Surgical Techniques To Improve The Appearance Of Scars
Scars – whether from accident or surgery – are unpredictable in the way they form. How they look during and after healing depends as much on your body as on the original injury or the surgeon’s skill. Variables that affect the degree of scarring include 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. Again, how much the appearance of a particular scar bothers you is a personal matter.
Scars cannot be removed completely, but a skilled plastic surgeon can often improve their appearance by the injection or application of certain medications, or through surgical procedures known as scar revisions. Dr. Coville has extensive experience with scarring of all types and frequently uses combination therapy to improve his results. This combination therapy can include topical creams and medications, microdermabrasion, chemical peels – most notably the Obagi Blue Peel, surgical subcision with the Surgiwire, dermabrasion, Dermaroller, or surgical revision. What can and should be done in your case will depend on a consultation with Dr. Frederick Coville. However, the following introductory paragraphs will, we hope, give you a basic understanding of the most common types of scars, the procedures available to treat them, and the results you can expect.
Scars that appear large and unattractive immediately after surgery naturally become less noticeable with time. Some initial tenderness and itching can also be relieved by treatment with steroids, other medications, or even some superficial chemical peels. For these reasons, many plastic surgeons recommend waiting as long as a year or more after the injury or surgery before you decide to have scar revision. Your first step, if scarring is bothering you, is to consult a qualified plastic surgeon such as Dr. Coville. He will examine you and discuss the available treatments, the risks and benefits involved, and the possible outcomes. Be frank about your expectations to make sure they are realistic and bring up all your questions and concerns.
Insurance usually does not cover cosmetic procedures. However, if scar revision is performed to minimize scarring from an injury, to decrease pain, or to improve your ability to function, it may be fully or partially covered by your insurance carrier. Please check with your insurer. We can help you with that when you come visit us at Cornerstone Plastic Surgery and Aesthetic Medicine.
Scar revision is normally safe, but complications can occur as with any surgical procedure. They include infection, bleeding, a reaction to the anesthesia, or further unsightly scarring. Reduce your risks by choosing an experienced and well-qualified surgeon such as Dr. Fred Coville, and by following his advice closely before and after surgery.
Type of Scars
The key to understanding the difference between Keloid Scars and other types of scars is that these thick, puckered, itchy clusters of scar tissue will grow beyond the edges of wounds and incisions. In other words, the scar that forms takes up more area than the original wound that caused it. Often, these keloid scars are red or of a darker hue than the surrounding skin. Keloids appear 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 are most common over the breastbone, on the earlobes, and on the shoulders. They occur more in dark-skinned people than in fair ones, but can and do occur in persons of any ethnic background or descent. The tendency to develop keloids can run in families; but the good news is that this tendency lessens with age.The initial treatment is often the injection of a steroid medication directly into the scar tissue to reduce redness, itching, and burning. Sometimes this also shrinks 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 a local anesthetic. You should be back at work in a day or two, and the stitches can be removed after a few days. A skin graft is occasionally used, although the site from which the graft is taken may itself develop a keloid.
Unfortunately, keloids have a stubborn tendency to recur no matter what techniques are used and sometimes they may be even larger than before. Combining scar removal with steroid injections, direct application of steroids during surgery and radiation therapy may all help. Another treatment is to wear a pressure garment with or without silicone sheeting over the area for as long as a year. Dr. Coville frequently uses a combined approach to treating these stubborn scars including the use of topical medications and chemical peels to improve the results. Even so, the keloid may return so that repeat procedures are necessary every few years. When you have your consultation with Dr. Fred, he will be happy to go over all the treatment options, and will explain what he feels will be a result you can expect based on his extensive experience in this area.
Like keloids, hypertrophic scars can be thick, red, and raised but are different because they remain within the boundaries of the original incision or wound. They often improve on their own taking a year or more to heal fully. Steroid applications, topical creams, microdermabrasion, chemical peels, or injections can help. Dr. Fred often uses several therapies concurrently to get the most improvement. Alternatively, or in combination with some of the other modalities, hypertrophic scars may often be improved surgically. Dr. Coville removes excess scar tissue, and may reposition the incision so that it heals in a less noticeable pattern. This surgery may be done under a local or a general anesthethetic. Non-surgical manipulations to control wound healing, such as steroid injections during surgery and at intervals for up to two years afterwards can help prevent the scar from reforming.
