Scar treatments

Scarring is the reuslt of an abnormal pattern of healing in previously injured skin. Scars occur due to injury to the deeper layers of the skin (dermal layer or deeper). Depending on the nature of scarring and the body’s response, scars maybe hypertrophic/ /keloid (raised scars) or atrophic (depressed). Essentially, in hypertrophic/keloid scarring- too much collagen is formed, whilst in atrophic/ depressed scars, not enough collagen is generated.

Hypertrophic scars are within the area of scarring, keloid scars extend beyond the border of the wound. Both types of scars are due to an exaggerated response of the body’s healing process that results in a firm, raised purplish- red scar. This scar maybe associated with itch and pain. This type of scarring usually occurs within 4 to 8 weeks after events such as surgery, acne, infected hair follicles, trauma, burns, piercings, and vaccinations. Spontaneous keloids is an uncommon disorder of scarring, and may present in the chest area. As the name suggest, they occur for no apparent reason.

Factors such as age, location of trauma, nature of trauma, race of the patient, surgical technique all play a role in the development of hypertrophic and keloid scarring.

Age - more common in young adults.

Location of trauma - more common to have scars on the chest, shoulders, back, and jawline areas.

Race / ethnicity of patient - hypertrophic/ keloid scars are more common in Asians, dark skin types.

Nature of trauma - more common in acne patients, burn injury and surgical excisions.

Surgical techniques - hypertrophic and keloid scars are more common if poor surgical technique is performed. To reduce incidence of these types of scars, it is essential to orientate the wound correctly, reduce wound tension and place special non- reactive sutures  within the wound in addition to ‘outside’ skin sutures. Correct timing for suture removal is also important.

Both hypertrophic and keloid scarring can be significantly improved. The aim of treatment is to make the scar less visible and to decrease any symptoms such as itch or pain. The end point is flattening of the scar and blending the colour to that of the surrounding skin.  On average 3-4 treatments are need for the best results.

Corticosteroid injections

The most common and also the most effective treatment for hypertrophic and keloid scarring. Injections are placed into the deeper layers of these scars.  Corticosteroids work by decreasing inflammation and decrease fibroblast activity -turning off unwanted collagen.

Silicone gel

This is an over the counter  treatment readily available from Australian pharmacist. Ask for Dermatix gel. Silicone gel is best used as a preventative solution for scars. It has limited ability in reducing well formed scars.

Pulse dye laser/ vascular lasers

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Progress in laser technology and refinements in technique have made laser therapy a good method in the treatment of hypertrophic and keloid scars. Vascular laser such as Pulse Dye lasers may yield significant improvements in scar redness, bulk and texture with minimal side effects and treatment discomfort.   

If you have red scars or early stretch marks (pink stretch marks), then Vascular laser can help. More on vasuclar laser treatments

Ablative laser / Erbium laser

Raised scars can also be flattened by erbium laser treatments. The skin typically takes  9 -10 days to heal up from this treatment. Erbium laser precisely planes the skin surface to within a hundred of a millimetre.  The regenerated collagen forms the basis of new skin.

More information on Laser Revision of scars

A history of keloid and hypertrophic scarring will place patients at greater risk of further scarring. It is essential to treat the primary process leading to scarring- for example, if acne or folliculitis is the cause of scars, then treating the primary process is important.  Correct surgical technique, including correct placement of incisions, reducing wound tension, and the use of deep sutures will also reduce the severity of scarring as will timely treatment with silicone gel and intralesional injections. We advise consulting a dermatologist or plastic surgeon if you are concerned in regards to scarring prior to any procedures. Treatments such as photodynamic therapy or erbium laser ablation maybe an alternative to surgery. Both of these procedures have a lower incidence of scarring compared to surgery.

Acne scarring is a specialist field in it self. Scars maybe present at different depths and types, in different skin types. All cases of acne scarring are assessed individually and a treatment plan tailored to the clinical examination of the patient.

Treatments include –

• Fractional laser resurfacing / Laser resurfacing
• TCA cross for acne scars
• Subscision
• Skin Needling
• Vascular lasers for red scars
• Dermal fillers and grafts
• Steroid injections for raised scars

More on acne scar treatments

This type of scarring is at the opposite end of the spectrum compared to keloid and hypertrophic scarring. In atrophic/ depressed scars there is not enough collagen in the base of the scar. Conditions such as acne and chicken pox may give rise to atrophic/depressed scars. These scars can be lifted or filled by a process known as ‘neogenesis’- stimulation of dermal collagen in the scar base. Neogenesis can be achieved with fractionated laser/ fraxel, chemical peels, subscision and dermal grafting.

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Fracionated laser treatment (Fraxel , ProFractional) produces hundreds of tiny but deep mico-columns of treatment into your areas of scarring. Each column is the diameter of your hair shaft. Laser ablates the scars and old collagen, but also leaves areas of your skin untouched forming the basis of fraxel / fractional laser treatments. For every micro column the laser treats, it leaves the surrounding tissue unaffected and intact. This fractional treatment allows your skin to heal much quicker than if the entire surface was treated at once as the untreated area heals the wound by removing the treated skin and replacing it with new tissue. Essentially, laser works by breaking down old collagen and stimulating new collagen to form (neogenesis).

