An exploration of scar revision surgery applications
Scarring following surgery can be a sticking point for many patients who are considering undergoing a plastic surgery procedure. There are plenty of stories about oversized or misshapen scars, but it's important to remember that even these types of scars can be improved with the right treatment.
Plastic surgeons offer scar revision procedures to address noticeable and unwanted scars, whether from a previous surgery, an accident or other cause. These procedures can be both surgical and nonsurgical, with a variety of options now available to treat scars of all types.
So, how does scar revision treatment work? Are the surgical options necessarily better than nonsurgical? Who would these treatments be best suited for? To answer these questions and to gather more insight into surgical and nonsurgical scar revision, we spoke with ASPS Member Surgeon Karen Horton, MD, MSc, FACS, and her practice's nurse practitioner for nonsurgical procedures, Emily Sespaniak, NP.
Scar revision basics
These procedures are popular treatments for many patients who are interested in minimizing the appearance and texture of scars.
"We perform scar revision procedures all the time," said Dr. Horton. "We usually wait up to a full year after surgery – or longer if there is delayed wound healing – to assess the final scar results before considering a surgical revision, and typically 12 to 18 months – for full scar maturity – before a nonsurgical scar treatment such as laser or microneedling."
These scar revision treatments include surgical and nonsurgical options, with the exact method used determined by the surgeon performing the procedure in tandem with the wants and goals of the patient.
"Surgical scar revision involves injecting local anesthesia – for awake scar revision – with an oral anti-anxiety medication and inhaled laughing gas, or general anesthesia for more extensive revisions," said Dr. Horton. "The scar is surgically excised full thickness, meaning from the top layer of skin all the way through the dermis and fatty layers down to muscle fascia."
Healing following a nonsurgical scar treatment can vary based on the intensity of the procedure and how the scar and skin of the patient react.
"After nonsurgical scar treatment with microneedling, expected recovery includes redness and swelling of the treated areas that typically lasts anywhere from 24 to 72 hours," said Sespaniak. "In some cases, pinpoint bruising may occur and persist for several days. Diligent sun protection during the healing phase is key for optimal results. It is also recommended that patients keep the area clean and dry, avoiding harsh exfoliants for one week following treatment."
The scar revision patient profile
Scar revision patients are of all ages and include both men and women. However, one commonality amongst them is that they are typically patients who have undergone previous plastic surgery because surgery creates permanent scarring.
"Our practice goal is for the best aesthetic surgical outcome – and nicest possible scars in every case, although we cannot control wound healing or other factors such as melanin (skin pigment) production that can affect the color and quality of scars," said Dr. Horton. "Surgical patients are usually quite amenable to surgical revision since they have already had surgery. Scar revision is offered under local anesthesia at a discounted fee most of the time."
It is common for surgeons to see patients who have already undergone a procedure with them, but there are patients who need to seek out scar revision after a disappointing experience with another surgeon or practice.
"Other patients we meet who had surgery elsewhere, who had a negative surgical experience or whose surgery was many years ago often gravitate toward nonsurgical scar treatments such as laser or pulsed light treatments and/or microneedling," said Sespaniak.
Doing revisions on past plastic surgery scars is popular, but scar revision treatments can also help patients who have scarring from previous trauma, such as accidents or injuries.
"On rare occasions such as old burn scars or procedures where tissue was missing such as trauma or skin necrosis after a surgical complication, a simple scar revision will not adequately address the problem," said Dr. Horton. "In these cases, a local or distant flap such as a free flap is the most appropriate method to create improved aesthetics, symmetry or function of the body. An example is a childhood scald burn to the chest where the breast is not growing well in an adolescent girl - in these cases, tissue expansion and/or a flap reconstruction may be needed to reconstruct the breast."
Improvements in scar revision
Patients are always going to be interested in minimizing the appearance of scars, which means doctors will continue to research new treatments. In recent years, microneedling has emerged as a promising option for scar revision. This innovative procedure is nonsurgical and typically performed with a topical numbing agent rather than anesthesia.
"Microneedling is a noninvasive way to potentially improve the quality and color of a scar," said Sespaniak. "The procedure is performed in the office and involves the use of a topical numbing agent to ensure patient comfort. Microneedling involves delivering tiny, controlled punctures to the skin to stimulate collagen. This results in improved skin texture, less noticeable fine lines and wrinkles and minimization in the appearance of pores. For scars, microneedling can help create a smoother, flatter scar so it appears less noticeable."
The use of microneedling can help to improve the color and appearance of scars when used in a continued sequence, which can range between four and eight treatments in total. This treatment option has proven to be highly successful, with minimal downtime and no surgical intervention needed.
Getting the most out of scar revision treatments
As with any plastic surgery procedure, there are certain steps that you can take prior to and following a scar revision procedure, both surgical and nonsurgical, to set yourself up for success.
When considering who would be the best option to perform a scar revision procedure, even if it's nonsurgical, it's important to always ensure that they are properly board certified, a member of ASPS and have experience in the specific treatment.
"Seek a board-certified plastic surgeon who not only has experience in surgical and nonsurgical scar revision, but experience in the original procedure that created the scar in the first place," said Dr. Horton. "This background knowledge will help to avoid the same result that is causing the patient to seek scar improvement in the first place."
It may be tempting to jump at the opportunity to make your scar vanish, but the truth is that it is impossible.
"Don't fall prey to med spas or non-plastic surgeon offices who offer promises of total scar elimination – a scar is permanent and will not 'go away' – or scar improvement that seems too good to be true," said Sespaniak. "These promises usually are not founded in science or reality."
One of the most valuable sources for information regarding a surgeon and their success with scar revision procedures is to speak to other patients who have previously undergone the specific type of procedure with them.
"Ask to speak to other patients whose scars have been treated at that practice and ask to see not only the best possible results, but average results and even disappointing results after scar treatment," said Dr. Horton.
It's easy to get caught up in the ins and outs of a surgical or nonsurgical procedure and forget about the recovery following. It's important to remember that the recovery process is just as crucial to achieving your goal results as the treatment itself.
"Surgically, post-scar revision treatment is equally as important as the surgical treatment itself," said Dr. Horton. "Specifically, sun avoidance, keeping fresh incisions out of the water until all scabs are gone and applying a medical-grade scar gel that typically contains silicone and SPF sun protections are all methods to avoid post-inflammatory hyperpigmentation (darker coloring) of scars."
Following any surgery, it can be enticing to jump right into scar revision treatment if you're already noticing that you're unhappy with the appearance of the scar. However, it's important to take some time before you do.
"It's best to wait until a scar is mature before seeking scar treatment with an energy-based device like IPL or BBL or laser treatment in order to avoid post-inflammatory hyperpigmentation (darkening) of the scar that may be irreversible," said Sespaniak. "While it can be tempting to immediately jump to trying various treatments in an attempt to improve the appearance of a scar, it's key to be patient in order to allow sufficient healing and therefore a better aesthetic outcome if and when you do seek treatment."
So, if you have a scar that is bothering you, rest assured there are plenty of modern treatment options available to minimize and improve the appearance of scarring. From nonsurgical options such as microneedling to surgical interventions, board-certified plastic surgeons have many tools for treating scars.
To find a qualified plastic surgeon for any cosmetic or reconstructive procedure, consult a member of the American Society of Plastic Surgeons. All ASPS members are board certified by the American Board of Plastic Surgery, have completed an accredited plastic surgery training program, practice in accredited facilities and follow strict standards of safety and ethics. Find an ASPS member in your area.
