Scar Revision

With Suzanne Rea.

Today I’d like to welcome to the PodMD studio Dr Suzanne Rea

Dr Suzanne Rea is a Specialist Plastic Surgeon at Fiona Stanley Hospital and Perth Children’s Hospital and the newly opened Scar Clinic Perth, and a clinician scientist with a special interest in burn surgery and scar treatment.

Dr Rea completed her undergraduate medical degree at the Royal College of Surgeons of Ireland and obtained her fellowship in Plastic Surgery from the Royal College of Surgeons. After relocating to Western Australia, she completed a fellowship in Burns Surgery under the supervision of Professor Fiona Wood. Suzanne was awarded her fellowship of the Royal Australasian College of Surgeons in the specialty of plastic and reconstructive surgery in 2014. She was also awarded a doctorate by research (PhD) for her research on scarring, which she completed at the University of Western Australia.

Today, we’ll be discussing the topic of scar revision.

*We do hope you enjoy this podcast but please remember that the advice here is of a general nature and is not intended as specific advice about a given patient. The views and opinions expressed in this podcast are those of the doctor, not PodMD.
If you do have a patient on whom you require specific advice, then please seek advice from a colleague with appropriate expertise in that area.

The topic of today’s discussion is scar revision. Suzanne, can you give us a brief overview about scar revision?

Suzanne: So first of all, it’s what is a scar and a scar results or a scar is formed and as a result of any injury to the body. And that’s the body’s completed stage in wound healing. And that injury can be trauma. It can be inflammatory, it can even be a surgical wound. Scar revision is the umbrella term that’s used to describe any technique that changes the appearance of that scar, so anything that we as surgeons or sky management therapists do to try and alter that appearance.

How do you determine if someone is a suitable candidate for scar revision?

Suzanne: So there’s lots of research in scarring that has shown quite clearly that different people have different responses to their scarring and that it’s not what I think or you think of their scar, it’s what the patient thinks about their scar and a suitable candidate for scar revision is a patient who is unhappy either with the physical or the cosmetic appearance of the scar or the scar is interfering with function in some way.

Frequently it’s a combination of the two, and research has shown that people can be just as concerned about visible and less visible scars. So I think again, we think it’s a scar on the face or a scar on the hand that’s going to bother a patient, but actually, it’s where the patient is most bothered by that’s really the suitable candidate.

Can you explain the surgical and non-surgical approaches for scar revision?

Suzanne: So immediately after an injury occurs, good wound healing and prevention of prolonged wound healing is probably the first step or the first approach. After that, then for immature scars, the first step is scar management and ideally, prevention of poor scarring and those measures include topical agents like silicone and pressure. Early referral to an occupational therapist who’s a skilled scar management therapist is important if you think that the patient has a predisposition to poor scarring or hypertrophic or keloid scarring. However, for an established scar, the next option on the list that’s probably simplest is laser therapy and there are excellent randomised trials that show that laser can reduce the size of hypertrophic scars. Hypertrophic scars are those raised itchy red scars that are quite troublesome and problematic for patients.

The research has shown that laser works really well for this. It’s the CO2 laser that works for this and there are clear randomised controlled trials. In burn patients, but also in scars, for example, troublesome caesarean section scars and early keloid scars as well. And maybe you might use a laser in combination with some intralesional steroid injection. So either steroid at the time or they may have had steroids previously and then go on and have laser treatment.

The next stage of the sort of interventional ladder is surgical options, so that might be simple. Things like rearranging the scar tissue with techniques like Z-plasties or little local flaps, and then in more extensive scars or more troublesome scars that might involve introducing new tissues. So moving. tissues such as skin or muscle from a different area into the scarred area using microsurgical techniques or techniques such as tissue expansion, which involves placing a little balloon under the skin and gradually inflating that and then using that newly created excess skin and moving that into the defect. So there’s quite a number of techniques ranging from very simple to quite interventional.

What are the main risks associated with scar revision procedures?

Suzanne: So I suppose the main risk really relates to patient selection. Scar revision is just that it’s revision, it’s not removal, there is no magic wand, and the patient needs to understand that the ultimate aim is a flat scar that’s colour-matched with the surrounding skin and is only visible at intimate distances, but it will never be taken away. Scarless healing remains sort of the Holy Grail for plastic surgeons, so really the big thing is actually identifying the patient and ensuring that they have appropriate expectations before we embark on any treatments.

What are the key factors that influence the success of scar revision procedures?

