Scar Revision

Scars are an inevitable part of life but we are often approached to perform scar removal. It is important not to lose sight of the purpose of scars in terms of restoring strength and integrity to the skin and we need to let them do their job before we as plastic surgeons intervene.

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Scar Removal

This means that if you are considering scar removal you should wait at least a year before thinking about intervention. The scar needs to build up strength and mature because in the first year scars will change dramatically.

Which scars are suitable for scar removal?

Scars cannot simply be removed and left as if nothing had ever happened. However we are able to manipulate and change scars and we can make them a lot less noticeable.

There is a huge variety and type of scarring and so it is difficult to give a one size fits all.

Here at the Staiano Clinic we pride ourselves on giving a bespoke one-to-one service and treatment and we encourage patients to come for a free consultation or to send us a photograph of the scar with a short note about the features that they would like changed. This means that we can often give you a tailored quote and treatment plan to give you the best outcome for your particular situation.

There are certain types of scars that are particularly amenable to intervention.

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We offer a variety of calls and in person consultations with the surgeons.

Size of the scar

We can’t do anything about the length of your scar but sometimes scars are too wide. There are certain areas of the body in certain situations where scars continue to stretch.

If there has been a problem with the healing particularly if some of the scar opened up or in locations such as the back, there is a tendency for the scar to stretch over time. This means that whilst the scar was initially a hairline over time it can widen and this is particularly true in areas where the scar is under tension.

We would need to look at whether there was a reason for the scar to stretch in the first place to see whether we could do anything differently to prevent stretching happening a second time.

Some areas of the body such as the back are so prone to stretching that we would sometimes advise you not to have a scar revision because there is a good likelihood that it could stretch again. However if there is a reason such as the wound not healing properly or dehiscence (the wound opening up), it is more likely that we would recommend a scar revision.

The scar could be excised and a fresh scar created in the same area and we would often use layers of sutures to increase the strength of the closure and reduce the risk of stretching again. However, there is always a risk of recurrence of the stretching.

Shape of the scar

Scars can be lumpy or scars can be dented or puckered in.

Lumpy scars

Scars are often raised and firm to start off with and then soften and flatten over time. However, some scars remain lumpy or take longer than normal to flatten.

Scars that remain lumpy may be ‘hypertrophic’ or ‘keloid scars’.

Keloid scars

Keloid scars are abnormal scars and they are more common in patients with Afro-Carribean skin types or in certain areas, such as over the breastbone, the shoulders and the ear. They are red and raised and often itchy.

Silicone

The treatment of hypertrophic and keloid scars begins with silicone applied to the scars. This can either be in the form of silicone ointment or silicone sheets and these are available from our clinic or most pharmacists.

The silicone needs to be applied for 23 hours a day and removed only to wash.

Pressure

Lumpy or hypertrophic scars can benefit from pressure to help soften the scar tissue. In its simplest form, this involves massaging the scar and we also have a silicone ointment applicator that has ball bearings to apply pressure to your scar while applying pressure – our dual action scar gel.

Depending on the location, pressure can be applied in different ways. If your keloid scar is on your earlobe, then we can custom make pressure clips to wear. If your scar is on the breast from a breast reduction or your tummy from a tummy tuck, then the wire of your bra or the band of your underwear might apply pressure to the scar.

Pressure can be difficult to apply in other areas and it is only for more extensive scarring such as burn scars on the face that we would employ custom made options like pressure masks.

Steroid Injections

Steroid injections are a bit more invasive than the other treatments mentioned so far and would need to be administered by a doctor.

However, steroid injections can be very effective in treating the itch, the redness and the lumpiness of a hypertrophic or keloid scar. Steroids are injected directly in to the scar (intralesional) and can be uncomfortable.

They often need to be repeated and can be combined with other treatments such as topical silicone or surgery.

Surgery

Surgery is usually one of the last options in the management of keloid scars and is reserved for scars that are very large or when the other treatment options have failed. The main problem with surgery is that the keloid scar can come back after surgery and there is the potential for it to come back worse than the original scar.