Burns or other injuries where a large area of skin is lost may form a scar that pulls the edges of the skin together. The resulting ‘contracture’ may affect adjacent muscles and tendons and so restrict normal movement. Surgical correction 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. Other advanced techniques, such as tissue expansion, are also playing an increasingly important role. Physiotherapy may be needed after surgery to restore full muscle function.
Some facial scars may be made less noticeable by cutting them out and closing the wound with tinier stitches to leaving a thinner, less noticeable scar. Others can be softened using dermabrasion, lasers, or chemical peels to achieve a controlled removal of the top layers of the skin. These techniques leave a smoother skin surface but will not completely erase the scar. Dr. Fred Coville will often use subcision, prescription topical creams such as the Obagi NuDerm, Dermarolling, and microdermabrasion to improve both the scarring and the hyperpigmentation that may be associated with scars.
Scar Improvement Procedures
This surgical technique repositions a scar so that it follows a natural line or crease in the skin more closely and so is less noticeable. It can also reduce the tension caused by contracture. Z-plasty is not right for all scars however. Essentially 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 different angles, giving the scar a Z-pattern. Fine stitches are used to close the wound and are removed a few days later. Usually performed as an outpatient procedure under a local anesthetic, Z-plasty can make some scars less obvious, but cannot make them disappear. A portion of the scar will still remain outside the lines of relaxation.
Dermabrasion has been around for decades. Originally, sandpaper was used to remove damaged skin. Now a machine rotates a small diamond burr, which removes the damaged skin. Of course, the skin is numbed or frozen first. After the procedure, your skin is raw and scabs will form – much like the scrapes you got on your knees when you were a kid. After the scabs heal, your skin can be reddish for several weeks but that will improve with time. You will see a dramatic improvement in the texture and thickness of any scars treated by this method.
Augmentation is a procedure where material like Juvederm, Restylane, Radiesse, or your own fat will be injected under the scar to bring it to the surface. Depending on the location, these treatments may last for about six months or more. Dr. Fred frequently combines this with Surgiwire Subcision first.
Subcision and Surgiwire Release
Subcision is a technique that detaches the scar from deeper tissue and creates an empty space under the scar. The SurgiWire Incisionless Dissector quickly releases deep linSes and scars in by separating connections to underlying deeper tissues. The empty space created by subcision with the SurgiWire Dissector can be filled with fillers such as Juvederm, Restylane, or Radiesse, or your own fat. If you and Dr. Coville choose not to use any sort of fillers, he may simply leave the small space to form connective tissue under the scar thereby leveling it with the rest of the skin surface. SurgiWire Subcision is usually combined with a Blue Peel chemical peel. The depth and shape of your scars along with other factors such as skin color will help Dr. Fred determine what treatment is best for you.
Skin Grafting and Flaps
Skin grafts and flaps are more major forms of scar surgery and are more likely to be carried out using a general anesthetic. Treated areas may take several weeks or months to heal, and a support garment or bandage may be necessary for up to a year. Skin Grafting involves the transfer of skin from a healthy part of the body to cover the injured area. The graft is said to ‘take’ when new blood vessels and scar tissue form in the injured area. Sometimes grafts do not take – and all leave some scarring at both the donor and recipient sites. Flap surgery is a complex procedure in which skin, along with the underlying fat, blood vessels, and sometimes muscle, is moved from a healthy part of the body to the injured part. 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. Both techniques can greatly improve function. However, the cosmetic results may be less satisfactory because of the difficulty of matching skin color and texture. Flap surgery generally produces better cosmetic results than skin grafts.
After Scar Revision
Carefully follow your Dr. Coville’s recovery instructions to make sure the wound heals properly. You may be out of bed very quickly but your normal activities should be resumed only gradually. Keep in mind that no scar can be removed completely and that 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. Your scar may look worse at first but do not panic. Chances are you will be pleased with the final results, which may actually not become apparent for a year or more.
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