What Is A Scar?
Any incision or break in the skin may form a visible area that appears different from surrounding tissues—a scar. Burns that break the skin and damage the upper layers may also leave a scar.
Some individuals take a certain pride in their scars and consider them a “badge of courage.” This is not uncommon among wounded soldiers. However, just as frequently, scarred men and women prefer to hide this outward sign that serves as a constant reminder of a bad experience and may even prompt questions about how it occurred. Battle wounds, car accidents, fires, and even bad relationships often leave scars that the individuals may want to remove.
I participate in a program sponsored by the American Academy of Facial Plastic Surgery (AAFPRS) that provides free reconstructive surgery to battered women attempting to build new lives. Of course, we all know that the scars these women cope with run much deeper than what we see on the surface. However, those of us involved in this work notice that even a slight improvement in the outward scars can make an enormous psychological difference. It’s as if renewed self confidence can emerge after an oppressing weight has lifted.
What Causes A Scar?
Our bodies have an amazing ability to repair injuries. If a skin wound stays superficial and doesn’t penetrate completely through the layers of the skin, then the skin is able to repair itself without leaving a visible scar. This kind of wound is similar to a scraped knee, or an intentional wrinkle-reducing laser burn. A visible scar forms when an injury breaks the integrity of all the layers of the skin to the underlying subcutaneous tissues.
As the wound heals, new, tiny red blood vessels are stimulated to grow toward the wound to provide more avenues to transport bacteria fighting cells and collagen-producing cells. The fibroblast, the collagen producing cells, lay down new collagen, and we see evidence of their presence as the edges of the skin contract to close the wound.
As the wound heals, the collagen continues to remodel itself in an attempt to fall within the natural tension lines of the skin. As time passes, the wound contracts and often forms a depression in the skin. When they’re no longer needed, red blood vessels retreat, which is why the scar becomes pale white. New collagen layers do not contain pigment or hair cells, in contrast to the tissues surrounding the wound. If too much collagen is laid down in a haphazard manner or the normal process of collagen remodeling doesn’t occur, then a hypertrophic or a keloid scar forms. In general, those who are older with thinner, fair skin tend to heal with less chance of scarring than a younger person with thicker, darker skin. Younger people with thick skin tend to have robust collagen-producing cells that respond strongly to an injury by creating an abundance of collagen.
Both hypertrophic and keloid scars are more common in the thicker, oilier skin of those of African descent, including African Americans, and those of Mediterranean descent. A hypertrophic scar is an enlarged, widened scar, but it stays within its borders and does not grow in size. It can usually be eliminated by excising (cutting) it out and re-sewing the edges back together. A keloid scar is bulky and tumor-like, in that it outgrows its borders and becomes increasingly larger and potentially disfiguring. Keloids are commonly seen on ear lobes, shoulders, and the chest. There is a general range in the aggressiveness of keloids: some are more aggressive than others and continue to grow to great sizes while others grow slowly. Why this happens is not well understood.
How To Prevent A Scar
Most relatively minor injuries, even those that are closed with sutures, will heal on their own and not require further treatment. Here are a few guidelines to prevent or minimize a scar:
Don’t smoke! This will significantly increase your chance of noticeable scarring.
Following a repair, with or without sutures (see below), unless otherwise instructed, be sure to keep the wound clean and moist. Vaseline and Aquaphor are good moisturizing products found in your local drugstore. If you use a topical antibiotic ointment, such as Bacitracin or Neosporin, on any healing wound, apply it for only 24 to 48 hours and then switch to Vaseline or Aquaphor. This can be left on for approximately a week. Antibiotic ointments can irritate the skin and you don’t need the topical antibiotics after 48 hours anyway because the body in most cases has already placed a protective film over the wound. After sutures are removed, treat the area gingerly to avoid re-injury. Avoid exposing the injured/repaired area to the sun, and protect the area with sunscreen. Sun exposure may lead to permanent skin color changes to the scar.
Topical And/Or Oral Treatments
Tissue glues are similar to the Super Glue or Krazy Glue you find in the hardware store. Although I don’t recommend using hardware store glue on your skin, I’ve seen maintenance workers who knew about the action of these glues and repaired their own skin wounds using just such a product—and rather successfully, too.
But I urge caution, because if this glue gets under the skin’s surface it irritates the deeper tissues, which results in a worse scar than likely would have occurred with another closure method. Some physicians may be too quick to use the Dermabond tissue glue instead of stitches, and I don’t think it is a good idea for a deep wound. If the glue is put on top of a deep wound, it’s almost certain that the patient will end up with a bad scar months later.
Once the wound penetrates through all the layers of the skin, to get the best healing result it should be closed with deep dissolvable stitches in addition to superficial stitches.
