Scar Revision

Scar revision is a general term meaning an assortment of treatments to help minimize the color, shape, size and texture of a scar. Scars form on the body as a natural healing response when repairing lost or damaged skin. Trauma to the tissue can be the result of an injury, previous surgery, a burn, insect bite or even acne. The treatment of scars varies according to what they look like as well as their location on the body. A scar's appearance depends on several factors including the nature of the injury, the size and direction of the wound, age, genetics and ethnicity. The physician will evaluate the scar and recommend the best treatment option.

Am I a Good Candidate for Scar Revision?

Patients who are GOOD CANDIDATES for scar revision include:

• Patients with a completely healed scar
• Patients who have scars which appear lumpy, flat or sunken
• Patients with scars that display a different color than their natural skin tone can have scar revision to blend the scar to match the surrounding skin tone

On the other hand, there are many patients who are NOT GOOD CANDIDATES and they include:

• Patients with certain skin disorders such as dermatitis and psoriasis
• Patients with serious or pre-existing medical conditions which could cause additional complications
• Patients with darker skin tones

Prospective patients should be in good health and have realistic expectations regarding the outcome of the surgery. Patients should have an understanding that the scar can be minimized but it (likely) cannot be completely removed. 

How is Scar Revision Performed?

Since there are numerous ways to improve the appearance of scars, the physician will first need to evaluate the damaged tissue in order to determine the most suitable treatment plan. Patients should talk to their physician to find out what medications they should stop taking prior to any treatment. They should also follow all pre-revision and post-procedure instructions. Some scar revision treatments can be done at home or in-office while others may require an outpatient surgery center depending on the patient's medical condition, degree of damaged tissue, location of the scar and the type of treatment procedure. The patient may be given a local anesthetic, pain medications or antibiotics during or after the procedure to minimize any discomfort.

• Topical creams, ointments or gels are generally a good way to improve the look and feel of some scars. A physician can recommend which method may work best. Most of these topical medications can generally be purchased over-the-counter. Creams, ointments and gels often include a steroid or antihistamine which can alleviate symptoms such as redness, itchiness and scar sensitivity. Patients who suffer from severe acne may benefit from silicone gel sheeting as a scar treatment since the sheeting normalizes the synthesis of collagen and reduces redness and irritation.
• Collagen injections may help the appearance and functionality of damaged tissue. Collagen is a natural protein in the body and it can be derived from cow collagen. It is purified and injected beneath the skin in order to replace the body's own natural collagen which is lost. Collagen injections can help raise, or fill-in, a sunken scar. However, collagen is slowly absorbed back into the body and will need to be re-filled.
• Cortisone injections help soften and shrink scars which have become hard. In addition, cortisone can reduce the bright red coloration some scars get due to inflammation. Cortisone is injected into the scar to help break down the skin's collagen and then new collagen forms after the wound has healed. It is important to understand that some types of scars may not respond well to injections so patients need to consult with a doctor about this treatment option.
• Micro-needling is used to treat patients with deep acne scars, sun damage and wrinkles. Micro-needling can be done in the doctor's office with minimal necessary recovery or downtime. The doctor uses a radio frequency device, also known as ultrasound therapy, to penetrate the dermis and deliver bipolar RF energy to the skin cells. The stimulation gently heats the skin and promotes collagen production. Micro-needling can be customized as a light or aggressive treatment.   
• Surgical scar removal (scar excision) might be necessary with:
  • A deep scar
  • Wide or long scars
  • Trauma scar that was initially not closed precisely
  • Scars that healed in an unusual way
  • Scars which are in a palpable location (easily touched or felt)

The first surgical removal option is excision in many of the above conditions. The surgeon may choose to perform scar removal under local or general anesthesia in order to remove the entire scar and then rejoin the skin. Even though a new scar will form, the objective is to create a less apparent scar. Zigzag closure or W-Plasty or Z-Plasty may be used to align the scar with natural tension lines of skin. Layered closure may be used to optimally close the wound. First, the layers below the skin's surface are closed and then the final closure is made on the surface.

Patients who do not have enough healthy tissue to suitably close the wound may need a skin graft. With a skin graft, the surgeon uses skin from another area of the patient's body. This is typically the surgical option when a patient has larger scars caused by burns. Punch grafts can be used to treat deep icepick acne scars. A punch graft is a small skin graft used to replace the damaged skin. The surgeon punches a small hole in the skin to remove the scar. The skin is usually taken from the back of the earlobe and placed where the former scar was located. Tape is used to secure the new skin graft in place for one week to promote healing. Although new scarring will transpire, the new scar is smoother and less conspicuous than the other.

• Dermabrasion can be used to treat scars as well as eliminate fine lines, wrinkles and age spots. Dermabrasion can be used to minimize small scars, surgical scars and acne scars. This technique utilizes an electric machine that abrades, or removes, the top layers of skin. After the skin heals from this scar revision technique, it gains a smoother appearance.
• A chemical peel is a technique used to minimize surface scars and irregular pigment. The chemical application, which is applied to the skin, essentially burns the top layer off. The patient can expect the treated area to blister and then eventually peel off. The skin that regenerates has an overall improved appearance. Superficial peels may be repeated at 1-4 week intervals until the patient receives their desired look. Medium-depth peels can be repeated in 6-12 months while repeating a deep peel needs to be determined by a physician.
• Laser treatments can be used to burn away damaged skin. During a laser treatment, the surgeon directs a highly focused light energy beam onto the scar and its surrounding area. The laser beam removes the outer layer of skin which begins the regeneration of new skin. In addition, the heat from the laser stimulates the production of collagen underneath the skin. The new scar will appear lighter in color and smoother. Depending on the severity of the scar, the patient may require several laser sessions in order to sufficiently improve the look of the scar.

