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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘keloid scars’

Scar Revision Strategies in Hypertrophic vs Keloid Scars

Monday, October 28th, 2013


While scars have a negative connotation due to the imperfect appearance of the skin, they are a normal result of most injuries and surgeries. This is part of the wound healing process and their appearance (or perpetuation) is the expected result of this dynamic process. It is only deviations from normal wound healing, hypertrophic scars and keloids, that should be considered abnormal.

The differences between hypertrophic scars and keloids is a confusing one for most people. One is often thought of as the other, most commonly hypertrophic scars being confused as keloid scarring. But they are in both appearance and biology distinctly different. Hypertrophic scars appear raised but stay within the confines of the original wound. They are more likely to occur in wounds that cross the so-called relaxed skin tension lines or in wounds that have been left open to heal on their own or have become infected.

Conversely, keloids extend beyond the confines of the original wound (mushrooming from the wound edges) and are often associated with ongoing growth. They may stop growing but many do not. It is this progression in size that is the hallmark of their behavior. They often cause pain and other symptoms such as itchiness. This is due to the tight scar tissue and a sign of ongoing growth. They may also be a family history of keloids due to a genetic inheritance. They are often associated with traumatic wounds such as ear piercings, tattoos and burns.

Just like their biology the treatments for hypertrophic scars and keloids is different. While hypertrophic scars may improve with time, significant improvement in their appearance is usually only going to come from excision and closure, with or without some form of geometric rearrangement.(e.g., z-plasty, running w-plasty) This almost always solves this particular scar problem or, at the least, provides significant in its appearance. While the same issue for improvement applies to keloids, careful consideration needs to be given to how recurrence is going to be prevented as the propensity for so occurring is remarkably high.

Combining some recurrence prevention strategy with keloid excision is standard and most commonly is the injection of steroids along the wound edges. This is best done before surgery to get some regression of the keloid and then the excision is performed.  At the time of excision the wound edges may be injected with steroid followed by repeat injections every several weeks after surgery for a few intervals. This is far more successful that just excising a keloid alone but is still associated with a near 50% recurrence rate.

For the refractory keloid, radiation therapy is the one known alternative approach that is often better than steroids. It is combined with scar revision and is started immediately, even on the day of surgery. It is known as low dose radiation and, while there is no standard dosing regimen, most patients receive between 1500 and 2000 rads over several sessions done daily for the first week after the surgery. This radiation-induced disruption of collagen synthesis at its inception has the best chance of preventing new keloid formation although it is not foolproof and recurrences have been known to recur .

Dr. Barry Eppley

Indianapolis, Indiana

Scar Types and their Descriptions

Sunday, August 8th, 2010

Any interruption of the skin, whether from a fall on the ground, an accident on the job, or from the surgeon’s knife, prompts the complicated and not yet fully understood process of healing, the end result of which is a scar. However, the word “scar” often invokes the image of an unwanted deviation of the healing process, that which is a physical derangement from the smooth and non-discolored appearance of skin that it replaces.

As do the injuries from which they result, the appearance of scars can vary tremendously. Differing scar appearances are because the scars are different from each other. Different scar types are treated differently! Like all of medicine, successful treatment is based on establishing the diagnosis first. The wrong treatment method on a scar results in not only no beneficial effect but a waste of your time and money.

Hypertrophic scars appear as raised, wide,firm,and red to purple-colored scars that

remain within the physical boundaries of the original skin injury. They are more likely to

occur in wounds that cross natural lines of skin tension or an original open wound that

healed on its own. These can cause some itching and discomfort to the touch but may

improve with time.

Keloids are also raised, reddish-purple, nodular scars that are usually firmer than hypertrophic scars.Keloids are the result of uncontrolled scar healing that the body does not stop once the wound is healed. The difference between keloids and hypertrophic scars is that keloids extend beyond the boundaries of the original injury site, encroaching upon surrounding uninvolved healthy tissue. Keloids can result from seemingly innocuous activities such as ear piercing and tattoos and unlike hypertrophic scars, keloids do not regress over time. While keloids can occur in all skin types, they are generally more common in darker skin.

Stretch Marks are linear bands of wrinkled skin that most frequently result from rapid weight loss or weight gain, for example following pregnancy, and tend to appear in areas like the abdomen, breasts, thighs, and hips. Initially, they tend to be red or purple, but often fade to white over time. They are essentially ‘partial tears’ on the underside of the skin from overextension.

Depressed Scars (atrophy) are due to the irreversible damage of the skin from the injury where the amount of scar formed is less thick than that of the surrounding normal skin. The level of the scar (thickness) is less than that of the surrounding skin. They can occur from a multitude of inciting events such as acne lesions, burns, or skin avulsive injuries from trauma. Trying to apply makeup to conceal depressed scars actually worsens their appearance as makeup enhances the textural variations.

Acne scars are a variety of depressed scars that have occurred due to loss of skin thickness from the body’s inflammatory response to a plugged sebaceous follicle. The inflammatory reaction (infection) results in thinning of the skin even though scar tissue has formed. Acne scars appear in a variety of shapes, which are important to distinguish, as they are often treated differently.

Icepick scars are usually narrow, sharply demarcated tracts that are wider at the surface and taper as they extend through the skin. Rolling scars are more superficial, wider, and produce an uneven appearance in the skin. Boxcar scars are round- to oval-shaped skin dimples with sharp margins and are wider than icepick scars.Most tend to have diameters from 2.0 – 4.0 mm.

Burn Scars are unique in that they have a very thin and atrophic underlying dermis. They are quite stiff and inflexible and do not heal well when cut and sutured. The fat layer underneath them is frequently gone or thinned due to the initial heat of the original injury. The burn scar can appear smooth and almost ‘glass-like’.

Scar diagnosis is critical to selecting the proper scar revision approach. These simple descriptions may help one better describe and identify their scar problem.

Dr. Barry Eppley

Indianapolis, Indiana

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