The purpose of scar revision is to optimize scar camouflage. A person considering facial scar revision must understand that there is no way to remove scars completely. The goal is to improve the appearance of the scar either by disguising it, relocating it, or minimizing its prominence. The ultimate appearance of a scar is dependent on many factors including the orientation of the scar, amount of tissue loss or injury, scar position, age of the patient, patient’s underlying health, genetic predisposition to abnormal scar formation, and technique of wound closure all contribute to the final result.
Understanding the mechanism of scar formation can be helpful in deciding on the method of scar revision. Blunt trauma, gun shot wounds, and burn scars tend to involve a larger surrounding area of injury than surgical incision scars. Scars resulting from these types of injuries my be less amenable to a satisfactory result or require staged revisions. Also, there are some guidelines for optimizing initial scar formation, which may facilitate later scar revision or even circumvent the need for a secondary procedure. All scars tend to improve spontaneously after a period of maturation of one year.
Different scars require different treatments. For example, severe burns that destroy large sections of skin cause the skin to heal in a puckered way. As the skin heals, muscles and tendons may be affected in this “contracting” movement. Keloid scars are a result of the skin’s overproduction of collagen after a wound has healed. These scars generally appear as growths in the scar site. Hypertrophic scars, unlike keloids, do not grow out of the boundaries of the scar area, but because of their thick, raised texture, can be unsightly and may also restrict the natural movement of muscles and tendons.
When a scar is of the contracture type, surgery generally involves removing the scar tissue entirely. Skin flaps, composed of adjacent healthy, unscarred skin, are then lifted and moved to form a new incision line. Where a flap is not possible, a skin graft may be used. A graft involves taking a section of skin tissue from one area and attaching it to another, and time must be allowed following surgery for new blood vessels and soft tissue to form. Z-plasty is a method to move a scar from one area to another, usually into a natural fold or crease in the skin to minimize its visibility. While Z-plasty does not remove all signs of a scar, it does make it less noticeable.
Dermabrasion and laser resurfacing are methods to make “rough or elevated” scars less prominent by removing the superficial skin layers. Clearly, the scar will remain, but it will be smoother and less visible. Keloid or hypertrophic scars are often treated first with injections of steroids to reduce size. If this is not satisfactory, the scars can be removed surgically and the incisions closed with fine stitches, often resulting in less prominent scars.
Both old and new scars can respond well to laser therapy. The Versapulse laser is an excellent treatment for scars when they are in the vascular phase, or red or pinkish in color. The scar will become smoother, less red, and less visible. The CoolTouch laser can soften and minimize the appearance of the scar by stimulating collagen production. This is the treatment for depressed scars or acne scarring. The laser therapy may require multiple treatments, but requires no down time, minimal discomfort, and can be performed easily in the office setting without anesthesia. Epigel sheeting is a simple, topical silicon sheeting which can be used in the management of old and new hypertrophic or keloid scars and can be used to aid in the prevention of scarring.
Insurance does not generally cover surgery that is purely for cosmetic reasons. Surgery to correct or improve scars caused by injury may be reimbursable in whole or in part. However, changing how a scar looks can help improve a patient’s self esteem.