Scar Revision

Obstetricians are clever at creating high-quality Caesarian Section scars, but cannot avoid all potential problems. They try to place the scar transversely low on the abdominal wall below the bikini line.

However, the low scar through pubic hair is also wherein a small proportion of patients risk keloid scars. We now have a genetic test to assess this risk before surgery and can treat the scar itself with Cadogan Scar Management.

The bigger problem is swelling above the scar which bulges through tight clothing. The cause is tethering of the healing scar to deeper structures as it heals and is difficult for the Obstetrician to avoid. It is a problem for even the skinniest patient but becomes more significant for plumper patients. We can surgically revise these scars very effectively at the Cadogan Clinic removing the bulge (Cadogan Caesarian Section scar revision), either under local or general anaesthesia as a day case.

Patients with stretched loose skin and more subcutaneous fat will often benefit from a mini-abdominoplasty, which includes the removal of surplus skin and liposuction of the lower abdominal wall.

Patients, who have Caesarian sections performed in a hurry, often undergo the  Classical Caesarian Section with a vertical midline abdominal scar. The scar is not only difficult to hide but also of lesser quality. Cadogan Scar management becomes a more likely option.

Patients who have multiple caesarian sections sometimes end up with multiple scars. We can revise these to replace them with a single good quality scar.

From £4,150 (Fellowship led £2,698)

From £1,900 (Fellowship led £1,235).

Some people produce better scars than others, for example, ‘poor scars’ such as hypertrophic scars stay visible and cause skin irritation for a number of months after formation. When these ‘visible’ scars fade they tend to whiten, flatten but, remain visible – unlike a ‘good scar’ which will fade significantly and blend with the tone of the surrounding skin.

Clearly good scars are those that you cannot see, where all conditions for good scaring are met.

What are these conditions?

The scar must be in the right direction in the lines of skin tension. Experienced trained surgeons will choose to position scars properly as for instance transversely across the abdomen rather than vertically downwards.

Scars may be in areas where it is naturally better, such as by avoiding the centre of the chest or tip of the shoulder.

Scars may be hidden below the breast, behind the ear, in the groin or in the armpit (axilla).

Surgeons can influence the result by meticulous technique and using dissolving sutures or glue and removing other stitches early enough to avoid stitch marks.

Have the right genes. Some people always tend to make bad scars. Very dark skin is more prone to make the worst ones- keloids. At the opposite extreme, Celtic skin and those with red hair are also poor scar makers.

A hypertrophic scar is one that continues to grow after healing. It is red and itchy, but after some months will mature to a scar that is pale, flat, but often slightly wider than the best scar.

A keloid is similar to a hypertrophic scar but goes on growing and spreading. It is painful as well as itchy.

Atrophic scars are those that widen after healing. Whatever the stitching, they just stretch.

Icepick scars are the pitted scars left behind on the face and back as acne heals.

Depressed scars form when skin heals with scars below the normal skin level.

The Cadogan scar management system has numerous treatments for all these scars. Ideally one would start treatment early as the wound heals.

We at the Cadogan can influence scars in many ways with the Cadogan Scar Management system, but we cannot make scars disappear.

Some people make better scars than others and this is genetically determined. We now have a genetic test to see if you are one of those that make bad scars. A positive result does not mean you should avoid all surgery. You just have to be aware, pick your scars and surgeon and perhaps have the Cadogan Scar management system ready to come into action and mitigate the worst outcome. The Cadogan Clinic is the first place in the UK to offer this test.

Genetically poor scar formers tend to make hypertrophic and keloid scars.

The worst scars may require surgery to remove them to start again with a clean sheet. Contractures will be released and extra skin as a graft or flap introduced. Scar direction might be changed by the classic plastic surgery technique of Zplasty.

Good rapid healing without crushing of skin edges, no infection and no stitch marks is essential.

Silicone applied as a gel or sheet will improve scars and speed up maturation to a pale, painless scar.

Ikon laser treatment is the next line of treatment and will improve colour and itch and  discomfort to produce a higher quality scar.

Keloid and some hypertrophic scars my need extra treatment and this needs sympathetic and determined care by experienced doctors with steroid injection and perhaps radiotherapy.

Scar revision surgery is performed to improve the appearance of a scar wherever on the face or body, but it is also often carried out to improve functioning as the formation of a scar can interfere with the movement of muscles and joints. A shortening or tightening of the skin and underlying muscles can accompany severe scars and this is known as contracture. Contractures may interfere with a range of motion and other aspects of joint functioning, as well as deform the shape of the scarred body part or affect the muscles in the face responsible for controlling facial expressions.

AT A GLANCE

• SURGERY TIME: 1 hour (although depends on the complexity of the scar)

• HOSPITAL STAY: Day case

• REASONABLY MOBILE: Immediately

• WASHING: Shower after 1 week, bath after 2 weeks.

