Scars
Whenever the skin is cut or injured through its full thickness, healing results in a scar. Some people heal better than others. It is not possible to accurately predict which patients will develop poor scarring, but in general it is known that individuals with very dark skin, as well as those at the opposite end of the spectrum — with freckles and red hair — tend to have a greater tendency to form hypertrophic scars and keloids. Certain areas of the body are also more prone than others. The sternum (chest) area is among the most susceptible to hypertrophic scars and keloids, even after minor injuries such as acne. The shoulder region is also particularly prone to problematic scarring. Fortunately, the face and neck usually heal with good-quality scars.
Scars that follow the natural skin tension lines tend to heal better than those that cross them perpendicularly. Plastic surgeons aim to place scars in favorable directions and in less visible areas; however, in cases of trauma, this is not always possible.
What is the difference between a hypertrophic scar and a keloid?
In both cases, the body produces excessive scar tissue.
Hypertrophic scars develop within the boundaries of the original wound shortly after injury. They are red, raised, rope-like in appearance, and often itchy. They usually improve over 1–2 years, gradually becoming paler.
Keloids, on the other hand, typically appear several months after injury and extend beyond the original wound margins. They are often associated with itching and pain and do not regress spontaneously. They are more common in people with darker skin and may run in families.
Treatment of active scars
Time is the best “healer” for most scars, which generally mature and fade over about one year. Contrary to what many patients believe, scar maturation is a long process. Some resistant scars, however — especially those accompanied by itching or pain — require targeted treatment.
The use of pressure — either in the form of bandages or specialized compression garments worn for several hours a day over many months — is a well-established approach that requires patience but has proven to be highly effective. The use of silicone sheets for up to 18 hours daily over a period of six months has also been shown to promote scar maturation. Finally, intralesional steroid injections are particularly effective in the majority of difficult scars, significantly reducing symptoms such as itching and pain, even when they do not dramatically improve appearance. These injections are typically repeated every 4–6 weeks, and treatment may continue for up to six months.
Another approach is surgical scar revision, particularly when the scar is believed to be the result of special circumstances such as wound infection or healing by secondary intention. We also believe that the use of atraumatic plastic surgery techniques can lead to improved outcomes. The old scar is usually removed under local anesthesia and carefully reconstructed. The new scar will initially appear red and slightly raised, but over time it will gradually soften and fade.
When necessary, additional techniques may be used, such as Z-plasty, which aims to reorient the direction of the scar into a line of lower tension, thereby creating better conditions for healing and improving the final appearance.
Finally, autologous mesotherapy with platelet-rich plasma (PRP), microneedling, and fractional laser treatments can be used to improve the appearance of both new and old scars.
Burn scars
Deep burns — full-thickness or deep partial-thickness — often heal with severe scarring. Children are especially prone to hypertrophic scars and keloids after burns. Main treatment includes compression garments and silicone sheets. When scars cause functional problems, surgical correction may be necessary.
“Healing” creams
There is currently no strong scientific evidence that commercially available “healing creams” significantly improve scar outcomes. What is important is keeping the scar well moisturized, especially during early healing. Because scars are sensitive to sunlight, the use of high-SPF sunscreen is also strongly recommended.
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