Winning over scar wars
A scar is always associated with a story that can either make or break you
Scars are the inevitable results of healing after tissue injury. A scar may just be a word to some but it’s always associated with a story that can either make or break you — like an adult fight, an accident, a fall, a complex blast/burn/bullet injury, an illness (drug reaction, severe infection) that leave a mark forever. Thanks to technology, scars need not be visible forever. While some people carry them proudly, a lot suffer from the embarrassment of sequelae — hideous scars.
Scars are not only repugnant because of how they look, but they can also reduce movement, especially if they occur near joints (elbows and knee) or folds like the neck or armpit. It leads to weakening of the muscles underneath and may affect a person’s ability to become functional and independent in extreme cases.
The skin is a dynamic organ, responsive to the environment and replenishes its surface continuously. However, when injured it has a limited capacity for regeneration and the resulting scarring leads to certain functional and aesthetic consequence.
Scar formation is dependent on specific individual predispositions, severity and type of injury, interventions during the healing process and complications during the healing process.
Acute trauma, burn injuries and chronic diseases often lead to skin defects. Partial-thickness skin defects play an important role in wound management because of their high incidence. These wounds are commonly treated with a broad range of wound dressings that protect the wound from further damage; they promote healing, improve functional and aesthetic outcomes and reduce hospitalization time and medical costs.
Wound dressings imitate important features of natural skin such as the releasing of water vapor, acting as a microbial barrier and providing elasticity to accelerate epithelialization and wound healing while avoiding dehydration of the wounds. Every type of wound, whether acute, chronic, dry, or moist, requires a specific kind of dressing.
Synthetic as well as biological substances like collagen are used for wound coverage. The choice of the best wound dressing is still challenging and an objective determination of the outcomes is difficult.
Changes in biomechanical properties (properties that allow the skin to protect and conform to the body that it covers) of skin may be due to trauma, ultraviolet light, mechanical and chemical strain, nicotine, alcohol, genetic predispositions, diseases, and others, is also an important determinant in scar formation. Stiff and clustered networks of collagen and elastic fibers may influence skin quality. So biomechanical skin parameters may influence wound healing, and also influence the quality of newly formed skin (scar formation).
As the wound heals and the epidermis stabilizes, ongoing care is important to protect its fragile surface this includes managing sun exposure until stabilization of pigmentation sets in together with moisturization in first six to 12 weeks until stabilization of glands recover. Modulation of scar formation with the use of creams to hasten scar maturation and prevent hypertrophy (elevation) is a must. Hygiene to ensure reduction of bacterial load is also important. In situations where the symptoms of scar are no longer tolerable there are a range of surgical options.
Traditional plastic surgical techniques may be used in conjunction with fractional or profractional laser resurfacing. For example in a burn injury you can release contractures (skin glued in folds together) using various techniques and when combined with lasers whose impact is on making the skin more pliable and releasing tightness as well, has a lot to do in the scar’s aesthetic improvement.
Large and deep acne scars will benefit much from surgical excision followed by laser surgery. Tummy tuck with liposuction is indicated for severe stretch marks of the lower abdomen.
Injectible dermal fillers or fat autograft transplants can be used for atrophic or depressed scars. Keloids and hypertrophic scars can be dealt with in many ways (the likes of anti proliferative therapy and lasers), too, with very good results.
Tissue-engineered constructs and cell-based therapies are also great innovations that are already widely use abroad. Cell-based therapies such as the Recell kit can be used to resurface the scar to improve the overall color and texture following wound bed preparation using laser or mechanical means. So old scars of many years can benefit from this technique.
In deep wounds involving large surface areas, use of tissue engineered composite skin constructs such as Integra, Matriderm, Alloderm etc. allow the excision of the scar and full thickness repair.
CEA (Cellular Epithelial Autograft) another cell base therapy can ideally provide coverage for large epidermal loss or defect using a small amount of donor tissue. This type of skin substitute however is associated with high rates of infection and graft loss, confirming the importance of the dermal layer in skin grafting.
Cultured skin substitute (CSS) is composed of a CEA combined with a cultured autologous dermal layer, which addresses both the dermal and epidermal skin layers. This provides a more biologically similar material for skin replacement.
Scar minimization can be addressed along the whole healing journey, and there is no substitute for meticulous attention to detail at every stage of wound healing to optimize the outcome. With a lot of innovative therapies to address this problem we are one lucky generation. So consult your dermatologic surgeon the soonest time possible when injury sets in.
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