As a plastic surgeon working in New York City I see all manner of injuries and surgical scars in every type and color of skin on this earth. Most times scars heal well or at least don’t bother patients. Occasionally however, the mark left behind is either in a particularly bad place (like the face) or heals with an unacceptably bad scar. These scars may not only be ugly to the observer, but can sometimes affect the functionality of the patient by causing constriction in movement (especially across joints). This is where the art of plastic surgery might be appreciated by even the most staunch opponents of plastic surgery.
Why Do Scars Heal Poorly?
This is one of the key questions of surgery and we may never get a 100% complete answer. Wound healing is clearly genetic to a large extent with some people being more prone to making thick scars than others. For instance, African American patients who come to my office are very cautious about their chances of producing a keloid scar (a scar that extends beyond the borders of the original injury). Interestingly, my experience has been that the Asian population is at greater risk of keloids than anyone else. That doesn’t mean that everyone in these populations makes poor scars, but when I do RARELY see a keloid, it is many times in one of these ethnic groups.
Beyond genetics or God’s will, there are environmental influencers of scar formation. For instance, if a wound was infected it may very well form a bad scar. Infections will many times lead to thickened scar tissue, wounds that open up and have to heal from the inside out, or scars that are tethered (stuck) down to the underlying tissues of the body creating divots or dents. If a wound is closed under tension, the body seems to react to the need for more aggressive healing by depositing more collagen in the area leading to a thicker scar. There are also parts of the body that are known to be more likely to create bad scars. The center of the chest, the earlobes, and in my experience the upper arm all fall into that category. All of these factors create a more obvious and less appealing scar long term.
Keloid Vs. Hypertrophic Scars
A “keloid” scar is a scar that grows out beyond the borders of the original wound. They are a terrible problem and can be very tricky to get rid of because once you have one, there is always a risk that any attempt to remove it could result in another keloid that is worse than the first one. There are a handful of treatments for keloids including the injection of steroids, anti cancer drugs, and even radiation therapy. The best results seem to require excision of the keloid with the immediate use of one of these adjuvant therapies. The theory is that by limiting the earliest wound healing processes (what doctors call an influx of “macrophages”) we can prevent an overabundance of collagen deposition in the area.
A “hypertrophic scar” in contrast to a keloid is simply a scar that is a little thick, or that we don’t particularly like. I have many patients who tell me about how they “keloid” when in fact they simply have a hypertrophic scar. Luckily, the treatment of a hypertrophic scar is a whole lot simpler than that for a keloid. Many times I will simply give the patient an injection of steroid and the scar settles down pretty quickly. Other times we go to any of the other treatments that I’ve described in this writing with good outcomes.
Vitamin E Is Bad For Your Scar, Silicone Gel Is Good
Plastic surgeons and dermatologists have known for years that vitamin E is bad for the cosmetic healing of scars. Vitamin E is proven to decrease the tensile strength of wounds and produce less favorable scarring than doing nothing at all. I’ve been telling patients this for years, but most don’t really believe me because their mothers, friends, and sometimes television tells them otherwise. It’s an uphill battle, but I keep trying.
In my practice, I suggest the use of silicone gel as an effective method to improve the appearance of scars. This is supported with real clinical research both on the laboratory bench and in clinical studies. Actually, silicone sheets are also very effective, but I find patients are more likely to stick with the gel because it is much easier to use. Patients tend to complain about the sheets and they become very expensive over time as repeated use seems to make them somewhat “dirty” and patients don’t want to use them after a while. The gel is simple, dries fast, and patients are more likely to stick with the regimen for the 6 to 8 months required to really make a difference.
Basic Scar Revision
Sometimes the most obvious thing to do with a bad scar is simply to remove the bad scar tissue and close the wound all over again in a very similar manner. This can work out well, depending on the situation. That is, one has to ask oneself why the scar is likely to form more favorably on the second go round than the first. For instance, were the wound edges lined up properly the first time? Was there some kind of contamination or infection that caused poor wound healing? In those cases, a simple scar revision can certainly result in a more acceptable cosmetic appearance of the scar.
Sometimes there can be too much tension on the closure of a wound the first time around which caused the body to react profoundly and deposit a lot of collagen in the area causing a thickened scar to form? If the surgeon can somehow relieve that tension (perhaps by creating a “flap”), then the outcome might be better the second time around as well. This situation comes up all the time in cases like bad tummy tuck scars or after general surgery.
Z-Plasty Can Help Release Constricting Scars
If a scar crosses a joint like an elbow, knee, or even your neck there is a procedure called a “Z-Plasty” that can help to release the constriction by recruiting some non scarred surrounding tissue into the central portion of the troublesome area. There are times when this makes the scar more cosmetically acceptable, but generally speaking this technique is used to restore function to the patient. It is a commonly utilized strategy in hand surgery (because there are so many scars that cross joints in that field) as well as burn surgery (because these wounds tend to be large and cause great constriction. However, Z-Plasty is used in any situation where we need a little tissue rearrangement.
