Correction of skin scars after plastic surgery

Skin scars, as an inevitable consequence of any open trauma or surgery, constitute one of the major 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 to the quality of scars, and it is the potential scars that are often the basis for the refusal of surgical intervention, and the scars are real for its implementation. That is why it is extremely important for a plastic surgeon to know what scars can occur after this or that operation, and whether it is possible to improve the appearance of scars already existing.

Classification of scars

An exceptional variety of characteristics of scars makes it difficult to classify them, which at the same time is necessary for a clearer understanding of the problem as a whole. The complex analysis of the characteristics of postoperative scars allowed the author to classify the latter (for applied purposes) in appearance, sensitivity, aesthetics, influence on the function of organs and tissues.

By their kind, scars are divided into deep (internal) and superficial (dermal). The latter 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 the normo- or hypoergic response of connective tissue to trauma, on the one hand, and relatively favorable wound healing conditions, on the other. According to the clinical characteristics, these are optimal scars, which practically do not change the overall relief of the skin surface, have a pale color, normal or decreased sensitivity, and elasticity close to normal tissues.

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

Hypertrophic scars are a mature connective tissue protruding above the level of the surrounding skin, which is covered with 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 of wound healing.

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

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

Keloid scars. Keloid is a cicatricial, isolated tumor that develops spontaneously on unaltered skin or occurs at the site of traumatic injuries. The formation of keloid scars is a reflection of the perverse response of tissues to trauma; they, as a rule, arise against a background of reduced indices of general and tissue immunity.

Keloid scars are characterized by morphological signs, which can be divided into normal and pathological.

The first include the signs inherent in normal tissue: the regular sequence of differentiation of fibroblasts, the stability of the molecular structure of collagen fibrils. The second group of symptoms reflects the pathomorphological features of the connective tissue of only keloid scars: a large number of active fibroblasts, including giant cellular 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; less than in normal cicatrixes, the number of mast cells and vessels.

Keloid scars have an elastic consistency, uneven, slightly wrinkled surface. At the edges of the rumen, the epidermis thickens and grows in the form of acanthosis, but it never flakes and does not peel off. The main clinical characteristic of keloid scars is the ability to constant, then slow, then, on the contrary, rapid growth. As a result, the volume of the outer (above the surface of the skin) part of the scar can be several times higher than the volume of its intradermal part.

Despite the fact that the formation of a keloid scar is a consequence of violations of a general nature, local conditions also to a certain extent affect its development. At the same time, in some cases there can be no direct connection between local conditions and a keloid scar. A classic example of this is the keloid scars formed after the perforation of the tissues of the earlobe for wearing ornaments.

Shape of skin scars

The most common are scars of linear and arcuate shape. Often there are figured scars, the correct form of which is characteristic for postoperative scars, and the wrong one for post-traumatic scars. The zigzag scar is almost always the result of a surgical operation. Flat scars differ in that they occupy a large area and occur with extensive tissue damage. Very often the scars have a mixed shape, which can be the most bizarre.

Sensitivity of skin scars

In the early postoperative period, the sensitivity of the scars is reduced and gradually restored as the scar tissue ripens. So, in the second or third month the young scar tissue contains a small amount of nerve fibers that have grown into it, so the scar is insensitive. Further, the number of nerve fibers in the rumen increases, and its sensitivity improves. The sensitivity of the scar is individual and largely depends on its thickness.

A significant problem is scarring 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 the formation of a painful scar are possible.

Formation of a relatively large diseased neuroma (neurromus) directly in the cutaneous rumen or in its immediate vicinity with damage to relatively large branches of skin nerves. Such painful neuromas can be identified and moved to an unloaded zone.

Painful sensitivity of the scar. It is based not so much on the formation within the scar tissue of sensitive micro-nerves as on the development of the neurodystrophic syndrome. In this case, attempts at surgical treatment are usually ineffective and can even increase the patient's suffering, since each new scar adds to the irritation zone.

Effect of skin scars on the function of body parts

Often, scars restrict the movement of various parts of the human body, which occurs when they are located in anatomical zones subjected to significant stretching.

Thus, scars that run parallel to the long axis of the limb at the level of large joints that have a significant volume of movements tend to hypertrophy, which often leads to a restriction of movements and is the basis for the operation. The same picture often develops on the front surface of the neck, on the face. Especially sensitive to the scar tissue of the eyelids, where the errors of surgeons can often not be completely eliminated.

[1], [2], [3], [4]