Improving Scars

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Scars, which are a part of the body’s natural healing processs, are formed when skin is damaged deeply by trauma, surgery, or disease, such as burns and chicken pox,. The more layers of skin destroyed, the more widely extensive the damage, and the longer a wound takes to heal, the greater the likelihood of developing a noticeable scar. Acne is arguably the best known cause for scars, which may result from either the severity of the disease itself or undue delay in obtaining appropriate treatment. Acne scarring is estimated to affect, to a greater or lesser extent, some 95 percent of sufferers.

Abnormalities in color, shape, contour and texture are the reasons that scars are visisble. Although each patient and each scar must be treated individually, it is generally the type of scar and its location that most determine the specific treatment.

Broadly defined, scars fall into three main categories: elevated, depressed, and atrophic. Hypertrophic scars and keloids, which result from an exaggerated healing response, are elevated scars that stand like mountains above the skin surface and cast broad, unsightly shadows. Both are composed of an overabundance of dense fibrous tissue. Hypertrophic scars, also called “proud flesh,” sometimes shrink on their own over time. Keloids, which develop in genetically prediscposed individuals, typically do not and require treament.

A depressed scar, as the name suggests, is sunken below the skin surface. It is especially visible due to the “craters of the moon” effect, where wide shadows are cast across the base of the scar making it stand out from the rest of the skin. While generally level with the remainder of the surface or only slightly depressed, atrophic scars have an ivory-colored or a crinkly, off-color, cigarette-paper like appearance that stands in sharp contrast to its surroundings.

Although all scars are permanent, many that are disfiguring at first become much less visible after several months and require no further treatment. For those that do not, however, we are fortunate to have a variety of miniminally invasive, office techniques for improving their appearance significantly. These include intralesional injections, surgical scar revision and punch-excision or punch grafting, dermaspacing, fillers, buffing (manual dermasanding), chemical peeling, microdermabrasion, and lasers and intense pulsed light (IPL). All are non-invasive or minimally invasive lunchtime beauty fixes that require topical or local anesthesia and engender little or no downtime.

Intralesional injections of an antiinflammatory corticosteroid remains the treatment of choice for both hypertrophic scars and keloids. Most hypertrophic scars respond quite rapidly and will shrink after a series of one to three treatments spaced at monthly intervals. Keloids, on the other hand, may require higher doses and additional techniques, such as pretreatment with cryotherapy to soften the tissue and permit the injections to disperse better, surgical removal to debulk the scar, and subsequent use of certain wound dressings and topical medications to suppress recurrence. In most cases, large unsightly keloids can ultimately be reduced to barely visible, flat, off-white skin discolorations with these methods. Fees for intralesional injections typically range from $150-$300 per session.

Surgical scar revision involves cutting out a scar and reorienting and restitching the resulting wound in such a way as to make the new surgical scar much less visible than the one removed. Fees for this procedure vary depending upon the size of the scar and the anatomic location and typically range from $350-$1000. Punch excision, punch elevation or punch grafting are all variations of surgical scar revision used for treating icepick scars.

The word punch refers to the razor sharp circular cutting instrument used by the dermasurgeons to core out the scar. In punch excision, the scar is extracted and the resulting wound either simply sutured closed or, if small enough, allowed to heal on its own. In punch elevation, the scar is freed up in the same manner, but is not removed. Instead, it is elevated to the surface to eliminate the depression, and then allowed to heal on its own. In punch grafting, a small piece of normal color-matching tissue, usually taken from skin overlying the bone directly behind the ear, is used to replace the cored out scar. Punch procedures often run between $250 and $500 per site.

Depressed scars, such as those from chicken pox or acne must be elevated. Dermaspacing, a technique that uses a small cutting needle to break up scar tissue creates a pocket within the scar under the skin into which fresh collagen can be produced and laid down, thereby elevating the surface of the scar above. The results of dermaspacing have the advantage of being permanent. If necessary, fillers, such as Radiesse, Juvederm or Restylane may also be used, either alone or in combination with dermaspacing to further raise up the depressed areas. Fees for dermaspacing may range from $300-$500 per session.

Icepick scars, which are typically very narrow and penetrate quite deeply and are often numerous, present perhaps the most difficult therapeutic challenge. In my experience, these are best treated by Chemical Reconstruction of Skin Scar (CROSS) technique, which is a modification of a deep chemical peel in which 100 percent trichloracetic acid is carefully placed deep within the pit (rather than applied to the whole face). The resulting wound closes the pit. A series of four to six treatments may be necessary. The accompanying figures represent pit scars of the cheek following a series of six monthly CROSS treatments. Fees vary according to the number of areas treated, and may range from $500 to $750 per session.

When surface irregularities are a prominent feature of a scar, buffing the skin (i.e. manually “sanding”), chemical peels, or light-based therapies, such as intense pulsed light (IPL) may be considered. Buffing the skin with a medical grade, sandpaper-like material and chemical peeling agents abrade and remove the surface of the scar and level out the irregularities. IPL penetrates the skin causing damage below that subsequently results in a thickening of the dermis via new collagen synthesis with a consequent smoothing out of the overlying upper layer of skin. Buffing generally costs about $500 a treatment, and IPL may range from $300-$400 per session.

Dermatologic science can take pride not only in the diversities of the currently available techniques, but even more in the reality that no one with disfiguring scars need any longer throw up his/her hands in despair.

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New York Dermatologic Surgeon