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Hypertrophic Scars and Keliods

What is a scar?

A scar is a natural part of the healing process. A scar is the normal response of the organism to a skin wound, which is covered and filled by fibrous tissue. Since tissue restoration process provides a new tissue, this is not identical to the tissue that it replaces.

Conditions of the scar depend more on the location on the body than the reconstruction technique. Although every surgeon´s goal is to achieve a scar as less visible as possible, sometimes a thick and irregular scar may form. These scars usually can be improved with the appropriate chemical peeling.

Wounds final appearance depends on many factors such as:

  • Unexpected reactions of skin.
  • Skin type.
  • Location of the wound.
  • Presence of old scars in the surrounding area.
  • Wound and tissue tension.
  • Caring of wounds.
  • Surgical technique.


Every patient develops a different wound healing process, even in the same procedure. Even with the best planning and the most meticulous surgical techniques, development of a scar is unpredictable. You can be sure your doctor makes every effort to hide, camouflage and have a less noticeable incision. Although some marks may be obvious, they may improve in time following some medical treatments. Enough time must have elapsed to allow healing of tissues before judging results. Body response to injury is a very complex process. As every person has a different wound healing response, the time this process may take is unpredictable.

Body response to wound healing is one of the most complex physiological processes.

In the wound healing process you may expect:


  • Inflammatory phase.
  • Proliferative phase.
  • Remodeling phase.


In each patient every stage develops in a different way. However, in most healthy patients´ wounds heal in a satisfactory way and with minimal intervention.


Abnormal scar formation


Some patients have an abnormal wound healing process. This is known as hypertrophic scarring. This is a complex matter, but what you have to understand is that scarring occurs as a natural part of the healing process, and therefore the way how tissues repair is uncertain. There are special treatments for skin scars. Before proceeding with any scar treatment, your surgeon must identify the wound´s stage.

Scar revision - What is the scar revision?

Scar revision is a surgical procedure to improve the appearance of scars. Most of the times, the surgeon may improve the appearance of a scar, making it less obvious, changing its direction or length. Sometimes, when the skin has been removed and the lesion has developed on a wide retractile scar, a skin graft may be needed.

A scar revision treatment may only be performed when the scar is sufficiently mature. An early revision may interrupt the natural healing process. The red, tight and unpleasant appearance of a scar may reveal an immature healing process. While a soft, normal color and flat scar provides better conditions to be treated.

How is the scar revision treatment made? . What kind of anesthesia is used?, What are the requirements for scar revision?

Most scar revision treatments can be done under local anesthesia, and in an outpatient basis.

Instructions for facial scar revision

  • Your surgeon may recommend the best face and hair washing routine. Good oral hygiene.
  • Male patients should be carefully shaven. Avoid injuries during the shaving. This may increase the incidence of wound infection.
  • On the day of the procedure, do not apply makeup on the area to be treated.
  • Dental prosthesis may modify the shape, appearance and location of the scar. If you wear dental prosthesis, you will be requested to wear it on the day of the procedure to observe any change.



The procedure

The scar is delimited

The scar is delimited. Then, local anesthesia containing adrenaline is injected in the incision site. An incision may be needed to surgically remove the old scar. The major part of the subcutaneous scar is excised. Finally, the defect is closed in layers, with soft sutures. The deep and superficial layers are closed with soft material sutures.

Changing scar direction

Scars that cross joints or skin creases at right angles are prone to develop shortening or contracture, and tend to be hypertrophic. In these cases, the surgeon changes the scar´s direction to alleviate the contracture and make the scar less visible. Z-plasty, W-plasty and V-Yplasty are the surgical techniques most commonly used to improve appearance of scars.



Hypertrophic scars and keloids - What are hypertrophic scars and keloids?

The hypertrophic scars and keloids are two kinds of excessive scarring in the normal healing process. Abnormal scars form when the body continues producing collagen after the wound has healed. The wound expands in all directions, and may be deeper and wider than normal.

Hypertrophic scar is red, thick and itchy, but does not grow beyond the boundaries of the original wound. Keloid scar is the skin lesion that grows beyond its edges, erythematous and prone to grow as a tumor. Keloids are different from hypertrophic scars, which are less thick and deformed. These scars may be improved through an appropriate scar revision and postoperative care.

Treatment

What is the treatment to correct abnormal scars?

Surgical treatment can help diminish the size of keloids, making possible to combine other therapies such as pressure, steroids or radiation. When the abnormal scar presents excessive tissue tension, the surgeon may:

  • Change the direction of the tissues if the scar is in opposition to the skin tension lines.
  • Provide new skin tissue using a graft or a flap to eliminate tension.
  • Remove the excessive collagen.



Radiation

Radiation therapy adversely affects fibroblast growth and collagen production. However, this therapy is no appropriate for children, can be expensive and complex and has to be applied in recently formed scars.

Pressure

The application of mechanical pressure by compression devices is a successful method in the treatment of abnormal scars. Pressure produces vascular occlusion and subsequent hypoxia, which may work over the scar tissue to prevent and modify scar formation. Pressure therapy may used in the treatment of large areas (burns). This therapy must be worn daily for as long 24 hours, and should not be removed for more than 30 minutes a day during at least 9 months. For facial burns a pressure mask should be worn for 9 months or as recommended by the surgeon. Although the mask may reduce the scar size, wearing the mask may cause social isolation and discomfort.


Triamcinolone

Triamcinolone is a strong anti-inflammatory medication that interferes with fibrosis. Multiple injections are required to obtain the desired benefit. Overdose may lead to complications. Different treatment options may be used for treatment of abnormal scars.