Scar Revision & Keloid Prevention

Many people are not fond of scars which may have resulted from surgeries or trauma (auto-wrecks, contact with broken glass or sharp instruments) - some of these individuals may not respond normally to these dermal traumas and may keloid or hypertrophy. For those of you who would like the appearance of your scar lessened and are not prone to keloid scar formation, scar revision surgery and treatments may help.

Some people may barely scar at all, fading into an imperceptible line. Whereas other may keloid which results in collagenation outside the barriers of the wound. These usually look dark and very "ropey". Not all of us are going to form scars the same. not all of us are going to treat or be subject to the same elements during the healing phase. From sun exposure to smoking, to the area on which the inured skin resides - all these factors and more will effect the outcome of the mature scar. Scars in areas which are not mobile will less likely stretch, while scars on the legs may seem to fade more than those on the arms, stomach or back. Exfoliation and skin thickness can also contribute to the factors which affect scar formation.

What Is Scar Revision?

Scar Revision is the surgery or treatment to lessen the appearance or remove traces of damaged skin due to injury, be it elective or accidental. There are treatments such as Silicone Sheeting which is non-invasive and require only diligent use of special sheets of silicone for many weeks to many months to help fade the offending scar. Some invasive procedures require scar excision and resuturing or tissue glue to help reduce the appearance. Some may require Z-plasty, which is a more serious application.

The Difference Between Keloid & Hypertrophic Scarring

Many people are confused at what differentiates a keloid from a hypertrophic scar. They both have excessive collagenation in common however, they act, look and are made up differently. For instance, hypertrophic scarring will usually begin to form in the weeks following a surgical procedure, whereas keloid formation may take many months and even up to a year later.

The tissue structure also varies between the two scar types. Collagen fibers formation in keloid scars are generally less "unorganized" and usually have no direction and spreads outside the wound. The collagen fibers in hypertrophic scarring seem to be a little more structured and less chaotic than the collagen formation of the keloid - but are still vastly different than unlearned tissue. Hypertrophic collagen fibers are shorter and grow in an undulating pattern, whereas collagen fibers in keloids are more compact and higher in number - best described as an overgrowth of collagen.

The simple way to tell is if the scar is starting to widen to outside the original incision or wound or if it is only raised and ropey. Hypertrophic scarring takes on the appearance of the latter while keloids infiltrate and spread to the normal, unaffected skin outside of your original wound.

Am I a Candidate For Scar Revision?

For less invasive means such as silicone sheeting and gels you must be dedicated in your application and continue to wear the products until the scar is greatly diminished or until your physician instructs. Silicone sheeting is not a miracle device but it can help prevent forming scars from becoming keloidal or otherwise pronounced. It can also help fade and flatten them.

If your options is a surgical means, first and foremost, an individual must be in good health, not have any active diseases or pre-existing medical conditions and must have realistic expectations of the outcome of their surgery. Communication is crucial in reaching one's goals. You must be able to voice your desires to your surgeon if he/she is to understand what your desired results are. Discuss you goals with your surgeon so that you may reach an understanding with what can realistically be achieved. It is also important to disclose any tendency to develop keloid scarring to your surgeon! Revision Keloid scars can actually make them worse! African-Americans and persons of Asian descent (and other darker ethnicities) may be prone to keloidal scarring. If you re not sure what keloids are:

ke*loid (noun)

: a thick scar resulting from excessive growth of fibrous tissue and occurring
esp. after burns or radiation injury
-- keloid (adjective)
-- ke*loi*dal (adjective)

Keloids usually develop on the chest, back and earlobes (usually from ear piercing). Acne can cause keloids to form in those who are prone - on the face, back and upper chest to sternum area. However, keloids can possibly form anywhere on the body. If you have larger, puckering scars or scars that appear as though they are experiencing an itchy, overgrowth of collagen - you may very well be developing keloids. Just know that keloids will usually return even years after a "successful" treatment.

Hypertrophic scars may appear to be keloidal, but t hey are not. In fact, they are often easier to treat than keloids as they usually do not "regrow" like keloids. Hypertrophic scars usually remain within the margins of the original wound and not form outside of this area like keloids do.

You must be mentally and emotionally stable to undergo an cosmetic procedure. This is an operation which requires patience and stability in dealing with the healing period. There is sometimes a lull or depression after surgery and if there is already a pre-existing emotional problem, this low period can develop into a more serious issue. Please consider this before committing to a procedure. It the above describes you and you have the desire to diminish or remove existing scars, you may be a good candidate for scar revision.

What to Expect at Your Consultation

After checking a few surgeons' backgrounds and credentials, you will make an appointment for a consultation. You will meet with these surgeons and discuss your goals and you will disclose all information regarding your health; if you smoke, what medications or vitamins you presently take, etc. - this is very important. You really should consider smoking cessation as this can significantly decrease healing. Visit the Medication & Supplements List for more information.

