Causes and Treatments for Unsightly Scars
Article by Corey S. Maas, MD
San Francisco Facial Plastic Surgeon
Scars are visible or noticeable for one or more of five principle reasons
1. the location or direction of the scar
2. the width of the scar
3. the color of the scar
4. the relationship of the scar to the surrounding skin – i.e. is the scar depressed or elevated (hypertrophic or keloid scars) relative to the surrounding skin
5. the length of the scar
I take an individual approach to the treatment of revision of scars and apply the principles of scar revision to each of the reasons for their unacceptable appearance. This individual approach takes into consideration the patient’s age, location of the scar their Fitzpatrick skin type (I-VII) and the age of the scar. Keep in mind that most patients have more than one of the reasons for their particular scares to be unacceptably visible.
Another basic premise in scar revision is to remember that scar formation is the normal process for the body to heal. Any approach to making scars less visible relies on this principle of wound healing. There are many false claims that various treatments, creams or surgery can “make scars go away”. This is simply not true. What is true, is that we can make scars almost invisible with of one or more combinations of treatments.
There are excellent options to improve their appearance or significantly eliminate scar visibility. In brief, I outline below the approach to treatment for each of the above listed reasons:
1. Location or direction of the scar
a. Scars that go across the natural lines of relaxed skin tension (RSTL) are invariably more visible that those that follow these lines. f one gently pinches the skin in any area of the body the RSTL are visible. There are a number of effective techniques I employ to change the direction of a scar so that the scar follows these lines of relaxed skin tension. By doing this, we can blend the line of the scar with the lines we (fine or other) that we see naturally in our skin. This, as all the procedures described is done with techniques used to limit the width of the scar. Ideally we like to see a scar no wider than one millimeter (0.04 inches)
b. Scars that cross natural facial boundaries like the nasolabial fold, the lip border, the jawline, navel or nipple are also much more visible as they distort these natural boundaries. I employ a number of techniques to change the direction of scars that cross these anatomic boundaries. Among them, Z-plasty and multiple Z- plasty techniques. These and others can align the majority of the scar into a small line within the boundary making very difficult to see.
c. Scars that are located in centrals areas of the face like the cheek, forehead or tip of the nose are particularly visible. These areas require a number of the techniques in this section to make imperceptible. Geometric broken line closure, multiple w-plastys are among the better techniques in these areas for primary therapy. They allow the scar to be “broken up” into tiny irregular segments that the eye has difficulty identifying. This technique is invariably followed by blending using one or more of the resurfacing techniques with which we have extensive experience: dermabrasion, chemical peels and most often now fractionated laser resurfacing using the optimally powered CO2 lasers (Active FX) which are described in more detail below.
Far too often I see patients referred to me after having poorly designed or executed cosmetic surgery. Facelift scars, browlift scars, eyelid scars (blepharoplasty scars) are often direction and/or location related scars. These can be successfully treated using the same techniques used for trauma-related scarring and in many cases can be combined to restore better contour and further lifting or restoration.
2. Width of the scar
a. The width of the scar is among the most reliably treatable conditions of scarring. I consider them in two categories. The first are areas of lower skin tension. Depending on the age of patient, low skin tension areas include the face and neck and in some cases the abdomen. Scars in children represent a unique challenge as the skin is highly taut and special techniques are used as described below, even in the face to avoid late-term scar “strech-back”. In general, as we discussed above, facial scars can be reliably revised to achieve a width of 1 mm or less.
b. Scar width in high tension area like the back, abdomen, breasts and extremities (arms and legs) require special attention both intraoperatively and post-operatively to reduce the tension or pull across the scar. This prevents late-term scar “stretch back” which many patients experience even if the initially the scar looks quite acceptable. Special subcutaneous sutures are used in these case which continue to hold the skin edges together for months to years. These high biocompatible sutures do not need to removed are not visible after the wound is healed. After time, the stretch back risk is substantially reduced and these sutures are safely resorbed or broken down by the body.
