Scars Definition and Meaning:
The negative impact of scars, those inevitable consequences of injury, disease, and surgery affect billions worldwide. But their definition and meaning remain poorly understood amongst most people. Scar tissue is best understood as a localized collection of a substance called collagen that is deposited by the body at the site of a wound. Scars are necessary to mend damaged skin, but in so doing, often created problems of their own.
Collagen
Once skin is injured, the wound healing process begins immediately. Around day 5, specialized cells called fibroblasts begin to produce and deposit collagen into the gaps between skin edges. Filling of the wound with collagen ultimately mends the damaged skin in the same way that cement is used to fill in a crack in the sidewalk. It is the amount of collagen laid down in the wound, as well as its color, and texture that determine what a particular scar will look like. A minimal amount of skin-toned collagen is ideal and produces a scar that is fine, flat, and blends beautifully into the surrounding skin. Too much collagen, and one that is raised, wide, and discolored can be the result. Collagen that stretches over time can lead to a flat, overly wide scar.
Types:
Practically speaking, there is no such thing as “scarless” healing. A simple way to understand the different types of scars is by classifying them as normal and abnormal.
Normal Scars
Normal scars are the types both patients and surgeons strive to see. This type of scar is the closest we can ever get to “scarless” healing. Normal, mature scars are fine, flush to the skin, blend well, and are minimally visible overall. Notably, even the best scars usually looked angrier, redder, and possibly even raised within the first few months of healing. Over 12-24 months, these normal, mature scars gradually flatten and lighten. This rather long maturation process during which the scar improves dramatically explains why it takes time to know exactly how it will turn out. It’s also why significant interventions are not recommended for at least the first 12 months after surgery.
Hypertrophic Scars And Keloids
Keloids and hypertrophic scars are thick, raised, and discolored. They result from the over-deposition of collagen during the healing process. With these, healing seems to get “stuck” in the phase of healing during which collagen is produced – something like a water tap that’s stuck in the on position overflowing a bathtub. Keloids and hypertrophic scars can be itchy and painful and many people find them very difficult to cope with. The severity of the impact that they have on peoples’ lives is hard to overstate. It is therefore imperative that their cause and potential preventative measures be understood well by patients prior to undertaking elective surgical procedures.
Hypertrophic And Keloid Scars: Similar, But Very Different
The substantial overlap in risk factors, appearance, and behavior between hypertrophic scars and keloids can make them difficult to distinguish by patients and even by experienced doctors. While hypertrophic scars and keloids share much in common, there are also some key differences between the two. One significant difference is that hypertrophic scars more or less stay within the boundaries of the incision or injury that created them. Conversely, keloids grow far outside of the incision line, behaving more like a growing tumor than a scar. Moreover, hypertrophic scars often improve over the first year, while keloids rarely do, and often get worse with time. Here are some of the differences between hypertrophic and keloid scars:
| Hypertrophic Scar | Keloid |
| more common | less common |
| from a wound or incision | from a wound, incision, or even a trivial injury like acne, piercing, or bug bite, sometimes seem “spontaneous” |
| usually seen a few months into healing | can arise many months or even years after a wound |
| extend minimally beyond borders of initial wound or incision | can extend greatly beyond borders of the initial wound or incision, showing almost tumour-like growth |
| generally improve over first year | rarely improve over time, often get worse |
| often occur over joints, high tension areas | commonly on upper back, earlobes, neck, knees, shoulders, face, upper limb |
| can be itchy, usually not painful | commonly itchy and painful |
| all skin tones | strongly associated with darker skin tones |
| weaker genetic association | stronger genetic association |
| often improve with surgical revision | recurrence rate is extremely high, can recur even larger than the original keloid |
Wide Scars
These typically start out flat and of normal width but become wider with time. They ultimately becoming wide, flat, and pale. Wide-spread scars are most common in areas of constant motion such as the knee, shoulder, and upper back. “Stretch marks” are a particular type of wide-spread scar. Many patients do not find wide-spread scars as distressing as keloids and hypertrophic variations due to their more subtle, less aggressive look. But if a wide-spread scar occurs on a cosmetically important area such as the face it can be a real aesthetic concern. Therefore, understanding, anticipating, and ultimately preventing them is worthwhile for all surgical patients.
Pigmented Scars: Too Dark Or Too Light
Healing incisions are prone to pigmentary abnormalities that can contribute to an undesirable aesthetic appearance of scars. Both hypo-pigmentation (too light) and hyperpigmentation (too dark) are commonly seen. These discolorations can make scars that have otherwise healed well far more conspicuous. In general, individuals with darker skin tones and larger wounds that are not closed surgically such as with stitches or skin staples are more prone to pigmentary abnormalities. Wounds that become infected, or open prior to healing are also more susceptible to abnormalities in pigmentation. Ensuring wounds heal in a complication-free manner is critical to avoid abnormalities in pigmentation. Healing areas should also be carefully protected from the sun for at least the first year after surgery. Direct sun exposure in the first year can darken scars permanently, making them more noticeable.
