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Scar Revision Surgery Staff Report
Medically Reviewed by Alex Denes, M.D.

Experts say scars can’t be removed completely. But your appearance can be vastly improved by disguising, relocating or minimizing the prominence with scar revision surgery. In 2005, plastic surgeons performed somewhere around 181,000 scar revisions in the United States, making it one of the top reconstructive procedures. Consequently, many cosmetic and plastic surgeons are coming up with novel ways to perform plastic surgery and leave no scars whatever in the skin.

At age 18, Adrianne Lopez loved the tattoos on her shoulder and lower back. But by the time she was 25, Adrianne had a B.S. in business management from North Carolina State University and was working in sales and marketing. She quickly saw that even tasteful, artsy tattoos like hers weren’t appropriate in highly professional settings. But Adrianne was in luck. Until lasers came into wide use just a few years ago, the only way to remove tattoos was to surgically cut them out of the skin and then suture the two edges of the wound together. The procedure left a circle of shrunken, wrinkled skin and a scar that was almost more unattractive than the artwork. Besides, many now consider the tattoo itself a type of scar.

Scarring is a major medical problem following accidents, surgery and self-inflicted damage like tattoos. Scar tissue can restrict the movement of joints, prevent growth and cause great pain, including psychological stress. Various treatments exist in plastic and reconstructive surgery, for keloid, hypertrophic, burn and contracture scars. Adrianne is currently having her visible bodywork removed at BodyLase Skin Spa in Cary, North Carolina. “My desire to project a grownup, professional image now outweighs my affinity for tattoos,” Adriane says.

Requests for Scar Revision Surgery

Other common requests for scar revision surgery come from acne patients who want the pockmarks in their faces removed. Acne causes deep “ice-pick” and “box car” scars that look like chickenpox marks along with “rolling” scars that give the skin a wavy appearance. Acne and other facial scar revisions are notorious for being hard to do. But patients especially dislike carrying the marks of adolescent acne long after their skin is free of active acne. Traditionally, acne scars were removed through dermabrasion, a process that surgically grinds down the scars, and other treatments. ?At the University of California, Los Angeles, dermasurgeon Ronald Moy, M.D., uses an up-to-date method of acne scar revision surgery: a Fraxel laser.“Fraxel is a lot easier and gets excellent results, more than any previous treatment I’ve seen in the last ten years,” says Dr. Moy who is also a clinical professor at the University of California Los Angeles. “Plus, the patient can leave my office immediately and use her own makeup right after treatment.”

Experts say a Fraxel laser works on sections of the face using microscopic pinpoints of light instead of a full beam which is more destructive and removes more skin. Your own fat can also be used in scar revision surgery to fill in hollows and wrinkles caused by aging. Fat and other fillers are used to plump up depressed scars and make it less visible by bringing the defect up to the same level as the surrounding skin. For instance, New York City plastic surgeon Sydney Coleman, M.D., developed a fat transfer procedure known as LipoStructure to plump up wrinkles and folds. After many years, Dr. Coleman noticed that when a patient’s own fat was injected into her face, the quality of the overlying skin vastly improved. So LipoStructure is now used as a repair agent to plump up scars; the fat is injected under the blemish.

Dr. Coleman thinks that human fat has such remarkable healing properties because it contains large amounts of stem cells, something that is in short supply in most adult bodies. Studies are now underway to confirm his observations. Tarick Smailil, M.D., a board-certified plastic surgeon at the California Surgical Institute in Beverly Hills, also uses fat transfer to fill indented and surgical scars. And, how do indentations get into the skin, you ask? Because liposuction is currently the top invasive surgical procedure, depressions are sometimes made in the body where the previous practitioner has too vigorously worked the cannula -- the fat-sucking wand -- in the patient’s fatty areas. Indentations also occur with aging, in patients with liposytrophy (a disorder of the patient’s fat metabolism) and in diabetics using insulin.?“We harvest fat where it is plentiful, put it in a centrifuge to wash out chemicals and dead cells and then reinject purified fat cells through various layers of skin and muscle under the scar,” says Dr. Smaili. “Usually 40 to 60 percent remains after a year, but it plumps up depressions and other scars nicely.”

New Scar Revision Products

New products also take aim at scar reduction. For instance, Juvista, currently being studied on humans in England, is an injectable substance placed in fresh surgical wounds to decrease scarring. Study trials show great promise so the substance may be used some day in the United States to improve the look and color of surgical scars. Juvederm, another injectable filler, received F.D.A. approval in June, 2006, and can also be used to repair scarring. “I have seen excellent results with Juvederm as a lunchtime procedure for our patients who require no down-time,” says Gary D. Monheit, M.D. president of the American Society for Dermatologic Surgery and a clinic investigator for the Juvederm F.D.A. studies. Yet another defect that has fallen into wide disfavor is the surgical scar left when a surgeon operates on a woman with inverted nipples. “Almost all surgical approaches for treating inverted nipples leave scarring and can lead to loss of nipple sensation,” says Lisa Donofrio, M.D., a board-certified dermatologist and dermatologic surgeon in New York. “So I often inject Restylane, a facial filler, under the nipple and that pushes it back up above the surface of the skin, resulting in an erect nipple.”

Some surgical procedures are designed at the outset to leave no marks at all in the patient’s skin, totally removing the need for scar revision. For instance, in some mid facelift procedures, the surgeon operates through the mouth or through the conjunctiva, the pink area you see under the eyeball if you pull down your bottom eyelid. “My eyes were looking very tired so I had my upper and lower eyelids surgically rejuvenated,” says 47-year-old Barbara Nazzaro, a receptionist in Shrewsbury, New Jersey. “The surgeon operated through the conjunctiva so there was no scar at all. In my upper eyelids, the surgeon put the scar in the natural creases in the eyelid.” Adds Valerie J. Ablaza, M.D. a board-certified surgeon in Montclair, New Jersey: “For a mid facelift, an operation that tightens sagging skin and tissues from the mouth to the lower eyelids, surgeons can operate from the inside of the upper lip and go under the facial tissues to work on the internal midface structures. The procedure leaves no scar on the face.” Other surgical procedures are done through tiny holes hidden well into the hairline. Long incisions can often be avoided in cosmetic plastic surgery by using an endoscope, a long, lighted instrument that allows surgeons to see and work under the skin. The cables of the endoscope are inserted through “stab” incisions less than a ¼ inch long. Some surgical wounds show less scarring because they have been treated with a surgical glue known as Dermabond, a first cousin of SuperGlue. Surgeons just hold the edges of a wound together, spread on the Dermabond and let it set up for few seconds. Not only are harmful bacteria sealed out, the substance does not scar the skin like stitches. Yet another recent innovation, a staple-like skin closure device, uses and implants absorbable stables just under the first layer of skin and allows surgical wounds to heal faster and with far less scarring. Using the device, a surgeon works faster than with a needle and sutures, thereby reducing the time the patient spends under anesthesia.

Acne Scar Revision Surgery

You might be wondering how Adrianne Lopez got rid of her tattoo? It is being lasered away. Little by little. According to BodyLase Skin Spa’s medical director and surgeon, Daniel Albright, M.D., laser tattoo removal is the latest and least invasive way to remove tattoos, even though it may require five to ten treatments. “Laser light fragments tattoo ink, which the body then absorbs and excretes,” says Dr. Albright. “At each treatment, the ink in the tattoo fades a bit more.”??And, as anybody with a scar will tell you, fading is a very, very important concept.

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