Scars : Why they form and How to Treat them
When ever the skin is damaged, the body heals the area damaged with the formation of scar. As Plastic Surgeons we try to hide our work by placing our incisions in skin creases or in the hair line. But every incision still heals with scar formation. A good scar is flat (depressed or raised scars catch light and are there fore more visible), narrow (wide scars are easier to see) and do not displace anatomic landmarks. A flat, thin scar can not be improved. A depressed scar can be raised. A raised scar can be flattened. Wide scars can be narrowed. Scars that displace anatomic landmarks can be rearrange to correct the displacement.
Raised scars come in two favors; Hypertrophic and Keloid. Under a microscope hypertrophic and keloid scars look the same but on the skin they are defined by the extent of the scar formation. A raised scars that does not exceed the borders to the original wound is called a hypertrophic scar. A keloid scar exceeds the border of the original scar and appears like a tumor.
Scar formation is a multifactorial problem. Factors that effect scar formation include:
- Age: as we age our abilities to quickly heal diminish. Young people heal very quickly and form heavy thick scars quickly. As we age our ability to form heavy scars diminish.
- Genetic Factors: People of color can form very heavy and large scars (Keloid). But not all people of color for Keloid or even hypertrophic scars. I have operated on many people of color with excellent results and no excessive scar formation.
- The source of the wound. A surgical scalpel cuts the skin sharply and will cause minimal surrounding tissue damage. A injury caused by a blunt object ( a rock) will cut the skin but also damage the surrounding tissues. The additional damage requires more healing and there fore more scar formation. Injured surrounding tissues contract and create depressed scars. Injuries caused by heat, lasers, radiation, chemicals and abrasion caused extensive surrounding tissue damage and scarring. And also possible loss of skin pigment cells, which creates a white patch.
- Tension and Inflammation: Incisions or injuries in areas were the skin is tight, tend to form wide scars. Incisions or injuries were the wound develops a significant amount of inflammation (reaction to the suture, infection, foreign body) form heavy thick scars.
Every wound takes up to two years to heal. The process is the same for a scratch and a tummy tuck.
- The wound seals it self in 24-48 hours
- During the first six weeks the wound begins to organize it self and strengthen.
- At six weeks the wound edges begin to redden up. Heavy collagen scar formation is occuring and the wound is bring in more blood flow. This collagen development takes six months to complete.
- From six moths to two years the final collagen organization is taking place. The red/purple color begins fade and the scar finally turns to hypopigmented (Translucent white). The raise portion of the scar flattens and softens.
How to Get the Best Post Injury Or Post Surgery Scar:
For my surgical patients I use different techniques depending on the the surgical location. My basic principles are the same: Reduce skin edge incision tension and to reduce wound inflammation. This involves layered wound closure with suture material that produces the least amount of wound inflammation. If it is possible, I will glue paper tape to the incisions , replacing it as needed and keeping it taped for the first six weeks.
After the three weeks (and starting at six weeks for taped incisions) I would recommend twice daily five minute scar massage with a moisturizing cream/ointment. I believe that the massage will help the scar mature quicker. Resulting in a flat scar with no redness. Scars will mature on their own but observations made with burn patients demonstrate more rapid scar improvement with the use of pressure and massage.
Patients frequently ask about advertised scar creams or ointments. It is my opinion that it is the massage which is the most important factor and that any of the moisturizing creams or ointments will work (As long as you spend five minutes massaging them in).
The use of lasers to remove the redness of a scar is also being promoted. If the scar is in a visible location, the expense may be warranted. Lasers do not help with raised scars, nor do they improve wide scars or depressed scars.
Chronic raised, heavy scar, depressed scars, wide scars and scars the displace normal anatomy may require revision. A consultation would be required in order to evaluate a particular scar and determine what would be needed to improve the scar. For a complimentary consultation call (858) 451 – 3060.
How Can Scars Be Treated?
Although scars cannot be completely removed, their appearance can be improved to some extent. Methods for improving the appearance of scars include:
- Topical treatments, such as vitamin E, cocoa butter cream, and several commercial skin care products like Vaseline and Aquaphor that are sold over the counter may be somewhat effective in helping to heal scars.
