In daily life, there are scars left behind for various reasons (burns and scalds, acne, abdominal births, various traumatic surgeries and car accidents), which affect the appearance, and in serious cases, scar contracture leads to dysfunction, causing a lot of trouble for people. We plastic surgeons often hear the words: “Doctor, I am a keloid. In fact, there are very few people who are really keloid, most of them are keloid. So how do keloids actually form? How to prevent it? How to treat?
1.Q:Why do I always grow keloid scars after injury or surgery?
A:Scar, usually called scar by the people, is a pathological change after the healing of tissue damage caused by various reasons, and is a normal process of tissue damage repair, which can occur in any tissue of the body. If there is no scar formation after tissue injury, the wound will not heal. That is to say, scar is the inevitable result of the repair of heavier tissue damage in the body, and is the product and symbol of tissue damage healing.
In the process of tissue injury repair, moderate scar formation is a normal manifestation of the body’s repair of the injury, which has a positive effect and is expected, and is medically known as physiological scarring. However, the formation of scar is influenced by both internal and external factors, which often leads to abnormal conditions: local thickening or depression of scar tissue, uneven surface, pigmentation and loss, redness and other manifestations affecting the appearance; itchy, painful, uncomfortable, broken and other symptoms causing discomfort to the patient; contracture of scar can occur, causing deformity and affecting the function of the body; even cancer can occur, affecting the patient’s life. The scar can be contracted, causing deformity and affecting the function of the body. All of these can cause physiological and psychological burdens to patients and affect their employment and marriage. These abnormal and harmful scars, collectively known as pathological scars in medical science, are an important complication of tissue injury repair, and are a situation that both doctors and patients should prevent and treat together.
Therefore, scarring after injury is not always a bad thing. Various traumas, burns, scalds, surgeries, infections, injections, etc. in daily life can trigger scarring, and long scars are almost inevitable, but people always hope not to grow scars, and even if they grow scars, they should not affect the beauty and function, although it is understandable emotionally, in fact it is not in line with scientific laws and difficult to achieve.
2.Q:I was in a car accident and left many scars on my face and body, is it possible to eliminate them completely?
A:Skin scarring is the inevitable product of skin damage repair. Research shows that almost all wounds that injure the dermis of the skin repair their wounds with scar healing, and scarring is a manifestation of self-repair taken by our body for trauma. There are three mechanisms at work in the natural wound healing process: first, wound contraction; second, the body mobilizes large amounts of material to form granulation tissue to fill the wound; and third, the epidermis grows to cover the granulation tissue. If there is no abnormality, the collagen secreted by the fibroblasts in the wound gradually transforms into connective tissue and the surface is covered with several layers of epithelial cells, and the wound is healed, which is actually the formation of “scar”. There are many different types of scar formation due to the different circumstances of trauma. If the trauma is only to the normal epithelial cell layer, the damage is repaired by the skin epidermal basal cells layer by layer, which can make the skin intact as before, and this is the reason why some minor injuries do not leave scars.
Is it possible to completely eliminate a scar that has grown? I think after understanding the above mechanism of scar formation, we should understand that a scar has grown, which means the skin damage is deep and it is almost impossible to eliminate it completely. The current medical practice also confirms that according to the existing medical technology, it is impossible to completely eliminate the scar, whether by topical medication, excision method, grinding method, etc., but only to reduce the serious scar, make the obvious one become inconspicuous, and minimize the harm of the scar. Therefore, the prevention and treatment of scarring has been one of the challenges to be tackled in the medical field.
At present, medical experts have researched various means of scar treatment such as minimally invasive surgical methods, laser therapy, drug therapy, radiation therapy, cryotherapy, and pressure therapy, which are jointly applied to scar prevention and treatment, and have achieved better results. For example, the plastic surgery method of scar removal uses very sharp blades, monofilament threads thinner than a hair and superb surgical techniques to avoid as much as possible the stimulating factors of scar proliferation, to make large scars smaller and hidden in the natural folds of the skin as much as possible, together with post-operative medication, radiation therapy and pressure therapy, etc., to strive to make the scars inconspicuous. Even so, it is still not possible to completely eliminate the scar and leave no trace.
3.Q：Many of my friends around me have scars on their bodies, what are the types of scars? How to treat them?
A:There are many different types of scars formed due to the many different conditions that cause them, and the scars that grow on each person are different. But in summary, there are mainly 3 types as follows.
