Initially we will have a period of wound healing during which the scar obtains strength and no longer requires sutures for support. Generally this will take one to two weeks. At this point the scar is often quite fine and there may not be a significant amount of pinkness surrounding it.
Next, pinkness increases and there is swelling around the wound such that the scar can become more prominent, thickened and even lumpy. This process will last for a variable period of time that is dependent upon a number of factors which included the genetic predisposition of patient perform bad scars. Other factors that can contribute to poor scarring include infection, bleeding or haematoma formation, excess movement, wound breakdown and delayed healing as well as the location in the body that the scar is made.
There are standard modalities that we apply to all patients to maximise the outcome of their scar. These Scar Revision methods are applied to all of our patients from the smallest procedure to the most complex.
There will still be patients who have difficult scars which may be due to the presence of a problem with healing, excessive movement due to the location on the body or due to a genetic predisposition towards bad scarring.
Problems with wound healing such as infection or wound breakdown causing delayed healing, excessive movement such as around the shoulders and joints of the arms and legs. Certain areas have a predisposition for poor scarring such as the skin in front of the breastbone and the upper part of the breasts
Young patients scar more aggressively than adults and the elderly
Many people with poor scars will have a genetic predisposition
Problem scars can demonstrate a variety of different problems:
Thickened and raised scars that tend to be quite pink and take significantly longer periods of time to lose their colour and flatten than normal scars. They tend to become pink and raised within the first month of surgery. With time they will eventually lose colour and flatten but there are a variety of modalities that we can apply to increase the rate of this maturation and improve the final outcome. These scars are more common in younger patients especially between the ages of six and 20 and genetically susceptible patients.
These are often the result of fully resolved hypertrophic scars. They are more frequent in certain areas where there is a lot of movement such as around the shoulder, around the joints of the arms and legs and on the back. All patients are at risk of this type of scarring in these locations.
These scars will often settle quite normally and abnormal changes occur sometimes many months after the initial surgery or even after fairly minor trauma such as a mosquito bite. These scars are the most difficult to treat and have very strong genetic tendency. They are more frequently seen in patients of Asian races and heavily pigmented patients. In these patients the scar actually expands beyond the original wound and spreads into normal tissue. It is frequent for patients to feel that they have a keloid scar or keloid scarring tendency however in the vast majority they are actually suffering from hypertrophic scars. Keloid scars are definitely the most difficult to treat.
Scars can also cause problems because of their location. During normal wound healing, scars shorten in length. If this scar crosses a joint surface then this shortening may limit the amount of movement that can be obtained in a joint before the scar becomes tight. This can create deformity. The same problem can occur across a curved surface such as the breast, nose or angle of the jaw. As the scar shortens it will attempt to travel along the shortest distance between the two ends of the scar. As a result of this, it will act like the string on a bow and either cut into a curved surface creating a contour deformity or create a webbing between the two ends of the scar.
Some scars will heal quite adequately leaving a fairly fine line however there may be a contour change at the junction of the skin edges with either a small groove that may resemble facial line or a prominence.
Some scars, particularly those associated with burn injuries treated by skin graft surgery, will have irregular or uneven surfaces. Irregularities in contour and pigment can also occur with acne scarring. Dermabrasion can be applied for these patients.
Some scars can have pigment abnormalities associated with them. People with Mediterranean type complexions can frequently have hyperpigmentation (increased colour compared with a normal skin). Hyperpigmentation is often the result of sun exposure to fresh healing wounds and may be relatively permanent. For many patients this can be managed with bleaching creams. All patients are capable of also producing hypopigmented scars. This commonly occurs in grazes, burns and cryotherapy wounds associated the treatment of skin cancer by freezing. It can also be associated with injuries such as dermabrasion, the deep skin peels (typically phenol and TCA peels) and Dr Magnusson treats many patients who suffer this after laser treatment. This is a problem that will often slowly reduce in size over time but for other patients will not resolve. The Scar Revision management of this problem is quite unique. To learn more about the management of hypopigmentation follow the link.
Many people will have a period of time that is required for the scar to settle but will never actually have a further surgical procedure to achieve their final outcome. Despite how scars may appear in the early stages, many of these scars will settle to an acceptable final outcome in due course. This will commonly occur after 3-6 months. For some people it may take as long as 2 years. There are methods of modifying scar maturation which will decrease the duration of time and improve the final outcome for these scars.
Some people will benefit from surgery especially if there are problems such as contour deformities in contractures around joints.
Further patients will benefit from a combination of surgery and other modalities of scar manipulation to maximise their outcome.