- Surgery. Although it will not remove a scar, surgery can be used to alter a scar’s shape or make it less noticeable. Surgery is not recommended in cases of hypertrophic or keloid scarring (raised scars) because there is a risk of recurring scars as well as more severe scarring that results from the treatment.
- Steroid injections. A course of steroid injections into a scar may help flatten it. Injections may help to soften the appearance of keloid or hypertrophic scars. 5-fluorouracil (5-FU) or bleomycin can be injected into scars to reduce the size of the scar and ease itchiness and pain.
- Radiotherapy. Low-dose, superficial radiotherapy is used to prevent recurrence of severe keloid and hypertrophic scarring. This treatment is used only in extreme cases because of potential long-term side effects.
- Dermabrasion. This treatment involves the removal of the surface of the skin with special equipment. Dermabrasion is useful to blend in the irregularities of a scar whether it is raised or depressed.
- Microdermabrasion is a much less invasive form of dermabrasion but is minimally useful for very superficial scars.
- Laser resurfacing . This procedure, similar to dermabrasion, removes the surface layers of the skin using different types of lasers. Newer types of lasers may achieve more subtle results by working on the collagen in the dermis without removing the upper layers of skin. This advancement results in little down time as opposed to traditional laser resurfacing and dermabrasion, which requires a longer recovery.
- Filler injections. These treatments can be used to raise sunken scars to the level of surrounding skin. The effects of these injections are only temporary, however, and the procedures may need to be regularly repeated. Newer forms of injectable fillers are now on the market and may be an option for some people.
- Microneedling. Many small puncture holes are made into the superficial skin to stimulate collagen production and even introduce collagen stimulators or other products to try to reduce the appearance of scars.
- Cryosurgery freezes the scar to reduce the size of the scar, and reduce pain, itchiness, hardness and discoloration. This may be combined with steroid or 5-FU injections.
What Are Possible Treatments for Scars?
Scar treatments may include:
- Over-the-counter or prescription creams, ointments, or gels. These products can be used to treat scars that are caused by cuts or other injuries or wounds. If you are under the care of a plastic surgeon and your scarring is from cosmetic or plastic surgery, ask your surgeon if over-the-counter treatment is an option. If not, there are prescriptions that may help. Often, treatments can include steroids or certain oral antihistamines for scars that cause itching and are very sensitive. Likewise, if you have scarring from severe acne, ask your dermatologist for advice. Your doctor can also recommend or use pressure treatment or silicone gel sheeting to help treat scars or as preventive care.
- Surgical removal or treatment. There are many options to treat deeper scars depending on your particular case. These include skin grafts, excision, dermabrasion, or laser surgery. In a skin graft, the surgeon uses skin from another area of your body. This is often used with people who’ve had burns. If you’ve got scarring that impairs function, surgery can help address the functional problems. If you’ve recently had surgery that has caused scars, it is best to wait at least one year before making a decision about scar treatment. Many scars fade and become less noticeable over time.
- Injections. You may get steroid injections to treat scars that stick out, such as keloids or hypertrophic scars. Your doctor may use this on its own or with other treatments.
Other types of injections, such as collagen or other “fillers,” may be useful for some types of pitted scarring, although these are not usually permanent solutions.
6 New Ways to Remedy Scars
They say every scar tells a story, but who says you have to share that story with the world? Most scars (triggered when the body’s repair system produces too much of the skin tissue collagen at the wound site) will improve on their own over time, becoming lighter and more pliable. But some scars remain lifelong reminders of surgery, a bagel-slicing slip-up or, worse yet, a painful life event. “No one knows why some healing goes bad,” says Tina S. Alster, M.D., a scar expert and director of the Washington Institute of Dermatologic Laser Surgery. The good news, however, is that there are an increasing number of options for diminishing the look of a scar. Here’s what you need to know.
