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You'll probably wish to discuss the pros and cons of the surgery with
your surgeon beforehand to make sure you fully understand the implications
of the treatment he recommends for your specific scarring. Please click on
the links below to read more about the procedure that applies to you.
- Keloid Scars
- Hypertrophic Scars
- Contractures
- Facial Scars
- Z Plasty
- Skin Grafting and Flap Surgery
Keloid Scars: Keloids are thick, irregular masses of scar tissue that grow beyond the
edges of the wound or incision. They are often red or darker in color than
the surrounding skin. Keloids occur when the body continues to produce the
tough, fibrous protein known as collagen after a wound has healed.
Keloids can appear anywhere on the body, but they're most common over the
breastbone, on the earlobes, and on the shoulders. They occur more often in
dark-skinned people than in those who are fair. The tendency to develop
keloids lessens with age.
Keloids are often treated by injecting a steroid medication directly into
the scar tissue to reduce redness, itching, and burning. In some cases, this
will also shrink the scar.
If steroid treatment is inadequate, the scar tissue can be cut out and
the wound closed with one or more layers of stitches. This is generally an
outpatient procedure, performed under local anesthesia. You should be back
at work in a day or two, and the stitches will be removed in a few days. A
skin graft (see the section on skin grafting) is occasionally used, although
the site from which the graft was taken may then develop a keloid.
No matter what approach is taken, keloids have a stubborn tendency to
recur, sometimes even larger than before. To discourage this, the surgeon
may combine the scar removal with steroid injections, direct application of
steroids during surgery, or radiation therapy. Or you may be asked to wear a
pressure garment over the area for as long as a year. Even so, the keloid
may return, requiring repeated procedures every few years.
Hypertrophic Scars:
Hypertrophic scars are often confused with keloids, since both tend to be
thick, red, and raised. Hypertrophic scars, however, remain within the
boundaries of the original incision or wound. They often improve on their
own, though it may take a year or more, or with the help of steroid
applications or injections.
If a conservative approach doesn't appear to be effective, hypertrophic
scars can often be improved surgically. The plastic surgeon will remove
excess scar tissue, and may reposition the incision so that it heals in a
less visible pattern. This surgery may be done under local or general
anesthesia, depending on the scar's location and what you and your surgeon
decide. You may receive steroid injections during surgery and at intervals
for up to two years afterward to prevent the thick scar from reforming.
Contractures:
Burns or other injuries resulting in the loss of a large area of skin may
form a scar that pulls the edges of the skin together, a process called
contraction. The resulting contracture may affect the adjacent muscles and
tendons, restricting normal movement.
Correcting a contracture usually involves cutting out the scar and
replacing it with a skin graft or a flap. In some cases a procedure known as
Z-plasty may be used. New techniques, such as tissue expansion, are playing
an increasingly important role. If the contracture has existed for some
time, you may need physical therapy after surgery to restore full function.
Facial Scars:
Because of its location, a facial scar is frequently considered a
cosmetic problem, whether or not it is hypertrophic. There are several ways
to make a facial scar less noticeable. Often it is simply cut out and closed
with tiny stitches, leaving a thinner, less noticeable scar. If the scar
lies across the natural skin creases the surgeon may be able to reposition
it to run parallel to these lines, where it will be less conspicuous. (See
Z-plasty)
Some facial scars can be softened using a technique called dermabrasion,
a controlled scraping of the top layers of the skin using a hand-held,
high-speed rotary wheel. Dermabrasion leaves a smoother surface to the skin,
but it won't completely erase the scar.
Z-plasty: Z-plasty is a surgical technique used to reposition a scar so that it
more closely conforms to the natural lines and creases of the skin, where it
will be less noticeable. It can also relieve the tension caused by
contracture. Not all scars lend themselves to Z-plasty, however, and it
requires an experienced plastic surgeon to make such judgments.
In this procedure, the old scar is removed and new incisions are made on
each side, creating small triangular flaps of skin. These flaps are then
rearranged to cover the wound at a different angle, giving the scar a "Z"
pattern. The wound is closed with fine stitches, which are removed a few
days later. Z-plasty is usually performed as an outpatient procedure under
local anesthesia. While Z-plasty can make some scars less obvious, it won't
make them disappear. A portion of the scar will still remain outside the
lines of relaxation.
Skin Grafting and Flap Surgery: Skin grafts and flaps are more serious than other forms of scar surgery.
They're more likely to be performed in a hospital as inpatient procedures,
using general anesthesia. The treated area may take several weeks or months
to heal, and a support garment or bandage may be necessary for up to a year.
Grafting involves the transfer of skin from a healthy part of the body
(the donor site) to cover the injured area. The graft is said to 'take' when
new blood vessels and scar tissue form in the injured area. While most
grafts from a person's own skin are successful, sometimes they are not. In
addition, all grafts leave some scarring at the donor and recipient sites.
Flap surgery is a complex procedure in which skin, along with the
underlying fat, blood vessels, and sometimes the muscle, is moved from a
healthy part of the body to the injured site. In some flaps, the blood
supply remains attached at one end to the donor site; in others, the blood
vessels in the flap are reattached to vessels at the new site using
micro vascular surgery.
Skin grafting and flap surgery can greatly improve the function of a
scarred area. The cosmetic results may be less satisfactory, since the
transferred skin may not precisely match the color and texture of the
surrounding skin. In general, flap surgery produces better cosmetic results
than skin grafts.
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