Scars can be caused by injuries, surgery or skin diseases such as acne and can be unsightly or cause functional impairment. Scar revision refers to techniques for improving the appearance of scars and includes surgical treatments, lasers, subcision, TCA CROSS and injectables.
Scar revision can be complex requiring a tailored approach that often combines multiple treatment modalities and Dr Lynch will discuss the different treatment options with you at the time of your consultation.
Surgical scar revision involves physically removing the scar tissue and suturing the skin back together to create a less noticeable scar. This can be an effective approach for scars that are large, raised, or deep. Surgical scar revision is typically performed under local anesthesia and can take several weeks for the skin to fully heal. While surgical scar revision can provide significant improvement in the appearance of scars, it is important to note that it does involve some degree of risk, such as infection, bleeding or poor healing. Meticulous surgical technique is required when performing this procedure. Dr Lynch performs hundreds of skin surgery procedures per year including complex facial reconstruction so is able to offer this treatment where appropriate.
Where patients have a relatively small number of small, deep scars - for example from acne or chicken pox - these can be be removed surgically using a punch device. A small, round core of skin is removed under local anaesthetic and one or more stitches are applied. This heals to give a straight line scar which is usually less noticeable.
Scarring caused by deep nodules and cysts can lead to the formation of fibrous bands which tether the skin to deeper tissues. This can exacerbate the dipped appearance. Subcision is a procedure that will divide these fibrous bands and is generally performed with a needle which is inserted under local anaesthetic through the skin surface and then manipulated to divide the fibrous bands. It is generally well tolerated, however complications include bruising, infection and cyst formation.
Trichloroacetic (TCA) acid is a chemical which causes inflammation when applied to the surface of the skin. TCA CROSS stands for TCA chemical reconstruction of skin scars. This involves the precise application of small amounts of TCA to the base of atrophic (depressed) acne scars. This triggers the wound healing response which can lead to the depressed scar filling out and becoming less noticeable.
TCA CROSS is used for atrophic (dipped) acne scars such as boxcar and rolling scars. In most cases more than one treatment is required.
Fractional laser resurfacing causes thousands of microscopic columns of precisely controlled injury within the dermis. This induces a healing process which leads to the formation of new collagen and can improve the appearance of superficial pitted acne scars and fine lines and wrinkles.
Fractional laser resurfacing cannot correct deeper areas of volume loss and I advise that more significant contour deformities are addressed instead with subcision, punch excision or TCA cross.
Fractional lasers can be broadly divided into non-ablative lasers and ablative lasers. Non-ablative lasers, such as the erbium glass (ICON) laser cause selective damage to the dermis. This is associated with some redness and swelling for a few days following the procedure, however there is generally not blistering, crusting or shedding of the skin and the risk of pigmentary change is low. Non-ablative lasers usually require a course of several treatments.
Ablative laser, such as the carbon dioxide laser, cause damage to both the dermis and epidermis. This greater degree of damage leads to greater stimulation of wound healing response and can generate more collagen potentially allowing correction of more significant scars. The healing process takes substantially longer than for non-ablative lasers and is associated with with greater risks and therefore a test patch is always required.
Redness of scars is caused by an increased density of blood vessels. It can be seen in all forms of scars including surgical scars, acne scars and keloid scars. It will generally settle with time however for some patients this redness can persist after the scar has healed. This can be treated with the pulsed dye laser which targets blood vessels in the skin.
Loss of dermal tissue volume is a particular challenge in treating depressed scars such as certain types of acne scars. Dermal fillers can be of benefit where there are larger areas of volume loss. It is important to use a filler material that is pliant since this filler is placed in a superficial location and firmer fillers can lead to the appearance of nodules beneath the skin surface.
Limitations of dermal fillers are that they are temporary and may need to be repeated.Risks include over correction - leading to a raised rather than a depressed scar. Additionally there is a risk that the filler material can track to the outside of the scar causing a 'doughnut' appearance.
Treatment of raised/lumpy (hypertrophic and keloid) scars is challenging because these have a tendency to reform after any interventional procedure. Cautious steroid injections can be helpful in this context but do have some risks including over-thinning of the skin, loss of fat and changes in pigmentation.
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