Scar Removal, Scar Prevention, and Scar Treatment:
Scarless healing, prevention, and scar removal remain amongst the holy grails of medical science. Practically speaking, there is no such thing as “scarless” healing or complete removal. Whenever someone describes surgery or a wound that “didn’t leave a scar”, the truth is that one is present but barely visible. While the goals of scarless healing and total prevention have yet to be achieved, major progress has been made in this area in recent decades.
Prevention
The first step in effective scar prevention is understanding what type of scars you are most likely to form because different scar types have different approaches. Scarring likelihoods are very difficult to predict in many cases because of the large number of complex factors that contribute to overall scar results from injury or surgery. Preventative measures for different types of scars are summarized here:
Everyone Should Do These To Optimize Scarring:
| Advice | Reasoning |
|---|---|
| adhere to all after-care instructions carefully | any healing complication can lead to poor scarring |
| don’t return to physical work or exercise too early | can lead to stitches opening or infection |
| use sunscreen as soon as the wound is healed (consistently for 1 year) | sun exposure can permanently darken scars |
| silicone gel or silicone strips for 3 months | proven to help prevent thicker scars |
If You’re Prone To Hypertrophic Scars:
| Advice | Reasoning |
|---|---|
| adhere to all after-care instructions carefully | any healing complication can lead to poor scarring |
| use sunscreen as soon as the wound is healed (consistently for 1 year) | sun exposure can permanently darken scars |
| prolonged use of silicone gel or silicone strips for 6 months | proven to help prevent thicker scars with prolonged use |
| pressure devices such as compression earrings after ear-piercing for 3-12 months | softens and flatten scars |
| consider cortisone injections if not improving by 6-12 months (as per the advice of your doctor) | a cornerstone of hypertrophic scar prevention |
If You’re Prone to Keloid Scars:
| Advice | Reasoning |
|---|---|
| adhere to all after-care instructions carefully | any healing complication can lead to poor scarring |
| use sunscreen as soon as the wound is healed (consistently for 1 year) | sun exposure can permanently darken scars |
| prolonged use of silicone gel or silicone strips for 6 months | proven to help prevent thicker scars with prolonged use |
| pressure devices such as compression earrings after ear-piercing for 6-12 months | softens and flatten scars |
| cortisone injections as soon as the wound is healed or even during the procedure consider cortisone injections if not improving by 6-12 months (as per the advice of your doctor) | a cornerstone of keloid scar prevention |
| Botox injections (botulinum type A toxin) | reducing muscle tension can help prevent thick scarring |
| less common options are injections of 5-FU, verapamil, and bleomycin | all have been shown to help prevent thick scarring |
If You’re Prone To Wide-Spread Scars:
| Advice | Reasoning |
|---|---|
| early and prolonged supportive taping with products such as Steri-Strips and | supports the wound edges to help prevent scar widening |
Treatment And Removal Of Scars You Already Have
Hypertrophic Scars:
| Advice | Reasoning |
|---|---|
| prolonged use of silicone gel or silicone strips for as long as improvement is occurring | proven to improve even scars that have been present for years |
| cortisone injections | softens and flatten scars |
| surgical scar revision if still problematic at 1 year, followed by preventative measures | removes scar completely; goal becomes preventing recurrence |
Keloids:
| Advice | Reasoning |
|---|---|
| prolonged use of silicone gel or silicone strips for as long as improvement is occurring | proven to improve even scars that have been present for years |
| cortisone injections | softens and flatten scars |
| less common options are injections of 5-FU, verapamil, and bleomycin | all have been shown to help improve thick scarring |
| Botox injections (botulinum type A toxin) | reducing muscle tension can help improve thick scarring |
| laser | softens scars and reduces discoloration |
| surgical scar revision if still problematic at 1 year, followed by aggressive preventative measures | removes scar completely; goal becomes preventing recurrence |
| radiation | powerful modality, usually used after surgery, many potential side effects so used only in severe cases |
Wide Scars:
| Advice | Reasoning |
|---|---|
| surgical scar revision early and prolonged supportive taping with products such as Steri-Strips and | removes scar completely; goal becomes preventing recurrence |
Summary:
There are wide variations in scar type and quality formed between individuals. This makes the anticipation of results from lacerations, surgery, and even simple ear-piercings a huge challenge. It is also not uncommon for one person to heal very differently on different body areas. Moreover, even the best surgeons have patients who have scarred poorly in their practices because surgical technique is only one of many factors that contribute to a patient’s results. Personal characteristics such as genetics, skin tone, and many others all play a role in every person’s innate scarring tendencies. Attempting to decipher how all of these factors will interact remains a challenge for doctors and patients alike.