Scars are the result of the body’s attempt at repairing damage. Depending on the nature of the injury, its depth and extent, and the patient’s intrinsic ability to heal, scars can be a cosmetic hindrance or a life-altering event.
Frequently, when I am removing a skin cancer or performing a biopsy, patients will ask if they will have a scar. My answer is always “yes.” This is because by definition the repair mechanism cannot provide an exact replacement for skin that has undergone sun or environmental exposure and a variety of other factors that affect its appearance.
There are several ways to help repair scars. Treatments can involve combinations of injections with cortisone, lasers, fillers, and surgery.
Scars are formed from thickened collagen fibers that replace the normal woven fibers. The outer layer of the scar has skin that is different from normal skin – there are usually few if any hair follicles, and the texture and color are not the same. Fixing a scar needs to address both of these changes to improve the appearance.
The Mechanics of Scarring
In general, skin repair occurs from the hair follicle, which provides skin for the surrounding injury. When the wound is deeper than the follicle base, healing can be impaired and the outcome will usually be worse than with a superficial wound.
For certain types of injuries, e.g. burns, the depth of the injury may not be apparent at first glance because the heat can spread the damage beyond what is immediately visible. This has implications in the scar formed.
Acne may damage the outer layer as well as the collagen and this can create deep “pockmark” scars. Similar scarring is seen with chicken pox and other skin infections.
Traumatic scars tend to heal less cleanly than those caused by surgery because the injury is more random and intense. Frequently, traumatic scars result from car or other accidents, burns, or military action. Some of these will require skin grafts to heal and others can be addressed with different methods.
Lasers Create 'Thermal Injury'
Lasers may be used to help minimize the impact of a scar. For scars that are still red or pink, the pulse dye laser can help soften the tissue and decrease the redness. Treatments should begin as soon as the scar has healed and the skin intact. Pulse dye laser sessions are scheduled three to four weeks apart and, depending on the depth of the scar and its color, require four to six sessions.
Fractional lasers (laser beams broken into pixels or points of light) are used to remodel scars. Some of these modify the superficial layers and these are great for superficial scars. The Fraxel laser can be used on scars that are not very thick. It takes several treatments to see an improvement.
Deeper penetrating lasers such as the CO2 laser can alter scars that are very thick. These treatments also require several visits.
These types of laser remodeling involve creating a thermal injury to remodel the damaged skin and there are risks associated with each.
Scars from acne, surgery, or trauma may have a relatively normal collagen layer but have a depressed surface. These depressed scars can be corrected using soft tissue augmentation with hyaluronic acids, collagen, or polylactic acid.
Beneath the Surface
The psychological and physical damage from scars is frequently underestimated. Some scars, particularly on the face, are associated with lower self-esteem and depression while others, such as those on the fingers, hands or feet, can be associated with decreased function.
If you have a scar that is problematic, consult with a dermatologist or plastic surgeon who is interested in this field.
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