3. The color of scars can be particularly distressing as even fine line scars when red, hyperpigmented (brown) or hypopigmented (white) can stand out and be quite noticeable. The treatment of scar color problems involves techniques that either improve the color the scar or blend the color of the surrounding skin to make the scar less visible.
a. Scars that are dark or hyperpigmented are treated using a combination of special creams that are prescribed from a compounding pharmacy. While many over the counter scar fade creams are marketed few if any have any real effect when compared to placebo. In addition, most scars in this category will quickly respond to Intense Pulsed Light (IPL) phototherapy and/or fractionated laser resurfacing (ActiveFX). Compounded combinations of medications placed into creams take longer but are often more effective in scars in Asian patients, scars in Latin or Hispanic patients and scars in other ethnic patients with darker skin types.
b. Scars generally have very little pigment and, while some laser therapies have been tried unsuccessfully to stimulate pigment production in scars, few options are available to stimulate pigment production in white or hypopigmented scars. Certain formulations of creams including retinoids and antioxidants have shown limited success and are certainly worth trying, but the best therapies for hypopigmented scars are to use a combination of techniques we have discussed to minimize the width of the scar and disguise the scar in facial lines and boundaries. Proactive measures, which are quite effective, blend the surrounding skin texture and color using a combination of IPL and fractionated laser resurfacing or dermabrasion. Tanning or surrounding sun damage makes this type of scar particularly noticeable and phototherapy (IPL) as well as compulsive sun protection can dramtically reduce their visibility.
c. Scars that are red are showing visible signs of ongoing inflammation. There are many reasons for chronic or ongoing inflammation of scars but it is important to understand that inflammation is part of the wound healing and scarring process. There are ways to accelerate the resolution of redness in scars depending on its cause. In normal scars, redness is resolving quickly by the 6-8 weeks. This resolution can be hastened by phototherapy (IPL) and in certain cases the use of corticosteroids either topically or by injection. In hypertrophic scars and keloid scars the redness and mass of the scar can be improved with intralesional corticosteroid injection (injected directly into the scar) and some combination of phototherapy and fractionated resurfacing.
4. Depressed or elevated scars
a. Depressed scars, ones that are lower than the surface of the skin, are among the more common of the five treatable characteristics of unfavorable scars. It is also one of the most reliably treated characteristics. Depressed scars can be elevated using a variety of dermal fillers. Treating depressed scars with Juvederm, Restylane and/or Cosmoderm are common with special scars like ice pick acne scars and we have had great success in using these product for that purpose. The longevity of improvement is variable with filler treatments and while many patients do have long term benefits with this simple office treatment, I encourage a more comprehensive approach with fillers and other combinations of therapy such as fractionated laser resurfacing (Active/DeepFX).
b. Elevated scars are usually the result of poor wound closure (poor alignment of the skin edges when suturing, resulting in uneven edges or ridges around the scar) or chronic inflammation of the scar resulting in hypertrophic or keloid scars.
Uneven edges or ridges in or around are scar are treated in the office with scar revision – excision of the bad scar, undermining and careful approximation of the wound edges with eversion. This assures a small scar that is level with the surrounding skin. Often, a fractionated laser skin resurfacing (Active FX) is performed 6-8 weeks after the revision to assure a superior blending of the scar with the surround skin.
Hypertrophic and Keloid scars represent special circumstances in the elevated category. These scars are the result of an exaggeration of the normal wound healing process that does not properly “shut off”. It is NOT necessarily the best option to use surgical excision as the primary therapy for these types of scars as excision stimulates more inflammation and may result in recurrence of the thickened scar. Expertise is required in the treatment of keloid scars, which occur more commonly in darker skin types. Many patients benefit from early therapy with intralesional corticosteroid or immunomodulator injections followed by surgery or some cases the order is reversed. In contrast to popular belief, keloid scars can be successfully treated in African American, Asian and Hispanic patients.
5. Scar length
Scars can effected be shortened by breaking them into many tiny nonlinear scars that are difficult for the human eye to identify. If one where to take a tiny ruler and measure these little segments, the scar would measure an over increase in length. This however is not what the human eye perceives and the result of geometric broken line or multiple M or W plasty is a net reduction in visibility of a scar. These techniques are almost always supported by the use of subsequent blending procedures such as fractionated laser resurfacing and IPL.