1. You don’t have to live with pockmarks anymore.
Fat or collagen injections can raise these scars instantly, but the effects last only about four months (average cost: $250 per injection). For deeper indentations, the Nd:Yag laser seems to help by stimulating the formation of collagen beneath the skin, which can smooth out scars. Four to six of these treatments followed by microdermabrasion ($400-$600 for the combined treatment) are very effective, says Robert W. Weiss, M.D., professor of dermatology at Johns Hopkins University School of Medicine in Baltimore.
Dermabrasion, an older method in which skin is “sanded” down with wire brushes, is still effective, particularly on new scars (four to eight weeks old), says John Marion Yarborough Jr., M.D., a New Orleans dermatologist. But the treatment is painful, and recovery from it can take anywhere from two weeks to one month.
2. You can flatten raised scars.
Silicone sheeting and scar-reducing polyurethane dressings have been shown in studies to help prevent raised scars from forming and to flatten them once they’ve set in (cost: $17-$105). While these products produce the best results on newer scars, older scars also show improvement.
Experts aren’t sure exactly how silicone sheeting works, but the prevailing theory is that it applies pressure to the scar, which may suppress excess collagen formation, says David Leffell, M.D., professor of dermatology at Yale University School of Medicine and author of Total Skin (Hyperion, 2000). The dressings can be used as soon as the scab falls off a wound and should be worn every day for two to four months. Want a faster fix? Try the gentle pulse-dye laser, which can flatten a raised scar in just one session (cost: from $400).
Mederma gel ($30; at drugstores) also may help reduce the appearance of raised scars. Its patented onion extract has been shown in manufacturer studies to help reduce the formation of part of the scar tissue, which is why it is most effective when used on new scars.
3. A combination of therapies works best on keloids.
There has been success in flattening keloids (knobby growths of scar tissue most common in people of Mediterranean or African descent) by first having the keloid sliced or frozen off, followed by a series of steroid injections — one right after surgery then three follow-up shots over the next three months (cost: de-pending on the extent of the scar, $1,000-$5,000 to excise it and $250 per injection). “This combination works in 70-80 percent of patients,”says Steven G. Wallach, M.D., assistant clinical professor of plastic and reconstructive surgery at Albert Einstein College of Medicine in New York City.
4. C-section scars can be minimized.
The incision for a Cesarean section (or appendectomy) goes so deep that as it heals, scar tissue affixes directly to underlying muscle, which pulls the scar down. The fix includes snipping underneath the skin to sever the connective tissue, causing the scar to spring up. Next, fat is injected to fill the gap that results and to prevent the skin from reattaching to the muscle (cost: $600-$1,000).
5. Pigmented scars can be lightened successfully.
Applying a prescription hydroquinone-based bleaching cream once the wound has healed may work, but it can cause redness, itching, stinging and even sun sensitivity if you have skin that’s easily irritated. You can also try more gentle over-the-counter lighteners like MD Formulations Vit-A-Plus Illuminating Serum ($65; mdformulations.com) with vitamin C and licorice extract, a botanical that has been proven in studies to be an effective skin lightener.
A new in-office procedure may also help. In it, tiny pieces of healthy skin are transplanted into the darkened area. The transplanted cells multiply, spreading normal pigment to the area after a few weeks, explains Leffell, who pioneered the procedure, called flip-top pigment transplantation. Talk to your dermatologist for more information.
6. You can effectively conceal a scar.
A dry concealer clings better to skin than a creamy one, says Los Angeles-based makeup pro Collier Strong. Try stick or pot formulas like L’Oréal Cover Expert Concealer ($10; at drugstores) for the face and set with a powder like Neutrogena Healthy Defense Protective Powder SPF 30 ($12; at drugstores). For large scars on the body, opt for corrective foundation like CoverBlend By Exuviance Corrective Leg & Body Makeup ($16; 800-225-9411) or Dermablend Leg and Body Cover Crème ($16.50; 877-900-6700).
With a little time and patience, it’s possible to reduce the appearance of a scar so that it’s flatter and less prominent or visible. While the initial scar will take time to heal over a period of weeks, the long-term appearance and texture can be improved using methods approved by clinicians, although results are governed by your genetics, your type of skin and how well it recovers from injury.
