Plastic surgery restores form and function through reconstructive procedures, cosmetic enhancements, and body contouring.
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Hypertrophic scars are raised, red, and rigid scars that remain within the boundaries of the original incision or injury. They occur due to excessive collagen production during the healing phase, often triggered by tension on the wound edges. While they may regress slightly over time, they usually remain elevated and distinct from the surrounding skin.
The physical indication for revision here is the palpable thickness and visibility of the scar. These scars can be itchy and sensitive. Revision focuses on excising the excess collagen and closing the wound with tension-relieving techniques to prevent the body from reacting aggressively again.
Keloids are pathological overgrowths of scar tissue that invade the surrounding healthy skin and grow larger than the original injury. They are tumor-like in behavior, though benign. They are firm, rubbery, and can grow to massive sizes, particularly on the ears, chest, and shoulders.
The indication for surgery is often functional (pain, itching) as well as cosmetic. However, keloids have a notoriously high recurrence rate. Surgical excision of a keloid is almost always combined with adjuvant therapies, such as steroid injections or radiation therapy, to suppress the fibroblast activity that drives regrowth.
Atrophic scars appear as indentations or pits in the skin. They are caused by the destruction of collagen and subcutaneous fat during the inflammatory process, common in acne scarring or varicella (chickenpox). The skin appears tethered down to the underlying tissue.
Revision techniques for atrophic scars aim to lift the depression. This can be achieved through subcision (cutting the fibrous tethers), punch excision (removing the pit), or filling the volume deficit with fat grafting or dermal fillers. The goal is to level the surface topography.
Widened scars occur when a surgical incision or wound stretches over time. This is common in areas of high movement, such as the back, knees, or shoulders. The scar tissue itself may be flat and pale, but the width makes it conspicuous.
These scars indicate that the original closure could not withstand the mechanical forces of the body. Revision involves excising the widened scar and closing the wound using deep, permanent sutures or fascia anchoring to bear the mechanical load, preventing the new scar from stretching open again.
A trapdoor deformity is a bulging effect that occurs when a U-shaped or C-shaped scar contracts. As the curved scar heals, the skin in the center becomes raised and puffy, resembling a trapdoor. This is caused by lymphatic obstruction and the concentric contraction of the scar tissue.
This deformity is physically distracting and creates shadows that highlight the scar. Revision involves breaking the continuous scar into segments using Z-plasty or W-plasty techniques. This relieves the constrictive forces, allowing the trapped tissue to flatten.
Contractures are scars that have shortened and tightened, physically restricting movement. They are a common biological consequence of burns or scars that cross joints at right angles. The scar tissue lacks the elasticity of normal skin, acting like a tight band that prevents extension.
The indication for surgery is functional impairment. The patient may be unable to fully straighten the elbow, turn the neck, or close the eyelids. Surgical release involves cutting the scar band and introducing new tissue (via flaps or grafts) to restore the necessary surface area for motion.
Scars can heal with abnormal pigmentation, appearing darker (hyperpigmentation) or lighter (hypopigmentation) than the surrounding skin. Hyperpigmentation is a biological response to inflammation and UV exposure, every day in darker skin types. Hypopigmentation results from the loss of melanocytes in the scar tissue.
While surgical excision can remove the discolored skin, it carries the risk that the new scar may also become discolored. Treatment often involves a combination of medical management (topical lighteners, laser therapy) and surgery, only when the scar width or texture also needs correction.
Genetics plays a significant role in how an individual heals. Some patients are biologically predisposed to excessive scarring. Those with darker skin tones (Fitzpatrick types IV-VI) are statistically more prone to keloid formation and hyperpigmentation due to increased fibroblast and melanocyte activity.
Understanding this genetic baseline is crucial. A patient who forms keloids easily is not a candidate for elective cosmetic revision unless the functional need is high, as the surgery itself could trigger a worse keloid. The biological cause dictates the procedure’s risk profile.
Scars near vital facial features can contract and pull these structures out of position. A scar on the cheek can pull the lower eyelid down (ectropion), exposing the eye and causing dryness. A scar near the lip can distort the smile or speech.
These are absolute indications for revision. The surgery aims to release the tension pulling on the feature. Z-plasties or skin grafts are used to lengthen the skin vector, allowing the eyelid or lip to return to its natural, functional position.
Traumatic tattooing occurs when foreign particles (asphalt, dirt, gunpowder) are embedded in the skin during an accident and heal into the scar. This results in a scar that is not only textured but also pigmented with blue, black, or grey discoloration.
This is a physical indication of excision. Lasers may be used to break up the pigment, but the foreign body is often too large or too deep. Surgical revision removes the skin containing the debris, effectively cleaning the “tattoo” and replacing the scar with a clean surgical line.
scars or scars over tight bony prominences (like the shin). The tissue is thin, poorly vascularized, and lacks durability. Chronic breakdown is painful and prone to infection.
Surgery is indicated to replace this fragile tissue with durable coverage. This often requires bringing in a flap of healthy skin and fat to provide padding and a robust blood supply, ensuring the area can withstand daily wear and tear without opening.
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A hypertrophic scar is raised and red but stays within the lines of the original injury and often improves over time. A keloid grows larger than the original injury, invading healthy skin like a tumor, and rarely improves without treatment.
Indented or atrophic scars occur when the underlying support structure of the skin (fat and muscle) is lost or damaged during the injury. The skin heals tethered to the deeper tissues, creating a pit or depression.
Yes, this is called a scar contracture release. The surgeon cuts through the tight scar tissue restricting your movement and rearranges the nearby skin, or adds a skin graft, to give the joint enough slack to move freely again.
A trapdoor scar is a U- or curved scar in which the skin within the curve becomes puffy and raised. It happens because the scar tissue blocks the lymphatic drainage, causing fluid to build up in the flap of skin.
Dark scars are caused by post-inflammatory hyperpigmentation. Inflammation during healing triggers pigment cells to overproduce melanin. This is more common in darker skin types and can be worsened by sun exposure during the healing process.
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