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SCAR REVISONS (SURGICAL TREATMENTS FOR SCARS)
If you're considering scar revision...
Scars -whether they're caused by accidents or by
surgery- are unpredictable. The way a scar develops
depends as much on how your body heals as it does on the
original injury or on the surgeon's skills.
Many variables can affect the severity of scarring,
including the size and depth of the wound, the blood
supply to the area, the thickness and color of your
skin, and the direction of the scar. How much the
appearance of a scar bothers you is, of course, a
personal matter.
While no scar can be removed completely, plastic
surgeons can often improve the appearance of a scar,
making it less obvious through the injection or
application of certain steroid medications or through
surgical procedures known as scar revisions.
If you're considering scar revision, this will give you
a basic understanding of the most common types of scars,
the procedures used to treat them, and the results you
can expect. It can't answer all of your questions, since
a lot depends on your individual circumstances. Please
be sure to ask your doctor if there is anything about
the procedure you don't understand.
MAKING THE DECISION
Many scars that appear large and unattractive at first
may become less noticeable with time. Some can be
treated with steroids to relieve symptoms such as
tenderness and itching. For these reasons, many plastic
surgeons recommend waiting as long as a year or more
after an injury or surgery before you decide to have
scar revision.
If you're bothered by a scar, your first step should be
to consult a board-certified plastic surgeon. The
surgeon will examine you and discuss the possible
methods of treating your scar, the risks and benefits
involved and the possible outcomes. Be frank in
discussing your expectations with the surgeon, and make
sure they're realistic. Don't hesitate to ask any
questions or express any concerns you may have.
Insurance usually doesn't cover cosmetic procedures.
However, if scar revision is performed to minimize
scarring from an injury or to improve your ability to
function, it may be at least partially covered. Check
your policy or call your carrier to be sure.
ALL SURGERY CARRIES SOME UNCERTAINTY AND RISK
While scar revision is normally safe, there is always
the possibility of complications. These may include
infection, bleeding, a reaction to the anesthesia, or
the recurrence of an unsightly scar.
You can reduce your risks by choosing a qualified
plastic surgeon and closely following his or her advice,
both before surgery and in follow-up care.
KELOID SCARS
Keloids are thick, puckered, itchy clusters of scar
tissue that grow beyond the edges of the wound or
incision. They are often red or darker in color than the
surrounding skin. Keloids occur when the body continues
to produce the tough, fibrous protein known as collagen
after a wound has healed.
Keloids can appear anywhere on the body, but they're
most common over the breastbone, on the earlobes, and on
the shoulders. They occur more often in dark-skinned
people than in those who are fair. The tendency to
develop keloids lessens with age.
Keloids are often treated by injecting a steroid
medication directly into the scar tissue to reduce
redness, itching, and burning. In some cases, this will
also shrink the scar.
If steroid treatment is inadequate, the scar tissue can
be cut out and the wound closed with one or more layers
of stitches. This is generally an outpatient procedure,
performed under local anesthesia. You should be back at
work in a day or two, and the stitches will be removed
in a few days. A skin graft (see the section on skin
grafting) is occasionally used, although the site from
which the graft was taken may then develop a keloid.
No matter what approach is taken, keloids have a
stubborn tendency to recur, sometimes even larger than
before. To discourage this, the surgeon may combine the
scar removal with steroid injections, direct application
of steroids during surgery, or radiation therapy. Or you
may be asked to wear a pressure garment over the area
for as long as a year. Even so, the keloid may return,
requiring repeated procedures every few years.
HYPERTROPHIC SCARS
Hypertrophic scars are often confused with keloids,
since both tend to be thick, red, and raised.
Hypertrophic scars, however, remain within the
boundaries of the original incision or wound. They often
improve on their own-though it may take a year or
more-or with the help of steroid applications or
injections.
If a conservative approach doesn't appear to be
effective, hypertrophic scars can often be improved
surgically. The plastic surgeon will remove excess scar
tissue, and may reposition the incision so that it heals
in a less visible pattern. This surgery may be done
under local or general anesthesia, depending on the
scar's location and what you and your surgeon decide.
