Scars can result from injury such as cuts and burns, as a result of surgery or skin conditions such as acne. The vast majority of scars settle down to virtually unnoticeable marks but a small proportion of scars remain troublesome and noticeable. Scars can become red and raised (hypertrophic or keloid scars), stretched, or in some cases pigmented. Some scars remain red for long periods of time. If there is extensive scarring it can cause contracture of the skin and this can cause pain or restriction of movements in the joints close to the scar. Most scars can be improved with treatment but there are many types of surgical and non surgical treatments available and a decision about the best treatment for scars is often complex. Mr Dunaway works closely with a team where expertise in all types of scar treatment is available. The most complex scars may require multiple treatments in order to achieve the best possible correction. The most common scar problems seen are: persistent redness, hypertrophic scars, keloid scars, pigmented scars, lumpy scars, stretched scars, tight scars (scar contracture), pitted scars eg acne scarring, indented scars and scars that have caused an abnormality of contour of the surrounding skin.
Before a decision can be made about scar treatment it is important to understand the history of the scar including how it occurred, how it responded to treatment, whether or not there were any problems with healing and how it has changed with time. With this information it is possible to determine the best possible treatment. Mr Dunaway works closely with dermatologists who have an interest in scars and it may be advisable to have a joint consultation. There is a joint scar clinic at 152 Harley Street.
- Simple scar treatments – In the early phases of wound healing and maturation, simple treatments including gentle massage, regular moisturising with a bland cream, the use of silicone creams and protection from sunlight can dramatically help with the improvement of scar appearance.
- Non-surgical treatment of scars:
- Silicone application – Silicone is one of the few substances that can be applied to the skin that has been shown to have a significant effect on red and lumpy scars. Silicone is available as a gel, which can be applied as a thin film to the scar twice daily. Commonly used silicone gels include Dermatix and Kelocote. For more troublesome scars silicone gel sheets can be applied. These combine the effect of providing gentle pressure along with the effects of the silicone itself. Silicone gel sheets are available in many pharmacy’s and products such as Cica-Care which are self adhesive can be very effective in the early management of red and lumpy scars.
- Pressure – It is well known that gentle pressure on irregular or hypertrophic scars can be very effective. The most effective way of providing pressure is through custom-made pressure garments. The part of the body to be treated needs to be carefully measured and a garment of elastic material is made to fit over the scarred area to apply gentle pressure. This treatment is often combined with a silicone gel treatment and garments can be made that contain silicone sheets which further flatten and reduce irregular scars. Pressure garments are very effective for wider areas of lumpy irregular scars and are commonly used on the face to treat irregular scars caused by broken glass or severe abrasions. They can also be very effective in treating contracted scars over joints.
- Steroid Injections – Keloid or hypertrophic scars often respond to micro-injections of steroid (triamcinolone) directly into the scar. The steroid dissolves the scar tissue and gradually flattens it over a period of weeks. This technique is particularly useful for hypertrophic post surgical scars.
- Laser treatment – Lasers are used in scar treatment for two reasons. Firstly, some types of laser such as pulsed dye laser can be very effective in reducing the redness of a scar, secondly, some types of laser can be used for resurfacing irregular scars.
- Dermabrasion – Other types of skin resurfacing including dermabrasion and micro-dermabrasion can be effective methods of flattening irregular scars such as acne scarring and injuries that have caused multiple tiny lacerations.
- Injection of dermal fillers – Dermal fillers such as Restylane or Juvederm which are made from hyaluronic acid can be very effective in treating contour irregularities beneath scars. They are effective in the treatment of acne scarring. The disadvantage of this type of treatment is that it is only temporary and often has to be repeated every 6 months to 1 year.
- Medical tattooing – Medical tattooing (micro pigmentation) can be an effective way of treating scars which are discoloured and stand out because of this difference in colour to the surrounding skin. Medical tattoos are translucent and match the natural tones and hues of normal skin.
- Scar camouflage make-up – Scar camouflage make-up has a role to play in the treatment of scars and is often an effective way of treating aspects of scars which cannot be corrected in any other way. It is also very helpful to use camouflage make-up whilst undergoing long term scar treatment.
- Massage and manual lymphatic drainage – Some types of scars are associated with persistent and troublesome swelling. This is often particularly a problem on the face. Specialised courses of massage (manual lymphatic drainage) can be very helpful in dispersing this swelling and have a significant role to play in many types of scar managements.
- Surgical treatment of scars – There are many types of surgical procedures that may be effective in reducing the visibility and functional problems associated with scars. These include:
- Scar revision – This is a technique where the troublesome scar is excised. After the removal of the scar the wound edges are carefully sutured together with fine sutures which encourage a more favourable scar formation. Surgical excision is usually used in conjunction with other types of non surgical scar treatment to achieve the best possible result.
- Z-plasty – Where scars are unfavourably aligned and noticeable, it is often possible to realign the scar in a more favourable direction with a technique called z-plasty which involves transposing two flaps of skin. An example where this type of treatment may be used would be where a scar crosses a natural crease such as the nasolabial fold on the face. By realigning the scar it becomes less noticeable and in general heals in a more favourable way. Z-plasties are also very useful for treating scar contractures across joints.
- Subcision – Some types of depressed scar are caused by dense scar tissue, binding the overlying skin to underlying structures such as muscle. Subcision involves passing a sharp needle beneath the skin to release the tethered part of the scar. It can be very effective for some types of acne scarring and is often combined with fat transfer.
- Fat transfer – Fat transfer/lipo-filling involves harvesting a patient’s own fat with a tiny liposuction device. It is usually taken from the abdomen around the umbilicus, buttocks or thighs. The fat is then prepared by centrifuging it. The resultant purified fat is then injected beneath the scar to correct any contour deformity. When combined with subcision it helps prevent the recurrence of tethered scars.
- Skin grafting – The most troublesome and contracted scars may require treatment with skin grafting. This is a technique where a wide area of scar is excised and a partial skin graft is harvested from another part of the body to be transferred to the scarred area. Nowadays skin grafting is often combined with the use of dermal substitutes (specially prepared materials that replace the deeper layers of the skin). An example of such a material is Integra. The advantage of using these dermal substitutes is that they produce a more natural looking and supple skin grafts. Skin grafts can be of full or partial thickness and the use of a particular skin graft depends very much on the particular problems of a situation. When skin grafts are used on the face, skin is usually harvested from behind the ear, neck or scalp because these types of skin have the closest colour match to facial skin.
- Tissue expansion – Another rarely used but potentially very useful technique for treating wide areas of troublesome scar is tissue expansion. This technique involves insertion of a silicone balloon beneath the normal skin surrounding the scar. The balloon is gradually inflated which stretches the surrounding normal skin making more sufficient skin available to excise a wide scar and reconstruct it directly from the surrounding tissue.