Scars keloids and hypertrophic-scars

Aaron Stone MD - Plastic Surgery: Scars, Keloids and Hypertrophic Scars

Aaron Stone MD - Plastic
Surgery
A board certified cosmetic and reconstructive plastic surgeon
performing plastic surgery of the eyes, face, ears, nose, breast,
abdomen, thighs in Los Angeles, California.

Monday, August 3, 2009
Scars, Keloids and Hypertrophic Scars
This blog covers skin scars only but does not include burn scars or scars related to breast implants.

Virtually everyone who lives long enough will have a skin scar from elective surgery or an injury.
There has been a barrage of cosmetic surgery procedure modifications to decrease total incision
length in the hope of creating less scarring. The healing of these disruptions in the skin surface
follows a specific process. After the injury or cut there is bleeding. Once this stops an
inflammatory process starts to get the cells needed for healing into the wound. New blood vessels
grow into the area bringing in the energy needed to complete the healing process. You see this as
a red color of the scar and the skin immediately next to the scar that blanches white with finger
pressure. Within a week or two the healing is sufficiently strong that the wound should not
reopen and any sutures that were placed can be removed. Even though the wound is healed it
then must mature over the next 6 to 9 months depending on the type of injury, affected body
part, age of individual etc. before the redness goes away and the increased chrome://foxytunes-
public/content/signatures/signature-button.pngblood flow is no longer needed. Once the scar has
fully matured it usually does not blanch with finger pressure. Any problems in this process such as
an infection, failure to suture a wound closed, certain vitamin deficiencies etc. prolong the
healing time and in doing so result in worse more visible scarring. The skin of younger individuals
makes strong repairs and tends to over heal, resulting in larger, thicker scars than on older skin.
Skin over the jawbone is tighter than skin on the cheek and will tend to increase a scar's
prominence. All scars are more amenable to treatment early in their life span before they
mature. It is easier to prevent a bad scar from forming by control/manipulation in the early
phases of wound healing than to treat one that has already formed.

Typically, a scar will become increasingly prominent at first. The tissue increases in height,
firmness, and redness (vascularity) and then gradually fades. Many disfiguring marks which seem
unsightly at three months may heal quite satisfactorily if given more time. The desired end result
is a flat (not indented or raised), soft, pale, less than 1mm wide scar. We can call that the
normal scar. The non-normal scar is more visible due to a number of factors, including its
difference in topography (surface contour or depth and height relative to adjacent skin), color,
thickness, pliability or texture versus the surrounding normal skin. Scar length, width or direction
can also contribute to visibility. A scar that crosses natural expression lines (Langer's lines) or
wrinkles will be visually striking because it will not follow a natural pattern for example a scar

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that obliquely crosses the natural skin fold between the corners of the mouth and the nose is
much more visible than one that lies along this fold. If the skin scar adheres to deeper structures
such as muscle or bone the skin may bunch up with movement as it is tethered to deeper
structures and that also contributes to visibility. In fact some scars may only become visible on
animation or movement. Some scars are accompanied by a loss of skin with or without a
corresponding loss of deeper tissues (a tissue deficit). In worse cases the patients complain of
scar itching, pain, breakdown to a raw surface with minor trauma (an unstable scar) and even
recurrent infections in addition to scar visibility. I take all of these factors into account before
treating a patient with scars and then develop a treatment plan specific to the patient's situation.

TYPES OF SCARS
The non-normal or non-desireable scars can be classified as significant skin loss/deficit, flat and
wide, hypertrophic and keloid.

--SKIN DEFICIT
These scars usually arise after injuries like bites and car accidents where the skin is disrupted by
an object that is not knife sharp. The skin at the edges of the wound is crushed in the process and
either dies on its own or has to be cut away by the surgeon.

This patient had a scar with significant loss of skin that shortened the vertical length of the
central upper lip and distorted the normal lip proportions.

