Scar Formation & Management
Presenter: Daniel Hailemichael PRS III
Moderator: Dr. Dagmawi Consultant
Plastic & Reconstructive Surgeon
Outline
• Response to Injury
• Scar formation
• Wound healing
• Abnormal healing
– Excessive scarring
• Prevention
• Treatments
Response To Injury
• Wound healing
– An organism’s global response to injury, regardless
of the location of injury.
– Progression from injury to stable scar
• Common Features
Scar Formation Vs. Tissue Regeneration
• Healing
– Scar formation
– Regeneration
• Evolutionarily adaptive response
Wound Healing
• Inflammatory phase
– Provisional matrix formation
– 48 hours
– 48-72 hours
– Days 5-7
Wound Healing
• Proliferative Phase: days 4-21
– Granulation tissue: fibroblasts, macrophages, &
endothelial cells.
– Collagen
– Endothelial cells
• As important as this phase of wound healing is
there comes a point where it needs to cease
Wound Healing
• Remodeling Phase: 21 days up to 1 year
• Wound contraction & collagen remodeling
– Myofibroblasts
– Collagen
Abnormal Response & Healing
• Balance between regeneration and Scar
formation
• Inadequacy in regeneration
• Inadequate Scar Formation
Abnormal Response & Healing
• Excess Regeneration
– Rare
– Disordered and uncontrolled growth
• Decreasing cellular proliferation
Excessive Scar Formation
• Abnormal scarring of the skin
– Keloid: <6% of population primarily affecting black
and Asian populations
• Thick collagen fibers composed of numerous fibrils
closely packed together
– Hypertrophic Scars
• Near universal outcome following extensive deep burn
injury
Hypertrophic Scars
• Sustained extracellular matrix deposition
• Remodeling and Maturation
• ECM
ECM
• Collagen: major ECM constituent
– Normal Skin: Type I ~80%, Type III~10-15%, and
Type V
– HTS: Type III 33%, Type V 10%
Proteoglycans & Glycoproteins
• Provide Skin with physical properties
• Growth factor & cytokine modulation
HTS & Keloids
• Diagnoses
– Differentiating between HTS & Keloid
– HTS: red, raised, pruritic
– Keloids: ear lobes, chest, shoulders, upper back
posterior neck, cheeks, & knees
• Burning, pruritus, pain, & hyperesthesia
Epidemiology
• Keloids occur equally across gender
– More common in younger individuals of African,
Asian, & Hispanic descent
– Heritability
• HTS incidence higher in persons 10- 30 years
old
Prevention
• Reducing Inflammation
– Minimizing Tension
• Reduce Mechanotransduction
• Pressure Therapy
– Reduction in perfusion to the wound
Prevention cont..
• Surgical Technique
– Meticulous technique
– Obtain a ‘pencil-line scar’
– Skin eversion
– Prevent Burrows triangles
– Properly align tissues of differing thickness
Prevention cont..
• Early removal of sutures
• Plan incisions parallel to natural skin tension
lines
Prevention cont..
• Silicone sheeting
• Scar reduction from silicone occurs through
– Oclusion and hydration of outer layer of
epidermis, generation of static electricity, and a
reduction in mast cells
• Start 2 weeks after primary wound treatment,
leave on as much as possible per day for a
minimum of 2 months
Prevention Cont..
