Posted by admin | Posted in Health and Beauty | Posted on 23-10-2009
Every scar tells a story — and one we mostly prefer to forget. Most scars fade gradually over a period of a year or 18 months, but almost always leave a mark even if it is barely visible.
And one in three scars becomes a permanent, often unsightly, fixture, retaining a hard, raised ridge of uncomfortable tissue.
Some can even continue to grow long after the healing process.
In a world where smooth, youthful skin is highly valued, it’s perhaps hardly surprising that the psychological impact of scars can be deeply distressing, particularly those on the face, neck, chest, arm or hand.
A recent study found that nine out of ten people who’d had a routine surgical procedure within the past six to 12 months were unhappy with their scar.
Seven in ten felt they were ‘more concerned than their surgeon was about the scar’.
It’s only recently that clinicians outside plastic and cosmetic surgery have considered the possibility of managing scarring, and even now, GPs routinely offer little advice beyond
handing out an antibiotic cream to prevent infection, while many surgeons take little interest in what happens after the operation.
‘Surgeons often take pride in doing a great job in the operating theatre, and don’t consider what their patients look and feel like afterwards,’ says Mohammed Jawal, a plastic surgeon at Chelsea & Westminster Hospital, West London.
‘For patients, it’s the opposite. They quickly forget about even the most dramatic life-saving operation. What’s important to them is the look and feel of a scar they’ve got to live with for the rest of their lives.’
However, disfiguring scars following surgery could soon be as much part of the past as polio or rickets — with a number of promising new approaches to scar avoidance.
Probably the most exciting is a new drug, Juvista, which is in its final development phase and promises to be the first scar prevention drug on the market.
Made from a naturally occurring human protein known as transforming growth factor, it has been shown to reduce dramatically the risk of scarring when injected into the margins of the wound after surgery.
It works by helping the skin weave back naturally — as if a hole in a pair of tights was magically restored to the pre-tear mesh, rather than having to make do with a disfiguring darn.
The drug is the brainchild of Professor Mark Ferguson, formerly head of the department of Life Sciences at Manchester University, and should be available within three years.
However, it might be available sooner for some. Patients who are undergoing repeat surgery are being recruited for a major international trial of the drug
In the meantime, far more can be done than most of us realise both to prevent abnormal scarring and to treat existing scars. Here, with the help of the experts, we present the latest on scarring old and new.
HOW SCARS FORM
Any wound that penetrates through the superficial layer of skin (the epidermis) and into the lower layer of skin, the dermis, will cause scarring. However, the severity of the scar depends on the success of the skin’s repair response — and, in particular, the behaviour of collagen.
This is the fibre-like protein which acts as glue in the healing of wounds. In normal, healthy skin, the bundles of collagen are in a criss-cross pattern, like basket weaving.
When healing is balanced, the epidermis around the edges of the wound close together with the gluey collagen, staying nice and flat and making the scar into the narrowest possible level surface, explains Gaylene Branstiter, a hand therapist at St Thomas’s Hospital in London.
Even when scarring goes smoothly, there can still be an adjustment phase of up to 18 months as the repair process is completed and the red colour of the scar slowly fades.
Cells known as fibroblasts — responsible for repairing the hole in the skin — go into overdrive, and a whole new system of blood vessels is set up to feed the scar.
This triggers extra collagen.
Instead of neat criss-cross patterns, bundles of collagen form rigid, parallel lines, sometimes glueing layers of tissue and tendon together, and forming lumps.
Sticky tape, silicone sprays… the first steps to smoother skin
There’s plenty that can be done to improve the look of scars, particularly in the first six months. Some change can be achieved up to 18 months, but after that you’ll need to try invasive treatments.
KINESIOTAPE
This elasticised tape is made from stretchy cotton that sticks to and lifts the skin. Relatively new to the UK, it works by improving the circulation of the blood and lymphatic system, says Gaylene Branstiter. At the same time, ‘pressure from the elasticated tape prevents movement that can pull apart the edges of the top layer of skin.’ This pressure also relieves pain. For cuts a strip of Kinesiotape can be placed along the wound like Elastoplast. Post surgery, the strapping is usually more complex.
SILICONE
In gel, spray or rubber-sheet form, silicone traps moisture to the wound, keeping the scar from becoming rigid. The favourite product with plastic surgeons is Kelocote, a spray or gel that dries to an invisible, breathable sheet within minutes. It’s recommended as the first line of treatment in the initial management of all scars and particularly in the prevention of keloid and hypertrophic scars. Applying it as soon as the wound has healed over will help reduce the risk of abnormal scarring.
