Scar Revision

• What is Perineorrhaphy?

  We all worry about whether a scar is going to heal into a fine – white line.
  Scars are the natural result of the body’s attempt to heal an open wound or tear in the skin surface or body tissues. All people form scars, and scars always result from surgical incisions or trauma which goes to or through the deeper layers of the skin or underlying tissues and structures. In fact, scars occur from any type of procedure, and there is no such thing as a “scarless” operation, regardless what is hyped or advertised. Unfortunately, sometimes the body’s healing results in scars which are unsightly or cause unwanted symptoms such as tightness or pain. The process of scar revision involves the removal of the offending scar and its replacement with an improved surrounding skin or soft tissue. This may allow the scar to be minimized and camouflaged in a much functional and aesthetic way.

  Scars may become a problem for a patient when they cause:

  – Pain
  – Itching and inflammation
  – Restricted movement
  – Poor appearance leading to self consciousness
  – Types of Problem Scars

  Hypertrophic Scars – usually raised, itchy and occasionally painful. These scars may improve with time but a stretched or wide scar may remain. The back, the chest and shoulders are areas prone to hypertrophic scarring.

  Keloid Scars – these are extreme forms of hypertrophic scars where the thickened scar “mushrooms” and extends beyond the boundaries of the original wound. These scars becomes thick, puckered, firm, itchy and occasionally painful. Darker skinned races, burn injuries, younger patients and wounds in the chest and ears are all prone to keloid scars.

  Stretched Scars – some areas, where the skin is under tension are prone to develop stretched scars, for example over the knee and elbow and back. If the wounds has been repaired with inappropriate suture material(the stitch itself), or if there is a problem with wound healing, stretched scars may result in these areas.

  Facial Scars – The face has an excellent blood supply and consequently heals quickly. However, the location of facial scars (e.g. acne scars and traumatic scars) may make them cosmetically unacceptable.

• Results of Scar Revision

  For longer-term results when treating displeasing scars, surgical intervention is often a better option. Surgical treatments include fusiform scar excision, shave excision, partial or serial excisions, local flap coverage, skin grafting, and pedicled or free flaps. In all surgical closures in the skin, care should be taken to avert the skin edges slightly so that upon healing and wound contracture, the scar will be level with the surrounding skin. In closing the wounds, tension should be avoided and should not cross the joint line in linear fashion.

• Candidates for Scar Revision

  Scar revision can be performed on people of any age.
  If any of the following apply to you, you may be an ideal candidate for scar revision:

  – You have any type of scar (as described above) on any part of the body that bothers you, impairs function, or limits movement of any of your joints
  – You have a scar that has been caused by trauma or did not heal perfectly at the first operation
  – You are physically and emotionally in good health

  You may not be a good candidate for scar revision if you have:
  – Active acne or other skin diseases in the area to be treated
  – Flatter, more widespread scars – these can sometimes be improved with resurfacing techniques such as laser skin resurfacing.
  – You are a heavy smoker
  – You have a family history of keloids
  – You have any other disorder or condition that may affect the healing of scar tissue, including diabetes, lupus, scleroderma, and other auto-immune disorders

  Good candidates for scar revision surgery also have a realistic understanding of the scar revision surgery’s risks and benefits, and realistic expectations of its potential outcomes. You must also be choosing to undergo the scar revision procedure for yourself, not to please anyone else.

• Your Consultation

  During the initial consultation, RVB will ask for a complete medical history and will conduct a careful examination to evaluate your overall health.

  The scar revision surgeon will examine you, take a full medical history, ask you about any medications or herbal supplements that you are taking, and discuss the possible methods of treating your scar, the risks and benefits involved and the possible outcomes. Be honest in discussing your expectations with the surgeon, and go prepared with a list of questions to ask and express any concerns you may have Before you choose to undergo a scar revision operation, you will need to discuss the pros and cons of the surgery with your scar revision surgeon to make sure you fully understand the scar revision operation, the possible side effects, risks, complications and recovery times of the treatment he recommends for your specific scarring.

• The Scar Revision Procedure

  Scar revision may take one to three hours to complete, depending on the techniques used and the extent of the areas to be treated. Smaller scars and areas can be treated under local anesthetic, but larger scars or those in very sensitive areas may require general anesthetic. Many patients are able to go home on the day of the surgery but some remain in the hospital for one or two days after scar revision surgery.

  Scar Treatment
  – It is impossible to remove a scar to its pre injury state. The medical and surgical treatments aim to improve not to eradicate the scar. This may produce a more comfortable, more mobile and less noticeable scar. Usually a combination of techniques is employed.

  Risks versus benefits of Scar Revision
  – Scar revision is usually not urgent and should be delayed until the scar is mature(provided no earlier complication have occurred.
  – You are in charge of making that decision. You should discuss the options fully with your surgeon before proceeding and only make the decision once you feel you have been fully informed.

  Non Surgical Methods
  – These may be used in isolation or as an adjunct to surgical methods. These techniques can be used initially to prevent problem scars from forming.
  – Adhesive Tape e.g. micropore tape, can be placed over a wound for six weeks to stop a thick scar from forming. This paper tape also helps to “stent” a wound to prevent it from forming
  – Steroids can be used as a topical cream or injected directly into a scar to reduce a thickened scar. Injections are more effective than creams, and several injections may be required.

  Silicon Gel is used as a dressing to help prevent or treat hypertrophic scars.
  Compression garments are routinely employed over large scars, such as burn scars, to apply a constant pressure. This has been shown to flatten raised scars or prevent their formation.

  Physical therapy such as massage, stretching and physiotherapy may help relieve the discomfort of contracted scars.