• Paper Tapes
– Placement over incision lines
• Flavonoids
• Hydration with emollient
• Scar Massage
Treatments
• Non-invasive • Surgical
– Occlusive methods – Cryotherapy
– Immune response – Revision
modifiers • Other
– CCB – Laser therapy
• Injectable – Radiotherapy
– Corticosteroids • Emerging/Experimental
– Pyrimidine analog – Botox
– Cytotoxic antibiotic – Mesenchymal Stem Cell
– Fat grafting
– Interferon-α-2β
Noninvasive Therapies
• Silicone sheeting & pressure therapy
• Imiquimod
• Verapamil
Injectable
• Intralesional Corticosteroids
– Anti-inflammatory, ant-proliferative,,
immunosuppressive, and vasoconstrictive
properties
– Triamcinolone 10-40 mg/ml every 4-6 weeks
• 5FU
– Intralesional can be combined with corticosteroids
• Bleomycin: cytotoxic antibiotic with antiviral,
antineoplastic, and antibacterial properties
Surgical Therapies
• Cryotherapy: topical or intralesional
– Recurrence uncommon & depigmentation is
temporary
• Freeze thaw cycles between 10-20 seconds
Modified Vancouver Scar Scale
Vascularity Pliability Pain
Normal 0 Normal 0 None 0
Pink 1 Supple 1 Occasional 1
Red 2 Yielding 2 Requiring 2
medicatio
n
Purple 3 Firm 3 Pruritus
Pigmentati Ropes 4 None 0
on
Normal 0 Contracture 5 Occasional 1
Hypopigme 1 Height Requiring 2
ntation medicatio
n
Flat 0 Total Score Out of 16
< 2 mm 1
Mixed 2 2-5 mm 2
Hyperpigm 3 > 5 mm 3
entation
Surgical Revision
• Indication
– Note: Scars take 12-18 months in order to mature
• Contraindications
– Cases where new scar will be worse
– Working with a mental health professional
• Timing
Surgical Revision
• Planning
– Single staged
– Multi-staged
• Serial excision
• Tissue Expansion
Scar Release
• Tethered Scar
– Concave defect
• Soft tissue filler, fat auto-graft, acellular dermis
• Acne Scars
– Resurfacing
Principles of Tissue Rearrangement
• Guided by same principles as prevention
• Restoration of anatomic landmarks
• Reorientation of scars
• Scar elongation & irregularization
Scar Revision Techniques
• Z-plasty
– 4 fundamental functions: length, breaking up a
line, moving tissue, & obliterating or creating a
web or cleft
Postoperative Care & Follow-up
• Optimize wound healing
– Adequate nutrition
– Blood sugar control
– Smoking cessation
– Activity precautions
• Tension off-loading
• Long term follow-up
Other Therapies
• Laser Therapy: 585 nm PDL ( most commonly
used)
• Radiotherapy
– External beam, internal radiation, or with radioactive
skin patches
– Postoperative radiotherapy more effective than
radiotherapy alone at lowering recurrence of keloids
Emerging/Experimental Therapies
• Botulinum toxin A
– Induce paralysis of musculature surrounding scar
• Mesenchymal Stem Cell (MSC) therapy
– Release of growth factors
• Fat grafting
– Injection or fat tissue grafting underneath or into
the wound
• Interferon-α-2β
Summary
• Prevention
– Technique & materials
• Proper evaluation & planning
– Benefits & drawbacks
– Expectations
• Conservative treatment
• Postoperative care
References
• Eun Mee Oh, Y. C. (2013). Assessment of Postoperative
Scar Using Modified Vancouver Scar Scale of 283
Patients Who Underwent Open Thyroidectomy in a
Single Institution. Korean J Endocr Surg.
• Herndon, D. N. (2018). Total Burn Care 5th ed. .
London.
• Michael 2. Hu, E. R. (2018). Scar prevention ,
treatment, and revision . In P. C. Neligan, Plastic
Surgery Principles (pp. 196-213). Toronto : Elsevier
Inc. .
Thank You.
Atrophic scars
• Develop as a result of intracutaneous
inflammatory process
– Results in reduced matrix regeneration and focally
reduced collagen production
– Focal contraction results in reduced uneven soft
tissue defects
• 3 clinical conditions present for reconstructive
management
– Acne, striae albae, and burns
Atrophic scar mgmt
• Microdermabrasion
– Minimally invasive technique that improves
texture but only addresses superficial scars,
combinaiton with aminolevulinic acid
photodynamic therapy is more effective,
– Subsequent remodeling results in neocolangenesis
and hence increased dermal thickness
– Mainly for well-defined superfical scars with
distinct borders or broad mbsed scars with
indistinct borders
Atrophic Scar mgmt
• Chemical Peels & microneedling
– Improve pigmentation, tone, & texture
– Potential adverse effects include prolonged erythema and post
inflammatory hyperpigmentation
– Side effects more prevalent but not limited to deep peels
– High concentrations of TCA high efficacy in atrophic scars
– Skin needling: based on principle of percutaneous induction of
collagen, creating dermal mircroclefts, with collagenases
resulting from cascade of growth factors unleashed by
wound0healing process
• More effective on rolling scars takes repeat sessions and up to a year
to be complete
Atrophic Scar mgmt
• Punch Excision
– Converts a discrete atrophic scar into a well-apposed,
well oriented surgical healthy scar
– Full thickness excision
– Wound sutured along relaxed skin tension lines
– Avoid closely spaced defects & thus excess traction
– Punch excision replaced by sharp elliptical excision to
avoid standing cone formation, when defect larger than
3 mm
– Once healed, resulting surgical wounds can be
incorporated into laser remodeling
