Everybody is familiar with the concept of a scar – the result of a cut or injury to an area of skin. Products and creams are sold in a billion dollar market that often promise or guarantee scars to disappear. For the most part, these are ineffective and do not result in “scarless” healing. To date, there are no scientifically proven products or techniques to eliminate scars completely. However, there are many ways to help improve the appearance of scars and minimize their visibility. Furthermore, there is ongoing research that may one day uncover the secret to reverse or avoid scarring altogether.
Definition
Scars are the final product in the process of wound healing. When a cut occurs (either from trauma or surgical), an inflammatory response occurs beneath the external skin and new cells generate collagen, one of the building blocks of skin. This lasts for approximate 3 weeks. A “remodeling” process then begins, which will last many months. During this time period the skin is trying orient its fibers to gain maximal strength. An early scar has a reddish or pink color and is often raised. As months pass, normal scar maturation occurs and eventually the scar will fade to a white line and flatten. This scenario is typical of a well-healing scar and can take up to 9 to 14 months to occur. Once a cut has occurred, the resulting scar will never fully regain the strength it once had; but, approximately 80-90% will be recovered. Wounds regain most of its strength by the 6th to 8th week after the injury/cut.
Good versus Bad Scars
“Good” scars are ones that are flat, whitish in color, thin, and are in inconspicuous areas. Bad scars are ones that are particularly noticeable for any reason. These are typically widened, raised, discolored (red, pink, brown, black), depressed (divot), irregular, or in a conspicuous location (for example, middle of the cheek). In general, scars become less noticeable if they can be hidden in natural lines or creases of the body and face.
Factors that affect scars
Not all scars are the same. Factors that can influence the quality of a scar include age, genetics, race, location of injury, tension, method of injury, sun exposure, method (or lack of) of repair, etc. If an injury occurs that is significant, it is wise to seek proper medical treatment. Deep cuts need multi-layered closure to heal optimally; otherwise, depressed or dented scars can result. Tension is an enemy of good healing. Skin over highly mobile areas of the body, such as elbows, knees, shoulders, chest, back, hips do not heal as well as other areas such as the face and neck. This is due to the tension created on the skin that causes widening of the scar. Children under the age of 2 to 3 heal better than any other age group. Between ages 3 and about 13, scarring is worse, and then steadily improves into adulthood. Scars in the elderly tend to heal well due to extra laxity of the skin (less tension) and because of more wrinkle lines to hide them.
Asians, Hispanics, and blacks tend to heal worse than Caucasians because of the thick, oily quality of the skin. Scars tend to undergo a more prolonged maturation process and are more susceptible to raised scarring. These ethnicities are also more prone to abnormal excessive scarring called keloids.
Sun exposure is the other great enemy of scars. At any point during the maturation phase of healing (when scars are red or pink), scars are adversely affected by sun exposure. It can cause permanent discoloration and/or delay the maturation process (can even double the time to heal).
Wound Healing
Regardless of whether your cut/abrasion is a result of a surgical incision or trauma, wounds heal the best in moist environments. Even with the best suturing techniques the line of the incision itself will have a small (sometimes microscopic) gap in the skin. Abrasions or raw wounds obviously have an opening in the outer layer of the skin, called the epidermis. The epidermal layer of a surgical incision usually takes 48 hours to form a water-tight seal. An abrasion or traumatic cut can take longer, depending on how much raw surface area was injured. Application of antibiotic ointment is a key initial step in wound management, to help prevent infection and to keep a moist healing environment. By doing this, the process of dermal and epidermal repair can be up to twice as fast.
Wound Care
Your wounds should be kept clean with either soap/water or with diluted hydrogen peroxide. This will reduce the amount of bacteria and germs and will help debride the scab that often forms. Tightly adherent scabs should not be forced loose, though loose scabs should be removed – these loose scabs can impair your wound healing.
Once a wound has healed to a point where there is no open raw surface, it can be considered a “scar.” Scars are very dynamic entities; they are constantly changing, and can be influenced positively or negatively by external factors, which were discussed previously. There are many philosophies regarding scar “management.” Dr. Ha can recommend his approach to scar management during a consultation and help determine when or if a scar revision would be beneficial.
What is a scar revision?
A scar revision refers to a surgical procedure to re-excise a scar and repair it again in a more favorable manner. It can also refer to a procedure to lengthen restrictive scars. If scars have one or several of the characteristics described previously, an improved appearance can be expected after the healing process is completed.
When is a good time to get a scar revision?
Scars, by definition, are a result of a repaired or healing wound. Healing is a dynamic process and takes 12 to 18 months to completely finish. Collagen is in a constant state of rebuilding in the deeper levels of the skin. The typical indication that a scar is still immature (changing) is the discoloration (red or pink) and its firmness. Most scar revisions should not be attempted until about 1 year after the injury/repair – this is when the scar is optimally stable. Why is this important? Imagine rennovating a house on an unstable foundation. The house may look good at first, but because of a shifting foundation, the house may end up being damaged and looking worse than ever before. Similarly, a scar may appear acceptable after a revision that is performed too early, but patients run the risk of it looking worse than before in the end.
If a scar revision is the same procedure as the closure of the original cut/wound, then why can you expect the scar to be better the second time around?
For many reasons, a scar revision has the potential of improving a scars appearance. The original injury typically is a result of a trauma, sometimes from great force. There is often more damage to the surrounding tissues than is readily apparent – this can be detrimental to the overall healing process and ultimate scar. Other problems associated with traumatic injuries can include infections and delayed repair, both causing unsatisfactory scarring. A scar revision is more controlled and does not traumatize the tissues as much. A multi-layer closure can be performed with the surrounding tissues in optimal condition – this sets the stage for improved scar appearance.