When a Scar is More than a Scar

  • November 23, 2022
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  • Surgery
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  • Dr. Benjamin Phillips

An organ is a group of tissues that perform vital life supporting functions such as pumping blood and removing toxins. Most agree there are 79 organs in the human body. The largest organ is………..our SKIN! Our skin is 2 mm thick, and the average adult is covered with approximately 8 pounds and 22 square feet of it! Skin performs a multitude of functions - it waterproofs, shields and protects our body. It helps synthesize vitamin D, act as a barrier against potential harmful bacteria and for some is a canvas (tattoos). Whenever the skin is injured, either by an injury or surgery, our bodies work to repair the wound. As the skin heals, a scar may form; this is a natural process.

Whether a wound is created by a scalpel or table saw, there are three overlapping stages involved in the healing process: Inflammation, proliferation and remodeling. During the first stage the wound is cleansed of bacteria and debris, this usually takes 4 -10 days. During the proliferative stage the wound is being sealed up, like laying down bricks for a retaining wall. This occurs simultaneously during the inflammatory stage and lasts for a couple of weeks. The final stage, the remodeling stage, is when the wound gains strength. This process can last for several months to over 1 year. A fully healed wound will gain 70 to 80% of the skin's original strength.

There is a spectrum of scar formation with scarless healing on one end, normal wound healing in the center and pathologic scar formation, including hypertrophic and keloid scarring on the other end. Keloid and hypertrophic scarring contribute to most of the morbidity associated with scarring after surgery or injury. A hypertrophic scar is larger and more raised than usual. These types of scars can occur secondary to tight wound closure, wounds in areas of high tension (e.g., shoulders, knees and elbows), or after infection. This type of scar stays within the border of the original wound. Keloid scars represent a more robust scar response with the formation of firm raised tissue outside the border of the original wound. Hypertrophic scars can regress and become less pigmented and flatter over the course of several months to over 1 year. It is unusual for keloid scars to change pigmentation or decrease in size. Keloid scarring can occur in any ethnicity but is more common in individuals with heavily pigmented skin and individuals of Asian descent. In some cases, it is difficult to determine whether a scar is hypertrophic or keloid in nature. Some believe that a keloid is an extreme form of a hypertrophic scar, and others believe it is a distinct entity.

Whether hypertrophic or keloid scars are suspected, there are treatment options available. The first therapy is prevention (a good defense is a better offense). Scar formation can be reduced by placing incisions within natural skin creases (Langer’s lines) and taking care to bring the top wound edges together with minimal tension by placing deep buried sutures. Simple cloth tape over healing incisions has been shown to reduce the incidence of hypertrophic scarring. The use of silicone sheets or silicone gel have become very popular options to reduce scarring. There is no good evidence that either of these options reduce the incidence of hypertrophic or keloid scarring. However, adhesive silicone sheets have shown as a benefit in reducing pathologic scar formation. The benefit is thought to be secondary to the adhesive property of the sheet decreasing tension across the incision or wound. Pressure garments or devices are often used, the thought being that the compression causes a mild hypoxia by compression of local blood vessels that reduces the appearance of the scar. There is no good evidence that compression therapy results in a significant reduction in scar appearance. Contributing factors to this conclusion may be the expense of the garments and patient compliance. Steroid injection therapy has proven to be a good treatment option for keloid scars and may be considered for hypertrophic scars. For keloid scars, steroids may be directly injected into the scar or used as a secondary treatment after surgical excision. The use of steroids with hypertrophic scars is usually a secondary treatment after surgical excision. Whether a keloid or hypertrophic scar are excised, most protocols consist of a series of steroid injections spaced between 7 and 14 days apart. Surgical revision of the scar is also an option. Immediate closure of an excised hypertrophic or keloid must be performed without excessive tension. Techniques to lessen the tension of the excision repair include breaking up the scar area into smaller segments and reorienting the scar. Other treatment options include laser therapy, dermabrasion and radiation. Radiation is ineffective when used alone, but when coupled with surgical excision has shown a benefit.

Scars are a natural part of our life. For some they are a badge of honor after a wild mountain biking trip and for others they are a memento of a cut that occurred while attempting to remove an avocado pit with a steak knife. For many wound healing and scar formation occurs behind the scenes and little thought is given to it. But for some scarring can cause discomfort, decreased range of motion and emotional stress. The general approach is to be proactive during the initial incision closure or wound evaluation and if a pathologic scar results, which may be inevitable regardless of the initial care, being aware of the treatment options available.