Massage the skin around the scar with moisturizing cream to encourage blood flow and to keep the underlying tissue mobile in the first few days after surgery. The University of Michigan Department of Plastic Surgery suggests that you massage in circular movements along the scar after 10 to 14 days following surgery, to keep the newly formed fibrous scar soft. Use firm pressure with your thumbs or your fingertips. During the first few weeks of scar formation, the scar is immature and pliable, so massage for five minutes at a time, three to four times a day.
Eat a healthy, balanced diet containing fruit, vegetables and proteins, and drink up to eight glasses of water per day to hydrate the skin and flush away waste products. A 2005 article in “Selected Readings in Plastic Surgery” stresses the importance of protein, vitamin C, zinc and iron in the formation of collagen for efficient wound healing. Ensuring that your scar heals well helps prevent infections that can distort and redden the scar, making it more difficult to minimize its appearance.
Keep your weight stable if the scar is on an area of your body that might stretch if you put on excess weight. Scars take at least a year to settle completely, during which time they are more susceptible to extra tension and stress and will remain stretched when you lose the weight again. If the scar is over a joint, such as your knee or your elbow, try to minimize bending the joint while the scar is healing.
Mobilize the areas where you are scarred if your scars are the result of burns, taking advice and direction from your clinician. Burn scars can form painful, raised contractures, resulting in restricted movement, so a program of movement therapy is usually advised to minimize the likelihood of contracture, as well as the appearance of the scars. A pressure garment worn 24 hours a day also helps improve the appearance of your scars over a longer period.
Keloid scars need specific treatment to reduce their appearance. Keloids are the result of an over-production of collagen during the healing process, resulting in growths that extend beyond the boundary of the original incision. Massage helps reduce the itching, but not the size of the raised scars. Do not over-expose your scar to sunlight while it is healing. Always use a sunscreen, but remember that sunlight helps your body manufacture vitamin D, a vital building block of skin health and repair. Researchers from the aforementioned “Selected Readings in Plastic Surgery” article advise against the use of Vitamin E oil or supplements when dealing with wounds, as they believe it undermines collagen production and limits the strength of the fibrous scar tissue.
Keloids are among the most conspicuous types of scars thanks to their raised appearance. They’re also one of the more challenging types of scars to minimize, since cortisone injections or laser treatments are usually required to make even a small difference in their size and color. A recent Instagram post on Girl Gaze, however, may inspire those who have keloids to embrace and even celebrate their scars instead of hiding or treating them.
The reposted image, which was taken by photographer Sophie Mayanne, shows a stunning 24-year-old woman with the Instagram handle @biancahoneybeex. In it, she looks over her shoulder with confidence, her braids flying around her head to reveal a patch of keloids on her back. The photo alone is enough to make anyone see keloid scars in a new light, and the caption — a quote from the subject, presumably named Bianca — is a powerful motivator for anyone who’s ever struggled to accept part of their physical appearance.
“My keloid scars developed after I had severe acne on my face, back and chest. I was prescribed tablets to clear the acne but unfortunately they turned some acne spots into keloids,” Bianca says, explaining that she has tried injections and surgery to flatten the ones on her face, even though there’s a risk of these itchy, uncomfortable scars growing back. “They’ve stopped me from living my life, wearing certain clothing, and caused anxiety and depression. Sometimes people don’t realise how scars/skin can ruin an individual’s mental health.”
After the difficulties she’s been through, Bianca has come to a remarkable and inspiring conclusion. “From the nasty comments I have received, I have now realised life’s too short to care what people think,” she says. “I am starting to try love my skin and to believe I am unique. This is the beginning of my journey to become free from negativity and to regain a positive mind set.”
Although this portrait is part of Mayanne’s #behindthescars series, a body-positive collection of images and stories, Bianca herself has been posting photos with captions that could easily start a keloid-positivity movement. “I gotta start to love these keloids because they’re not going no where,” she says alongside a selfie showing the scars on her chest. “I hope other keloid suffers will find the seed to bloom/blossom and feel unique in their own skin,” she wrote alongside another. Her hard-won confidence may well inspire others going through similar struggles to see their own beauty, too.
