Scars, Keloids and Hypertrophic Scars

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This blog covers skin scars only but does not include burn scars or scars related to breast implants.

Virtually everyone who lives long enough will have a skin scar from elective surgery or an injury. There has been a barrage of cosmetic surgery procedure modifications to decrease total incision length in the hope of creating less scarring. The healing of these disruptions in the skin surface follows a specific process. After the injury or cut there is bleeding. Once this stops an inflammatory process starts to get the cells needed for healing into the wound. New blood vessels grow into the area bringing in the energy needed to complete the healing process. You see this as a red color of the scar and the skin immediately next to the scar that blanches white with finger pressure. Within a week or two the healing is sufficiently strong that the wound should not reopen and any sutures that were placed can be removed. Even though the wound is healed it then must mature over the next 6 to 9 months depending on the type of injury, affected body part, age of individual etc. before the redness goes away and the increased blood flow is no longer needed. Once the scar has fully matured it usually does not blanch with finger pressure. Any problems in this process such as an infection, failure to suture a wound closed, certain vitamin deficiencies etc. prolong the healing time and in doing so result in worse more visible scarring. The skin of younger individuals makes strong repairs and tends to over heal, resulting in larger, thicker scars than on older skin. Skin over the jawbone is tighter than skin on the cheek and will tend to increase a scar's prominence. All scars are more amenable to treatment early in their life span before they mature. It is easier to prevent a bad scar from forming by control/manipulation in the early phases of wound healing than to treat one that has already formed.

Typically, a scar will become increasingly prominent at first. The tissue increases in height, firmness, and redness (vascularity) and then gradually fades. Many disfiguring marks which seem unsightly at three months may heal quite satisfactorily if given more time. The desired end result is a flat (not indented or raised), soft, pale, less than 1mm wide scar. We can call that the normal scar. The non-normal scar is more visible due to a number of factors, including its difference in topography (surface contour or depth and height relative to adjacent skin), color, thickness, pliability or texture versus the surrounding normal skin. Scar length, width or direction can also contribute to visibility. A scar that crosses natural expression lines (Langer's lines) or wrinkles will be visually striking because it will not follow a natural pattern for example a scar that obliquely crosses the natural skin fold between the corners of the mouth and the nose is much more visible than one that lies along this fold. If the skin scar adheres to deeper structures such as muscle or bone the skin may bunch up with movement as it is tethered to deeper structures and that also contributes to visibility. In fact some scars may only become visible on animation or movement. Some scars are accompanied by a loss of skin with or without a corresponding loss of deeper tissues (a tissue deficit). Factors that contribute to bad or non-normal scar include:

1. location (worse on chest and shoulder)
2. hormones (worse if skin injured during pregnancy or puberty)
3. genetic
4. chronic inflammation (such as those due to acne)
5. tension of closure
6. delayed wound healing (the incidence of bad scarring increases by 50% in wounds not healed within 3 weeks of injury)

 In worse cases the patients complain of scar itching, pain, breakdown to a raw surface with minor trauma (an unstable scar) and even recurrent infections in addition to scar visibility and in some cases limited range of motion due to scarring. I take all of these factors into account before treating a patient with scars and then develop a treatment plan specific to the patient's situation.

White scars are visible because they have lost all of their pigmentation. Excimer laser or dermal needling (a tattoo like needling of the skin without tattoo pigment) can be used to stimulate pigment cells to migrate into these types of scars from adjacent non-scarred skin. A more expensive approach would abrading the surface of the scar and spraying pigment cells harvested from elsewhere on the body onto the surface of the wound. The cheapest approach in such cases is camouflage make up.

TYPES OF SCARS
The non-normal or non-desireable scars can be classified as significant skin loss/deficit, flat and wide, hypertrophic and keloid.

--SKIN DEFICIT
These scars usually arise after injuries like bites and car accidents where the skin is disrupted by an object that is not knife sharp. The skin at the edges of the wound is crushed in the process and either dies on its own or has to be cut away by the surgeon.

This patient had a scar with significant loss of skin that shortened the vertical length of the central upper lip and distorted the normal lip proportions.