--FLAT AND WIDE
The final scar width is dependent on the tension of closure and distracting or separating forces
applied to the scar with movement before the scar has fully matured. If an injury causes a wound
and crushes skin at the edges of the wound that crushed skin is usually removed. The non-crushed
skin at the edges is of better quality but when the edges are sutured together it may be under
tension from skin loss and that leads to a wider more visible scar. Alternatively the scar may lie



along the scalp, front of the knee or back of the elbow where movement will constantly stretch
the scar along the length of the limb or skull before it has fully matured and widen it. The visible
linear scar of the scalp can be a cosmetically serious complication of a scalp incision in scalp
surgery, forehead lift or craniofacial surgery, especially on the temple scalp where it is harder to
hide by combing the hair over it. This area of hair loss is usually due to incisions or cuts that
damage the hair follicles along the cut or laceration as well as widening of the scar line after
healing. Treatment limited to removal of skin only increases tension around the scar and results
in a high recurrence rate of these types of scars.

I had a patient with a scar over the jaw line that would alternatively turn red and then
pale as the patient moved his jaw -speaking, eating, or making facial expressions. This was due to
the tension applied across the scar with jaw motion.

This photo shows a knee scar after orthopedic surgery. The scar is wide and flat and lies over
those parts of the knee that are constantly placed under tension with knee movement. You can
test this for your self by pinching the skin over the while the knee is extended. When you then
flex the knee you can feel the tension of the pinched skin that would be applied to a scar over
the knee with knee motion. Also note the small punctate scars along side the main scar these are
stitch mark scars from the sutures. The scar is widest where it lies over the joint itself due to the
greater amounts of tension across the scar. The scar is normal over its lower third because of the
absence of tension across the scar. These scars are best treated by taping the scar for some
months after surgery. Once they widen it is very hard to fix them because of the motion at the



joint and the increase in tension when you remove any skin as you would be doing if you cut out
the scar.

This is the type of scar seen after injury or cosmetic surgery (browlift, facelift). It is much harder
to hide one of these types of bald scars on the side of the head than on top of the head where
hair can be combed over it. Although the scar may be of good quality the associated loss of hair
along the scar makes it much more noticeable than it otherwise would be.

--HYPERTROPHIC
Hypertrophic scars are seen as a ridge within the confines of the original wound. They develop
soon after surgery, usually subside with time (mature), are confined in size/growth and usually
occur across moving areas of skin (abdomen, palm, front of the elbow, in the fold under the
breasts). They are thickened scars over areas of skin compression. They can also arise from a
prolongation of the healing process. More tissue than is required is produced to close/cover the
wound. They can be a single raised line along the scar (linear) or a raised area of variable shape
(widespread).

--KELOID
Keloids appear sometime after the original surgery or injury, rarely subside with time, grow out
of the confines of the original wound, (a minor injury can produce a large keloid), are
independent of skin motion (such as earlobe keloids), rarely occur across joints and can become
much worse after surgery without concomitant steps to prevent recurrence. The incidence of



keloid scarring increases in darker skinned individuals but not ever darker skinned individual gets
them. Despite that my keloid patients are mostly Afro-American followed by Asians and then
those of non-European Hispanic descent. I have only had a few Caucasian patients with this
problem. Keloids have not been reported in albino's of any race, suggesting a potential role of
skin pigment in this type of scarring. There is an increased incidence of keloid formation running
in families so it is inherited to some degree. Keloid scarring does not follow the same pattern of
evolution, stabilization, and involution of the normal or hypertrophic scar. It may develop
directly after an initiating event or some years later, arising from a mature scar. Earlobe keloids
usually occur months are years after the initial ear piercing. Keloids also can occur
spontaneously. Virtually all keloids that are cut out will return if steroids and pressure are not
applied after surgery. In some cases radiation may be used instead of pressure.

This patient had a keloid from an ear piercing removed with inadequate care afterwards to
prevent it from coming back. It of course grew back and you can see how it grew out of the
boundaries of the original piercing so that it began to block the ear opening and affect hearing.

