New Approaches to Scar Revision and Management - Surgical and Non-surgical Techniques

What Is a Scar?

A scar is formed when the body is healed naturally and replaces lost or damaged skin and the scar consists of fibrous tissue. There are many reasons for the scars to form such as surgery, infections, injuries, or inflammation of tissue and it can appear anywhere in the body that appears flat, sunken, lumpy, or colored. These scars may be painful or itchy and the look of the scars depends upon various factors such as type of skin and location on the body, type of injury, age of the patient, and nutritional status of the patient.

What Is a Scar Revision?

A scar revision is done on a scar which will alter the appearance of the scar and improve the cosmetic appearance of the scar, restore function to a part of the body that is restricted by a scar, or improve an itchy scar.

What Are Factors to Consider Before Doing Scar Formation?

The factors to be considered before scar formation are:

• Unrealistic Expectations: The patient must be aware that the scar revision will improve and not erase the scar and thus surgical procedures might require multiple sittings along with adjunct treatment to get an optimal result over many months or years. It is necessary to explain to the patient so that they don’t have any unrealistic expectations.

• Scar Revision Timing: For the scar to mature, it takes around 12 to 18 months due to continuous collagen remodeling, and uninjured skin gains tensile strength of 70 to 80 percent. Hypertrophy is seen in immature skin and gives poor results after scar revision. During this period, adjunct treatments can be given by using silicone sheets and intralesional steroid injections.

• Medical History: It is essential to consider the nutritional status and medical history of the patient. For good protein synthesis, a balanced diet is essential. Wound healing occurred with the help of vitamins A, C, E, and zinc. Medicines that will increase bleeding and herbal supplements should be stopped three days to two weeks before scar revision. Diabetes mellitus and immunosuppression will negatively affect wound healing.

• Smoking: It is advisable to inform the patient to stop smoking from four weeks before to four weeks after scar revision as tobacco can delay wound healing and cause hypoxia, thrombogenesis, vasoconstriction, and aberrant cell function.

What Are the Non-surgical Techniques for Scar Revision Management?

The non-surgical techniques for scar management are:

• Camouflage: The scar can be camouflaged by make-up, hair, accessories like tattooing and scarves.

• Topical Therapy: Hyperpigmented Scars can be lightened by using hydrocortisone, hydroquinone, and kojic acid.

• Cryotherapy: For the management of hypertrophic scars and keloids, cryotherapy is done alone or in combination with intralesional corticosteroids, or surgical excision is used. Intralesional cryotherapy will maximize the destruction in the deeper part of the scar and minimize the damage to the epithelium.

• Non-ablative Lasers: The redness of the scar is decreased by the flashlamp-pumped pulsed dye laser as it destroys the blood vessels. The collagen remodeling is stimulated and the scar is softened by the use of lower sub-purpuric fluence.

• Soft Tissue Fillers: For elevating depressed and pitted scars, synthetic fillers such as bovine collagen, fat, hyaluronic acid, and homologous human collagen are used.

What Are the Surgical Techniques for Scar Revision Management?

The various surgical techniques for scar revision management are:

• Fusiform elliptical excision.

• Z-plasty.

• Half Z-plasty.

• Four-flap Z plasty.

• Planimetric Z-plasty.

• S-plasty.

• Jumping man procedure.

• W-plasty.

When Is the Fusiform Elliptical Excision Technique Indicated?

This technique is most appropriate for revising a mature depressed or spread scar which is present along the relaxed skin tension lines and respects the facial subunits. A fusiform elliptical incision is made in this technique to excise the scar. The length-to-breadth ratio is kept at 3:1 and fusiform ends should have an angle of 30 degrees or less so that ‘dog ear’ formation can be prevented.

In extra marginal scar excision, small margins of the normal tissue are excised along with the scar to get the normal tissue at the wound margins.

In intramarginal scar excision, at intervals of six to twelve weeks, serial excisions are used for revising a wide and round scar that can’t be excised completely in one sitting, in scars with surrounding inextensible skin, and if the length of the ellipse creates an unfavorable scar. For facial scars, this method is particularly used as it preserves normal skin as much as possible.

What Are the Advantages of Z-Plasty?

Based on geometric principles, this technique is used and it is most commonly used for scar revision. The advantages of this technique are a linear scar is ir-regularized which will make it less noticeable, the direction of scars is changed and aligns them to relaxed skin tension lines, helps in lengthening the contracted scar and helps to change the position of a displaced anatomical point by elevating or depressing it.

When Is S-Plasty and W-Plasty Indicated?

S-plasty is used to manage the oval contracted scar when large triangular flaps are required to be transposed. There is better survival by rounding off the flap ends.

W-plasty is used for linear scars measuring greater than 2 cm and at an angle of more than 35 degrees to the relaxed skin tension lines and this will make it more prominent and cause it to spread. It is also used for short scars that are present on the forehead and cheeks, closures in pre-tracheal areas, and closure over curved surfaces such as inferior border mandibles.

What Are the Emerging Trends in Scar Revision and Reduction?

• Autologous Fat Grafting: The regenerative potential is present in adipose stem cells and these can improve the scars and the quality of the overlying tissue.

• Gene Therapy: Studies have proved that this therapy improves wound healing and scar formation.

What Are the Complications of Scar Revision?

The complications of the scar revision procedure are:

• Scar widening and hypertrophy.

• Hematoma formation.

• Wound dehiscence.

• Infection.

• Hyperpigmentation.

• Keloid formation.

Conclusion

The scar is not erased through scar revision but it helps to make it less noticeable and more acceptable. For revising a scar, both surgical and non-surgical techniques can be used. By planning meticulously, experience and sound technique, postoperative complications, and unsightly scars can be minimized. To get an aesthetically pleasing outcome, surgeons will decide on when to act and the type of technique to be used for scar revision.