You may receive steroid injections during surgery and at
intervals for up to two years afterward to prevent the
thick scar from reforming.
CONTRACTURES
Burns or other injuries resulting in the loss of a large
area of skin may form a scar that pulls the edges of the
skin together, a process called contraction. The
resulting contracture may affect the adjacent muscles
and tendons, restricting normal movement.
Correcting a contracture usually involves cutting out
the scar and replacing it with a skin graft or a flap.
In some cases a procedure known as Z-plasty may be used.
And new techniques, such as tissue expansion, are
playing an increasingly important role. If the
contracture has existed for some time, you may need
physical therapy after surgery to restore full function.
FACIAL SCARS
Because of its location, a facial scar is frequently
considered a cosmetic problem, whether or not it is
hypertrophic. There are several ways to make a facial
scar less noticeable. Often it is simply cut out and
closed with tiny stitches, leaving a thinner, less
noticeable scar.
If the scar lies across the natural skin creases (or
"lines of relaxation") the surgeon may be able to
reposition it to run parallel to these lines, where it
will be less conspicuous. (See Z-plasty)
Some facial scars can be softened using a technique
called dermabrasion, a controlled scraping of the top
layers of the skin using a hand-held, high-speed rotary
wheel. Dermabrasion leaves a smoother surface to the
skin, but it won't completely erase the scar.
Z-PLASTY
Z-plasty is a surgical technique used to reposition a
scar so that it more closely conforms to the natural
lines and creases of the skin, where it will be less
noticeable. It can also relieve the tension caused by
contracture. Not all scars lend themselves to Z-plasty,
however, and it requires an experienced plastic surgeon
to make such judgments.
In this procedure, the old scar is removed and new
incisions are made on each side, creating small
triangular flaps of skin. These flaps are then
rearranged to cover the wound at a different angle,
giving the scar a "Z"pattern. The wound is closed with
fine stitches, which are removed a few days later.
Z-plasty is usually performed as an outpatient procedure
underlocal anesthesia.
While Z-plasty can make some scars less obvious, it
won't make them disappear. A portion of the scar will
still remain outside the lines of relaxation.
SKIN GRAFTING AND FLAP SURGERY
Skin grafts and flaps are more serious than other forms
of scar surgery. They're more likely to be performed in
a hospital as inpatient procedures, using general
anesthesia. The treated area may take several weeks or
months to heal, and a support garment or bandage may be
necessary for up to a year.
Grafting involves the transfer of skin from a healthy
part of the body (the donor site) to cover the injured
area. The graft is said to "take"when new blood vessels
and scar tissue form in the injured area. While most
grafts from a person's own skin are successful,
sometimes the graft doesn't take. In addition, all
grafts leave some scarring at the donor and recipient
sites.
Flap surgery is a complex procedure in which skin, along
with the underlying fat, blood vessels, and sometimes
the muscle, is moved from a healthy part of the body to
the injured site. In some flaps, the blood supply
remains attached at one end to the donor site; in
others, the blood vessels in the flap are reattached to
vessels at the new site using microvascular surgery.
Skin grafting and flap surgery can greatly improve the
function of a scarred area. The cosmetic results may be
less satisfactory, since the transferred skin may not
precisely match the color and texture of the surrounding
skin. In general, flap surgery produces better cosmetic
results than skin grafts.
AFTER SCAR REVISION
With any kind or scar revision, it's very important to
follow your surgeon's instructions after surgery to make
sure the wound heals properly. Although you may be up
and about very quickly, your surgeon will advise you on
gradually resuming your normal activities.
As you heal, keep in mind that no scar can be removed
completely; the degree of improvement depends on the
size and direction of your scar, the nature and quality
of your skin, and how well you care for the wound after
the operation. If your scar looks worse at first, don't
panic-the final results of your surgery may not be
apparent for a year or more. |
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