The Disappearing Scar

Sunday, November 18th, 2012

We all have scars, the result of any injury to our skin. Have you ever wondered what makes one different from another?

Whether a scar is readily seen depends on many factors, mainly color. The scar itself can be a different color than the surrounding skin, most commonly red (all early scars), but also white or pigmented. If the scar is either raised or depressed, or just a different texture than the surrounding skin, light striking the area produces shadows and highlights and these then make even a skin colored scar visible.

Scars result from several causes, an incision (from glass, scalpel, etc.), blunt injury and surface injury (abrasion/burn/freeze). Healing of each generally results in markedly a different scar. An incised wound heals with a very minimal scar since no tissue beyond the edge is injured. Blunt injuries where the tissues split apart at the weakest point have tissues injured away from the wound edge. In them, not only does the point where the tissue came apart heal, but the tissue on either side also heals as a scar. This can result in a wide or raised scar.

Another difference is whether the scar resulted from a planned or unplanned injury. We as surgeons try to put incisions in the most advantageous place for them to heal well. Unplanned (traumatic) injuries may be in any position and may cross normal skin crease lines or be in a place where there is significant tension on the scar. If the latter occurs, the scar may spread resulting in an area with a different texture than the surrounding skin making it visible even if it is not raised, depressed or discolored.

One of the most common discolored scars is that from freezing or doing a shave biopsy for a malignancy, premalignancy or occasionally a benign problem. If the area is frozen or shaved deeply, the majority of the pigment cells are destroyed and the resultant healed area is white. This can generally be prevented by treating only superficially, even if this requires coming back a second time to re-treat the area. Additionally, we can also take into account any known healing problems to try and prevent problems.

We, as surgeons, can also generally control other intentional scars. We try to make incisions along natural lines, folds and creases so that they essentially disappear. We also consider one’s history of how other wounds have healed and try to find a way to prevent any known problems from developing. Though not frequently used by many surgeons, there are also wounds closure tricks that can reduce scar visibility. As scars heal, the wounds are held together initially by tissue glue that has no strength. The body then begins to strengthen the wound. This latter process takes up to six months. If simple skin stitches are used and removed quickly, the scar can stretch if there is any tension present. Therefore, in most wounds, I generally place sutures below the surface that will provide strength to the wound for up to six months before dissolving. This generally assures that the scar is as thin and minimal as possible.

In traumatic wounds, the placement may not be ideal and there is very little that can be done initially other than to remove any significantly injured tissue if the wound was caused by a blunt injury and to try to support the wound. It this is done, any resultant visibility is generally the result of the initial injury itself, since the amount of injury frequently can only be assumed from the history of the type of injury. Additionally, the resultant scar is also the result of how one heals. With accidental injuries it is difficult to take these factors into account.

Injuries that do not heal well can usually be improved. We can treat a discolored scar with an IPL or other laser-like machine. We can remove the scar in a controlled manner and even change the position of the scar. If the scar thickens, we can inject it with steroid to modify its healing.

Over the years there have been many products reported to improve how scars heal. Although there are many on the market, only a few have been actually proven to improve the appearance of scars. One, steroid injection, has already been mentioned. Silicone sheeting with pressure over it is also proven to improve certain scars. This is especially useful in burns with multiple scars. It only works, however, if you use it continuously for a minimum of one year. Any less has been shown to produce no improvement whatsoever. Therefore, all the silicone sheets that people use intermittently or for a short time without pressure do absolutely no good. All the creams that are on the market to rub on scars to improve them have also been shown to be of no help. It is not the cream that causes the improvement in the pictures; it is time. The same improvement would have happened anyway without the cream.

In summary, scars are the natural result of any injury to the skin. When this happens accidentally, the resultant scar is more related to the injury than the repair. When done intentionally, the resultant scar is determined by where the scar was placed, how it was made, and how it was repaired. It is, thus, important to know who is controlling that scar.