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Scar revision

Definition

Scar revision is surgery to improve or reduce the appearance of scars. It also restores function, and corrects skin changes (disfigurement) caused by an injury, wound, or previous surgery.

Alternative Names

Keloid revision; Hypertrophic scar revision; Scar repair; Z-plasty; Tissue expansion

Description

Scar tissue forms as skin heals after an injury (such as an accident) or surgery. The amount of scarring may be determined by the wound size, depth, and location; the person's age; heredity; and skin characteristics including color (pigmentation).

Depending on the the extent of the surgery, scar revision can be done while you are awake (local anesthesia), sleeping (sedated), or deep asleep and pain-free (general anesthesia).

Medications (topical corticosteroids, anesthetic ointments, and antihistamine creams) can reduce the symptoms of itching and tenderness. A treatment called silicone gel sheeting or ointment has been shown to benefit swollen, hypertrophic scars. There is no evidence showing that any other topical (applied directly to the scar) treatment works. In fact, Vitamin E applied directly to the skin may actually cause the wound to heal more slowly and may cause irritation.

When to have scar revision done is not always clear. Scars shrink and become less noticeable as they age. You may be able to wait for surgical revision until the scar lightens in color, which can be several months or even a year after the wound has healed. For some scars, however, it is best to have revision surgery 60-90 days after the scar matures.

There are several ways to improve the appearance of scars:

• The scar may be removed completely and the new wound closed very carefully
• Dermabrasion involves removing the upper layers of the skin with a special wire brush called a burr or fraise. New skin grows over this area. Dermabrasion can be used to soften the surface of the skin or reduce irregularities.

  • Massive injuries (such as burns) can cause loss of a large area of skin and may form hypertrophic scars. These types of scars can restrict movement of muscles, joints and tendons (contracture). Surgery removes extra scar tissue. It involves a series of small cuts (incisions) on both sides of the scar site, which create V-shaped skin flaps (Z-plasty). The result is a thin, less noticeable scar, because the way the wound closes after a Z-plasty more closely follows the natural skin folds.
• Skin grafting involves taking a thin (partial, or "split thickness") layer of skin from another part of the body and placing it over the injured area. Skin flap surgery involves moving an entire, full thickness of skin, fat, nerves, blood vessels, and muscle from a healthy part of the body to the injured site. These techniques are used when a large amount of skin has been lost in the original injury, when a thin scar will not heal, and when the main concern is improved function (rather than improved appearance).
• Tissue expansion is used for breast reconstruction, as well as for skin that has been damaged due to birth defects and injuries. A silicone balloon is inserted beneath the skin and gradually filled with salt water. This stretches the skin, which grows over time.

Why the Procedure Is Performed

Problems that may indicate a need for scar revision include:

• A keloid, which is an abnormal scar that is thicker and of a different color and texture than the rest of the skin. Keloids extend beyond the edge of the wound and are likely to come back. They often create a thick, puckered effect that looks like a tumor. Keloids are removed at the place where they meet normal tissue.
• A scar that is at an angle to the normal tension lines of the skin.
• A scar that is thickened.
• A scar that causes distortion of other features or causes problems with normal movement or function.

Risks

Risks for any anesthesia are:

• Reactions to medications
• Breathing problems

Risks for any surgery are:

• Bleeding
• Infection
• Blood clots
• Scar recurrence
• Keloid formation (or recurrence)
• Separation (dehiscence) of the wound

Exposing the scar to too much sun may cause it to darken, which could interfere with future revision.

After the Procedure

For keloid revision, a pressure or elastic dressing may be placed over the area after the operation to prevent the keloid from coming back.

For other types of scar revision, a light dressing is applied. Stitches are usually removed in 3 to 4 days for the facial area, and in 5 to 7 days for incisions on other parts of the body.

When you return to normal activities and work depends on the type, degree, and location of the surgery. Most people can resume normal activities soon after surgery. Doctors usually recommend that you avoid activities that stretch and may widen the new scar.

If you have long-term stiffening of the joint, you may need physical therapy in addition to surgery to restore full function.

Avoid exposure to the sun for several months after treatment. Use sunblock or a dressing (such as a Band-Aid) to keep the sun from permanently tanning the healing scar.

Outlook (Prognosis)

No scar can be removed completely. How much the scar improves will depend on the direction and size of the scar, the age of the person, the skin type and color, and hereditary factors that may affect the healing process.

References

Thomas JR, Mobley SR. Scar revision and camouflage. In: Cummings CW, Flint PW, Haughey BH, Robbins KT, Thomas JR, eds. Otolaryngology: Head & Neck Surgery. 4th ed. Philadelphia, Pa: Mosby Elsevier; 2005: chap 24.

Zurada JM, Kriegel D, Davis IC. Topical treatments for hypertrophic scars. J Am Acad Dermatol. 2006;55(6).