Scar Revision Surgery: Everything You Need to Know

Scar revision surgery encompasses a range of surgical techniques used either alone or in combination with other surgical or non-surgical scar treatments. The surgery is used for cosmetic purposes or to restore function to a part of the body that has been restricted by scar tissues. The choice of surgery depends on the type, location, and size of the scar.

What Is Scar Revision Surgery?

Scar revision surgery is sometimes referred to as scar removal surgery, although it does not erase a scar but rather reduce its appearance or impact. They are scheduled procedures, some of which can be performed on an outpatient basis, while others require post-operative inpatient care.

Contraindications

Scar revision can be performed on both children or adults, but there people in whom the surgery is used with extreme caution. This includes people who cannot stop taking anticoagulant drugs like Coumadin (warfarin) due to the risk of thrombosis. Taking anticoagulants during the early recovery phase can impair healing and lead to an even worse scar.

The same applies to people with hemophilia or uncontrolled diabetes in whom wound healing can often be significantly impaired.

Possible Risks

The risks of scar revision surgery are more or less the same as any procedure involving an incision, including a risk of bleeding, infection, and wound dehiscence.

Arguably, the greater concern is whether the procedure will lead to even worse scarring. In older people with thinning skin, for example, care must be taken to weigh the benefits and risks of treatment and to establish whether the person has reasonable expectations about the outcomes.

Types of Scar Revision

There are several techniques that plastic surgeons will use for scar revision based on the type, location, and size of a scar.

Fusiform Elliptical Excision

Fusiform elliptical excision is a basic surgical technique used to repair a mature scar that is either deep or has spread beyond the margins of the original wound. It involves the removal of scar tissue along with a small margin of normal tissue, the edges of which are then delicately stitched together with fine sutures.

To minimize the appearance of the wound, one edge of the scar is beveled and the opposite edge is counter-beveled so that they fit together in a tongue-and-groove fashion.

Z-Plasty

Z-plasty is a versatile surgical technique used to improve the function or appearance of a scar. The technique involves making a Z-shaped incision along the line of the greatest tension of a scar, after which the upper and lower triangular flaps are "switched" to the opposite positions.

Z-plasty has several advantages over an elliptical incision:

• It "irregularizes" a linear scar, breaking it up and making it less noticeable.
• It can disguise a scar by repositioning it along natural skin creases.
• It realigns the direction of a linear scar, releasing tension.
• It can lengthen a linear or webbed scar, reducing skin contraction.

Geometric Broken-Line Closure

Geometric broken-line closure (GBLC) is a more complex surgical technique used for larger facial scars, particularly those on convex or concave surfaces (such as the cheek or forehead).

For this surgery, an incision is made down the center of the scar. On one side of the incision, random geometric patterns (e.g., semicircles, triangular teeth, square notches) are cut into the skin. On the other side, a mirror pattern of the same cuts are created, the edges of which are then fitted together like a puzzle.

GBLC can greatly minimize the appearance of a linear scar due to the random twists and turns that are difficult for the eye to follow.

V-Y and Y-V Enhancement

There are two procedures, called the V-Y and Y-V enhancement, that are used to treat small contracted scars or depressed scars with visible bulging around the edges. The procedures are used for aesthetic purposes and are especially useful around the eyes and mouth.

The V-Y enhancement effectively lifts skin upward, while the Y-V enhancement draws the skin downward, as follows:

• V-Y procedure: A V-shaped incision is aligned with the edge of a scar, cutting away a large margin of tissue on both sides. After the resected tissue is removed, the bottom of the scar is pinched and sewn together. The rest of the wound is then stitched upward, creating a Y-shaped wound.
• Y-V procedure: A Y-shaped incision is aligned with the edge of a scar with a large margin on both sides. After the resected tissue is removed, the top triangular portion is pulled down and stitched to the bottom of the incision. The suturing then continues upward, creating a V-shaped wound.

Flaps and Grafts

Local flaps and skin grafts are used when there are significant areas of burned or scarred tissues.

Flaps are made by cutting a portion of healthy skin and shifting it to an adjacent area with the blood flow still intact. Skin grafts involve moving a healthy patch of skin to a distant part of the body, severing the blood flow and requiring the growth of new blood vessels.

Purpose

Scar revision surgery can be used for a variety of reasons. In addition to diminishing the scar's appearance, the surgery can treat areas where tissue contraction is causing a loss of mobility and/or range of motion. Scars can also be painful sometimes, particularly if a neuroma (the abnormal growth of nerve tissues) is involved.

For others, the reduction of a scar's appearance can help overcome an emotionally traumatic event or reduce feelings of embarrassment that can lead to social isolation.

There are different types of scars, each of which are treated differently. These include:

• Hypertrophic scars: Red, raised scars caused by the excessive build-up of collagen, typically within the margins of a wound
• Keloids: Fibrous tissue outgrowths that are raised and brown and can extend beyond the margins of a wound
• Contracture scars: Areas where scarred tissues have pulled together during healing
• Trapdoor deformity: A depressed scar circumscribed by raised tissues

Scar Assessment

When embarking on scar revision surgery, the surgeon will conduct an assessment using one of several systems. Some like the MCFONTZL classification are used specifically for facial lacerations, while others like the Vancouver burn scar assessment score are used solely for burns.

