As we all learn early in life, scars are the permanent marks that form following damage to the skin. They may occur as the result of trauma, surgery, or conditions and diseases of the skin. Sometimes they become reminders of a traumatic event, or their formation negatively impacts a person’s appearance. Scar revision surgery performed by Dr. Schoenfeld at Renu – Artful Medicine in Washington DC is a procedure that artfully camouflages the presence of scars in the skin.
How Do Scars Form?
Scars develop in the skin after the dermis, or deepest tissue layer has been damaged. The body is adept at self-repair and forms a response to renew the skin at the injury site. The skin is the largest organ found in the human body and serves the important function of containing each of the body’s systems and protecting against disease and infection. Because of this, our body begins to repair the wound in the skin immediately, to protect the delicate tissues underneath. Collagen, which is a protein that occurs naturally in the skin, is produced to fill the gap that exposes underlying tissues. Normally, collagen forms in a basket weave pattern, but in scars, the fibers are formed in one direction only.
Scar tissue differs from normal skin in a number of ways. After scar forms, a person may notice that the texture is raised above the normal skin level. Other scars appear lowered, producing a pitted appearance. While the skin may be smooth, the scar may be irregular in its appearance. Scars may begin as dark, noticeable formations that are purple and red in color, and may eventually fade to appear closer to the normal skin tone, but often lighter.
Different Types of Scars
There are a number of types of scars that can occur in the skin, and each requires different cosmetic approaches during scar revision.
Keloid scars form when the natural skin repair phase produces more collagen than necessary, producing a large, abnormal growth that expands beyond the initial injury. Keloids typically form as dark, smooth lesions that may cause some irritation. These types of scars are common in African-American skin and must be treated by a medical professional. Patients with keloid scars may require a short series of steroid injections into the formation, or laser therapy to reduce the size of the growth. Compressing and massaging the scar can also be beneficial. A combination of treatments is often necessary for keloids.
Similar to keloid scars, hypertrophic scars are raised and smooth in appearance and texture, or form grooves due to excess collagen production. Hypertrophic scar tissue, however, remains within the boundaries of the skin defect. Generally, hypertrophic scars begin as thick red or pink growths. They may slowly fade to a lighter color and shrink down in size, but they are permanent fixtures in the epidermis and will always be somewhat noticeable. These common scars can benefit from microneedling, dermarolling, or dermabrasion treatments. It may seem counterintuitive that micro-injuries to the skin could decrease the look of a scar, but this produces a controlled healing process that can improve the appearance of a hypertrophic scar. Other treatments include collagen injections, laser resurfacing, and topical or injected steroids. In many cases, however, scar revision surgery is the best solution to minimize the look of large or prominent hypertrophic scars.
The opposite of hypertrophic scars, atrophic scars develop in patterns that are lower than the plane of the skin. Sunken scars can draw attention due to the shadows they create with their depth. Atrophic scars may also be flush with the skin. Laser skin resurfacing, microneedling, and scar revision surgery are all possible solutions to improving the look of atrophic scars.
Skin breakouts affect many people beyond puberty. Those who are genetically predisposed to acne generally have an excess production of sebum or oily skin. The excess oil can get trapped and create tiny infections. Certain types of acne can lead to skin depressions even when the acne is expertly treated through prescription skin care and oral medications. Acne scars may be classified as ice pick (narrow, deep) or boxcar scars (wide, atrophic). Laser treatments and dermal fillers are a trusted approach to pitted scarring. This promotes a turnover of skin cells and collagen remodeling for long-term skin improvement. The fillers provide a temporary fullness below each defect that can be repeated as needed to camouflage the scars.
Also known as burn scars or scar contractures, contracture scars occur when the skin withstands thermal injury. Following second and third-degree burns, the adjacent skin is pulled toward the injured skin and results in a contraction of the area skin. Burn scar contractures may be replaced by skin grafts, tissue expansion, and skin flap surgery. Burns scars not only appear irregular in the skin, but they also limit movements of the body due to the surrounding contacting skin.
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Scar Revision Surgery
Plastic surgeons are trained to create improvements in the skin that are aesthetically pleasing, and this includes managing scar tissue. There are a number of ways to minimize the look of a scar. Following a procedure, patients will feel more confident and typically enjoy improved self-esteem.
In some scar cases, a ballooning procedure may be an ideal solution because it utilizes the patient’s own tissue during this skin restoration process. Patients are fitted with an expandable medical device that is implanted under the nearby healthy skin. Over time, the tissue expands and extra skin can be cut away to replace scarred skin.
Various flap and wedge techniques are performed to break up a linear scar, drawing focus away from the mark. Z-plasty is a surgery that camouflages scars along the natural folds of the skin, taking into consideration how a particular face or body part moves. This conceals any irregular tissue and smooths out the skin. Also named for the incision shape, W-plasty is performed similarly, but with one or more additional cuts. Geometric broken line closure (GBLC) requires an irregular shape to be cut around the scar, but planned so the tissues on opposite sides are sutured to match up, the same way puzzle pieces fit together.