What is the Cost of Scar Revision?

The cost of scar revision depends on the type of treatment performed by the doctor. In general, the costs for the revision treatments are:

• Topical creams, ointments and gels – They run anywhere from $15-$50 depending on the size of the product.
• Collagen and cortisone injections – Collagen injections can cost from $250-$800 while cortisone injections run from $100-$300 per shot.
• Micro-needling – The average cost runs from $100-$500 per session.
• Surgical scar removal – Depending on the size and severity of the scar, the cost can be anywhere from $500-$5000.
• Chemical peels – The cost ranges from $150-$900 depending on the severity of the peel.
• Laser treatments – The cost can be $200-$800 for smaller scars and $800-$2000 for larger and more complex scars.

Recovery and Downtime

The RECOVERY from scar revision varies depending on how invasive the procedure is and where the scar is located. Some minor revisions to improve scars may not cause any changes to the patient's current lifestyle while others require some healing time. During any recovery period, patients are instructed to stay hydrated with water to help regenerate and replace tissue. In addition, a proper balance of nutritional foods is important to help with the healing process. With all treatment options, patients should refrain from smoking to avoid infections and ensure proper healing.

Topical creams, injections and micro-needling have minimal recovery and downtime. The discomfort from the needle is minimal and no pain medications are needed. Patients can expect to see a little redness and inflammation due to the needle prick but this is temporary and usually subsides within 12 to 48 hours. It is important to understand that more aggressive micro-needling treatments require a longer recovery. Since the natural skin cells have been disrupted with micro-needling, patients are advised to stay out of the sun during the healing process. Patients should not use any skin products for the first 24 hours after micro-needling due to the fact that micro-needling boosts the absorption of products placed on the skin.

Laser treatments, dermabrasion and chemical peels can be customized to a light or aggressive treatment. Therefore, the recovery and downtime can also vary. For a light treatment, the patient can expect a reaction similar to bad sunburn. Redness and scaling will occur over the first week as new skin is regenerated. With a medium or aggressive treatment, the patient may also experience swelling. Deep peels can create blisters that may break, crust, turn brown and then peel off and they can take 7-14 days to heal. Bandages may be applied to all or part of the treatment area with these treatment options. The new skin will be pink or red but that usually fades within 6-12 weeks. Makeup can be worn to cover the discoloration until it fades.

The recovery time from surgical scar revision depends on the extent of the surgery and if the patient properly follows the post-surgery instructions given by the doctor. In general, patients can expect to see some swelling and discoloration for a few weeks as the new scar heals and then refines and fades.

Results

Injections such as collagen and cortisone can improve the look of pitted scars and decrease inflammation which causes a red tone. Plus, the results can usually be noticed immediately.  The results from injections for scar revision are usually long lasting but the injections may need to be repeated depending on the type of scar and treatment.

Patients can expect to see an improvement after micro-needling in regards to a plumping of the skin, tighter appearance and a fresher look. Patients will continue to have an increase in collagen production approximately 48-72 hours after micro-needling so the final results may not be seen for at least 4 weeks. Micro-needling results are considered long lasting due to the fact that the results can last for several years.

The results from dermabrasion, chemical peels and laser treatments vary depending on several factors including:

• Patient's skin type
• Condition of the skin
• Skill of the doctor
• Technique used by the doctor
• Equipment used for the revision
• Patient's lifestyle after the procedure
• Limitation to sun exposure

The results of surgical scar revision are considered long lasting although it can take several weeks, or months, to see the final results.

Limitations and Risks of Scar Revision

Patients may be LIMITED with scar revision if they do not have enough healthy tissue in the treatment area for closure during surgical scar tissue removal. Patients with darker skin tones may be limited from certain scar revision techniques such as laser treatments, dermabrasion and chemical peels due to the fact that these procedures can cause uneven skin tones.

Although the RISKS of having injections, topical gels and creams, micro-needling and laser treatments are minimal, there are a few complications which can occur with these techniques including:

• Redness
• Tenderness
• Bruising
• Inflammation
• Itchiness
• Bleeding at the injection site
• Infection
• Scarring
• Dark red blotches
• Tissue atrophy
• Hyperpigmentation (darkening of the skin)
• Hypopigmentation (lightening of the skin)

Surgical removal, dermabrasion, chemical peels and lasers are invasive techniques with greater risks and complications due to the nature of the procedure. Some of the risks can include:

• Temporary or permanent color change in the skin
• Redness
• Bleeding
• Infection
• Enlarged pores
• Loss of freckles
• Rash
• Chemical burn
• Additional scarring
• Adverse anesthesia reaction

Research is Key

Since there are many different types of scars, there is a broad range of scar revision treatments. It is important to remember that not all scars respond to the same types of treatments. Therefore, it is best to consult with a doctor about which type of scar revision treatment is best for the scar being treated. In addition, patients should understand that scar revision is not a means to completely erase a scar but is a method used to improve the look, texture and functionality of the damaged tissue.

Written by Cosmetic Town Editorial Team - MA

Based on an exclusive interview by Dr. David Shafer in New York, NY