Planning your procedure
Keloids are thick, puckered, itchy clusters of scar tissue that grow beyond the edges of the wound or incision. They are often red or darker in color than the surrounding skin. Keloids occur when the body continues to produce the tough, fibrous protein known as collagen after a wound has healed.
Keloids can appear anywhere on the body, but they’re most common over the breastbone, on the earlobes, and on the shoulders. They occur more often in dark-skinned people than in those who are fair. The tendency to develop keloids lessens with age. Keloids are often treated by injecting a steroid medication directly into the scar tissue to reduce redness, itching, and burning. In some cases, this will also shrink the scar.
If steroid treatment is inadequate, the scar tissue can be cut out and the wound closed with one or more layers of stitches. This is generally an outpatient procedure, performed under local anesthesia. You should be back at work in a day or two, and the stitches will be removed in a few days. A skin graft (see the section on skin grafting) is occasionally used, although the site from which the graft was taken may then develop a keloid.
No matter what approach is taken, keloids have a stubborn tendency to recur, sometimes even larger than before. To discourage this, Dr. Nikolov may combine the scar removal with steroid injections, direct application of steroids during surgery, or radiation therapy. Or you may be asked to wear a pressure garment over the area for as long as a year. Even so, the keloid may return, requiring repeated procedures every few years.
Hypertrophic scars are often confused with keloids, since both tend to be thick, red, and raised. Hypertrophic scars, however, remain within the boundaries of the original incision or wound. They often improve on their own-though it may take a year or more-or with the help of steroid applications or injections.
If a conservative approach doesn’t appear to be effective, hypertrophic scars can often be improved surgically. Dr. Nikolov will remove excess scar tissue, and may re-position the incision so that it heals in a less visible pattern. This surgery may be done under local or general anesthesia, depending on the scar’s location and what you and Dr. Nikolov decide. You may receive steroid injections during surgery and at intervals for up to two years afterward to prevent the thick scar from reforming.
Burns or other injuries resulting in the loss of a large area of skin may form a scar that pulls the edges of the skin together, a process called contraction. The resulting contracture may affect the adjacent muscles and tendons, restricting normal movement.
Correcting a contracture usually involves cutting out the scar and replacing it with a skin graft or a flap. In some cases a procedure known as Z-plasty may be used. And new techniques, such as tissue expansion, are playing an increasingly important role. If the contracture has existed for some time, you may need physical therapy after surgery to restore full function.
Because of its location, a facial scar is frequently considered a cosmetic problem, whether or not it is hypertrophic. There are several ways to make a facial scar less noticeable. Often it is simply cut out and closed with tiny stitches, leaving a thinner, less noticeable scar.
If the scar lies across the natural skin creases (or “lines of relaxation”) Dr. Nikolov may be able to re-position it to run parallel to these lines, where it will be less conspicuous. (See Z-plasty)
Some facial scars can be softened using a technique called dermabrasion, a controlled scraping of the top layers of the skin using a hand-held, high-speed rotary wheel. Dermabrasion leaves a smoother surface to the skin, but it won’t completely erase the scar.
Z-plasty is a surgical technique used to reposition a scar so that it more closely conforms to the natural lines and creases of the skin, where it will be less noticeable. It can also relieve the tension caused by contracture. Not all scars lend themselves to Z-plasty, however, and it requires an experienced plastic surgeon like Dr. Nikolov to make such judgments.
In this procedure, the old scar is removed and new incisions are made on each side, creating small triangular flaps of skin. These flaps are then rearranged to cover the wound at a different angle, giving the scar a “Z”pattern. The wound is closed with fine stitches, which are removed a few days later. Z-plasty is usually performed as an outpatient procedure underlocal anesthesia.
While Z-plasty can make some scars less obvious, it won’t make them disappear. A portion of the scar will still remain outside the lines of relaxation.
SKIN GRAFTING AND FLAP SURGERY
Skin grafts and flaps are more serious than other forms of scar surgery. They’re more likely to be performed in a hospital as inpatient procedures, using general anesthesia. The treated area may take several weeks or months to heal, and a support garment or bandage may be necessary for up to a year.
Grafting involves the transfer of skin from a healthy part of the body (the donor site) to cover the injured area. The graft is said to “take”when new blood vessels and scar tissue form in the injured area. While most grafts from a person’s own skin are successful, sometimes the graft doesn’t take. In addition, all grafts leave some scarring at the donor and recipient sites. Flap surgery is a complex procedure in which skin, along with the underlying fat, blood vessels, and sometimes the muscle, is moved from a healthy part of the body to the injured site. In some flaps, the blood supply remains attached at one end to the donor site; in others, the blood vessels in the flap are reattached to vessels at the new site using microvascular surgery. Skin grafting and flap surgery can greatly improve the function of a scarred area. The cosmetic results may be less satisfactory, since the transferred skin may not precisely match the color and texture of the surrounding skin. In general, flap surgery produces better cosmetic results than skin grafts.