Scar Revision

Scarring is the body’s natural response to a wound. Yet, this healing process can create significant functional and cosmetic problems. It impacts daily life and can create issues in self-esteem. Traditionally, the treatment of scars has been surgical. Despite meticulous surgical technique, scars still form. Revision may be in the form of excising the scar to create a “thinner” line, or the surgeon may perform a geometric broken line to create an illusion of natural creases. Lasers or mechanical dermabrasion can also be performed to minimize the scar. Lasers including the pulse dye laser has also been used intraoperatively and in the acute postoperative period to suppress scar formation. Topical treatments such as silicone may also help soften a scar. Yet the cicatrix still exists. Other types of scars such as those from inflammatory processes including acne create a skin topography that features alternating depressions and papules. There is no single satisfactory treatment for acne scars. Because of the complexity of this scarring process, a combined approach must be undertaken. Historically, dermabrasion has been performed. For Fitzpatrick Skin I, II, and III, conventional ablative laser resurfacing has been used. Despite many case series, it is not clear if the carbon dioxide laser or the erbium laser alone provides a long-term significant improvement. More recently, fractionated resurfacing both nonablative and ablative have been shown to have some effect on subsets of acne scars. Subscision which manually breaks apart the acne scars is often combined with the laser treatment. Subscision can be performed with Nokor needles through small puncture sites, or more recently using a roller device that percutaneously disrupts the scar. Other techniques including punch grafting and excision may ameliorate acne scars. On the other end of the spectrum of acne and small surgical scars are those from burns. Because of the severe trauma of a burn, large deforming contractures can occur, or large areas of denuded skin. An artificial or natural skin substitute may need to be used foremost for coverage and protection from the environment, but also to minimize scars. Perhaps the reason that clinicians have difficulty in eradicating scars is because we do not quite understand the mechanism from a cellular and molecular basis. Breakthroughs have been made in the past 20 years, particularly from fetal surgery and the discovery that fetal skin does not scar after wounding. The treatment implications of this type of research has still not been fully realized. Yet, it is no doubt that in the future, the prevention and treatment of scars will be in the form of targeted molecular therapies including the use of stem cells.