--FLAT AND WIDE
The final scar width is dependent on the tension of closure and distracting or separating forces applied to the scar with movement before the scar has fully matured. If an injury causes a wound and crushes skin at the edges of the wound that crushed skin is usually removed. The non-crushed skin at the edges is of better quality but when the edges are sutured together it may be under tension from skin loss and that leads to a wider more visible scar. Alternatively the scar may lie along the scalp, front of the knee or back of the elbow where movement will constantly stretch the scar along the length of the limb or skull before it has fully matured and widen it. The visible linear scar of the scalp can be a cosmetically serious complication of a scalp incision in scalp surgery, forehead lift or craniofacial surgery, especially on the temple scalp where it is harder to hide by combing the hair over it. This area of hair loss is usually due to incisions or cuts that damage the hair follicles along the cut or laceration as well as widening of the scar line after healing. Treatment limited to removal of skin only increases tension around the scar and results in a high recurrence rate of these types of scars.

I had a patient with a scar over the jaw line that would alternatively turn red and then
pale as the patient moved his jaw -speaking, eating, or making facial expressions. This was due to the tension applied across the scar with jaw motion.


This photo shows a knee scar after orthopedic surgery. The scar is wide and flat and lies over those parts of the knee that are constantly placed under tension with knee movement. You can test this for your self by pinching the skin over the while the knee is extended. When you then flex the knee you can feel the tension of the pinched skin that would be applied to a scar over the knee with knee motion. Also note the small punctate scars along side the main scar these are stitch mark scars from the sutures. The scar is widest where it lies over the joint itself due to the greater amounts of tension across the scar. The scar is normal over its lower third because of the absence of tension across the scar. These scars are best treated by taping the scar for some months after surgery. Once they widen it is very hard to fix them because of the motion at the joint and the increase in tension when you remove any skin as you would be doing if you cut out the scar.

This is the type of scar seen after injury or cosmetic surgery (browlift, facelift). It is much harder to hide one of these types of bald scars on the side of the head than on top of the head where hair can be combed over it. Although the scar may be of good quality the associated loss of hair along the scar makes it much more noticeable than it otherwise would be.

--HYPERTROPHIC
Hypertrophic scars are seen as a ridge within the confines of the original wound. They develop soon after surgery, usually subside with time (mature), are confined in size/growth and usually occur across moving areas of skin (abdomen, palm, front of the elbow, in the fold under the breasts). They are thickened scars over areas of skin compression. They can also arise from a prolongation of the healing process. More tissue than is required is produced to close/cover the wound. They can be a single raised line along the scar (linear) or a raised area of variable shape (widespread).

--KELOID
Keloids appear sometime after the original surgery or injury, rarely subside with time, grow out of the confines of the original wound, (a minor injury can produce a large keloid), are independent of skin motion (such as earlobe keloids), rarely occur across joints and can become much worse after surgery without concomitant steps to prevent recurrence. The incidence of keloid scarring increases in darker skinned individuals but not ever darker skinned individual gets them. Despite that my keloid patients are mostly Afro-American followed by Asians and then those of non-European Hispanic descent. I have only had a few Caucasian patients with this problem. Keloids have not been reported in albino's of any race, suggesting a potential role of skin pigment in this type of scarring. There is an increased incidence of keloid formation running in families so it is inherited to some degree. Keloid scarring does not follow the same pattern of evolution, stabilization, and involution of the normal or hypertrophic scar. It may develop directly after an initiating event or some years later, arising from a mature scar. Earlobe keloids usually occur months are years after the initial ear piercing. Keloids also can occur spontaneously. Virtually all keloids that are cut out will return if steroids and pressure are not applied after surgery. In some cases radiation may be used instead of pressure.

This patient had a keloid from an ear piercing removed with inadequate care afterwards to prevent it from coming back. It of course grew back and you can see how it grew out of the boundaries of the original piercing so that it began to block the ear opening and affect hearing.

A scar can have mixed properties along it's course for example a midline scar extending down from the chest into the abdomen can be normal in the upper half and hypertrophic in the lower half or the mixed scar in the knee photo above.