W-Plasty to Help Camouflage Scars
A “W-Plasty” is similar to a Z-Plasty in that we create a zig-zag scar, but in the W-Plasty the zig-zag is continuous along the length of the scar. It is particularly useful in scars that run in the opposite direction as the natural lines in the body or face because we can take (for instance) a vertical scar and create a series of smaller 45 degree angles that are closer to the horizontal lines we normally find in nature. This seems to throw off the eye of the onlooker so that the scars is not quite so noticeable. That is, the wound runs opposite to the normal creases we would see naturally, but the series of smaller scar lines are now 50% closer to them. It is a very handy procedure in the right circumstances, but patients in general are reticent to the idea because they are afraid the wound might look more like the mark of Zorro than a better scar.
Dermabrasion to Help Scars Blend In
Once a scar has been optimized by any of the other methods described here, we still have a few techniques that can help scars to “blend” into the surrounding skin. One of these is called “dermabrasion“. This is a technique that essentially uses a small grinding wheel as a handheld device to physically file down a scar and the normal tissues immediately surrounding it. By removing the top layer of skin in these areas we cause the entire area to heal or “re-epithelialize” in unison and that can help the scar to be less noticeable. It is very effective and handy. Plastic surgeons like this technique for getting rid of wrinkles around the mouth that a facelift can’t quite achieve. Sometimes dermatologists will try to cover large areas of skin like the cheeks after acne scarring and they call this “derma planing”. Amongst the limitations with this procedure is that it is very user dependent and difficult to get large areas of skin to be completely uniform.
Complete Removal of a Scar
To say that we can “remove a scar” is sort of a misrepresentation of our abilities. Once a scar has been formed, it may fade with time, but it will never completely “go away”. On the other hand, we do have the ability to remove one scar and “trade” it for a different one… and this trick is worth doing from time to time. For instance, perhaps there is a vertical scar on the lower tummy of a woman after having a Cesarean Section (“C-section”). We certainly have the ability to remove all of the lower tummy skin and convert the “up and down” scar, which is visible to the whole world, to a gentle horizontal “smile” scar across the lower bikini line with the use of a classic tummy tuck procedure. The only visible scar to the public would be around the umbilicus and I’ve written quite a bit about that issue in my other posts. Other examples might include any number of breast procedures or thigh lift operations – all of which involve removing skin which, if scarred, would eliminate an unfavorable scar for a more cosmetically acceptable or hidden scar.
Laser Treatments That Lessen Scars
There are several types of lasers that can be helpful in our battle against scars. These can be categorized as Ablative, Vascular, and Fractional Non-Ablative lasers.
Ablative lasers can be used in much the same way as dermabrasion. They essentially sear the surface of the skin and take away the surface level of skin in the hopes that when the scarred area and surrounding tissues heal they appear more uniform. The advantage over derma planing is that these devices are less user dependent and results seem to be more reliable when treating large surface areas – as with acne scarring.
Vascular lasers help to remove redness from scars. They use a specific wavelength that is absorbed by the red color and essentially burns it out of the area. The result can be a scar that is less red, and hopefully has a pigment more like the surrounding skin.
Fractional Non-Ablative lasers are not supposed to take away the skin surface, but rather they deliver heat down into the scar in micro “tunnels”. The theory is that they can burr thousands of microscopic holes of heat into the scar and encourage the skin to heal again in a more uniform manner. While the idea is inviting, I have not been impressed with this technology in my practice and have completely abandoned the technology for now.
Injections to Improve the Appearance of Scars
There are some occasions when injectable materials like Juvederm can help scars to look better. For instance, let’s say that there is a depressed scar that looks like a dent in the skin. It may not make sense to operate because the scar is so small and we want to do as little as possible to get a favorable outcome. So in these cases we can sometimes inject a little filler under the scar to make it “pop” up to the same level as the surrounding surface skin. When it works, it’s a home run, however fillers are a little pricey and the results may only last a year or so (based on the longevity of the filler). For these reasons I typically will check to see if I can get the scar to pop by injecting saline first. If the scar is not tethered down to the underlying tissues it will smooth out, and then I know that a filler can help. On the other hand, if the scar won’t budge because of the connections below, then I know that I need to try some kind of lysis (sub dermal release of the scar). This can sometimes be achieved with a needle or a device such as a “diamond wire” that is specifically designed for “subcision” of the scar.
Will Insurance Pay for Scar Revision?
Your health insurance company is supposed to be there to help pay for “health” or medically necessary procedures. As such, insurers are not exactly going to leap at the opportunity to help you get a cosmetic scar revision. However, if a scar is actually preventing you from leading a healthy and productive life, then they may. For instance, if there is a scar restricting movement of your hands or arms so that you can’t work, then a scar revision would be deemed “medically necessary” and your insurance carrier would likely pay for that kind of revision. On the other hand, if a patient doesn’t like the appearance of your acne scarring, that is probably going to be considered an elective cosmetic procedure and the expense would be on the individual. The tricky part here is that some insurance companies will deny any and all scar revisions because some patients will make claims about their inability to work due to a cosmetic scar – so there is definitely a struggle in many cases to determine what is fair. As a plastic surgeon, I do my best to walk the line between these opposing views. I want what is best for my patients and I advocate for them every day, but sometimes we need to concede that a given procedure is simply cosmetic in nature.