How plastic surgeons treat self-harm scars

Self-harm scars are not uncommon in the United States. It is the act of repetitive self-injury to the body through cutting, burning or picking as a means to cope with emotional pain, according to the Eisenberg Family Depression Center at the University of Michigan.

These behaviors are common in adolescents and young adults. Each person's experience is unique. Some have one self-harm episode while others may have multiple. There are evidence-based mental health treatments to help with self-harm and mental health difficulties that could be fueling the behavior. Many are able to develop better coping mechanisms and leave self-harm behaviors behind. Yet, scars from past episodes can bring up feelings of shame, unpleasant memories of past suffering and judgment from others.

If you are seeking treatment for self-harm scars, a thorough evaluation by a board-certified plastic surgeon who is an ASPS member is recommended to determine the best treatment. A direct referral from your primary care physician, mental health counselor, psychologist or psychiatrist, if applicable, can also help improve your care.

Understanding self-harm scars

Self-harm scars are seldom recognized by family and friends, often resulting in further feelings of physical and emotional isolation. Guilt, regret and fear of social embarrassment may also discourage individuals from seeking medical care. Treatment of self-harm scars begins with a thorough physical examination to assess your emotional and physical wellness to pursue scar revision.

There can be a variety of different types of self-harm scars on the face and body, making it hard to navigate treatment options for the problem. Most clinicians begin with an assessment of wound or scar characteristics to help determine if a particular scar wound requires emergency treatment or long-term care. Open wounds may often require immediate care, whereas old scars may require multiple sessions of treatment spaced out over time to improve the scar's appearance.

Are you emotionally ready for treatment?

Your emotional state may also influence a physician's decision to begin care. Patients often have strong emotional responses when talking about their self-harm scars, so it is important to have a strong support system to accompany you on your journey through treatment. ASPS advocates for additional treatment approaches in connection with plastic surgery to enhance the overall quality of life for those seeking care.

Telephone-based, live online chat and direct patient-clinician resources are available to help guide you through the emotional and psychological challenges of dealing with self-harm scars and mental health support. Many of these services provide directed expertise towards teens and adults facing emotional and mental health hurdles.

Medical care for self-harm scars has many benefits besides improving the appearance of the scarring.

"Treatment of self-harm scars may help bring closure to those who have overcome this behavior," said Gregory Sayer, MD, DFAACAP, a board-certified psychiatrist specializing in child, adolescent and adult psychiatry.

Newly formed self-harm scars

Time is of the essence if a scar is actively bleeding, infected or needs emergency treatment. Doing so can help reduce your scarring long-term. Contact 911, your local emergency department or helpline centers for suicide and self-harm support immediately. Experts at the 988 Suicide & Crisis Lifeline are available 24 hours a day, 7 days a week.

In an emergency or urgent care setting, your clinician may recommend local wound support, emergency suture repair or laceration/burn care to help lessen the complexity of your injury. These decisions can only be made after a thorough examination and should be guided by direct medical care made by a qualified clinician.

An emergency or urgent care physician may seek the expertise of a wound care specialist or plastic surgeon if the wounds are complex or spread out. Proper wound care may minimize future scarring by reducing complications associated with poor wound healing. By speeding up your wound healing process, you may reduce your need for more advanced scar revision in the future.

Treatment of mature self-harm scars

Seeking treatment for self-harm scars begins with an examination of scar characteristics. This includes texture, color, scar configuration, contour, inflammation level and micro-topography. These scars can be raised and thickened, whereas others may be sunken and atrophied.

A board-certified plastic surgeon who is an ASPS member can help you navigate the scar assessment to determine the best treatment option, whether it is scar revision surgery, drug therapy, nonsurgical treatment or a combination therapy.

Scar revision surgery for self-harm scars

There is no typical self-harm scar. Clinicians may see patterned linear cut lines or dissimilar injuries with no uniformity. Your surgeon may suggest scar revision surgery to help improve your scar, depending on the type of scar you have. Patients should understand the risks and have reasonable expectations for scar revision. Scar treatments do not result in scarless skin, but rather improve the appearance of an existing scar.

Options for scar revision surgery are many. Scar excision is used to remove thicker scars in favor of a thinner scar. Yet, there are limitations to this procedure that can affect the amount of improvement you will see in the scar's visibility. The most appropriate scar revision technique is usually determined after a thorough medical examination and medical assessment.

Red and inflamed scars

Newly formed scars can have a pinkish-to-reddish hue as they heal. The redness is usually caused by waning inflammation and the development of microscopic blood vessels underneath the skin. The redness and remaining inflammation may respond well to laser therapy or phototherapy. The two most common treatments for superficial redness include the pulsed dye laser (PDL) or intense pulsed light (IPL) treatments that target scar color.

Both the PDL and IPL treatments have limited downtime and temporary redness that lasts for several hours. In most cases, multiple treatments are required and may be combined with other approaches to scar revision. The number of sessions required usually depends on the severity of the scar inflammation and redness and your skin tone.

Treatment of scar discoloration

Scar discoloration is caused by abnormal deposits of melanin pigmentation or hemosiderin in the skin. Hyperpigmentation can be worsened by prolonged wound healing, chronic inflammation, sun exposure and wound infection.

Another hyperpigmentary concern is the development of pigmentary framing, a process wherein the central scar is non-pigmented with a rim of discoloration on the outer edge of the scar. Hyperpigmentary discoloration can be treated in a variety of ways, including drugs or ointments with Arbutin-based skin lighteners, tyrosinase inhibitors, rapid exfoliation and retinoids. Clinic-based treatments include laser therapy, phototherapy and rapid-exfoliation protocols involving brightening peels.

There can also be hypopigmentation. Poorly closed wounds from self-harm may lose their color. Such scars are very difficult to treat as there is little potential to re-pigment scars. Options include plasma pixilation, a process developed to redirect pigmentation into the hypopigmented scars using fractional plasma therapy.

Color differences in self-harm scars can also respond well to medical pigmentation tattoos. There are risks with tattoo scar treatment, including future changes in tattoo color, bleeding of tattoo ink within the scar and oxidation of tattoo pigments leading to color changes within the scar tissue.

Textural scars

Scar texture is very important to scar revision in self-harm scars. It may have a surface texture that is unlike the surrounding normal skin. This can affect the look of the scar in different lighting.

In most cases, these textural differences are permanent, but can be improved with lasers that add depth and dimension to the skin-scar surface. Many of the changes after laser are subtle, but can slightly improve the appearance of the skin.

Treating the self-harm scars with plastic surgery

Self-harm scars can be improved using a dedicated approach to scar assessment, diagnosis and treatment. Revision should incorporate a team effort that includes optimization of your mental health, support system, family and friends, plastic surgeon and primary care physician when appropriate.

Your emotional readiness for surgical or nonsurgical scar revision should be tempered by realistic expectations, understanding that multiple treatments may be necessary and improvements may be incremental. As with any procedure, proper understanding of informed consent is essential in evaluating your readiness for treatment and the risks of each procedure.

*Gregory Sayer, MD, DFAACAP, Levon Karamanoukian and Lucas Karamanoukian contributed to this blog