TREATMENT
The goal of treatment is to make scars less visible and relieve itching and pain if present. Silicone gel sheeting and corticosteroid injections into scars are the only treatments for which there is sufficient published medical journal evidence to justify their use. Studies of scar treatment are complicated by the natural tendency for scars to improve over time. Having said that most physicians including myself rely mostly on what has worked for our patients rather than referring to published studies involving large groups of patients. Looking at the accompanying photos you can judge for yourself what is effective.

Frequently a combination of treatment modalities is required because not every modality works on every patient or scar by itself. When applied together some modalities have a much greater effect than the sum of their individual contributions.

--SURGERY
Surgery is commonly used to cut out a scar. The resulting sutured wound creates a young immature scar that responds better to the modalities described below. In the case of tissue loss new skin can be brought to the area by skin grafting or small surgical procedures to move around adjacent skin. Surgery can also be used to break up a scar, detach the scar from deeper tissues, change scar direction or manipulate adjacent tissue to decrease tension along the scar line -all of which can make a scar less visible. These procedures are usually performed under local anesthesia so the patient does not have to go to sleep under general anesthesia. Surgical removal alone for keloids without any of the adjunctive procedures below has a 45 to 100% recurrence rate. This treatment modality is the one I most commonly use on my patients.

--SILICONE GEL SHEETING
Silicone gel sheeting has been in use since the early 1980s for the treatment of scars and has been proven to be effective. It is available over the counter as a solid sheet or a gel that you apply which hardens. Despite its track record my patients have not liked it and it has not been effective in my practice.

--PRESSURE THERAPY
Pressure has been used in the treatment of scars since the 1970s. The effectiveness is dependent on how long the pressure is applied for. Some doctors recommend 6 to 9 months of pressure but the majority of my ear lobe keloid patients only require 2 to 3 months of pressure earring wear. Certainly scars that have recurred after previous treatment should have pressure applied for a longer period of time. Scar massage has the same effect as pressure with the additional effect of breaking up scar connections between layers of tissue.

This is a widespread hypertrophic scar on the right buttock. After 6 months of pressure applied to the scar the part of the scar that received pressure is flatter. Pressure definitely works if applied long enough.

--CORTICOSTEROID INJECTION
Corticosteroids are most effective when injected and not so effective when applied topically (except when applied as a medicated tape). This is the second most common modality I use on my patients, mostly in conjunction with surgery and it has been in use since the 1950s. Only very small amounts of the appropriate strength should be injected at a time very close to the surface in order to avoid thinning or depigmentation of the skin or creation of spider vessels around the injection site. If too much is injected too deep into the skin the risk of these problems occurring goes up. Except in the case of keloids the injections should not be closer than 4 to 6 weeks apart in order to avoid these problems as well. When used together with surgery for keloids the recurrence rate drops below 50% .

--RADIATION
Radiation applied right after surgery for keloids drops the recurrence rate down to 10%. 4 treatment sessions are required. Despite that I have found that the majority of these patients will require corticosteroid injections and/or medicated tape to get the best result. Although the keloids do not come back these scars tend to hypertrophy but are very sensitive to corticosteroid treatment.

--LASER
When the ablative lasers (those that vaporize surface skin) appeared in the mid-1990s the general public was lulled into believing they caused less scarring than scalpels. This turned out to be science fiction. There is no advantage to using these types of lasers in surgery to prevent scarring at the time of surgery. Both ablative and non ablative flashlamp lasers have proven useful once the area is healed to prevent or treat scars.

Fractional ablative lasers vaporize tissue in narrow columns.

The skin is left intact between the columns, which are so narrow that they heal within a few days without adding to the scar load. In the process of ablation they remove scar tissue so that after up to 3 treatments spaced a month apart significant scar flattening and softening occur. This has been studied mostly in hypertrophied burn, surgical and traumatic scars beginning as early as 1 to 3 months after the inciting injury. Some doctors use the fractional laser on keloids to soften them and report a greater effect of injected medications into the keloid afterward.
Lasers that obliterate small blood vessels near the skin surface without destroying the skin (flashlamp lasers) have been used to decrease superficial blood flow to the scars making them less red and mature more quickly.


--DERMABRASION
Dermabrasion involves the application of a rough surfaced rotating device to abrade the surface of the skin. It flattens scars the way sanding a wooden surface makes it smoother. Dermabrasion in general is much less commonly performed than it was prior to the introduction of skin lasers.