In addition to a physical exam, the surgeon may use a variety of tools to map the surgical plan, especially for those with severe or disfiguring scars. This may include:

• High-resolution ultrasound: A non-invasive tool that can classify anisotropy (tissue stiffness) and hypertrophy (tissue thickness) with high-frequency sound waves
• Laser Doppler flowmeter: A form of ultrasound that can map the vascularity of a scar
• Optical profilometers: A non-invasive tool that maps the contours of a scar with a three-dimensional array of light beams

How to Prepare

If surgery is indicated, you will meet with the plastic surgeon to discuss the surgical approach and what you need to do to prepare. The surgeon will also provide you with reasonable expectations of the results based on the location and characteristics of your scar.

It is important to ask as many questions as you need to understand the benefits, risks, and likely outcome of surgery. Most plastic surgeons can offer photos of others who have undergone the same procedure.

Location

Scar revision surgery is typically performed in a hospital or specialized surgical center. In addition to standard surgical equipment, the surgeon will rely on specialized tools to perform more delicate tissue repair.

This includes the use of optical loupes and magnifying eyewear to apply ultrafine 0/5 to 0/6 sutures for facial surgery and larger 0/3 to 0/4 sutures on the arms, legs, and torso.

What to Wear

Wear something comfortable you can get into and out of easily as you may be asked to remove some or all of your clothing. A hospital gown will be provided for you to change into. Pull your hair into a bun and ponytail if it is long. Leave any jewelry or other valuables at home.

Depending on the surgery and anesthesia used, you may be asked to remove dental appliances and lip or tongue piercings. Things like eyeglasses, hairpieces, false eyelashes, and hearing aids may also need to be removed.

Food and Drink

Again, depending on the type of anesthesia used, you may be required to fast at least six hours before surgery.

If any form of general anesthesia, regional anesthesia, or intravenous sedation is used, fasting will be needed, and your surgeon will typically advise you to stop eating at midnight the night before the surgery.

On the morning of your surgery, a small amount of water can be consumed to take your morning medications. Within four hours of surgery, nothing should be taken by mouth, including gum, breath mints, or ice chips.

Scar revision surgery performed under local anesthesia may not require fasting, but speak with your surgeon to be sure. Monitored anesthesia care (MAC) is sometimes used with local anesthesia and require the same restrictions as the other forms of anesthesia.

Medications

Any medication that impedes wound healing may need to be temporarily stopped before and after surgery. These included drugs that impair circulation, blood clotting, and the local function of the immune system. Any disruption of these functions can lead to hypertrophy and the formation of visible scars.

The drug restrictions can vary by surgery but typically involve:

• Anticoagulants ("blood thinners"): Drugs like Coumadin (warfarin) and Plavix (clopidogrel) are usually stopped five days before surgery.
• Nonsteroidal anti-inflammatory drugs (NSAIDs): Painkillers like aspirin, Advil (ibuprofen), Aleve (naproxen), and Celebrex (celecoxib) promote bleeding and are usually stopped one to two weeks before and after surgery.

What to Bring

Only the day of your procedure, be sure to bring a photo ID (like your driver's license), your insurance card, and an approved form of payment if copay or coinsurance fees are required upfront.

You will also want to bring someone along to drive you home. Even if local anesthesia is used, you may experience significant pain or discomfort as the effects of the drug wear off. Local anesthetics can also cause headaches, blurring, and dizziness in some people.

If general anesthesia, regional anesthesia, or MAC is used, you need to organize a friend, relative, or car service to drive you home without exception.

Pre-Op Lifestyle Changes

If you smoke, your surgeon will advise you to quit cigarettes before and after scar revision surgery. Tobacco smoke causes extreme and persistent vasoconstriction (narrowing of the blood vessels), depriving surgical wounds of the oxygen and nutrients they need to heal.

Most plastic surgeons will recommend quitting four weeks before surgery and three to six weeks after (and ideally forever).

What to Expect on the Day of Surgery

Upon arrival at the hospital or surgical cancer, you will need to register and fill out the necessary forms, including a medical history questionnaire and a consent form stating that you understand the aims and risks of the surgery.

Arrive no less than 30 minutes in advance of your appointment to complete the documents and settle in.

Before Surgery

Once register, you are escorted by a member of the surgical team to a preoperative room or cubicle, where you will be asked to change into a hospital gown. A nurse will then take your vital signs (temperature, blood pressure, heart rate) and record your height and weight (which are used to calculate the anesthesia dose).

A sample of blood may also be taken, usually for more extensive procedures, to check your blood chemistry, oxygen saturation, and any signs of inflammation or infection. The surgical site may also need to be shaved if it is especially hairy.