(1) Superficial scar: also called flat scar, mostly caused by mild skin injury, characterized by superficial scar, soft texture, abnormal color, affecting aesthetics, but mostly without functional impairment. Post-surgical scars are mostly superficial scars, and some of them have a “centipede-like” appearance. Most of the depressed scars can also be classified as superficial scars, such as the common acne pit scars and cigarette burn scars. Therefore, this type of scar is the most common. Treatment methods include surgical excision, grinding, chipping, laser, freezing, etc. The effect of surgical excision is obvious.
(2) Proliferative scar: also called proliferative scar, hypertrophic scar or hypertrophic scar, which is caused by deeper skin injuries such as deep II degree burns or above, is more common. Characteristically, the growing scar does not exceed the extent of the injury and has a typical proliferative phase, receding phase and mature phase, which is able to fade and become flat on its own. The proliferative stage is mostly within six months to one year after the injury, when the scar tissue is obviously higher than the skin surface, with local thickening and hardening, irregular shape, uneven height, flushing and congestion, accompanied by itching and painful discomfort, which is a good time for non-surgical methods of prevention and treatment. Afterwards, the scar gradually undergoes degenerative changes (decompression phase), the congestion decreases, the surface becomes lighter in color, softer and flatter, and the itching and pain sensation decreases or even disappears (maturation phase). After the scar has matured and stabilized, surgery should be given.
Proliferative keloid scars can contract and affect the form and function of the body, called scar contracture deformity or contracture keloid, such as lid ectropion, lip ectropion, chin-thorax adhesion, claw-shaped hand, etc. Part of the scar contracture that becomes webbed is called webbed contracture keloid, all of which need early surgical treatment. In addition, it can develop ulceration and cancer. It is recommended to choose a specialized physician to use the appropriate method according to the site, period, and impact on the function and form of the body of the scar.
(3) Keloid scars are essentially fibrous tumors on the skin. It can be treated by surgical excision plus postoperative drug scar injection or electron beam radiation.
4.Q:I have acne on my front chest and back of my shoulders that leaves many raised bumps, am I a keloid?
A:There are often patients with scars on their bodies who ask their doctors, “Doctor, do you think I am a keloid?” Many people give up the treatment of keloid or other surgeries because the doctor said they have keloid, and “keloid” seems to be the “source” and “culprit” of scarring. In fact, keloid is very rare.
The concept of keloid is that any injury to any part of the patient’s body can cause keloid growth, and it runs in families, with multiple members of the same family having similar keloid growths. The key points are keloid growth and family genetic characteristics. The diagnostic criteria for keloid scars should generally meet the following conditions: (1) the lump is elevated on the skin surface, hard, with a smooth and shiny surface and irregular boundaries; (2) the lesion can exceed the edge of the original injury, infiltrate into the surrounding normal tissue, and grow in a crabfoot pattern; (3) it has clinical symptoms such as persistent growth, redness, pain and itching, and has no tendency to heal itself and cannot subside on its own; (4) it is very easy to recur after simple surgical excision, and the recurrence range The scope of recurrence can exceed the original scar. Therefore, physicians are very cautious in diagnosing keloid, and patients do not need to let the “keloid” label weigh heavily on their minds.
Why are there so many people who are troubled by keloid scars? The reason for this is that some physicians put all the reasons for scarring on the head of “keloid”, making the patient carry the “keloid” hat, which is actually irresponsible behavior. The other reason is that patients do not understand and spread fraud by fraud and influence each other.
It should be understood that scarring and keloid are two different things. As far as the previous introduction, scarring is a pathological change after trauma healing, which is a normal process of tissue damage repair. In the process of tissue damage repair, moderate scar formation is a normal manifestation of the body’s ability to repair damage and has a positive effect, as is the case with many superficial scars. However, scar formation is influenced by both intrinsic and extrinsic factors, often leading to abnormal conditions and the formation of proliferative scars and keloids. The most common of these is hyperplastic scarring, which differs from keloid scarring in terms of onset, pathologic process, treatment options, and prognosis. The treatment of superficial scars is a cosmetic need, like a single eyelid asking for double eyelids; the treatment of hyperplastic scars is mostly a curative need for both. Keloid treatment also belongs to the treatment of disease, but it is very difficult to treat. Therefore, you should not easily put the “keloid” hat on your back and affect your normal life.
5.Q: My child burned his face and hands and had surgery in the hospital, how can I prevent scarring?