Surgical Scar Removal
Scar excision extracts the fibrous collagen growth from the skin, leaving behind a finer line that is expertly sutured for the most discreet results. The final scar may be treated with steroid or silicone sheets, prescription-grade medications, and after it heals, laser therapy or dermabrasion. These techniques help to fade the scar more quickly.
Ablative lasers like the CO2 Laser and the Erbium: YAG Laser uses thermal energy to remove the top layers of tissue to promote fresh regrowth that replaces the scar. Numerous treatments may be necessary to achieve ideal results. Other lasers may target the blood vessels to cut off the nutrient supply to the scar that allows it to thrive.
Unsightly scars may form in the skin for a number of reasons. The injury may have impacted the deep layers of skin and required stitches, but the patient may have instead treated the wound at home. Infection and complications during the healing process can also lead to scarring, regardless of medical attention. Dermabrasion involves “sanding down” the skin to abrade the scar tissue. This is a controlled elimination of the skin, allowing skin regrowth to create a better aesthetic. Dermabrasion may be performed in different sessions, and healing occurs in between each treatment. This promotes cellular turnover without creating additional damage.
Microdermabrasion utilizes similar technology, but is less invasive and provides less dramatic results. While dermabrasion is performed by a doctor, microdermabrasion is appropriate for other practitioners, like licensed aestheticians to administer. Microdermabrasion may be combined with other procedures for the treatment of scars or may serve as the final abrading procedure on a scar.
Microneedling uses tiny needles to penetrate the skin at varying depths to create vertical injuries to the skin. When performed over a scar, tissue regeneration is encouraged, and healthy skin can replace scar tissue. Generally, microneedling is performed in a series of sessions for improved results. Microneedling may be combined with other scar revision treatments.
Compression and Massage
Some scar tissue may respond well to compression and massage, though it is important that these tactics are employed while the scar is still healing. After a scar has reached maturity, other methods may be used to treat scars. The doctor may recommend either at-home technique or both techniques following surgical scar revision.
Candidates for Scar Revision Surgery
Potential candidates for scar-improvement procedures include men and women who are in good health, have realistic expectations and are looking to improve the appearance of a scar. It is important that patients understand that while scar revision can minimize the appearance of a scar, the scar often cannot be entirely removed. Patients who have not fully healed, are prone to keloids and other scar abnormalities or have skin conditions that affect the scar may be more carefully screened for cosmetic procedures. Because each scar is unique and prospective patients must have their candidacy assessed, a one-on-one consultation with Dr. Schoenfeld will be scheduled to go over the options and customize the procedure to suit each patient’s individual needs.
Scar Revision FAQs
Following Cesarean section, women will have a long linear scar between their lower abdomen and pubic area that is generally a few to several inches long. While the line is usually hidden by underwear or a bathing suit, women may be self-conscious of its appearance and wish to undergo aesthetic revision. Depending on the type of scar that forms, there may be different treatments prescribed. In many cases, scar excision, skin resurfacing treatments like microneedling and laser sessions, or a combination of both, may be the best repair options.
Burns can cause serious disfigurement of the affected areas and may serve as traumatic reminders of the incident that caused them. The scars also can lead to discomfort because of area skin that contracts around them, creating tightness and limited motions. Skin grafts performed through tissue expansion use the patient’s own healthy tissues to replace that which has been damaged.
During a consultation, Dr. Schoenfeld can advise which treatment may be best for a particular scar given a patient’s skin history, but in general, keloid scars may still be removed with surgery. The doctor will take precautions during excision and may administer steroid injections, and can provide at-home care for the healing process, like silicone or steroid post-surgical sheeting to dress the incision site.
What type of anesthesia is used during scar revision procedures?
Most scar revision treatments are performed in-office at Renu, and some treatments may require local anesthesia only. Dermabrasion, microneedling, laser resurfacing,
What can I expect during scar revision surgery recovery?
Recovery after this procedure will depend on the treatment. Tape is often used after surgery to cover the scar and may remain in place for about a week. Surgical procedures often result in swelling and bruising. Some activities may need to be limited for a period of time after this treatment.
Philip Schoenfeld, M.D., F.A.C.S.
Dr. Schoenfeld is the resident plastic surgeon at Renu – Artful Medicine in Washington DC. Dr. Schoenfeld specializes in plastic surgery of the face and skin, and also provides a number of advanced non-surgical procedures at his office. The doctor has been in practice in the DC area for the past 20 years. Dr. Schoenfeld has been rated a Top Doctor in various publications – both local and national – and is a trusted expert in aesthetic medicine.
Contact Renu to schedule a scar revision consultation with Dr. Schoenfeld by calling the Chevy Chase, MD office at (301) 652-RENU (7368), or email office staff through the practice’s Contact form.