Read more stories about amazing examples of body positivity:
- This College Student’s Rare Birthmark Is Going Viral for the Best Reason
- Body-Positive Yogi Jessamyn Stanley Wants the Wellness Industry to Embrace Fat
- This Stunning Photo Series Features Women Covering Their Insecurities in Glitter
Watch how this lupus advocate finds beauty in illness:
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Management of Keloids and Hypertrophic Scars
Other therapies with limited studies include intralesional verapamil, fluorouracil, bleomycin, and interferon alfa-2b injections. Although all of these have results comparable or sometimes superior to corticosteroid injection and silicone sheeting, the optimal keloid therapy remains undefined. Combinations of therapies have proved superior to individual approaches.
Intralesional verapamil (2.5 mg per mL) in conjunction with silicone sheeting reduced keloid postsurgical recurrence by 90 percent at 18 months (54 percent of patients were keloid-free; 36 percent had partial success) compared with only 18 percent showing any improvement with silicone sheeting alone (no patients were keloid-free).17 Calcium antagonists appear to work by reducing collagen production and may be a reasonable and safe alternative to corticosteroid injection in the future.
Intralesional fluorouracil (50 mg per mL, two to three times per week) appears to shrink keloids safely while avoiding the tissue atrophy and telangiectasia that may occur with repeated corticosteroid injections.30 Combining fluorouracil with corticosteroid injections and pulsed dye laser produced superior results more rapidly than corticosteroid injections alone or corticosteroids with fluorouracil.13 Good to excellent responses at 12 weeks as rated by a blinded observer were 15 percent for triamcinolone acetonide, 40 percent for triamcinolone plus fluorouracil, and 70 percent for all three modalities (all significant). Combining corticosteroids and fluorouracil diminished the adverse effects of corticosteroids. Rare skin complications of fluorouracil may include hyperpigmentation and wound ulceration. No systemic adverse effects (e.g., anemia, leucopenia, thrombocytopenia) occurred in this study.
Bleomycin is another useful chemotherapeutic agent; a standard approach is bleomycin tattooing 0.1 mL (1.5 IU per mL) over two to six sessions, with a maximal dose of 6 mL.31 Results of one study showed a total regression of 84 percent.18 Multiple intralesional punctures are probably safe because it is likely that less than 5 percent of the dose ever reaches the bloodstream.18 Compared with triamcinolone injections combined with cryotherapy, bleomycin tattoo performed significantly better for keloids larger than 100 mm2 (P = .03).19 Systemically administered bleomycin is capable of causing pulmonary fibrosis (at doses greater than 400 U) and various cutaneous reactions (at doses of 200 to 300 U), including hair loss, hyperpigmentation, fibrosis, and vasospasm, any of which warrants cessation of treatment.32
Intralesional interferon alfa-2b (1.5 million IU twice daily for four days) reduced keloid size by 50 percent over nine days, proving superior to intralesional corticosteroids.31 Interferon alfa-2b was also more effective than corticosteroids for preventing keloid recurrence after excision. Injection pain and expense (about $100 per treatment) are the main concerns. A liposome-encapsulated interferon alfa-2b cream is also being investigated for scar reduction.33
Radiation, alone or (more commonly) after keloid excision, is a much more controversial option. It may pose a risk of local growth inhibition in children and possibly subsequent cancer. Commondosesrangebetween1,500to 2,000 rads over five to six sessions following surgery.28 The success rate for radiation alone is 56 percent (range of 10 to 94 percent), but this increases to 76 percent (range of 25 to 100 percent) if administered immediately after surgery.9 Another study showed a 67 percent success rate with radiation, increasing to 75 percent if delivered within 48 hours of surgery.20 Most physicians would reserve radiation as a last resort for keloids refractory to all other approaches.
Many patients use topical vitamin E (alpha-tocopherol) hoping its antioxidant properties will prevent scars. However, there is little evidence that it is helpful, and some patients develop a contact dermatitis that may delay healing.34 Used early on, vitamin E may also reduce the tensile strength of the scar, and its use should be discouraged.