The advantage of treating skin this way is that there is less downtime and side effects while obtaining a significant clinical improvement. This type of scar treatment is also safe in darker skin types such as in Asian skin/ Ethnic skin.

More information on Fraxel/ ProFractional laser resurfacing

Subscision

This surgical technique is often combined with Fraxel / ProFractional laser systems to treat deep bound down scars. This technique breaks down collagen that puckers the scar downwards. The surrounding scar is injected with local anesthesia, and a needle is inserted to run parallel to the skin. The aim of subscision is to release the collagen bands that bind down the scar. Each session of subscision is aimed at elevating the scar by 20-30%.

Chemical peels

Can achieve mild to modest improvement in early scarring ( depends on the degree and age of scars.) Glycolic acid peelscan stimulate collagen early in the course of scar repair.

High strength TCA peels (TCA Cross) is a method used for treating isolated deep ice pick acne scars. Application of high strength Trichloroacetic acid encourages collagen formation.

Dermal fillers / dermal grafting

This method maybe effective in treating depressed scars. Fillers last 4-8 months. Dermal grafts for acne scars last longer.

Scar and cyst excisions

With deep scars and persistent cysts, excision maybe needed. Deep scars such as ice pick scars are best treated with either punch excision or TCA cross. Fractionated laser is NOT effective in treating this type of scarring however maybe used on the surrounding skin. 

Blue and red light treatments

These wavelengths of light have been effective in treating acne and acne scarring. Treatments are best conducted early in the process of scarring. Improvement are mild to modest.The wavelength of red light has been shown to stimulate collagen formation, and aid in wound recovery. We often combine LED treatments with Fraxel/ Fractionated laser resurfacing for the best possible outcome. LED treatments are NOT recommended for patients with moderate to severe scarring or acne- there are more effective treatments available.

Scarring is a frequent event after surgical skin cancer surgery and trauma. Depending on the type of scars, procedures such as intralesional corticosteroids or laser resurfacing may apply. Treatment will depend on the type of scar, the age of the scar, and the location. New scars that are red or pink in colour can be treated with Pulse Dye laser, with subseqent treatments of Fractionated/ Fraxel laser. This combination usually gives the best scar result after several treatments.

Laser resurfacing

Laser resurfacing is perfomed with either a Carbon Dioxide laser or with an Erbium laser. Resurfacing can be perfomed on acne scars, or on post surgical scars. Lasers function as precision instruments, resurfacing and ablating scars. Laser energy vapourises precise depths of skin and scar tissue, enabling remodelling of the skin.  We often combine various techniques including injections, subscision and laser to achieve the best possible results for scar revision.

Surgical scar revision

In some situations surgical intervention is the treatment of choice for scar revision. Procedures Z plasty can reduce scarring. Most surgical scar revision involving excisions are handled by plastic surgeons. For optimal results, a dermatologist will often work in with a Plastic Surgeon to facilitate scar revision.  Laser resurfacing of revised scars can often give excellent results.

We recommeded Dr Eddie Cheng, Plastic Surgeon for complicated surgical scar revision and Z plasty operations.

www.brisbaneaestheticplasticsurgery.com

Prevention of future surgical scarring

PDT ( Photodynamic therapy) may be used to treat certain types of skin cancers including superfical basal cell cancers and intraepithelial/ intraepidermal carcinomas. In the majority of cases this procedure yields far superior scar results compared to surgery. Your dermatologist will discuss with you the appropriate application of this procedure.

In procedures such as revision of acne,surgical, and traumatic scars, a Medicare rebate may apply.

Chemical peels NOT covered under Medicare

Trusting a physician to revise scars can be daunting form many patients. Our dermatologist that specialise in scar revision will guide you as to which treatments are best suited for your scars and talk you thru the various procedures in greater detail. As we are Specialist in our field, a referral from a GP will enable you to claim a percentage of the consultation and in some cases a rebate for procedures.

Call us directly on 07 3871 3437 to make an appointment, or to discuss issues regarding the referral process.

moreDr. Davin S. Lim

Dr Davin S. Lim, Consultant Dermatologist

Scar revision continues to be a challenging condition to treat for dermatologist  and plastic surgeons.  The advancement of laser surgery, in particular Fraxel and Fractionated laser, in expert hands,  provide a safe, but effective treatment option for patietnts. For revision of surgical scars, a combination of techniques is often best, including intralesional injections and laser resurfacing.

Acne scar revision is a complex subspeciality field. For best results, the Specialist must combine several techniques including surgery, subscision, lasers, and TCA cross. Acne scars come in all shapes, depths and sizes, and in different skin types. Chosing the right technique is very important for results.

"I never thought that my surgery scar could vanish that easily. Noticable results in just over a week." John T, Newfarm

"My plastic surgeon did a great job removing the skin cancer from my nose…laser resurfacing made the scar nearly invisible." Jodie J, Grange

"Dr Lim walked me thru what to expect before, during and after laser surgery…very comfortable with everything. Very happy with the results." Bruce D, Gold Coast