If general anesthesia, regional anesthesia, or MAC are used, other pre-operative procedures would be performed, including:

• Electrocardiogram (ECG): Involving the attachment of adhesive probes to your chest to monitor heart electrical activity
• Pulse oximetry: Involving the attachment of a clamp to your finger to monitor your blood oxygen
• Intravenous (IV) line: Involving the insertion of a tube into a vein in your arm to deliver anesthesia, sedation, fluids, antibiotics, and other medications

You may also meet with an anesthesiologist before surgery to discuss any drug allergies you have or drug reactions you've experienced in the past. You will likely only see the surgeon when you are taken to the operating room.

During the Surgery

After being prepped for surgery, you are wheeled into the operating room and placed on the procedure table in a position that provides the best access to the scar. For some minor facial surgery, the procedure may be performed in a reclining chair (similar to those in a dentist's office).

The choice of anesthesia can vary by the surgery. There may several options the surgeon can use:

• Local anesthesia: Delivered by a series of injections, first into the upper epidermal layer and then into the lower dermal tissues
• Regional anesthesia: Delivered intravenously or by injection (into the spine or nerve bundle) to block pain signals
• General anesthesia: Delivered intravenously to put you completely to sleep

MAC, delivered intravenously, may be used with local or regional anesthesia to help induce relaxation and "twilight sleep."

Once the chosen anesthetic has taken effect, the parts of the body not being treated are draped with sterile sheets.

Irrespective of the surgical technique used, the surgeon will adhere to certain principles and practices to ensure minimal post-operative scarring. These include:

• Incision direction: Incisions are always made perpendicular to the skin to keep the edges clean and in the direction of hair follicles to prevent hair loss.
• Tissue handling: The gentle handling of the skin with fine-tooth forceps and skin hooks reduces tissue trauma.
• Skin hydration: By continually hydrating the skin with a moist sponge, conjoined tissues are more likely to adhere smoothly.
• Layered skin repair: The surgeon will approach the surgery in layers (epidermis, dermis, subcutaneous), repairing the lower layers first to provide a more stable foundation for the upper layers.
• Wound edges: The edges of the wound are cut so that they fit together precisely. Beveling is sometimes used as opposed to suturing two blunt edges. To finish, the edges are slightly everted (turned inward), allowing them to flatten out as the wound heals and naturally contracts.

After the wound is bandaged, you are wheeled into the recovery room or, for major surgeries, to a post-anesthesia care unit (PACU).

After the Surgery

It usually takes around 15 to 20 minutes to awaken from MAC and up to 45 minutes to awaken from general anesthesia. Side effects like headaches, dizziness, nausea, and fatigue are not uncommon. The same can occur with regional anesthesia.

Post-operative pain is a common denominator among all types of scar revision surgery. If needed, Tylenol (acetaminophen) may be provided for short-term pain relief. If experiencing post-anesthesia nausea, ask the nurse for antinausea drugs like Zofran (ondansetron) or Phenergan (promethazine).

You can usually go home once you steady enough to dress yourself and your vital signs are normal.

Recovery

The initial healing phase (called the inflammatory phase) generally takes between one to two weeks, during which time you may experience pain, localized swelling, and wound discoloration. During this period, you will need to carefully follow wound care instructions to avoid infection and wound dehiscence.

Every effort should be made to keep the wound clean and to dress it regularly with sterile gauze and breathable bandages to prevent moisture build-up. Some wounds require nothing more than a simple dressing, while others need specialized dressings and adjunctive therapies like hyperbaric oxygen to aid with healing.

Healing

The transitional (or proliferative) phase immediately follows the inflammatory phase. This is when the collagen matrix that makes up soft tissues starts to rebuild itself.

During this phase, your healthcare provider may prescribe hydrogel dressings that keep the skin hydrated without oversaturating tissues. Collagen dressings may also be prescribed if the wound is healing slowly (particularly if the surgical area was large). Silicone/gel sheeting should be added to reduce scarring.

Some plastic surgeons recommend vitamin A, vitamin C, vitamin E, and zinc supplements to aid with tissue repair. A well-balanced diet can provide all of the protein needed to promote collagen production and generate connective tissues.

Smoking should be avoided during the transitional phase and well into the maturation phase (which begins seven to 12 weeks after surgery). If you cannot quit, ask your healthcare provider about prescription aids like Zyban (bupropion) or Chantix (varenicline), both of which may be fully covered by insurance under the Affordable Care Act.

Scar tissue massage, thought by some to improve circulation and speed healing, has not been shown to offer any real benefits and may cause harm if performed too aggressively or too soon in the healing process.

Long-Term Care

During recovery, your plastic surgeon will schedule regular check-ups to see how your wound is healing.

Although scar revision surgery often requires only one procedure, it can sometimes take multiple surgeries to achieve the desired effect. This is especially true with extensive scars, severe burns, or skin grafts. In cases like these, a roster of surgeries may be scheduled, separated by six to 12 weeks or even more.

A Word From Verywell

The techniques used by plastic and reconstructive surgeons have advanced enormously in recent decades, reducing the appearance of severe or unsightly scars like never before. Even so, you need to gauge your expectations so that they are realistic and don't leave you disappointed.

In addition, ask about newer non-surgical techniques, like laser resurfacing or non-ablative pulse lasers, which can be used on their own or in tandem with scar revision surgery.