This is because keloid scarring is caused by an abnormal reaction of your body to the healing process. This means that when your body is healing the scar following excision of your keloid, it may become keloid again and it may be larger than the original.

One of the features of keloid scars is that they are larger than the original scar, so if you start with a small scar that becomes keloid and you have it excised, this resulting scar will be bigger than the original and if this then goes keloid, it will be bigger again.

For this reason, surgery is reserved for only the most troublesome keloid scars and only in cases where you accept there is a risk it could be made worse.

In order to reduce the risk of it coming back bigger, we usually perform an ‘intralesional’ excision of the keloid scar whereby we leave a rim of keloid behind, so we are not creating a new scar in dress tissue, but rather debulking your original keloid.

This then leaves a small rim of keloid scar that can then be treated with steroid injections to help shrink the last bit away.

Dented / puckered scars

Dented or puckered scars are usually due to the scar tissue tethering down in to the underlying tissues.

They are common where the scar is made through several layers of tissues such as Caesarean scars or appendicectomy scars in the abdomen.

…or where there are muscles nearby such as the face, where the scar tissue in the skin can get tethered to the underlying muscle. They can also occur in situations where there has been tissue loss, so if a lump has been removed or if there has been trauma to an area resulting in a loss of fat or underlying structures creating a dented in scar. The treatment of puckered scars is more difficult than you might think.

Sometimes patients feel that the scar can simply be excised and re-sutured and this might look fine initially.

…but over time, the scar is likely to become puckered in again.

As plastic surgeons, we cannot make scars disappear, we can only create more scarring. We just have to make sure that the scar that we create is in some way different to the scar we are removing. Puckered scars have a high chance of recurrence following revision because the puckering is due to scar tissue extending deep beneath the skin.

Any attempt to simply remove this scar tissue will result in fresh scar tissue forming in its place which will contract over time. Scar removal for puckered scars involves removing the old scar but then filling the space with some healthy tissue to prevent it from scarring down again. This is often done by mobilising the fat on either side of the scar to interpose some healthy ‘padding’ and break up the block of scar tissue.

Position of the scar

When people ask for ‘scar removal’, they often realise that their scar can’t be removed, but it can be changed.

The position of a scar is very important and something that we, as plastic surgeons take a lot of time and attention in planning and designing. The body has relaxed skin tension lines which will naturally result in a better, less visible scar.
When we are preparing for surgery, we will analyse these lines and natural contours and areas of shadow so that we can place our incisions where they will be difficult to see.

However, if an incision has been poorly planned, or worse still, if a scar has been created by a traumatic injury, it may lie in an unfavourable orientation or position. It may be able to remove all or part of the scar and change its alignment so that it runs in a natural crease.

This can help to break up the scar and will also mean that that part of the scar will blend in much better with the surrounding features.

Colour of the scar

Scars are always red to start off with and then they fade over time. As they fade, they can become darker in colour and more obvious.

This is a natural process and happens to a greater or lesser extent to everybody. Probably the best thing to allow scars to fade is time.

Moisturising and massaging your scar will help this process and allow the scar to soften and fade. While your scar is fading, you can use cosmetic camouflage makeup to hide your scar which can be very effective. You can wear makeup on your scar once it is healed and dry which is usually after 2-3 weeks but check with your surgeon first.

If your scar remains red or is slow to fade, then laser can help to take the redness out of the scar and allow it to fade and blend in with your normal skin.

Some words from our patients

“I had a very deep scar on my tummy & since surgery its totally different, it’s given me much more confidence. I am extremely happy with the outcome. Plus Id like to add Mr Staiano was brilliant, he made me feel totally at ease.”

Words by DP

Procedure: Scar Revision

“I had a horrible looking appendix scar from when I was a young child. It now looks absolutely brilliant, can’t thank Doctor Staiano enough. Would definitely recommend.”

Words by DP

Procedure: Scar Revision

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