the skin graft was taken may then develop a keloid. To discourage recurrence, a doctor may combine the keloid removal with steroid injections, direct applications of steroids during surgery or radiation therapy.
Tissue Expansion
Tissue expansion is a method of growing new skin to replace a patient's scarred skin. With this technique, a special balloon is placed under the skin next to the area where the new tissue is needed. Over several weeks, the balloon is gradually blown up until the skin is stretched, similar to a woman's abdomen during pregnancy, resulting in extra skin that resembles the original.
Skin flaps, grafts, and tissue expansion are most often performed in an outpatient facility or in your doctor's office with general anesthesia. The treated areas may take several weeks or months to heal and it may be necessary to wear a support garment or bandage for up to a year. If a contracture has existed for some time, physical therapy may be necessary to restore full function to the area.
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