Many variables can affect the severity of scarring, including the size and depth of the wound, the blood supply to the area, the thickness and color of your skin and the direction of the scar. How much the appearance of a scar bothers you is, of course, a personal matter. Many scars that appear large and unattractive at first may become less noticeable with time. Some can be treated with steroids to relieve symptoms such as tenderness and itching.
Keloids are thick, puckered, itchy clusters of scar tissue that grow beyond the edges of the wound or incision. They are often red or darker in color than the surrounding skin. Keloids occur when the body continues to produce the tough, fibrous protein known as collagen after a wound has healed.
Keloids can appear anywhere on the body, but they are most common over the breastbone, on the earlobes, and on the shoulders. They occur more often in dark-skinned people than in those who are fair. The tendency to develop keloids lessens with age.
Keloids are often treated by injecting a steroid medication directly into the scar tissue to reduce redness, itching and burning. In some cases, this will also shrink the scar.
If steroid treatment is inadequate, the scar tissue can be cut out and the wound closed with one or more layers of stitches. This is generally an outpatient procedure, performed under local anesthesia. You should be back at work in a day or two and the stitches will be removed in a few days. A skin graft is occasionally used, although the site from which the graft was taken may then develop a keloid.
Hypertrophic scars are often confused with keloids, since both tend to be thick, red and raised. Hypertrophic scars, however, remain within the boundaries of the original incision or wound. If a conservative approach does not appear to be effective, hypertrophic scars can often be improved surgically. Dr. Fisher will remove excess scar tissue and may reposition the incision so that it heals in a less visible pattern. This surgery may be done under local or general anesthesia, depending on the scar’s location.
Burns or other injuries resulting in the loss of a large area of skin may form a scar that pulls the edges of the skin together, a process called contraction. The resulting contracture may affect the adjacent muscles and tendons, restricting normal movement.
Correcting a contracture usually involves cutting out the scar and replacing it with a skin graft or a flap. In some cases a procedure known as Z-plasty may be used. New techniques, such as tissue expansion are playing an increasingly important role. If the contracture has existed for some time, you may need physical therapy after surgery to restore full function.
Because of its location, a facial scar is frequently considered a cosmetic problem, whether or not it is hypertrophic. There are several ways to make a facial scar less noticeable. Often it is simply cut out and closed with tiny stitches, leaving a thinner, less noticeable scar.
If the scar lies across the natural skin creases, or “lines of relaxation”, Dr. Fisher may be able to reposition it to run parallel to these lines, where it will be less conspicuous.
Some facial scars can be softened using a technique called dermabrasion. Dermabrasion leaves a smoother surface to the skin, but it will not completely erase the scar.
Z-plasty is a surgical technique used to reposition a scar so that it more closely conforms to the natural lines and creases of the skin, where it will be less noticeable. It can also relieve the tension caused by contracture. In this procedure, the old scar is removed and new incisions are made on each side, creating small triangular flaps of skin. These flaps are then rearranged to cover the wound at a different angle, giving the scar a “Z” pattern. The wound is closed with fine stitches, which are removed a few days later. Z-plasty is usually performed as an outpatient procedure under local anesthesia.
SKIN GRAFTING AND FLAP SURGERY
Skin grafts and flaps are more serious than other forms of scar surgery. Grafting involves the transfer of skin from a healthy part of the body (the donor site) to cover the injured area. The graft is said to “take” when new blood vessels and scar tissue form in the injured area. While most grafts from a person’s own skin are successful, sometimes the graft does not take. In addition, all grafts leave some scarring at the donor and recipient sites.
Skin grafting and flap surgery can greatly improve the function of a scarred area. The cosmetic results may be less satisfactory since the transferred skin may not precisely match the color and texture of the surrounding skin. In general, flap surgery produces better cosmetic results than skin grafts.