--FREEZING - CRYOTHERAPY
Freezing scars has been used in the past but is not currently popular because of the high risk of damaging pigment and the creation of scabs that take some time to heal over and separate, especially if the freezing agent is applied externally. In 1993 doctors began injecting the freezing agent into the keloid. In 2002 a new device was developed, CryoShape, to make injection of the freezing agent into the keloid easier.


--TAPE
This is the modality I use the most after surgery both for scars and after cosmetic surgery. By applying the tape you decrease motion along the scar line and it is preventative against wide flat scars. The greatest advantage is that it is cheap and easy to do. It is not effective for the treatment or prevention of keloids.

--CORTICOSTEROID MEDICATED TAPE
Over the years I use more and more medicated tape in my patients. Patients that respond to corticosteroid injections but require more than 1 or 2 injections get this treatment. The medication is mixed with the adhesive and the tape prevents the medication from evaporating so it can be absorbed into the skin. This treatment has been a lifesaver for many of my patients, and me also.

--CAMOUFLAGE TATTOO
This is reserved for men who have scars on the face with loss of the beard hair in the scar. The medical tattooist tattoos small black dots to match the facial hair and the result can be very good. The only problem is the tattoo may fade over time and require touch ups.

--OTHER MEDICATIONS
Interferon an immune medication and some cancer chemotherapy medications have shown effectiveness in scar treatment when injected in small amounts into the scar. Currently these are not the most popular treatment modalities.

--SUNSCREEN
Sunscreen should be consistently used to protect scars from sun exposure until they have fully matured in order to prevent the scars from becoming permanently hyperpigmented (darker).

The company Crescendo marketed of a drug called, HybriSil (methylprednisolone acetate 1% in silicone gel), for the treatment of skin scars. The idea was that combining a topical steroid with silicone to the skin surface was beneficial. The problem was this combination had never been placed through FDA required trials. In November 2011 the FDA sent them a warning letter that Hybrisil was illegal because it had never been approved and was being misbranded. It was an unapproved new drug product, which could not be marketed without approval by the FDA based on data showing that the product is safe and effective for its intended use. It took Crescendo until January 2012 to file an investigational new drug (IND) application that permitted the limited distribution of the product for investigational use only.. The FDA made a return inspection of Crescendo in late January 2012 and determined the company still was distributing the product for noninvestigational purposes and the labeling failed to carry adequate directions for use.. In early May 2012, the FDA ordered Crescendo to discontinue manufacturing, and the company agreed. The FDA said it has not received any reports of adverse reactions associated with HybriSil. The company reports that it has begun clinical trials and intends to work with the FDA to secure approval of a prescription HybriSil, and eventually, an over-the-counter version but that does not change the fact that it tried to circumvent the drug approval process.

CASES

This patient had a keloid arising in an acne scar. I could not cut it out because there was not enough surrounding loose skin so I shelled out the keloid at surgery. Radiation and medicated tape were used after surgery and the after photo is 7 months after surgery.


In this case the scar from previous surgery connected the skin to the stomach muscles. The surgery involved separating the deep from the superficial layers and a little bit of liposuction to even the surface contour. The after photo was taken 1 year after surgery.


This patient had a keloid on his back that was removed elsewhere twice and grew back within 2 months of surgery. There was enough loose tissue around the keloid that I could cut the whole thing out. Radiation was used after surgery and then taping. This patient did not wear the tape as directed and so the end result was a wide flat scar but that was still better than a keloid. The after photo was taken 1 year after I did this surgery.


This patient began losing hair 1 year after a facelift by a surgeon other than myself. She had a wide flat bald scar on the temple scalp and hair loss behind the ear. I grafted hair from the back of her head to hide these scars.


For this patient I surgically removed the keloid under local anesthesia and then treated with corticosteroid injections and 2 months of pressure earring wear.


In this case I removed a wedge of scar tissue and damaged lip and then realigned the lip margins. The only treatment modality required was surgery under local anesthesia.


This is one of the easiest scars to treat. I removed the hypertrophic scar under local anesthesia and just sutured it. No additional treatment was required. The hypertrophic scar appeared because the original wound was not sutured.