• DRIVING: 1 week

• EXERCISE: INCLUDING GYM 2-6 weeks (again depends on the complexity and position of the scar)

• FULL RECOVERY: 2 weeks

• TIME OFF WORK: None

SURGICAL EXCISION - This is a procedure in which the surgeon shaves down and cuts out scar tissue to reduce the size of the scar. This technique is most commonly used on large scars that cannot be treated adequately with medications or other nonsurgical means. When excision is done in stages, it is referred to as "serial excision". This is performed if the area of the scar is too large to remove at one time without distorting nearby skin.

FLAPS, GRAFTS, AND ARTIFICIAL SKIN.- Flaps, grafts, and artificial skin are used to treat contractures and large areas of scarring resulting from burns and other traumatic injuries. When there is not enough skin at the site of the injury to cover the incision made to cut out and remove the scar tissue, a skin graft (thin layer of skin) from another part of the body carefully matching colour and texture is placed over the excision site. The graft tissue itself is harvested preserving its own blood supply so that the donor tissue can successfully ‘bed in’ to its new location.

Z-PLASTY AND W-PLASTY. Z-plasty and W-plasty are surgical techniques used to treat scarring contractures and help to minimize the visibility of scars by repositioning them along the natural lines and creases of the skin. They are not usually used to treat keloids or hypertrophic scars. With a Z-plasty, your surgeon makes a Z-shaped incision with the middle line of the Z running along the scar tissue - the flaps of skin formed by the other lines of the Z are rotated and sewn into a new position that reorients the scar about 90 degrees. In effect, the Z-plasty minimizes the appearance of the scar by breaking up the straight line of the scar into smaller units. A W-plasty is similar to a Z-plasty in that the aim is to minimize the visibility of the scar by turning a straight line into an irregular one. The surgeon makes a series of short incisions to form a zigzag pattern to replace the straight line of the scar. The primary difference between a Z-plasty and a W-plasty is that a W-plasty does not involve the formation and repositioning of skin flaps.

The incision sites are usually very discreet indeed but this does again depend on the complexity of the scar to begin with and the surrounding tissue and the technique employed – in all cases the aim of a scar revision treatment is to minimise the existing wound site, so your surgeon will discuss in detail their preferred techniques during consultation.

It is not uncommon to experience altered sensation following your treatment, this may either manifest in increased sensitivity (apart from the early discomfort of surgery), or the reduction in feeling around the treated area. These changes in sensation usually last for a month or so following surgery.

Most patients will be able to return to work the same day or the following day. Your surgeon will give you clear instructions at your consultation.

The most important aspect of long-term aftercare is protecting the affected area from the sun because the surgical scar will take about a year to mature and is only about 80% as strong as undamaged skin. Sunlight can cause burns, permanent redness, loss of pigment in the skin, and breakdown of the collagen that maintains the skin's elasticity.

Aftercare following the use of skin grafts or flaps is slightly more ridged. You will be scheduled to return to the clinic at regular intervals so that your graft sites can be monitored. If artificial skin has been used you must keep the site(s) completely dry until advised otherwise – this may require specific restrictions around bathing or showering as well as clothing choice, i.e. wearing loose comfortable clothing can help reduce the disturbance to the treated area.

Massaging the treated areas after surgery when comfortable enough to do so (usually 2 weeks following surgery) is a very important part of the healing process and helps to soften your skin, adjacent tissue, and helps accelerate healing - you will be given exact instructions about aftercare and which movements when massaging would be best.

Not all bad scars require a surgical scar revision. At the Cadogan Clinic, we have an array of non-surgical treatments designed to improve scar quality.

Young scars, still red and often itchy, respond well to silicone applied as gel twice a day or as a sheet applied over the scar. The next level of treatment is Icon laser sessions usually repeated at 2-week intervals. Really active scars growing and sore may be treated by very careful injection of steroids at 6-week intervals and finally, Radiotherapy is the most serious treatment.

All these treatments are not painful apart from the injection of steroids, which can be done under local or even General Anaesthesia.

Older established scars, even when tethered to deeper tissue are improved by the transfer of stem cells, simply as fat aspirated from elsewhere in the body or with as a special Cadogan concentrated solution of stem cells extracted from your fat.

Surgical scar revisions become necessary, where the scar is so bad that an improved scar is not adequate and it is better to just take it out and start again. Often this will extend to modifying distorted adjacent soft tissues. Is this painful? Not, of course, once local anaesthesia is given either as new powerful cream or injection. Bigger procedures will require a general anaesthetic in the form of TIVA (Total IntraVenous Anaesthesia) as a day case.

If you have young children, babies or pets, please ensure that the area(s) treated are not pushed, kicked or disturbed for at least 1 week. Your tissues have been agitated and require a period to heal without further disturbance. It is recommended that you organise help with caring for young children (lifting/carrying) during the first few days of recovery.

Wounds must be kept completely dry for the first week. If you have had surgical treatment you may be able to shower after this first week. After your first post-operative check with the nurse at the end of week 1, you will be advised that you can shower or bath as usual.

Do not sit out in strong sunlight for the first 2 weeks after surgery. Once fully recovered and the scars are matured you may expose areas on the body or face that have been treated (this is usually after 12 months).