A scar can have mixed properties along it's course for example a midline scar extending down
from the chest into the abdomen can be normal in the upper half and hypertrophic in the lower
half or the mixed scar in the knee photo above.

TREATMENT
The goal of treatment is to make scars less visible and relieve itching and pain if present. Silicone



gel sheeting and corticosteroid injections into scars are the only treatments for which there is
sufficient published medical journal evidence to justify their use. Studies of scar treatment are
complicated by the natural tendency for scars to improve over time. Having said that most
physicians including myself rely mostly on what has worked for our patients rather than referring
to published studies involving large groups of patients. Looking at the accompanying photos you
can judge for yourself what is effective.

Frequently a combination of treatment modalities is required because not every modality works
on every patient or scar by itself. When applied together some modalities have a much greater
effect than the sum of their individual contributions.

--SURGERY
Surgery is commonly used to cut out a scar. The resulting sutured wound creates a young
immature scar that responds better to the modalities described below. In the case of tissue loss
new skin can be brought to the area by skin grafting or small surgical procedures to move around
adjacent skin. Surgery can also be used to break up a scar, detach the scar from deeper tissues,
change scar direction or manipulate adjacent tissue to decrease tension along the scar line -all of
which can make a scar less visible. These procedures are usually performed under local
anesthesia so the patient does not have to go to sleep under general anesthesia. Surgical removal
alone for keloids without any of the adjunctive procedures below has a 45 to 100% recurrence
rate. This treatment modality is the one I most commonly use on my patients.

--SILICONE GEL SHEETING
Silicone gel sheeting has been in use since the early 1980s for the treatment of scars and has
been proven to be effective. It is available over the counter as a solid sheet or a gel that you
apply which hardens. Despite its track record my patients have not liked it and it has not been
effective in my practice.

--PRESSURE THERAPY
Pressure has been used in the treatment of scars since the 1970s. The effectiveness is dependent
on how long the pressure is applied for. Some doctors recommend 6 to 9 months of pressure but
the majority of my ear lobe keloid patients only require 2 to 3 months of pressure earring wear.
Certainly scars that have recurred after previous treatment should have pressure applied for a
longer period of time. Scar massage has the same effect as pressure with the additional effect of
breaking up scar connections between layers of tissue.



This is a widespread hypertrophic scar on the right buttock. After 6 months of pressure applied to
the scar the part of the scar that received pressure is flatter. Pressure definitely works if applied
long enough.

--CORTICOSTEROID INJECTION
Corticosteroids are most effective when injected and not so effective when applied topically
(except when applied as a medicated tape). This is the second most common modality I use on
my patients, mostly in conjunction with surgery and it has been in use since the 1950s. Only very
small amounts of the appropriate strength should be injected at a time very close to the surface
in order to avoid thinning or depigmentation of the skin or creation of spider vessels around the
injection site. If too much is injected too deep into the skin the risk of these problems occurring
goes up. Except in the case of keloids the injections should not be closer than 4 to 6 weeks apart
in order to avoid these problems as well. When used together with surgery for keloids the
recurrence rate drops below 50% .

--RADIATION
Radiation applied right after surgery for keloids drops the recurrence rate down to 10%. 4
treatment sessions are required. Despite that I have found that the majority of these patients will
require corticosteroid injections and/or medicated tape to get the best result. Although the
keloids do not come back these scars tend to hypertrophy but are very sensitive to corticosteroid
treatment.



--LASER
When the ablative lasers (those that vaporize surface skin) appeared in the mid-1990s the general
public was lulled into believing they caused less scarring than scalpels. This turned out to be
science fiction. There is no advantage to using these types of lasers in surgery to prevent scarring
or to treat scars. The lasers that obliterate small blood vessels near the skin surface without
destroying the skin have shown some promise in treating and preventing the formation of bad
scars but multiple treatments are required and the best results are those given in combination
with other treatment modalities like corticosteroid injections.

