Scars

There are various reasons people develop dissatisfactory scars. These could be secondary to injury or trauma or an operation. Sometimes they can develop for unknown reasons but usually this will be due to an injury which the patient is not aware such as picking at a pimple. Scars can be raised (hypertrophic & keloidal), widened or stretched, depressed, atrophic, pigmented or depigmented.

Hypertrophic scars are usually red & itchy, raised scars which are confined to the limits of the initial injury or incision. They tend to regress & become better with time.

Keloid scars are also raised scars but they usually extend beyond the limits of the original wound. They are more difficult to treat. Keloid scars are more common in black skin & may be worse in certain black families. The most common sites where these raised scars develop are in between the breast area (the sternum), the shoulders & earlobes.

Treatment:  Hypertrophic scars are more responsive to treatment than keloidal scars. It is important not to embark on any invasive treatment until after extensive consideration as most scars improve with time. The natural history of scars is that they are initially red, with time they lose their redness, become more mature & become paler than the normal skin on white skin & on black skin can become darker than normal skin. So the options would depend on the kind of scar.

Non-surgical: Patients can be advised to massage the scar with moisturising cream three to four times a day for a period of about three months. The scar is firmly kneaded with the tips of the finger, using the cream as a lubricant.

• Pressure therapy – pressure garments can be applied. These are more effective with hypertrophic scars. With respect to the ears, custom made clip-on earrings which apply pressure can be made. These will need to be worn for at least a period of six months.
• Silicone – this is available in either sheets or most recently in a gel form. Prolonged use of this is required. The use of the recently available gel form has increased compliance with this method of treatment.
• Steroids – these can be administered topically by means of adhesive tape or by intralesional injection (the steroids are injected into the scar). This can be done in the out-patient clinic. Most children will require some form of quick general anaesthetic. These injections are normally administered usually every 4 - 6 weeks. Most patients require a few injections for a consistent effect. Side-effects of the use of steroids include thinning of the skin (atrophy), loss of pigment (this can be quite troublesome in afro-carribean people) & development of thread veins (telangiectasia).
• Radiotherapy – usually reserved for keloid scars that have not responded to any other form of treatment. Usually combined with surgical excision. The risks of radiotherapy include skin changes & in the long term risks of malignancy including skin cancer.

Surgical: usually combined with the previously mentioned modes of therapy. The most common form of excision is an intralesional excision where the bulk of the scar is reduced, leaving only the rim. This is followed by the application of steroids at the operation & an interval intralesional injection of the steroids at 6 week intervals to reduce the chances of recurrence.

• Depressed scars can be treated by excising the scar & use of zig-zag operation (z-plasty) underneath the skin to elevate that level of skin. More recently injectable fillers can also be used to elevate the scar.
• Other methods of revising the scars include: small flap operations or Z-plasties where the skin is rearranged, skin grafts, dermabrasion, use of lasers to reduce the redness, staged or serial excision & even tissue expansion where balloons which are progressively filled with saline & put on the normal skin to expand it enough to excise the scar & close the wound directly.

Duration of operation:  This will depend on what particular technique is being used.

Anaesthesia:  Most can be done under local anaesthesia. The larger & more extensive scars will require general anaesthesia.

Duration of stay in hospital:  Most can be done as an out-patient stay. Some may require an overnight stay.

Risks/Complications:  Complications include bleeding, infection, wound breakdown. The most difficult to treat complication is recurrence. Overall the treatment for scars is usually a combination of different modalities.