This patient was left with wide depressed scars on his arm after limb saving surgery in another country. The skin could not be sutured at the time and that contributed to the scars. I stretched the adjacent skin with sutures for a month or two before cutting the scars out. That allowed me to close the excision sites with less tension and decrease the chance that the scars would widen again. The after photos were taken about a year after surgery.

This scar is visible because it lies in the middle of an aesthetic unit of the face and is not aligned with any naturally occurring facial skin folds or wrinkles. The treatment is to excise the scar with irregular geometric shapes to make it less noticeable. If you used only one shape such as a triangle the result would not be as good. Photo courtesy of Dr. David Hendrick

In this case a circular scar causes the skin within the confines of the scar to protrude outward. The treatment is to make the scar zig-zag and thin the fat layer within the confines of the scar. Photo courtesy of Dr. David Hendrick



In some cases it is best to just cut out the skin scar and suture the resulting wound closed.

This patient had subtotal excision of a central chest keloid followed by radiation and then application of medicated tape. The photos were taken before, 1 1/2 months after and 1 year after surgery.

This patient also had subtotal excision of a central chest keloid followed by radiation and then application of medicated tape. The photos were taken before, 9 months after and 14 months after surgery.

In this case a burn scar of the face was camouflaged using follicular unit hairgrafts.

The ultimate goal, seldom achieved, is to hide a scar so that it is not visible to the unaided eye and the area in question looks as though nothing untoward has occurred. Scars never disappear and in many cases only a partial response is possible. The treatment of scars is usually not covered by health insurance unless a bodily function such as range of motion is affected or the scar is unstable. Some health insurance will cover scars from repaired injuries up to 1 year from the date of the injury.

Addendum March 12, 2012:
 Neodyne Biosciences patented their Embrace Advance Scar Therapy system in 2010.

They received FDA approval in 2011. Just published studies on scars after abdominoplasty surgery show the system significantly improves the appearance of these scars. The system uses an applicator to stretch silicone tape which is then applied over the scar. The stretched tape contracts after application and protects the scar from tension and skin movement along the scar which would otherwise result in a bad scar. I cannot see the preferred use of this over regular medical tape which when properly applied can give the same kind of stress shielding at a fraction of the cost.

Addendum February 15, 2015:
A just published Dutch study of 29 keloids treated with injection of a freezing agent into the keloids followed for 1 year showed a 24% recurrence rate, loss of pigmentation in 69% of treated scars and an average 69% (range 16 to 100%) decrease in keloid volume. Some of these cases resulted in replacement of the keloid with a wide depressed scar containing abnormal looking skin. In conclusion intra-keloid freezing such as the CryoShape does not completely remove the keloid in all cases, is associated with a recurrence rate and can permanently whiten dark skin. It is not the gold standard in treating keloids. 


Addendum July 1, 2015:
A review of 8 published studies on the use of intra-keloid cryotherapy revealed average scar volume decreases ranging from 51% to 63%, but no complete scar eradication was achieved on average. Scar recurrence ranged from 0% to 24%. Hypopigmentation after teatment was seen mostly in Fitzpatrick 4-6, darker, skin type patients. Finally, complaints of pain and itching decreased significantly in most studies. The evidence proved limited and inconsistent resulting in an American Society of Plastic Surgeons grade C recommendation for this type of treatment of keloid scars. My conclusion is this treatment is best restricted to lighter skin patients who main complaint is pain and/or itching.

Addendum March 3, 2018:
A randomized controlled split treatment scar study performed by researchers in China could be another game changer. The showed that 10 units injected 5mm from each wound edge per centimeter of wound at the time of wound closure resulted in major improvements in scar height and thickness and possibly width. This would cost about $600 per inch of scar. Since the injections were into the dermal layer of the skin the action is a different mechanism than that involved in reduction of forehead wrinkles using botox for muscle paralysis. Someone needs to study its use in the treatment of keloids.

Lip Scar Revision
Keloid of the Face
Earlobe Keloids
Facial Keloids
Chest Keloids
Aaron Stone MD - Plastic Surgeon Los Angeles
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