You will discuss your complaints and concerns and discuss the various looks one can achieve, the amount that can be removed or diminished, etc. Your surgeon will explain the technique and incision placements that may be most appropriate for you. He or she should discuss the risks associated with scar revision with you, as well.

You will also discuss the available anesthesia that will be used for your procedure if you are being sedated. Most scar revision procedures are performed under Regional or even an oral sedative (valium) and local anesthetic for simple scar revision work. If your scar revision is extensive or if on younger patients or in difficult areas - you may undergo your procedure with General Anesthesia, Light Sleep Sedation, Twilight anesthesia. Either way, discuss this beforehand as many people are not aware of the risks of Anesthesia. If you do go under Deep General, ascertain that the anesthesiologist is certified. Please read the All About Anesthesia Page - the risks regarding anesthesia should be considered for a fully informed choice.

If you would like more information on consultations or a list of questions to ask your surgeon please visit the Consultation Help Page. If you should choose to book or reserve a surgery or treatment date you will usually give a deposit to hold your surgery date. Most times if you cancel a few days beforehand, this amount is non-refundable. After paying your deposit and scheduling a surgery date, you will also schedule a pre-operative appointment...

Your Preoperative Appointment

This appointment addresses more questions you may not have thought to ask at the initial consultation, such as more surgical details, concerns and even ascertaining that your surgeon is aware of what you desire from your procedure. Just as your surgeon will make certain that you know what it realistically possible from this procedure. NO scar can be removed completely. Your treatment may only slightly improve the appearance of the scar as it is now. Also know that any treatment worsen your condition.

You will also discuss your pre-operative instructions and speak about the recovery period instructions and what to expect in the months ahead. You will be given prescriptions for antibiotics, pain relievers, perhaps blood pressure medicines, prescription anti-inflammatory drugs and perhaps a box or directions for gaining a box of SinEcch - a pharmaceutical grade form of Arnica montana. Perhaps you will be instructed to obtain Bromelain or other types of remedies, although many surgeons would rather have you not take ANYTHING other than your prescription medications, please do not go against your surgeon's wishes. Remember, always ask your doctor before taking any of these products.

Please do not hesitate to address any concerns that you may have during this time and even after your pre-operative appointment. If you remember something when you get home or the next day or even the day of surgery - don't be afraid to ask.

Preparing for a Surgical Treatment

You should be given a pre-operative information packet that explains everything you should do and know before your surgery date. The packet should include a list of all the medications you should not take starting usually at 2 weeks before your surgery. These medications will include, but are not limited to, aspirin containing products, stimulants, seratonin supplements, etc. Would you like to view a typical Medication & Supplements List? We have a printer-friendly version as well. Also, if your surgeon advised that you may take Arnica montana, Bromelain, Vitamin K, etc. for swelling and bruising you should either have this in your packet or begin shopping for your necessities.

It is quite possible that you will have "blood work" performed. This is normally an extra out-of-pocket expense that the patient must participate in to check your white and red blood cell count and check for disease or disorders beforehand. If you are a female they may take an extra vial for a pregnancy test. Some surgeons ask that you have physical. This can be yet another out of pocket expense so ask at your consultation what will be needed when you are quoted a price.

So many things to do... so little time. Surgery will be here before you know it so visit the Preparing For Surgery page and relax. This section contains, printer-friendly pre-op lists, tips and advice as well as things you must do to prepare for your big day.

How a Scar Revision Treatment or Surgery Is Performed

This depends entirely on your condition and needed treatment. For simple measures your physician may have you try less invasive means such as silicone sheeting and gels you must be dedicated in your application and continue to wear the products until the scar is greatly diminished or until your physician instructs. Silicone sheeting is not a miracle device but it can help prevent forming scars from becoming keloidal or otherwise pronounced. It can also help fade and flatten them.

For problematic scars (keloids): Some problematic scars may be somewhat remedied by injections of Kenalog (a corticosteroid) which seems to break up collagen such as scar tissue. In very problematic cases, surgical revision will not even be attempted for fear of worsening the current condition of the scar.

For hypopigmented scars: Scar tissue lacks melanin, melanin gives your skin its color or skin tone and darkens with sun exposure or hormones. If your scars are lighter than the skin around it you may try Micropigmentation. Micropigmentation is the art of implanting ink subdermally (such as a tattoo) into the lightened areas to match the skin around it. Just be sure that your micropigmentation technician is skilled in scar revision tattooing and has photos of his or her work to show you. Scar tissue tattoos differently than unaltered (normal) skin and make appear darker than the intended pigment. Be sure that you choose a natural color that you are able to upkeep (such as not being tanned) so that your result looks normal. Please see our Micropigmentation Section for more information.

For surgeries or invasive treatments you may or may not be sedated. If you are being sedated the below few paragraphs may pertain to you:

First, you will have monitoring "pads" attached to you so that the surgical team can properly monitor your vital statistics before, during and after your operation. When you are brought to the operating room, electrodes will be "plugged" into these pads which are connected to the monitoring equipment.

