Michael S. Kluska, D.O., a plastic and reconstructive surgeon at The Center for Plastic and Cosmetic Surgery, in Greensburg, Pa., reserves surgery for scars that are recalcitrant to first-line therapy. Dr. Kluska’s normal protocol for scars that are symptomatic includes topical steroid cream for two to three months, injectable steroids (if scar is refractory to topical steroids), IPL/RF for two to five treatments, and, if no response, surgical revision. “Surgical intervention is primarily reserved for scars that become symptomatic to the patient,” says Dr. Kluska. “Painful scars that restrict motion and have been refractory to conservative management, including topical creams, steroids, dermabrasion and laser, usually will require some type of revision.”
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“In addition, when scars are a result of a trauma they usually are repaired under suboptimal conditions and many times aesthetics are not taken into consideration. It is these scars (especially when on the face) that will respond the best to plastic/cosmetic surgery and ultimately will heal faster.”
Standard surgical choices include Z-plasty, W-plasty and rotational flaps, according to Dr. Kluska. “Surgical scars placed into natural lines or creases of the body are more inconspicuous and aesthetically pleasing,” he says. “That said, my favorite advancement for minimizing the presence of surgical scars is the use of Quill barbed suture. This suture relaxes lines of tension across the wound in an ‘X, Y, Z’ axis, and ultimately creates a scar that heals quicker and has better cosmesis.” He also uses topical creams and silicone sheeting.
“Many times though, scars are a result of traumatic injury and are found in very conspicuous areas. Traumatically induced scars can be treated with a variety of different techniques with the major focus of creating undue tension on the scar borders. There are many ways to decrease tension along traumatic scar lines including Z-plasty, which redirects tension lines or the use of tissue expanders that help stretch the surrounding skin, so that the scar can be excised and re-approximated in a tension-free fashion.”
Dual treatment modality is elected for scars that have a history of recurrent keloid formation. Dr. Kluska often treats these scars with Z-Plasty combined with steroid injection at the wound edges prior to closure. “A patient who has a history of hypertrophic or keloid scar formation, many times will require topical treatment options and/or laser in conjunction with surgical correction of the scar.”
Dr. Kluska says his surgical approach depends on the type of scar, body area affected and individual patient characteristics (including age). “High tension areas on the body (i.e., scalp, chest, upper back, and tibial regions) respond differently to trauma and require different surgical techniques to be treated appropriately.”
While scar revision surgery can help to improve scars by releasing tension, it also produces a scar — yet one that is hopefully less conspicuous. “I inform all of my patients that ‘once a scar, always a scar’ and that they will always have some type of scar that will remind them of their surgery,” says Dr. Kluska. “I also inform them that scar healing is a bit unpredictable and that some patients may develop hypertrophic or keloid scarring no matter what treatment option is used. With that in mind, I ask my patients to do the following in order to minimize their scars:
- “Follow my instructions on local wound care initially after surgery, including daily wound cleansing combined with topical antibiotic cream for the first 10 days.
- Four to six weeks following surgery, the patient is placed on topical scar recovery gel from SkinMedica.
- The patient is instructed on refraining from sun (tanning bed) exposure the first three months.
- If there are any signs of increased thickening or redness, the scar is immediately treated with topical steroids and/or IPL/RF light therapy.”
Dr. Kluska says he also offers his patients a variety of topical scar treatment options, including vitamin E, Mederma and silicone sheeting, because of the varying cost of the products.