Scars -whether they're caused by accidents or by surgery- are unpredictable. The way a scar develops depends as much on how your body heals as it does on the original injury or on the surgeon's skills. Many variables can affect the severity of scarring, including the size and depth of the wound, the blood supply to the area, the thickness and color of your skin, and the direction of the scar.

While no scar can be removed completely, plastic surgeons can often improve the appearance of a scar, making it less obvious through the injection or application of certain steroid medications or through surgical procedures known as scar revisions.

Many scars that appear large and unattractive at first may become less noticeable with time. Some can be treated with steroids to relieve symptoms such as tenderness and itching. For these reasons, we recommend that you wait from 6 months to a year after an injury or surgery before you decide to have scar revision.

THE PROCEDURE

Keloids are thick, itchy clusters of scar tissue that grow beyond the edges of the wound or incision. They are often red or darker in color than the surrounding skin. Keloids can appear anywhere on the body, but they're most common over the breastbone, on the earlobes, and on the shoulders. They occur more often in dark-skinned people.

Keloids are often treated by injecting a steroid medication directly into the scar tissue to reduce redness, itching, and burning. In some cases, this will also shrink the scar.

If steroid treatment is inadequate, the scar tissue can be cut out and the wound closed with one or more layers of stitches. A skin graft is occasionally used, although the site from which the graft was taken may then develop a keloid.

No matter what approach is taken, keloids have a stubborn tendency to recur, sometimes even larger than before. To discourage this, we may combine the scar removal with steroid injections.  A pressure garment may be helpful in preventing recurrence of scar.

Hypertrophic scars are often confused with keloids, since both tend to be thick, red, and raised. Hypertrophic scars, however, remain within the boundaries of the original incision or wound. They often improve on their own-though it may take a year or more-or with the help of steroid applications or injections.

If a conservative approach doesn't appear to be effective, hypertrophic scars can often be improved surgically. After removal of excess scar tissue, the incision is repositioned so that it heals in a less visible pattern. This surgery may be done under local or general anesthesia, depending on the scar's location.  You may receive steroid injections during surgery and at intervals afterward to prevent the thick scar from reforming.

Burns or other injuries resulting in the loss of a large area of skin may form a scar that pulls the edges of the skin together, a process called contraction. The resulting contracture may affect the adjacent muscles and tendons, restricting normal movement.

Correcting a contracture usually involves cutting out the scar and replacing it with a skin graft or a flap. In some cases a procedure known as Z-plasty may be used. And new techniques, such as tissue expansion, are playing an increasingly important role. If the contracture has existed for some time, you may need physical therapy after surgery to restore full function.

Skin grafts and flaps are more complex than other forms of scar surgery and are more likely performed as inpatient procedure, using general anesthesia. The treated area may take several weeks or to heal, and a compression garment may be required during this period.

Grafting involves the transfer of skin from a healthy part of the body (the donor site) to cover the injured area.  Most grafts from a person's own skin are successful. However, all grafts leave some scarring at the donor and recipient sites.

Flap surgery is a complex procedure in which skin, along with the underlying fat, blood vessels, and sometimes the muscle, is moved from a healthy part of the body to the injured site. In some flaps, the blood supply remains attached at one end to the donor site; in others, the blood vessels in the flap are reattached to vessels at the new site using microvascular surgery.

Skin grafting and flap surgery can greatly improve the function of a scarred area. In general, flap surgery produces better cosmetic results than skin grafts. 

WHAT WILL MY RECOVERY BE LIKE?

As you heal, keep in mind that no scar can be made to disappear completely; the degree of improvement depends on the size and direction of your scar, the nature and quality of your skin, and how well you care for the wound after the operation. If your scar looks worse at first, don't panic-the final results of your surgery may not be apparent for a year or more.