While topical antibiotic creams, Bacitracin and Neomycin, for instance, exist to help heal the wound, they only indirectly address the scarring itself. If a wound heals without infection or significant scab formation it may result in a better appearing scar. But it is most beneficial to use these products within the first 24 to 48 hours after the injury occurs. After that period of time, any moist occlusive product such as Vaseline will be just as beneficial. This is the reason for the claim that these products improve the appearance of scars.
Over-the-counter topical agents, such as Mederma, are reported to improve the appearance of scars, but most do very little if anything to help the appearance of the scar, especially if it is an old scar. OTC products such as Vaseline and Aquaphor will help keep the tissue moist while it heals, thus minimizing the scar.
Procedures And Other Treatments
When Sutures are Recommended
If an injury penetrates through the skin to the subcutaneous tissues, then we need to help the repair process through sutures (stitches), which give us the best chance to minimize the scar. If the injury is on the face, it is important to have the wound seen by a physician within 12 to 24 hours following the injury.
After that 24 hour window, an open wound is at high risk for infection and may not be treatable with stitches. In such a case we will have to allow it to close on its own over time, which will leave a noticeable scar.
Cosmetic doctors recognize the importance of bringing the edges of the skin together in a way that gives a wound the best chance to heal well. In addition, certain inherent lines of resistance exist in the skin; in order to be hidden, it’s important that the scars fall into the lines of least resistance. A scar that goes against the normal tension of your facial skin is worse than one that “works” with the lines of least resistance.
After a wound is closed with stitches, you’ll likely be instructed to use a topical ointment on the wound’s surface for one week. With the exception of a few rare situations, moist wounds always heal better than dry wounds. Dry wounds lead to scabs, which we try to avoid because they increase the chances that a scar will form. Approximately a week after the initial injury, we remove the stitches. If we take them out too early, then we increase the risk that the wound will reopen, but if they’re left in too long they too can leave track marks or scars. Sometimes a tissue glue (Dermabond) is placed on the wound after the stitches are taken out to assure the skin edges stay together.
Once the stitches are removed, the wound is weakly held together, so you have to be careful not to re-injure the area and reopen the wound. During this early healing phase, there are things we can do to end up with the least noticeable scar possible, such as trying the OTC gel Mederma.
We can bring about greater improvement with topically-applied silicone sheeting. This is cumbersome, but it’s been shown to improve the appearance of the scar during the early phases of scar remodeling. It is during this early phase that patients often consult with me about ways to minimize the appearance of the scar.
Older Medical Treatments
In older scar management, we allowed the wound/scar to completely heal, which usually took about a year, after which a plastic surgeon offered a scar revision. This generally meant cutting out the scar and re-sewing the skin back together. This meant that for another period of time, the scar would look red and swollen before eventually getting better.
Although many patients didn’t like this long process, it was what we believed would lead to the best results.
Newer Medical Treatments
In my practice, I prefer to treat scars early in their development phase. Shortly after the stitches are removed, I start laser treatments. This has been an enormously successful way to avoid a surgical scar revision a year later. Scars work hard to remodel themselves and patch up the wound during the first 90 days after an injury. The collagen is laid down haphazardly rather than in a neat, orderly fashion. We’ve learned from doing laser treatments to remove wrinkles that we can influence the way collagen remodels itself following a laser treatment.
Therefore, using this same philosophy, I now address scars very early on with a series of ablative erbium laser treatments.
Special Considerations
Older scars, defined as more than one year old, are often pale in color, have irregular edges, and are associated with a shadow-catching depression in the skin. Once a scar has reached this point, we can get effective results with the ablative laser, but the impact isn’t as great as what we achieve with a scar in the early phase.
In these cases, only a surgical scar revision will bring the desired result, but then the patient has to accept the risk that another scar will form and take a long time to heal. If someone is looking for a quick improvement in an older scar, then I generally offer a filler agent, such as Restylane or Juvederm to fill in the scar and bring it to the surface level. Over time, most scars contract and form a depression, but if we elevate the scar to the surface level, then the scar no longer captures shadows, which makes it much less noticeable.
We see incredibly impressive results with these treatments and for certain areas of the face I can now recommend a filler rather than the older surgical scar revision treatment. If the person is happy with the temporary improvement we achieve with the filler, then I may offer a permanent filler such as silicone or Artefill.
We also have other new and novel treatments for Keloid and Hypertrophic scarring using a combination of triamcinolone/5FU/ Botox all mixed together in a defined ratio. The mixture is placed into the scar in serial treatments each separated by about a month. After three treatments most people can expect prolonged quiescence. This newer combination has resulted in significant improvement in what has traditionally been a very difficult scar to treat.
Acne Scarring can now also be significantly improved using a combination of fat transfer and simultaneous deep ablative fractionate laser treatments. Your own fat has many stem cells and growth factors which seem to repair damaged skin. In combination with the collagen and wound repairing properties of laser treatments the two work synergistically to reduce the appearance of the scars. The procedure requires an anesthetic but the results are the best we ever seen for improving old box car and ice pick scars.