A:At present, there is no special treatment for scar, so the prevention of scar is more important than the treatment of scar to a certain extent. All kinds of trauma, burns, scalds, surgeries, infections, injections, etc. in daily life can cause scarring. Therefore, first of all, people should be aware of safety and health care in daily life to avoid accidental injuries and keep their body healthy as much as possible. However, the accidental situation that causes body damage cannot be prevented, how to prevent scar growth after tissue damage healing?
1, the prevention of scar should be paid attention to before the formation of scar, which is medically called the prevention of scar formation, including the prevention of therapeutic factor scar and the prevention of non-therapeutic factor scar. In the former case, also known as medical factor, the main cause of scar formation is surgery, which is preventable to a large extent. The specific measures for prevention are aseptic principle, non-invasive techniques, tension-free minimally invasive sutures, no foreign body or dead cavity residue, proper surgical methods and appropriate timing of surgery. Non-therapeutic scarring mainly refers to scarring caused by trauma and burns, which are non-medical factors, often heavy and accompanied by different degrees of infection, so the focus of scar prevention for such injuries is to prevent and control infection, and appropriate treatment methods to promote early healing of the wound.
During the scar formation period, the use of compression therapy, topical silicone gel, topical and intra-scar injections, electronic radiation therapy, physical therapy (wax therapy, ultrasound and medium frequency electricity, etc.) and integrated functional rehabilitation therapy can reduce the discomfort caused by the scar and inhibit the proliferation of the scar. These methods can reduce the discomfort of the body, inhibit the proliferation of keloid scars, and promote the smooth transition of keloid scars through the proliferative phase and into the receding and mature phase. These methods have their own characteristics and indications, so a professional physician should choose 2 to 3 methods with less side effects, easy to use and precise efficacy according to the specific conditions of the scar to carry out comprehensive prevention and treatment, which is more effective than a single method.
6.Q:I have multiple scars on my body and I don’t want to have surgery, what non-surgical treatment methods are available for scars? How to choose?
A:The common non-surgical treatment methods for scarring are as follows.
(1) Laser therapy: CO2 laser was the first laser used for scar treatment, mainly through laser cauterization, vaporization or carbonization of the scar to remove the scar, but the efficacy is poor and the recurrence rate is high. Then argon laser and Nd:YAG laser were put into application and achieved certain effect. At present, the application of ultra-pulsed CO2 laser, fractional laser and pixel laser has greatly improved the efficacy and is one of the methods of choice for superficial scars.
(2) Intra-scar drug injection therapy: Corticosteroids are widely used at home and abroad for the treatment of hyperplastic scars and keloids. Their mechanism of action is to inhibit the synthesis of collagen alpha-peptide chain and prolyl hydroxylase to reduce collagen synthesis, and at the same time can induce fibroblasts to produce collagenase to increase collagen degradation. For small proliferative keloids or keloid scars, the commonly used drugs are tretinoin and Depo-Provera. Only a few drugs in the biologics class, such as interferon and hyaluronidase, are available for clinical use. Antineoplastic drugs such as 5-fluorouracil (5-FU) and cetepe, and the antiallergic drugs trinostat (Tranilast) and benadryl are also used in the treatment of keloid scars. Currently, most of these drugs are used clinically in combination with local injections within the scar.
(3) Radiation therapy: Both superficial X-rays and β-rays can drastically reduce the number of fibroblasts, impair their function, reduce the synthesis of collagen fibers and matrix, and increase the decomposition, allowing the scar to flatten and soften. The main indications are keloids and hyperplastic scars that are unwilling to undergo surgery or are not suitable for surgery. The treatment method is to irradiate once every 1~2 weeks, 300~500 rad each time, 4~6 times in a row for a course of treatment.
(4) Traditional Chinese medicine: with a long history, the main treatment methods are internal treatment, such as using Fuyuan and blood circulation soup with addition and subtraction, and oral administration of cumene tablets; external treatment, which is the main treatment method for keloid scars, such as using black cloth ointment paste, cumene ointment, and scar softening cream for external application; combined internal and external treatment, such as internal administration of anti-colonial and drainage soup, and external application of Ganwu powder. It is suitable for the systemic and local treatment of various kinds of scar.
(5) Molecular therapy: The more promising methods of using biomolecules to treat scar are gene therapy and anti-transforming growth factor beta therapy, which are still in the experimental stage.
