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Scars

What is a scar?

A scar is the body's natural way of healing and replacing lost or damaged skin. A scar is often made of fibrous tissue. Scars may be formed for many different reasons. They may be due to infections, surgery, injuries, or inflammation of tissue. Scars may appear anywhere on the body. The composition of a scar may vary. A scar may look flat, lumpy, sunken, or colored. It may be painful or itchy. The final look of a scar depends on many factors. These include:

  • Skin type

  • Where the scar is on the body

  • The direction of the wound

  • The type of injury

  • The person's age

  • The person's nutritional status

How can a scar be minimized?

Treatment will depend on your symptoms, age, and general health. It will also depend on how severe the condition is.

Scars often fade over time. Makeup can help cover the scar while it's healing. Some scars can be minimized by certain treatment methods. Treatment may only improve the appearance of a scar since it may not completely remove it.

Here are some of the more common scar-minimizing procedures:

  • Dermabrasion. This may be used to reduce small scars, minor skin surface irregularities, surgical scars, and acne scars. This method removes the top layers of skin by scraping (abrading) the skin. As the skin heals from the procedure, the surface looks smoother and fresher.

  • Chemical peels. These are often used to minimize sun-damaged skin, irregular color (pigment), and superficial scars. A chemical solution is applied to the skin causing it to exfoliate and peel off. After the top layer is removed the skin regenerates which often improves how the skin looks.

  • Dermal fillers. These are generally used to treat wrinkles, scars, and facial lines. There are a few types of dermal fillers that can be given by a shot (injection). These include synthetic solutions, semi-permanent fillers, and hyaluronic acid. Talk with your healthcare provider about which type is best for you.

  • Cortisone injections. A steroid is injected directly into the scar. This can help soften and then shrink hard scars. Keloids and hypertrophic scars often soften after this treatment. 

  • Cryosurgery. This can help reduce the size of scars by freezing the top skin layers. The freezing causes the skin to blister.

  • Laser resurfacing. This treatment uses high-energy light to burn away damaged skin. Laser resurfacing may be used to reduce wrinkles and refine hypertrophic scars.

  • Punch grafts. These are small skin grafts to replace scarred skin. The surgeon uses a small tool to make (punch) a small hole in the skin and remove the scar. Then the scar is replaced with a small piece of unscarred skin. Punch grafts can help treat deep acne scars.

  • Surgical scar revision. This is surgery to remove the entire scar and rejoin the skin. A new scar will form. The goal of this surgery is to create a less obvious scar. Surgical scar revision is often done on wide or long scars, scars that healed in an abnormal way, or scars in very visible places.

  • Radiation therapy. This is not used often. It's used mainly for scars that are resistant to other treatments. 

What are the different types of scars and treatment?

Abnormal scars sometimes form after a wound has healed. There are many different types of scars, including:

Keloid scars

These are thick, rounded, irregular groups of scar tissue. They grow at the site of a skin wound. But they can be much larger than the wound itself and expand outside of the area of the initial wound They often look red or darker in color, as compared to the nearby normal skin. Keloids are formed from collagen that the body makes after a wound has healed. These scars may appear anywhere on the body. But they are more common on the chest, back, shoulders, and earlobes. They occur more often in darker-skinned people. Keloid scars may occur up to 1 year after the original skin injury.

Treatment for keloid scars varies. There is no one simple cure. It's common for these scars to come back after treatment. Often more than one treatment is needed. Treatment may include:

  • Steroid injections. Steroids are injected directly into the scar tissue. This helps to reduce the itching, redness, and burning feelings that these scars may produce. Sometimes the injections help to decrease the size of the scar and soften the scar tissue. The main side effects are skin discoloration and a sunken area of skin at the injection site (atrophy).

  • Cryotherapy. The scar is frozen off.

  • Pressure therapy. A type of pressure appliance is worn over the scar area. These may be worn day and night for up to 4 to 6 months. It's not clear how well this treatment works.

  • Silicone dioxide. This is applied in the form of a gel or pad. This can help soften and decrease the redness of keloids. 

  • Surgery. If the keloid scar does not get better with other treatments, then surgery may be done. One type of surgery directly removes the scar formation with a cut (incision). Stitches help close the wound. Sometimes skin grafts are also used to help close the wound. This means replacing or attaching skin to an area that is missing skin. Skin grafts are done by taking a piece of healthy skin from another area of the body (called the donor site) and attaching it to the needed area. Unfortunately, even after surgery keloids can come back again. And sometimes even larger keloids are created.

  • Laser surgery. Scars may be treated with a variety of different lasers, depending on the underlying cause of the scar. Lasers may be used to smooth a scar, remove the abnormal color of a scar, or flatten a scar. Most laser therapy for scars is done together with other treatments. These include steroid injections, special dressings, and bandages. Multiple treatments may be needed, regardless of the first type of therapy. Pulse dye laser is a good choice for keloids. 

  • Radiation. This can be used for scars that don't respond to other treatments.

Hypertrophic scars

Hypertrophic scars are similar to keloid scars. But they don't grow as big as keloid scars and remain within the area of the original injury. They may also respond better to treatment. Hypertrophic scars may also look red, and are often thick and raised. They often start to develop within weeks after the skin injury. These scars may get better on their own. But that may take up to a year or more. Steroids may be the first treatment used to treat hypertrophic scars. But there isn't one simple cure. Steroids may be injected. Or they may be placed right on the scar, although topical application may not be useful. These scars may also be removed surgically. Often steroid injections are used along with the surgery. The injections may be required up to 2 years after the surgery to help maximize healing and decrease the chance of the scar returning. Like keloids, hypertrophic scars may respond to topical silicone dioxide application.

Contractures

Contractures occur when a large area of skin is damaged and lost, resulting in a scar. The scar formation pulls the edges of the skin together, causing a tight area of skin. This can then affect the muscles, joints, and tendons. This causes a decrease in movement. There are many different surgery options for contractures, including:

  • Skin graft or skin flap. Skin grafts or skin flaps are done after the scar tissue is removed. For a skin graft, skin is replaced or attached to a part of the body that is missing skin. Skin grafts are done by taking a piece of healthy skin from another area of the body (called the donor site) and attaching it to the needed area. Skin flaps are geometric cuts near the scar allowing local skin to be moved over the scar area. Flaps may be used when the area that is missing the skin does not have a good blood supply. That may be because of the location or because of damage to the vessels.

  • Z-plasty. This type of flap uses a Z-shaped incision to help decrease the amount of contractures of the nearby skin. It also may try to reorient the scar so that its edges look more like the normal lines and creases of the skin. Small stitches may be used to help hold the skin in place.

  • Tissue expansion. This is a newer method. It uses a process that increases the amount of existing tissue available for reconstructive purposes. This procedure is often used in addition to the flap surgery.

Adhesions

This is another type of scarring that may form between unconnected internal organs. Adhesions may cause problems during some surgeries.

Recovery from scar revision surgery

Follow all instructions to help maximize your recovery and healing. Your healthcare provider will advise you on all activity restrictions, depending on the type of surgery that was done. Scars can't be removed completely. Many factors will affect how your particular scar heals. It can take some scars more than a year after surgery to look better.

Medical Reviewers:

  • Michael Lehrer MD
  • Raymond Kent Turley BSN MSN RN
  • Rita Sather RN