Overview
Annually, 200 million incisions are performed worldwide and approximately 170, 000 scar revisions are performed in the United States.
The treatment of aesthetically unappealing scars can be challenging at times, although it is not without several options. The available options are vary widely, extending from invasive options such as scar excision to less invasive options such as topical silicone therapy. The varied choices for the patients should be carefully considered on a case-by-case basis by a qualified plastic surgeon.
Patients often present to a plastic surgeon after having exhausted other means of disguising their troublesome scars through the use of cosmetics, clothing, and hairstyle modifications. While various treatments exist, none is perfect, and the cornerstone of any scar revision is a thorough understanding of the patients’ dissatisfaction, functional limitations as a result of such scar and their expectations following treatment. Patients must understand that the best result may require multiple treatments and that initially, little improvement may be noticeable relative to the preexisting deformity.
Other considerations of paramount importance when considering scar revision include (1) anatomical location, (2) functional impairment from current scars such as in burn patients, and (3) the likelihood of functional impairment after scar revision (eg, increased tension and decreased range of motion). Prior to any intervention, the quality and skin type, as well as availability of surrounding tissue, must be assessed.
Oftentimes, no treatment may be the best management if expectations cannot be met or if the resultant scar may not be reasonably improved.
An overview of scar revision and management is presented in this article. Operative and nonoperative alternatives are reviewed. This overview addresses the complex preoperative considerations, basic plastic surgical techniques, wound healing biochemistry and biomechanics, preferred revision techniques based on anatomic site, and technical considerations in revisional wound closure. Topical choices, cryotherapy, laser therapy, and steroid therapy for scar treatment are examined.
More aesthetically pleasing scars match the surrounding skin in color, texture, distensibility, elevation and are therefore less noticeable and desirable. For example, scars often have fewer dermal appendages or lack them altogether. In areas of hair-bearing skin, a scar’s lack of hair follicles is particularly noticeable. In other areas with sparse hair follicles, this is a desirable attribute of scars.
Patient characteristics also play a large factor in scarring, as do the quality of closure and cleanliness of the wound. Although many authors claim that patients at the extremes of age often scar to a greater degree, no indisputable evidence in the literature supports this claim.
Individuals with connective-tissue disease, on long-term steroid therapy, with diabetes mellitus, or with vitamin deficiencies or those who prematurely return to activity, smoke, have a predisposition to keloid formation, or subject themselves to harmful UV light exposure may experience healing complications that result in greater final scarring.
Technical details of the wound and approximation play an important role in eventual scar formation. Wounds that are excessively traumatized during closure may develop wound dehiscence or undergo skin-edge necrosis, thus leaving unsightly scars. Likewise, wounds that are unevenly or improperly repaired, become infected, or undergo foreign body reactions to sutures more frequently yield poor cosmetic results. Traumatic wounds traditionally yield poorer eventual scars. Common etiologies of widened or dehisced scars include wounds closed under tension, repairs not formed parallel to relaxed skin tension lines (RSTLs), or wounds located on the trunk or extremities Proper screening of patients prior to surgery, proper nutrition, good technique, and appropriate wound care favor faster wound healing and more aesthetic results.
Revision of unsightly scars is a frequent concern to surgical patients. Although residual scars can be aesthetically displeasing, form and function should be taken into consideration and should not be compromised at the cost of cosmesis. As with other cosmetic procedures, the main goal is to make the patient more comfortable with his or her appearance, even though the deformity may not be completely alleviated. A thorough understanding of the patient’s expectations is warranted prior to modification. Teamwork between the physician and patient helps ensure the optimal result in scar revision.