Scar Management & Scar Revision

The growth of scar tissue is determined by many factors. One cannot change the way skin reacts to hereditary factors such as race, heritage or skin colouring. Wounds heal by forming scars, and vary according to the severity of the injury and the location of the wound. Chest, back and shoulder scars tend to be most at risk of problem scarring.
Surgical clean cuts heal better than traumatic lacerations, depending on the person’s health. Diabetes and smoking can also slow healing of wounds and lead to increased scarring.

The plastic surgeon can help by using good surgical technique and ensuring good conditions for healing. These include debriding the contaminated wound edges, minimising bleeding and conditions for infection.

Problem Scarring
Plastic surgeons are consulted about scars if they affect a person’s appearance and self esteem, if the scar contracture limits mobility, if the scar is tender, sensitive, or itchy. Surgeons may also be consulted about hypertrophic and keloid scar behaviour.

Prevention
Depending on the wound size and location, ideal healing conditions in most cases prevent problem scarring. Adhesive tape can be used to minimise scar stretching and suture techniques using a long lasting absorbable suture can also prevent excess stretching.

Management of scars
Conservative management for hypertrophic or keloid scars would include scar massage to break up the scar, silicone gel or a silicone sheet to settle the redness and thickness of the scar.
Surgery for stretched scars would include an excision of the scar, followed by careful suturing with absorbable sutures that last several months. These absorbable sutures support the scar during the healing phase, and help prevent scar stretching.

A useful surgical technique for contractures across joints is to perform a “z plasty”, which changes the direction of the scar and lengthens it.
Sometimes, scars that limit function need to be excised, and the defect repaired with a skin graft or a flap. An example would be a burn scar involving the armpit.
Depressed scars may benefit from fillers or fat injection and acne scars may benefit from Fraxel laser treatment.
Hypertrophic and keloid scars usually respond to steroids (Kenacort). Kenacort injections are usually done at 4 to 6 week intervals. Several injections are required for best results. A side effect of the Kenacort is redness of the scar, which responds to Silicone gel or sheet.
Intractable keloids may require excision, with radiotherapy following (usually 3 short courses commencing the day after surgery).