  Cryotherapy is the application of liquid nitrogen. The freeze-thaw cycle causes blistering which then heals as a more shrunken and less noticeable scar.

  Chemical peels cause the skin surface to be shed and produce an effect similar to dermabrasion

  Soft Tissue filler may either be from the patient (fat) or artificial (Restylane, collagen, implants). These can fill out depressions left from scars.

  Radiotherapy 2 or 3 sessions of radiotherapy immediately after surgery may be used. This is generally reserved for extreme cases of keloid scars that have failed other forms of treatment.

  Surgical Methods
  Smaller scars can be revised under a local anaesthetic and be performed as a day case or out patient procedure.

  Dermabrasion refers to a precise electronic “sanding” machine which removes the top layers of skin. When the skin surface re heals, the scars become less obvious. This is used for ice pick or pockmarks which can follow acne and chicken pox.

  Laser resurfacing Numerous types of laser can be used, and are selected according to the scar. Laser light is a high energy light which is delivered to a selected skin area, at a precise depth, to remove scar tissue

  Excision Simply removing the scar and closing the new wound accurately, with approximation of all the layers of the skin, can produce a thinner, less noticeable scar.

  Z or W Plasty “Z” or “W”shaped incisions are made across a scar. The Limbs of the Z/W are then swapped around. This has numerous effects including :

  – Lengthening a short scar, and increasing mobility of the skin contracted by a scar,
  – Bringing fresh, non scarred tissue into the wound
  – Re-aligning anatomical features,
  – Changing the orientation of a scar so that it is less noticeable,
  – Breaking a long scar into multiple shorter ones that are less noticeable.
  – Skin grafting may be required where extensive scars need to be excised, and the resultant raw surface needs to be resurfaced

  Flap surgery involves the transfer of healthy skin, fat and muscle along with its blood supply. The importation of new tissues leads to improved function and mobility.

• Risk

  While scar revision is normally safe, there is always the possibility of complications. These may include infection, bleeding, a reaction to the anesthesia, or the recurrence of an unsightly scar. You can reduce your risks by choosing a qualified plastic surgeon and closely follow his or her advice, both before surgery and in follow-up care.

• Recovery

  After your scar revision surgery, you will normally be sent home the same day. Arrange for someone to drive you home, and stay for a couple of days if possible to help you out.
  A pressure or elastic dressing may be placed over the area after the scar revision operation to prevent the keloid scar from returning. For other types of scar revision, a light dressing will be applied. You may experience some localized swelling, discoloration or discomfort. Your doctor may prescribe some pain medication if you are in pain.

  Initial wound healing after your scar revision operation may take one to two weeks. Further healing will continue for several weeks and as the new scar heals it will gradually refine and fade. You should be able to resume your daily activities within a week or so. Your scar revision doctor will probably recommend that you avoid activities that stretch and may widen the new scar, and will advise you about when to gradually resume your day to day activities.

  The stitches will be removed three to four days after your scar revision surgery for the facial area, and in five to seven days for incisions on other parts of the body.

  During the scar revision surgery recovery time, careful attention to your skin care regime and religious use of sun protection are essential to encourage healing. Sunlight can cause burns, permanent redness, loss of pigment in the skin, and breakdown of the collagen that maintains the elasticity of the skin.

  The final results of your scar revision surgery will take a very long time to become completely apparent. No scar can be removed completely – improvement depends on the size and direction of your scar, the nature and quality of your skin, and how well you care for the wound after the operation. Your scar may look worse at first, but don’t worry, it may take up to a year or more to see the final results.

FAQs

• What type of anesthesia is used for scar revision?
  The type of anesthesia used for scar revision will depend upon the particular technique or procedure used.
• Does Mederma (onion extract), Strivectin, or Vitamin E oil work to help improve my scar?
  - We’re not believed that any of these remedies work to help a scar mature well. In fact, rigorous scientific studies that have involved blinded, prospective, randomized, split scar analysis (in other words, good and controlled scientific research) have indicated that these treatments provide no improvement at all in an incision or scar. In fact, Vitamin E oil has been shown actually to worsen wound healing in some cases. However, with recent evidence to the contrary, we no longer believe that any of these topical ointments do any good to help with scar healing.
• How does scar revision surgery work?
  - To learn how scar revision surgery works, you must first understand what makes a scar visible. A scar is oftentimes noticeable because it is an obvious straight line that your eye can easily follow. One of the principles of scar revision is to transform that straight line into a complicated, irregularized line (see next question) so that your eye simply has a very hard time following that line even with close inspection. The second reason a scar is visible is that the scar is darker or lighter than the surrounding skin color. Dark color fades over time, whereas a light color incision line will most likely need to be removed and resutured following the good principles of scar revision. Third, a scar may be visible because the incision line or the area adjacent to it is depressed or raised, a so-called contour deformity.
• - The scar will then have to be revised to minimize or eliminate this contour problem. Another reason that a scar is unfavorable in appearance is that the scar tethers a nearby structure either all the time or only when you move your face, e.g., restricting or tethering the lip, the nose, or the eyelids.
• Will my scar look better immediately after scar revision?
  - Actually, your scar will most likely look worse initially after scar revision. In most cases, when you come to see your surgeon again your scar has already faded to a large extent and looks much better than when you just sustained the injury. However, the surgeon must not only make that incision line look fresh again but take a straight line and make it irregular so that it becomes more obvious initially but less visible only over time, i.e., much later in time. Initially, the repair will be quite visible and may remain so for many months thereafter. Oftentimes, the scar does not look considerably better for even a year afterwards, especially in Hispanic, Asian, and darker skin types that tend to maintain redness or darkness along the incision line for many months following the scar-revision procedure.