Suzanne: So the key factors that affect or influence the success of scary vision really go back to patient selection and ensuring that you’re doing the right procedure for the right patient at the right time. So, for example, you know, doing a scar revision on a 12-year-old boy who is incredibly keen on foot. And choosing to do that just at the start of the footy season, which then means that he’s not going to comply with his period of rest he’s not going to wear his pressure garment and he’s not going to want to sit on the sideline. That’s a guaranteed way for that procedure to fail. So ensuring that you pick the right patient at the right time and then that you build confidence and rapport with the patient and family so that they understand the need for adherence to those protocols is very, very important.

Have there been any developments in scar revision in the last few years or are there any in trials or development now?

Suzanne: Scar revision and scar treatment goes back really, from the beginning of plastic surgery and a lot of the actual techniques have remained the same. Some of the interventions have really come into the management of less significant and less severe scarring. So what traditionally would have been called minor scars, but are still major for the person who has them. So things like micro-needling where you’re just trying to remodel the collagen at a very superficial level and CO2 laser is probably the biggest game changer.

The laser was probably first introduced in burns patients and is now more readily available for all types of scarring. It’s very low downtime, very well tolerated by the patient, doesn’t require an anaesthetic usually and works quite well, to reduce the pain and itch and redness associated with scarring. There have been lots of clinical trials of different agents, both topically and systemically, which are anti-inflammatory and antifibrotic and there’s a number of trials still in process that were involved in a number of them, but as yet they’re not really readily available on the market to reduce scarring. Scarless healing still remains the ultimate goal, but we’re probably still some time away from that.

How do you manage patient expectations when it comes to scar revision outcomes?

Suzanne: The first step in the in management of expectations is really to talk to the patient and have a proper full and frank discussion about what exactly is bothering them. Is it the tightness? Is it the itch? Is it the appearance? Is it the pain? Is it the function? What exactly is the problem and what are the top priorities for that individual? And then an honest conversation about what can be achieved and so understanding that you’re both on the same page before we even start.

Maybe a test procedure or a test scar revision on a smaller scar before embarking on more extensive surgery again to ensure that. But ensuring this whole trip to the hospital, this whole experience is not excessively triggering for both them and their family, and that they are in the mindset to embark on this journey. And often when we see patients who have been maybe referred to us who got burnt as children and haven’t seen anyone for twenty ears and have now re-presented because they saw something on TV or they’ve seen something in the news that they wanted to come and have a chat about. That’s the series of steps that we go through with those just to make sure that this is the right time for that patient to have these procedures.

What advice can you offer to GPs for post-operative scar care and monitoring?

Suzanne: Timely referral to an occupational therapist with an interest in scar management or to a plastic surgeon is important. So an itchy red and raised scar will probably not settle by itself. And certainly will probably not leave a nice, thin, pale flat scar. So if that scar is red and itchy and raised at six weeks, its probably good to get that referred sooner rather than later because prevention is always better and some of those early interventions like topical silicone pressure, and massage may make a difference.

Avoid sun exposure from the outset, making sure, especially if it’s on the face of the sunscreen and if it’s other parts of the body that it’s physically covered from the sun. Because sunburn and sun damage to those scars will result in that scar staying redder for longer or may result in pigment changes and hyper-pigmented scars are quite hard to correct once developed, it’s really quite challenging to fix that. So prevention is always better than cure and moisturising that wound from the time of wound healing is important and really patients don’t need to use super expensive agents and oils and things that are marketed. We just recommend sorbolene because we find that it works just as well and is about 1/4 of the price.

When should a GP refer?

Suzanne: Anybody who has a history of previous poor scarring, so if they’ve got a keloid somewhere else or they’ve got a family history of keloids going or hypertrophic are going. Any anxious or super concerned patients who are very troubled by the presence of this scar should be referred early to try and improve that.

Red raised itchy or dyspigmented scars, so where there’s a significant colour mismatch with the surrounding skin and obviously the paramount importance is any functional issue. So pulling on an eyelid causes an ectropion interfering with finger or hand function or movement of a major joint, those patients should be referred sooner rather than later.

Thank you for your time here today in the PodMD studio. To sum up for us, could you please identify the three key take-home messages from today’s podcast on scar revision

Suzanne: Most importantly, prevention is best. Good wound management, prevention of wound infection and timely wound healing is the first step. When that has failed and when the scar becomes problematic. For example, it’s itchy or red.

Early referral may mean simple options are suitable and that patient may not require scar revision so that is better.

And thirdly, managing patient expectations is vital. Scar revision is exactly that – it’s revision, it’s not removal. And making that very clear to the patient at the outset is important.

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