What causes scarring?

Scarring occurs any time there is a break in the skin layer called the dermis.  Scarring is both genetic and acquired. Some people are predisposed to hypertrophic scars or keloids, as their body makes too much collagen in their healing scar.  However, the vast majority of wide scars are acquired.  These wide scars are secondary to results of tissue damage at the time the scar is acquired, and also by the amount of tension present at the wound edge.  As an example, a dog bite will scar worse than a surgical incision of the same size because there is more tissue trauma from the crush element of the bite.  Also, a scar over a surface where there is constant movement and tension, like a shoulder or knee, will be larger than one in which there is no movement.

What can be done to prevent scarring?

The first thing that can be done to help prevent scarring is to try and get the wound closed under the least tension possible. This can be accomplished by closing the deep layers of the wound before closing the skin.  As a result, there is less tension on the skin.  After the incision is healed, I recommend the usage of topical silicone gels.  Topical silicone is the only thing consistently proven to improve the quality of scars, both old and new.  A testament of its effectiveness is the fact that almost every major burn center uses topical silicone to modify the burn scars they encounter.   Lastly, it is important to wear sunscreen over the scars.  Sunlight will darken a scar, therefore for the first year it is important to either keep the scar covered or apply sunscreen daily.  At our practice we offer two topical options: Kelocote and Biocorneum.  Kelocote is a topical silicone gel that is effective for scar remodeling.  Biocorneum is a combination silicone gel and sunscreen, which combines the two important elements and makes for simpler application.

When is a good time to get a scar revised?

Scar remodeling is a lengthy process.  A scar will evolve, soften, and fade actively for the first year after trauma.  For this reason, Dr. Graham will observe scars during this time as the majority will not need intervention.  However, he does recommend application of sunscreen and silicone gels within the first month of trauma.

What are some options for scar revision?

Scars can be revised by lasers, topicals, and surgery.  Dr. Graham usually recommends topical silicone as a first intervention.  If the scar does not show satisfactory improvement he will then consider injecting the scar with steroid, which will often lighten and flatten the scar. As a final resort, one can excise the old scar and reapproximate the skin under optimal conditions, meaning with little tissue trauma and with minimal tension. For some acne scars, injectable fillers can be used to alter the appearance.