7.Q:How to get good results in surgical treatment of scar?
A:Surgical treatment is needed for scars that affect appearance, have self-conscious symptoms, ulcers, cancer and contracture deformities, and psychological disorders. Surgery is the main means to treat superficial scars, mature proliferative scars, scar ulcers, contracture scars and large keloids with definite results. In order to obtain better results, the following precautions should be taken.
The surgical method should be selected appropriately. Commonly used surgical methods include scar excision and suturing, skin grafting, flap grafting, grinding, skin soft tissue expansion, etc. The surgical method needs to be selected according to the scar type, area, location and patient requirements. For example, small scars can be excised and sutured directly, superficial scars can be grinded, children and large scars are often treated with skin grafting, and those with normal skin around the scar are treated with flap grafting and skin soft tissue expansion.
The principle of surgery is to remove all the scar as much as possible, and it is best if the scar can be directly sutured by Z reshaping or other forming techniques after excision, and if it cannot be directly sutured to repair the wound, flap approach is better than skin grafting, and full-thickness skin grafting is better than edge-thickness skin flap grafting. It should be emphasized that the recurrence rate after keloid surgery is extremely high, and single surgery is generally not advocated, but rather a combination of radiotherapy, drug injection therapy and surgery.
The timing of surgery should be appropriate. Proliferative keloid scars enter the maturity stage about 12 months to 2 years after the injury, when the congestion of the scar subsides, the appearance approaches the normal skin color, the texture becomes soft, the thickness becomes thin, and the conscious symptoms disappear, which is the time for surgery. Some contracture scars that occur in important parts of the body not only affect the function, but also can cause serious complications such as deformation of tissues and organs, so they should be operated as early as possible.
Post-operative adjuvant therapy should be paid attention to. Comprehensive measures such as compression therapy, silicone therapy, drug therapy, radiotherapy, physical therapy and functional rehabilitation should be actively used after surgery to improve and consolidate the effect of surgical treatment.
Choose a professional physician for treatment. Although many physicians can treat scarring, in order to obtain better functional recovery and satisfactory cosmetic results, a detailed treatment plan and program should be made according to the patient’s general and local conditions, requiring proper technical operation and post-operative treatment, and for this reason it is recommended that scarring patients seek professional treatment.
It should be emphasized that any surgical procedure cannot eliminate the scar completely, but only improve or correct the harm caused by the scar to the maximum extent; moreover, after the surgical incision heals, it faces the occurrence of new scar again, and the evaluation of its treatment effect needs to be observed for more than one year.
8.Q:What is skin soft tissue dilation?
A:Skin tissue expansion is a surgical method to obtain additional skin soft tissue for skin defect repair and organ reconstruction by using the expansion effect of tissue expander. It is a revolutionary achievement in the field of plastic surgery for more than 20 years and is most widely used in scar treatment, which not only improves the treatment quality of plastic surgery, but also reduces the surgical damage, solves many difficult clinical problems and replaces some skin slice grafting.
Skin tissue expansion can induce tissue growth, which can increase the skin area and provide a good skin source for skin defect repair. The basic steps include three stages: the first stage is to select the skin expansion area and the size and shape of the expander according to the scar and its surrounding skin, and to bury the selected expander on the deep surface of the skin to be expanded. The second stage is to periodically inject water into the buried dilator to expand the dilator, and the soft tissue of the skin on the surface of the dilator grows and expands. Water injection into the dilator for expansion usually takes 2-6 months, usually 1-2 times a week, each injection until the patient feels distended. The third stage of treatment is performed when a certain level is reached and is predicted to meet the treatment needs. The third stage is the excision of scar and other lesions to prepare the flap recipient area and the transfer of the expanded flap to repair the skin defect area.
Skin expansion is suitable for the treatment of body surface lesions such as scarring in all parts of the body, especially for scarring baldness and body surface organ reconstruction. The advantages are that it can provide skin soft tissue that exactly matches the recipient area, no posterior deformity or serious scarring in the donor area after flap expansion transfer, and good treatment effect and low cost; the disadvantage is that it requires a second operation and a longer treatment period.
The treatment effect and the number of complications of skin soft tissue expansion are related to the operator’s operation level, dilator factors, treatment period management factors and individual patient factors. With the increase of experience in its clinical application, it has now become a routine treatment for scarring and is a good choice for patients who want to repair the function and at the same time the best aesthetic results.