Another over-the-counter option is onion extract topical gels (e.g., Mederma), but limited clinical trials have failed to demonstrate any clinical improvement in scar height, erythema, or pruritis.35,36 Contractubex gel (not available in the United States) contains onion extract with heparin, which is thought to promote scar maturity. Although one trial compared this product favorably with corticosteroids, another showed that it was ineffective in improving scar height and itching.21,37
Moist exposed burn ointment contains multiple herbs with betasitosterol, which provides hydration and possible benefits to wound healing.38 Another plant extract product contains Centella asiatica and Bulbine frutescens (Alpha Centella cream), which may increase wound strength if used in the first six to eight weeks.39 All of these commercially available products emphasize preventive use because they are unlikely to reverse well-established keloids.
Laser Scar Removal: Which Types of Scars Can It Treat?
In theory, you know your scars are simply another aspect of your beauty. In reality, you might be tired of looking in the mirror and seeing those permanent reminders of teenage acne, an old injury, or the chickenpox you had as a kid. Luckily, there are ways of making those scars less visible. Laser treatment is a popular method for scar removal that satisfies many patients. If you’re wondering whether or not laser treatment is an option for you, here’s a guide to the types of scars that can be treated by lasers.
Raised scars from surgery, piercings, or other traumas
Your body has lots of built-in mechanisms for healing itself. Unfortunately, sometimes it gets a little carried away. When traumas like surgery, body piercings, vaccinations, or blisters injure the skin, the body can sometimes heal a little too aggressively, producing an excess amount of skin to close up the site of injury. When this happens, a keloid scar can form. Keloids are firm, raised scars that appear red or purplish in color. They can grow over time, and if keloid scars get big enough, they may even start to hamper your movement.
Another type of raised scar is hypertrophic. These scars form just like keloids, but they stay close to the site of the injury, whereas keloid scars extend to a larger area of skin. Hypertrophic scars usually look pink, and they can fade over time. Laser therapy can help flatten both keloid and hypertrophic scars and reduce the redness, making them less prominent.
Acne scars can be raised or pitted. Either way, they’re no fun. Most people get pitted scars after a bad bout of acne, which means the acne leaves little indentations in the skin. There are varying types of acne scars, including ice pick scars, boxcar scars, and rolling scars. Depending on the severity of your acne and how well your skin heals naturally, your acne scars may be large or small. In some cases, they might be barely noticeable. Other times, large, deep acne scars can make you extremely self-conscious.
Laser treatment can help close up your pitted acne scars and reduce their size. Using light to poke tiny holes in the skin, the laser will stimulate your skin’s growth so that it fills in the depressions for a smoother, more even look. This approach can also work for other types of pitted scars, like those left over from chickenpox.
Burn scars can be tricky to get rid of, but there are lasers that can help. For example, the pulsed dye laser targets damaged blood vessels in your skin, reducing redness and inflammation by focusing on one small area at a time. Other lasers use light and heat therapy or poke holes to stimulate the growth of new, healthy collagen in place of the burned skin.
Who shouldn’t get laser therapy?
Laser therapy is generally a very safe procedure, but there are certain situations in which it isn’t advisable or simply won’t be effective. Patients with skin conditions like psoriasis, dermatitis, and cystic acne will probably want to steer clear of laser treatment. Also, some forms of laser therapy aren’t recommended for people with darker skin types – though more options are opening up all the time.
If you decide laser treatment is for you, you may want to make a few small adjustments to your lifestyle leading up to the procedure. For example, if you take acne medication like isotretinoin, your dermatologist may suggest that you stop taking it for six months prior to your laser treatment. You’ll also need to watch out for sun exposure, as laser treatment works best on skin that’s not sunburned or too tan. It’s a good idea to tell your dermatologist if you’re prone to cold sores, and if you’re taking any vitamins or supplements. Meeting with your dermatologist ahead of time for a consultation will take care of any other loose ends and prepare you with all the information you need to make the decision about moving forward with laser scar removal.