CORTISONE TAPE OR CREAM
One of the simplest methods of reducing a red, raised hypertrophic scar is treatment with cortisone, which softens the scar and reduces the activity of the fibroblasts. This is best for scars up to six months old. Cortisone tape (the best-known brand is Haelan) contains slow-releasing cortisone cream. A cheaper option is cortisone cream. ‘It’s a good alternative to more expensive, invasive options,’ says Dr Nick Lowe of the Cranley Clinic in London.
The collagen also overflows onto the skin surface, creating rubbery scars that spread over healthy tissue.
Exactly why this happens with some scars and not others is not fully understood.
But a number of factors affect healing: poor surgical technique, genetic predisposition and, perhaps most importantly, the location of the wound. Scars above moving joints are the most problematic.
There are two main types of ‘unhealthy’ healing.
A hypertrophic scar is formed when the collagen is able to build up on the surface of the wound. The scar remains within the confines of the original injury, but is hard, raised and red, though not usually painful.
Hypertrophic scars are common after all types of operations and even cosmetic procedures if these are not properly managed. The scars improve slowly, fading often over several years, although there is usually a white scar of collagen as a permanent reminder.
A keloid scar is formed when the collagen spills out beyond the original injury, affecting healthy tissue and creating large, lumpy scars that can continue to grow with time. Anyone can get a keloid scar, but they are up to 15 times more common in people with dark skin.
Red-haired, fair-skinned Celts are also prone to them.
Keloid scars are more common in the under-30s, as young skin has a tendency to over-repair.
They are particularly common on the chest, shoulders and back, as well as the ear lobes following piercing.
Other scarring problems include widened scars – where the edges of the wound separate during the healing process, either because the stitches have been taken out too early or because there’s too much movement of the joint, tendon or muscle below the wound.
These are most common on the arms legs and stomach.
An adhesion is an internal scar. Some adhesions are formed deep inside the body, and occur when the tissue that’s been operated on develops a scar which literally ‘sticks’ organs to other tissues, leading to pain and further symptoms.
Visible adhesions occur just below the skin surface, causing problems with muscles and tendons. This is most common on the chest, where the scar can connect to the sternum.
However, it’s on the hand that adhesions cause most problems, when the top layer of skin of the scar becomes attached to the muscle or tendon beneath it — causing, for instance, a finger to curl and become rigidly fixed.
PREVENTING SCARS
If you’re worried about scarring, especially where the wound is in a prominent position, mention your concerns to your GP before deciding where to have your operation.
He or she might have inside information about surgeons that can inform your choice.
Before an operation, tell your surgeon that the appearance of the final scar is important to you.
‘Bad cutting is obviously a factor in bad scarring,’ says Mr Javal.
‘If a surgeon is rough cutting through the layers of skin, or cuts more deeply than necessary, the scar is going to be bigger and take longer to heal, both of which are factors in abnormal scarring.’
Any wound should be covered to keep it moist and prevent a scab forming.
‘A scab will create a barrier to healing,’ says Kim Rock Stockheimer, an expert in scars from the University of Wisconsin.
‘The aim is to keep the wound moist and thereby keep the collagen away from the surface of the skin.’ She recommends using a light compressive dressing or pad.
Once the dressing is removed, use a moisturising lotion to hydrate the skin around the scar, says Greg Williams, a burns surgeon at the Chelsea & Westminster Hospital. Moisturised skin improves wound-healing and ensures a balanced release of collagen.
Nor do you need an expensive moisturising cream.
‘Nivea, E45 or baby oil are all good, as long as you’re not allergic to them,’ says Mr Williams.
Gently massaging the scar for 30 seconds to a minute several times a day , from the moment the wound has healed over, will ‘break up the scar’, says Branstiter.
‘To keep the collagen from becoming lumpy, you need to make sure the fluid in the skin is moving around. Massage the whole area with lotion in a circular motion.’
LASERS HELP OLD WOUNDS
Older scars may respond better to more invasive treatments. One option is pulsed dye lasers.
These were invented initially to treat red birthmarks on babies, and work by targeting the blood vessels that feed raised red scars.
However, the treatment is only available privately and is expensive — £100 for a single treatment on a small area — and several treatments are usually required.
It works best in scars under 18 months old.
Surgical removal is often the only way forward for large, old scars, usually from an accident or botched operation in childhood.
Ask your GP whether you are eligible for scar revision on the NHS, or to recommend a private plastic surgeon.