Scars form when the skin is injured from any cause, most commonly trauma or surgery. While it is not possible to make a scar disappear, there are many options available to improve or minimize the appearance of a scar. The severity of a scar varies widely based on the location, skin type, skin color, and individual genetic makeup, history of previous surgeries or radiation, and underlying medical conditions of the individual. Scar maturation is a lengthy process and many scars will continue to undergo changes up to 12 months after the initial injury.
Often the best time to impact the final appearance of a scar is during the initial healing period. Early interventions include careful wound cleansing and care with various topical agents. Protection of a maturing scar from sunlight is important for the first year of healing to limit pigment changes that can occur from sunlight exposure.
Dermabrasion is a very effective procedure that takes advantage of the body’s natural healing mechanisms. Most superficial abrasions, like a skinned knee, heal without a scar, and dermabrasion works much the same way. In dermabrasion the outer layers of skin are carefully abraded throughout the scar and the skin around the scar. This creates a superficial injury that will weep some clear to blood-tinged fluid for several days, during which time the wound is kept clean and covered. After about seven to ten days a new layer of skin has grown over the wound and no dressing is needed. Make up can be applied at this time if desired. As this area heals the skin will remain quite pink for some time, but the new skin that grows tends to be smoother, flatter, and more regular in color than the original scarred skin.
Dermabrasion is a good option for scars that have slight irregularity to the edges or changes in pigment making them darker than the surrounding skin. Dermabrasion can make the visible scar fade somewhat and blend in better with surrounding skin. This procedure can be performed in clinic with local anesthesia or in an operating room with sedation or general anesthesia. Dermabrasion can be effective during the healing phases of scar maturation or once full healing is compete.
Various types of lasers can be used to improve the appearance of scars. One class of lasers that is beneficial works by targeting hemoglobin, the molecule in blood that gives it a red color. These lasers, such as the pulsed-dye laser (PDL), work very well for scars that develop persistent redness or small dilated blood vessels as they heal. The PDL can also improve the appearance of healed or hypertrophic scars as well. PDL treatments can be performed in the office with local anesthesia or in the operating room with sedation or general anesthesia. Effects of treatment typically include some temporary discomfort and potential bruising that is short lived. To achieve the best results, more than one treatment may be necessary.
Another laser type that is effective on scars includes the ablative or fractional lasers such as CO2, erbium or YAG lasers. These lasers work much like dermabrasion by producing a very targeted injury to the superficial layers of the skin and allowing new skin to grow in that is smoother and more even than the previously scarred skin. Treatment can be performed in the office with local anesthesia or in the operating room with sedation or general anesthesia. Effects of treatment include temporary discomfort and a period of wound healing that requires temporary wound care and dressings, but these are less involved with fractional lasers.
Some scars heal with uneven edges, depressions, tight contracture, or other abnormalities that will not respond adequately to dermabrasion or laser treatments. These scars may benefit from surgical scar revision. This involves creating a new, surgically precise scar in place of an existing traumatic scar. This can be very helpful to better align the wound edges, re-orient the scar, or divide scar tissue that may be pulling the skin abnormally. Scar revision does require a new period of healing and care for the incision, but often will yield a much better looking scar than was present initially.
A keloid is an abnormal scar response following skin trauma that tends to run in families and typically affects individuals with darker skin types. While the exact cause of keloid formation is not known, the process involves an over-abundant growth of fibrous tissue and collagen. Keloids tend to grow beyond the borders of the original scar and can cause troubling symptoms such as pain, burning, or itching sensations. Keloids commonly affect certain areas of the face such as earlobes, jawline, and neck but are very uncommon on the lips or nose.
Keloids are difficult to cure and have a tendency to come back following excision, often multiple treatment types are combined to give the best chance of a complete cure. Keloids that are just beginning to form can be managed with a combination of therapies. Compression and massage of the keloid can help soften the scar and application of a silicone sheet dressing can also provide benefit. Laser therapy, such as the pulsed dye laser (PDL) can improve symptoms of keloids as well as produce some softening and decrease the vascularity of keloids. Medication injections into the keloid with corticosteroids can help to shrink and soften the keloid, and a series of injections is often recommended to achieve the best result. Additional medical injections such as fluorouracil (5-FU) may be combined with steroid injections for improved results in problematic keloids.
Keloids that are more mature may be less responsive to medical or laser treatments and are often managed with surgical excision combined with additional therapies. Great care is taken during keloid excision to limit the chance of recurrence by minimizing surgical trauma and avoiding tension on wound closure. Often a steroid injection is performed at the time of surgery. The skin surrounding the excised keloid may have a tendency to form a new keloid so it is very important to treat this area with a variety of measures including silicone, compression, massage and a series of injections while the new scar is healing. This requires a commitment to follow up regularly, but provides the best chance for cure. Rarely, for keloids that have recurred several times or are especially large or symptomatic, excision of the keloid may be followed with a low dose of short term radiation therapy.
Keloid after treatment
Hypertrophic scars have many similarities to keloids and result from an overgrowth of fibrous connective tissue during healing, but they tend to be less severe than keloids. Hypertrophic scars do not extend beyond the border of the original injury, but can cause localized itching and tenderness. Early in their formation, hypertrophic scars may be difficult to distinguish from keloids and many of the early treatments are the same. Management options include topical therapy with silicone gel or sheet and scar massage along with steroid injections or laser treatments. Excision of hypertrophic scars may also be necessary if they fail to respond to more conservative treatments, but the recurrence rate is lower than for keloids.
Elongation of the earlobes or ear piercings is a very common problem that can occur naturally with aging, from wearing heavy earrings, or trauma. This can range from minor elongation of the earlobes or a lengthening of the piercing hole into a longer “slit” opening, to complete separation of the lower edge of the earlobe from an earring that has been traumatically pulled through the skin.
Repair of elongated or split earlobes is typically performed as a short, in-office procedure with local anesthesia to numb the entire earlobe. Repair of an elongated piercing typically involves precisely removing the tract of skin surrounding the piercing and closing the piercing with sutures to allow for healing. Once healing is complete the earlobe can then be re-pierced. For completely split earlobes the procedure involves creating two small flaps of skin that are carefully repositioned to create a natural looking earlobe. Once fully healed, this procedure typically results in a pencil thin scar that is difficult to see and allows for re-piercing.
Gauge style earrings progressively stretch out the earlobe to accommodate larger and larger rings. If a person later decides not to wear this type of earring they are left with a permanently stretched out earlobe around a large hole. Repairing this type of earlobe is also easily achieved in the office and often involves removal of a portion of the stretched out earlobe to create an intact, more natural appearing lobe.