--FREEZING - CRYOTHERAPY
Freezing scars has been used in the past but is not currently popular because of the high risk of
damaging pigment and the creation of scabs that take some time to heal over and separate.

--TAPE
This is the modality I use the most after surgery both for scars and after cosmetic surgery. By
applying the tape you decrease motion along the scar line and it is preventative against wide flat
scars. The greatest advantage is that it is cheap and easy to do. It is not effective for the
treatment or prevention of keloids.

--CORTICOSTEROID MEDICATED TAPE
Over the years I use more and more medicated tape in my patients. Patients that respond to
corticosteroid injections but require more than 1 or 2 injections get this treatment. The
medication is mixed with the adhesive and the tape prevents the medication from evaporating so
it can be absorbed into the skin. This treatment has been a lifesaver for many of my patients, and
me also.

--CAMOUFLAGE TATTOO
This is reserved for men who have scars on the face with loss of the beard hair in the scar. The
medical tattooist tattoos small black dots to match the facial hair and the result can be very
good. The only problem is the tattoo may fade over time and require touch ups.

--OTHER MEDICATIONS
Interferon an immune medication and some cancer chemotherapy medications have shown
effectiveness in scar treatment when injected in small amounts into the scar. Currently these are
not the most popular treatment modalities.

--SUNSCREEN
Sunscreen should be consistently used to protect scars from sun exposure until they have fully
matured in order to prevent the scars from becoming permanently hyperpigmented (darker).

CASES



This patient had a keloid arising in an acne scar. I could not cut it out because there was not
enough surrounding loose skin so I shelled out the keloid at surgery. Radiation and medicated
tape were used after surgery and the after photo is 7 months after surgery.

In this case the scar from previous surgery connected the skin to the stomach muscles. The
surgery involved separating the deep from the superficial layers and a little bit of liposuction to



even the surface contour. The after photo was taken 1 year after surgery.

This patient had a keloid on his back that was removed elsewhere twice and grew back within 2
months of surgery. There was enough loose tissue around the keloid that I could cut the whole
thing out. Radiation was used after surgery and then taping. This patient did not wear the tape as
directed and so the end result was a wide flat scar but that was still better than a keloid. The
after photo was taken 1 year after I did this surgery.

This patient began losing hair 1 year after a facelift by a surgeon other than myself. She had a



wide flat bald scar on the temple scalp and hair loss behind the ear. I grafted hair from the back
of her head to hide these scars.

For this patient I surgically removed the keloid under local anesthesia and then treated with
corticosteroid injections and 2 months of pressure earring wear.

In this case I removed a wedge of scar tissue and damaged lip and then realigned the lip margins.
The only treatment modality required was surgery under local anesthesia.

This is one of the easiest scars to treat. I removed the hypertrophic scar under local anesthesia
and just sutured it. No additional treatment was required. The hypertrophic scar appeared
because the original wound was not sutured.



This patient was left with wide depressed scars on his arm after limb saving surgery in another
country. The skin could not be sutured at the time and that contributed to the scars. I stretched
the adjacent skin with sutures for a month or two before cutting the scars out. That allowed me
to close the excision sites with less tension and decrease the chance that the scars would widen
again. The after photos were taken about a year after surgery.

The ultimate goal, seldom achieved, is to hide a scar so that it is not visible to the unaided eye
and the area in question looks as though nothing untoward has occurred. Scars never disappear
and in many cases only a partial response is possible. The treatment of scars is usually not
covered by health insurance unless a bodily function such as range of motion is affected or the
scar is unstable. Some health insurance will cover scars from repaired injuries up to 1 year from
the date of the injury.

Lip Scar Revision
Keloid of the Face
Earlobe Keloids
Facial Keloids
Chest Keloids
Aaron Stone MD - Plastic Surgeon Los Angeles


Scars keloids and hypertrophic-scars

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