Correction of skin scars after plastic surgeries

Skin scars, as an inevitable consequence of any open injury or operation, are one of the serious problems of plastic surgery, as they remain for life and in many cases create a noticeable cosmetic defect. In aesthetic surgery, patients often make claims about the quality of scars, and it is potential scars that are often the basis for refusing surgical intervention, and real scars for its implementation. That is why it is extremely important for a plastic surgeon to know what scars may appear after a particular operation, and whether it is possible to improve the appearance of existing scars.

Classification of scars

The exceptional diversity of scar characteristics makes their classification difficult, which at the same time is needed for a clearer understanding of the problem as a whole. A comprehensive analysis of the characteristics of postoperative scars allowed the author to classify the latter (for applied purposes) by type, sensitivity, aesthetics, and impact on the function of organs and tissues.

According to their appearance, scars are divided into deep (internal) and superficial (skin). It is the latter that are the main subject of discussion in the following sections of this chapter.

Types of skin scars

Normo- and atrophic scars are the result of a normo- or hypoergic reaction of connective tissue to trauma, on the one hand, and relatively favorable conditions for wound healing, on the other. According to clinical characteristics, these are optimal scars that practically do not change the general relief of the skin surface, have a pale color, normal or reduced sensitivity, and elasticity close to normal tissues.

Atrophic scars differ from iormotrophic ones primarily by their location below the level of the surrounding skin and their smaller thickness. With a small scar width, the difference between a normo- and atrophic scar is difficult to determine.

Hypertrophic scars are mature connective tissue protruding above the level of the surrounding skin and covered by a layer of epidermis. The formation of hypertrophic scars is a consequence of the influence of two main factors: 1) excessive (hyperergic) reaction of connective tissue to trauma, 2) relatively unfavorable conditions for wound healing.

Among the latter, the leading role is played by longitudinal stretching of the scar, predominantly of an impulsive nature, which is accompanied by hyperproduction in the tissues of fibrous structures oriented in the direction of the dominant force.

Unlike keloid scars, hypertrophic scars do not contain areas of immature connective tissue and are not capable of rapid growth.

Keloid scars. A keloid is a cicatricial, isolated tumor that develops spontaneously on unchanged skin or occurs at the site of traumatic injuries. The formation of keloid scars is a reflection of a distorted tissue reaction to trauma; they usually occur against the background of reduced indicators of general and tissue immunity.

Keloid scars are characterized by morphological features that can be divided into normal and pathological.

The first group includes features inherent in normal tissue: regular sequence of fibroblast differentiation, stability of the molecular structure of collagen fibrils. The second group of features reflects pathomorphological features of connective tissue of keloid scars only: large number of active fibroblasts, including giant cell forms; reduction of capillaries; presence of polyblasts in connective tissue; mucoid swelling of collagen fibers; absence of elastin fibers; absence of plasma cells in perivascular infiltrates; smaller number of mast cells and vessels than in normal scars.

Keloid scars have an elastic consistency, uneven, slightly wrinkled surface. At the edges of the scar, the epidermis thickens and grows in the form of acanthosis, but never peels off or flakes. The main clinical characteristic of keloid scars is the ability to constantly, sometimes slowly, sometimes, on the contrary, quickly grow. As a result, the volume of the external (rising above the skin surface) part of the scar can be several times greater than the volume of its intradermal part.

Although the formation of a keloid scar is a consequence of general disorders, local conditions also influence its development to a certain extent. At the same time, in some cases there may not be a direct connection between local conditions and a keloid scar. A classic example of this is keloid scars that form after perforation of the tissue of the earlobe to wear jewelry.

Form of skin scars

The most common scars are linear and arcuate. Often, there are figured scars, the regular shape of which is typical for postoperative scars, and the irregular shape is typical for post-traumatic scars. A zigzag scar is almost always the result of a surgical operation. Flat scars are distinguished by the fact that they occupy a large area and occur with extensive tissue damage. Very often, scars have a mixed shape, which can be the most bizarre.

Sensitivity of skin scars

In the early postoperative period, the sensitivity of scars is reduced and gradually recovers as the scar tissue matures. Thus, in the 2nd-3rd month, young scar tissue contains a small number of nerve fibers that have grown into it, so the scar is insensitive. Later, the number of nerve fibers in the scar increases, and its sensitivity improves. Scar sensitivity is individual and largely depends on its thickness.

A significant problem is scars with increased sensitivity and especially painful scars. Their formation is associated with increased individual sensitivity of nerve fibers to trauma and perverted sensitivity of damaged nerve endings ending in scar tissue. The following main variants of painful scar formation are possible.

Formation of a relatively large painful neuroma (neuromas) directly in or near a skin scar when relatively large branches of cutaneous nerves are damaged. Such painful neuromas can be identified and moved to a non-load-bearing area.

Painful sensitivity of the scar. It is based not so much on the formation of sensitive microneuromas within the scar tissue, but on the development of neurodystrophic syndrome. In this case, attempts at surgical treatment are usually ineffective and can even increase the patient's suffering, since each new scar increases the area of irritation.

The Effect of Skin Scars on the Function of Body Parts

Often scars limit the movement of various parts of the human body, which occurs when they are located in anatomical areas that are subject to significant stretching.

Thus, scars running parallel to the long axis of the limb at the level of large joints with a significant range of motion are prone to hypertrophy, which often leads to limited motion and is the basis for surgery. The same picture often develops on the front surface of the neck, on the face. The tissues of the eyelids are especially sensitive to scars, where surgeons' mistakes are often impossible to completely eliminate.

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