Scars from prior surgery or from accidental injury can sometimes heal in an undesirable fashion. While scars can not be eliminated, they can often be improved in appearance, either by making them appear finer or re-orienting them in a direction that hides them more effectively. In general, there are two types of scars that tend to thicken and grow abnormally: keloids and hypertrophic scars.
Keloids are raised, thick scars that continue to grow. For example, some patients with recently pierced ears will see a scar that starts off as a small growth that eventually grows larger. Certain parts of the bodies are more common to develop keloids such as earlobes, the chest, and outer shoulders. Often times, patients with more pigment such as African-Americans, Latinos, and Asians are more prone to suffer from keloids. Cases are seen less commonly in Caucasian populations with less skin pigment.
Hypertrophic scars are usually very thick, red, and raised scars that can develop in any area over the body. It is more often seen after wounds which take a long time to heal and close, in burns, and in surgical scars which were closed under significant tension.
In many cases, scars can be revised to improve their appearance. These are highly dependent on all of the individual factors relative to the scar, such as the location, the orientation, proximity to a joint, skin quality, and availability of surrounding excess skin.
In general, Dr. Hsu recommends that patients wait for one year after the scar initially heals before going forth with a scar revision procedure. Typically the body is still remodeling during this first year, and sometimes the body can remodel the scar more effectively than what can be done with surgery.
Good candidates for this procedure:
- Patients with scars from previous surgery or trauma
Patients who are reminded of unpleasant memories associated with a highly visible scar
- Patients with keloids or hypertrophic scars with abnormal growth
What to expect: Consultation
All cosmetic consultations are complimentary and serve as a great opportunity to gain further insight by voicing your concerns and having questions answered. During the initial consultation, Dr. Hsu will ask some questions to get to know you and determine if you are a good candidate for scar revision.
Dr. Hsu will want to know about the circumstances or details surrounding how the scar was obtained, whether from prior surgery, or from an accidental laceration, or otherwise. He will also ask about your medical history, including existing medical conditions, past surgeries, tobacco usage, daily medications, supplements, and allergies. Finally, he will examine the scar and surrounding skin to assess whether there is a good chance for successful revision. If he determines that you are a good candidate for the procedure, Dr. Hsu will explain the next steps in going forth with the procedure. In order to reach your aesthetic goal, both you and Dr. Hsu will work together to decide all the necessary details that will ultimately give you the best results.
Scar revision is a straightforward hour-long procedure that can be done under local anesthetic. After numbing the area, Dr. Hsu will excise the scar, free up the skin on each side, and sew the sides together to obtain an aesthetically improved appearance. Dr. Hsu uses a special technique to close the skin that involves multiple layers of stitches to relieve skin tension on the wound. Freeing up the skin on both sides and using the multiple layer technique prevents the new incision from being pulled apart as it heals, helping it to heal in a thin line and not to be widened over time.
For keloids and hypertrophic scars, Dr. Hsu may also inject steroids into the area after making the incision in order to minimize the chance of recurrence. It should be noted that for keloid and hypertrophic scar revisions, there is a chance that the keloid or hypertrophic scar can return. However, the steroid injection will decrease this chance.
Recovery & Post-operative Instructions:
After the surgery, Dr. Hsu will wrap dressings around the surgical area which will remain there for the first week during healing. Most importantly, you should keep the surgical area dry until Dr. Hsu gives his approval to shower or get the area wet. In most cases, you can wet the area after a couple of days. To clean the rest of your body, you can bathe or use wipes until clean. Swelling & bruising will peak about 48 hours after surgery but have generally resolved in about two weeks.
Because scar revision is a minor procedure, most patients can return to work right away. The biggest limitation for post-operative patients is driving as Dr. Hsu prefers that patients do not drive while they are on pain medication. Patients are usually off their pain medication after a day or two depending on the size of the scar, so plan your work schedule accordingly.
Dr. Hsu likes to follow patients after surgery for an extended period of time to make sure the patient is satisfied and healing well. If you are a keloid or hypertrophic scar patient, Dr. Hsu will want to closely monitor your post-operative results to catch any signs of scar recurrence. Most follow up appointments are scheduled immediately after surgery and for up to a year afterward.
Dr. Hsu's view on Scar Revision.
I’ve seen a variety of scars, from either trauma, prior surgery, piercings, and many other causes, and they can exist anywhere in the body. Although scar revision is a conceptually simple procedure, there needs to be some careful thought to determine why the scar did not heal well the first time, in order to individualize the revision procedure to maximize the outcome. Not all scars are the same!
Overall, I utilize techniques to try to camouflage the scar (either by moving it into a natural skin crease, if possible, or by breaking it up) as well as techniques to help the scar heal in a thinner fashion. Scar revision is really a case of trading the old, widened and thickened scar for a new scar that is thinner and flatter. My approach is to use some of the techniques used in reconstructive surgery to minimize tension across the incision and to help it to heal in an optimal way. Even for what appears to be a simple scar revision, I’ve found that these small details matter, and the outcomes can be better when careful thought is placed into exactly how the revision is performed.
In the special case of keloids, the recurrence rate can be high if surgery alone is used -- keloids have a way of coming back. For this reason, I will typically use some additional therapy (scar gels, steroid injections, or others) to minimize the chance of recurrence. With the combination of careful surgical technique and adjunctive procedures, keloid excision can often times be quite successful.