9.Q:My relative recently had a burn injury, what are the drugs used to prevent and treat scarring? How to use them?
A:To prevent and control scarring after burns, the first thing is to strengthen nutrition, avoid wound infection and promote wound healing as soon as possible. There are two types of drugs for scar prevention and control after the wound heals: one is the drug-approved products and the other is the mechanical-approved products.
The drug-approved products are divided into three categories: systemic drugs, topical scar drugs and intra-scar injectable drugs. Systemic medication is mainly cumecloside tablets, which are oral medication for scar prevention and control is 2-4 tablets per time, three times a day, and need to be applied for more than 3 months after the wound heals. The more commonly used topical medications for scar topical application are Kangrep, Centella Asiatica ointment, Danxiong scar coating and scar anti-itch ointment. 1 of them can be chosen for application for all kinds of scars, especially suitable for children and patients who cannot tolerate the pain of other treatments. Both are applied as a thin layer on the surface of the wound or scar, 3 times a day, noting that the wound should be cleaned before application. If there is no discomfort, it can be used until the scar is mature and stable. The more commonly used drugs for intra-scar injections are tretinoin, Depo-Provera, hyaluronidase, 5-fluorouracil, etc. Most of them are mixed with 2-3 drugs mainly tretinoin, injected once in 1-4 weeks, 4-5 times a course, generally used for small area hyperplastic keloid and keloid scars.
The products with approved names are mainly silicone products. Silicone is smooth, soft and non-irritating, and was used as a liner for compression therapy in the early days. Afterwards, after a lot of clinical practice, it was proved that silicone film patch has certain efficacy in treating hyperplastic keloid scars, which can reduce local itching and pain of keloid scars, induce softening of keloid scars and even shrink them. Currently, it is widely used for scar prevention and treatment. Available products include silicone gel patches, spray preparations and creams for the prevention of keloid scar growths at any age and as an adjunct to their post-surgical treatment. Patches are mainly used for scars on relatively flat areas and are generally more difficult to use across joints; spray preparations and creams are more convenient to use, especially for joints and uneven scars.
How to use silicone gel products: ①Silicone gel film should be properly attached to the surface of the scar without any gap in between; ②Use 8-24 hours a day, the longer the use time the better the curative effect; ③Clean the silicone gel film and the scar every day, the silicone gel film can be used repeatedly after it is cool and dry; ④The treatment course should be at least 3 months. Precautions: ①The more common complications of applying silicone gel film are skin papules and sweat stains and itching on the surface of the scar, which can be relieved after cleaning treatment and suspension of use and do not affect the continuation of treatment; ②The product should not be used when the wound has not yet healed; ③The product should be applied or not used for a short time in the early stage (within 1 month) after wound healing to avoid the wound from breaking down due to the silicone gel film moisturizing.
10.Q:I heard that scars can become cancerous, I would like to ask what are the developmental results of scars?
A:Although the process of organism trauma repair is complex and people cannot control the scar proliferation to the ideal degree yet, most of the scars formed can regress to three aspects with the passage of time.
(1) Softening: Most of the scars reach the later stage, the scar tissue matures, the fibroblasts and capillary components gradually decrease, the collagen fibers are arranged in parallel and more regular bundles with each other, and the chondroitin sulfate A content also decreases significantly. At this time, the clinical scar tissue becomes less congested, lighter or light brown in color, flatter in shape, softer in texture, looser in base, and less itchy or painful. This degenerative change is called scar softening. Due to individual differences, the duration of scar softening varies from a few months to several years. However, the general trend is towards stabilization, thinning and softening.
(2) Contracture: It is mainly seen in scars caused by third-degree burns, severe trauma, or those occurring in the joint area. This type of scar is highly contractile, deforming normal tissues, and the adjacent tissues can be stretched to cause dysfunction, and can also affect the development of muscles, blood vessels, nerves and other tissues. The common clinical deformities caused by scar contracture include lid ectropion, lip ectropion, chin-thorax adhesion, claw-shaped hand, foot scar contracture deformity, etc. For this kind of scar contracture, early surgical correction is recommended.
(3) Malignant change: Malignant change of scar mostly occurs in unstable scar, especially when the scar breaks down due to friction, pulling and other reasons, and produces a long-lasting ulcer. At present, most scholars advocate that scar ulcers that do not heal over time and unstable scars that heal from time to time should not be treated lightly, but should be excised in time to repair the wound properly to prevent the occurrence of scar carcinoma.