Scar Prevention and Revision Timing
Surgeons creating primary surgical scars, repairing traumatic wounds, or revising scars should prioritize the
prevention of abnormal scar formation. Surgical technique plays a major role in avoiding excessive trauma to the
tissue. Planning of incisions parallel to the relaxed skin tension lines (RSTLs), avoiding excessive tension,
and providing skin eversion all play critical roles in the ultimate scar. For traumatic wounds, using atraumatic
technique, minimizing risk of infection, debriding nonviable tissue,
and providing early wound coverage are all equally important.
After wound closure, the surgeon’s goal should be to provide tension relief, hydration of the wound
(moisturizing emollient, moisture-retentive dressings such as silicone gels or sheets), occlusion of the wound,
pressure/pressure garments for the wound, and guidance on avoidance of UV light. [4, 6] With recognition of early scar
hypertrophy and increased erythema, the above measures should be implemented and followed to attempt the
reduction of hypertrophy. Surgical revision should be the last resort and adjunct therapies such as
silicone gel sheeting, silicone creams, taping, and coaptive films should be used as first-line measures.
The timing of scar revision,
invasive or noninvasive, depends on a variety of factors, including type
and location of injury, softness and suppleness of scar, and, finally, the psychological readiness of the patient.
One popular practice adopts a 6- to 18-month waiting period following initial injury, but experience shows
that this waiting period must be individualized because an earlier or even later approach may be undertaken.
Before any revision procedure, a thorough assessment includes characteristics of the initial injury,
relationships to anatomic location and RSTLs, recognition of pathologic healing (eg, hypertrophic scar, keloid),
and any regional functional impairment by deformity (eg, oral or ocular impairment).
The timing of revision surgery is influenced primarily by the well-characterized biochemical and histologicevents
following injury. Scars mature or remodel over 12-18 months, resulting in a final scar that has a tensile strength of
70-80% of uninjured skin. Hence, the final visible outcome of a scar can best be assessed after this period of
remodeling and collagen reorganization as type I collagen replaces type III collagen and overall scar dimension
and erythema decrease. For this reason, scars that initially appear erythematous and elevated may be managed
satisfactorily without surgery after 1 year if they have an initially favorable RSTL
and regional aesthetic facial unit configuration.
Scars considered unfavorable
because of their relationship to facial anatomic units, RSTLs, angle of incision,
or depth and type of injury may be revised on a much earlier schedule. Performing scar revision earlier
than 6 months following initial trauma is not unreasonable in certain circumstances.
Early intervention may promote earlier maturation, redirect the aesthetic and functional outcome,
and help alleviate the psychological tension patients often experience while waiting for definitive treatment.
While awaiting the appropriate interval before the revision operation, patients may persist in their efforts to influence
the surgeon toward an inappropriately timed revision. The surgeon must be steadfast during this time
and not schedule the procedure until the wound has attained an acceptable degree of primary healing
and the patient possesses a more realistic expectation of the likely result.
Psychological Considerations
Patients who desire scar revision after physical trauma have a different mind-set than those
who desire cosmetic facial surgery in the absence of physical trauma. Patients who have
been injured frequently bear psychological trauma induced by the initial event.
This trauma often persists irrespective of the time between injury and surgical consultation.
While the timing of scar revision usually dictate by the interval following the initial event,
a waiting period allows the patient sufficient time to adjust psychologically to the prospect
of undergoing another surgical procedure and to make a more dispassionate consideration
of the surgeon’s treatment plan. Patients should have a realistic perspective of the lengthy healing time
following revision procedures, likely outcomes given the injury characteristics, and the possibility
of future disjunctive procedures such as dermabrasion, laser resurfacing, or multiple steroid injections.
It may be in the best interests of both surgeon and patient to seek disjunctive consultation with
a therapist well versed in the treatment of post traumatic stress disorder (PTSD) for patients
whose scar revision follows significant psychological trauma. Likewise, when the facial scars result
from domestic violence, the surgeon may want to seek the services of a qualified psychotherapist or social worker.
When facial scars cause by domestic violence, the objective of scar revision is more than just beautification.
Camouflaging the daily physical reminders of former domestic abuse with a scar revision procedure
ultimately may serve as the avenue by which a person regains lost self-esteem. Finally, in the appropriate setting,
the surgeon may want to inquire about the patient’s social situation, because compliance
with postoperative wound care may impede by adverse social settings.
Moreover,
the importance of the professional services of a licensed cosmetologist knowledgeable
in the application of cosmetics to camouflage facial scars cannot overstate. While the patient is
waiting for the operative date, these professionals can provide a way for patients to acceptably cover their wounds.
Cosmetologists also are helpful in the postoperative period, while revised scars undergo maturation
and require camouflage, for cosmetic reasons and to prevent solar-induced cicatrix erythema.
Finally, because some scars may not be amenable to revision surgery or for those that still
are suboptimal after revision, a cosmetologist may be of great assistance.