Once you are on the operating room table, you will then be given your choice or your surgeon's preference in anesthesia as discussed prior to your surgery date. If you had been given an oral sedative or valium prior you will have less anxiety. They will more than likely insert an IV for a saline drip to keep you hydrated and have a vascular "doorway" for anesthesia, antibiotics, and other medications. If you haven't been given a sedative, it is more stressful for some patients. If you feel that you may experience anxiety inquire beforehand regarding an oral sedative. Having an IV inserted feels sort of like blood being drawn, but for a shorter period of time. It's the initial placement of the IV that may sting a bit. Some people get heir IV placed in the crook of the elbow, some the hand - it all depends upon your veins though. So if your veins are not very prominent this can be a problem. You are then brought to the O.R. if you aren't on the table yet. After the needle is injected into the vein it is pulled out and a little plastic tube is left in your vein. This is called a "catheter". The catheter is taped to your skin so it is not accidentally knocked or pulled out and is ready to be used as a sort of entryway for anything the surgical team deems necessary for your body. This is usually done before you get into the actual O.R. - by a nurse - and you have a saline bag hooked up to you. The medications will usually be given with a drip system with this saline. As said before, the saline will keep you hydrated both during and post-operatively.

If you have chosen an IV Liquid Sedative, they will insert a hypodermic into your tube that you are attached to or they attach the bag of it with a drip system to add a few drops every few seconds and when they spring open the stopper and it starts heading towards your body. The the effects of the anesthesia are felt soon after injection or opening the stopper - a few seconds in fact. It may feel similar to a sensation of "heat" entering your arm or hand at the catheter site. It then feels as though it is creeping up your arm - then it "jumps" from your shoulder to a metallic-like taste under your tongue and then you are blissfully anesthetized. The anesthesiologist or surgeon will then determine if you are sedated properly, your stats are stable and if you are ready for the surgery to begin.

You will then be marked with a magic marker type pen for the incision placement areas. You will then be scrubbed with Betadine, the surgical marker markings will remain - although not as dark. You will be injected with a solution of Lidocaine, epinephrine and saline. The epinephrine is a vasoconstrictor. This will impede your skin's ability to bleed excessively. Lidocaine is an anesthetic.

Your scar may be excised if in a more straight line, the skin pulled together and resutured with either hairline sutures or tissue glue (although this depends upon the area). Treatment areas which are more mobile such as knees, elbows, etc. may need thicker sutures.

Areas which cross the natural lines and folds of the body may need revision methods closer to flap rotation. Even Z plasty may be an issue where the scar has contracted and is limiting movement or covers an area such as the knee or the elbow. Please discuss these techniques with your surgeon as not all surgeons will offer the same treatment.

The Road To Recovery

You may get sick (especially if you have had General anesthesia or if you are sensitive to pain medications) on the ride home from the surgical center or hospital so have a bucket or can with a lid as well as water and some Ritz or "Goldfish" crackers. Bring pillows and a blanket if need be. If you hurt take your pain relievers. There is simply no reason to suffer. Besides studies have shown that patients with increased pain heal slower than patients who are not in pain.

If you were sedated for your treatment, you may be groggy from the anesthetic and or oral medications and probably won't remember much of the first day or two. You will have to take it easy for a few days. Bruising and swelling are a normal occurrence in most surgeries. Don't worry, it is all a part of the natural healing process.

Although any discomfort should be alleviated by your prescribed pain medication if you have excessive pain, redness, pus or other symptoms that do not appear normal, contact your surgeon immediately! Take your temperature regularly. An elevated temperature could mean an infection. Take those antibiotics on time. Also, don't forget if you are a female taking birth control pills that some antibiotics can interfere so in the event that you do have relations, use another form of protection as well.

UV Exposure: You MUST keep your treatment area out of the sun (including indirect sunlight and tanning beds) for about a year. Scar tissue takes approximately a year to mature and is actually 80% as strong as non-altered skin. Sun exposure can cause collagen degradation, hypo- and hyperpigmentation, burns, permanent redness and more.

Risks, Complications & Contraindications of Scar Revision

First and foremost if you are prone to keloids or have keloidal scarring in your family PLEASE let your surgeon know. Although your surgeon may already know this if your problem scar/treatment area is affected.

Unfortunately, all surgery has risks and complications. With scar revision under anesthesia, these include an allergic reaction to the anesthetic used and infection. For risks related to anesthesia - please see our Introduction To Anesthesia section. There could be asymmetry, general dissatisfaction, hematoma or seroma, or bleeding.

Numbness is possible, it usually subsides within the first few months but it may become a permanent issue. Puckering of the skin may occur and deeper than desired depressions may result. Excess scar tissue, stretching and lumps are possible as well. Please go over all risks with your surgeon at your consultation and your pre-operative appointment.