Article medically reviewed by Dr. Gavin Chan (MBBS, cosmetic physician, liposuctionist)
Templestowe Lower and Berwick Clinics
Dr. Gavin Chan has a background in intensive care, anaesthesia, and emergency medicine. Since 2004, Dr. Chan has provided cosmetic procedures, including anti-wrinkle injections, dermal fillers, liposuction, fat transfer, skin needling, and laser treatments. He is a doctor trainer for various dermal fillers and anti-wrinkle injections.
What is scarring?
The word scar originates from the Greek word eskhara, which means scab. A scar does not have normal skin markings and may be skin coloured, hypopigmented (lighter than normal skin) or hyperpigmented (darker than normal skin), flat, raised or indented, and results from a wound or injury to the skin.
Scarring is caused by a particular pattern of healing in previously injured skin. If the wound is partial thickness (it only involves the most superficial layers of the skin – the epidermis and superficial dermis), it may heal without scarring. If it is full thickness (it involves the deep dermis), the skin heals with scarring. As a general guide or rule of thumb, a wound that heals under two weeks does not lead to scarring.
There are many degrees and types of scarring, from flat pigmentation changes in the skin e.g darkening of the skin or lightening of the skin, raised scarring (hypertrophic or keloid), and atrophic (indented) scars such as pitted acne scars.
What types of scarring are there?
Scarring can be a ‘normal’ response of the skin to heal if an injury to the skin extends into the dermis. Early scars are formed 7 to 10 days after the initial injury and have only 5 to 10% of the skin’s normal breaking strength. Over 6 to 12 months the wound remodels (see above), and a mature scar is formed, which has approximately 80% of the orginal skin tissue strength.
Raised scars – keloid and hypertrophic scars
Sometimes wounds heal abnormally and produce scar tissue that is in excess of what is required to heal the wound. Keloid and hypertrophic scars are two types of scars that have excessive scar tissue. Excess collagen is deposited in these scars and keloid scars tend to grow outside the border of the initial injury, and can become large, painful or itchy. Keloid scars don’t tend to involute spontaneously. Hypertrophic scars tend to remain within the boundary of the initial injury, are asymptomatic, and tend to get better with time.
Indented scars – atrophic scars
This is a common scar type and can often be seen in areas that have been affected by acne and can occur on the the face or body. In this scar type, there has been inadequate scar tissue formation to create a surface that is flush with the adjacent skin or loss of fat beneath the skin.
What are the stages of wound healing?
We have elucidated the process of wound healing here, as the process of scarring is better understood with this background information.
Blood clot (haematoma) formation is the first step in wound healing and stops the continued haemorrhage from ruptured vessels whilst providing a temporary barrier to external pathogens (bacteria etc) from passing through the wounded skin. Platelets then release a number of growth factors that lead to the recruitment of inflammatory cells. Neutrophils and monocytes, immune cells, then migrate to the wound site and help to reduce any micro-organism growth at the wound. Macrophages (the ‘pac-man’ cell) are also signaled to the wound and help to clear residual pathogens, and cell debris from the wound.
Proliferation involves the replacement of damaged or missing tissues with new skin or scar tissue. Full thickness wounds cannot regenerate by re-epithelialisation (skin regeneration) alone, and scar tissue is formed to fill the defect. Growth factors at the wound stimulate fibroblasts to proliferate. Fibroblasts lay down extracellular matrix composed of fibrin, fibronectin, vitronectin, and glycosaminoglycans, and collagen – the building blocks of skin. New blood vessels form to supply the new tissues. Transformed fibroblasts (myofibroblasts) can help to contract larger wounds, to decrease the quantity of new tissue required to fill the defect and re-epithelialisation. This process starts hours after the injury.
Excess collagen and matrix from the proliferation phase are removed during the remodeling phase by tissue enzymes. Inflammatory cells leave the wound. As the scar matures, there is a balance between the matrix degradation and new collagen biosynthesis by fibroblasts. Enzymes help to break down and remodel the new tissues. The remodeling process occurs over 6 to 12 months, but can persist for much longer. Scar tissue only achieves 70-80% of the tensile strength of normal skin, and is more prone to re-injury.
What types of treatment are there for scarring?
The treatment(s) required will depend primarily on the type of scarring. These are as follows;
Treatment for pigmentation changes in skin
Scarring can cause the skin to become lighter than normal skin. Usually this may improve gradually with time, but in most cases is permanent and not treatable. However, it is possible to use cosmetic tattooing to ‘colour in’ the scar to a colour that is similar to your normal skin colour.
Sometimes, the skin will also become a darker colour than normal in response to a certain skin injury. It is condition called post-inflammatory hyperpigmentation. If it is not raised, it is technically not a scar in most cases, although it is often perceived as a ‘scar’ by those affected with this problem. An example of post-inflammatory hyperpigmentation is the pigmentation
that may remain after acne. The treatment of this in most cases is a prescription only product called Kligman’s formula. It contains lightening agents such as hydroquinone as well as a topical retinoid called tretinoin (which helps skin turnover), both of which help to lighten the skin back to its normal colour. In usually takes several months.
Treatment for raised scars
Raised scars are the result of scar tissue formation that is in excess of what is required to heal a wound. Raised scars are often categorised into keloid and hypertrophic scars. Keloid scars, in particular, are very active scars, can increase in size, and have symptoms such as pain and itch. The mainstay of treatment for these scars is injection with corticosteroids to help reduce their activity, reduce symptoms and flatten the scars. Often corticosteroids are injected into raised scars, and this reduces scar activity and flattens scars. Although effective, one risk of this treatment is causing atrophy (wasting) of the skin or fat which leads to an indentation in the treatment area.
At Victorian Cosmetic Institute, we use fractional carbon dioxide (CO2) lasers to treat raised scars. This laser works by reorganising collagen fibres within the scar tissue, giving it a smoother appearance. Also, the laser drills very fine columns into the skin, and it is possible to apply cortisone topically immediately after laser to help reduce the activity in the scar and flatten it. Unlike injecting cortisone, the delivery of cortisone to the scar using laser is much more even and has significantly less risk of causing atrophy of the skin or fat.
Unusually, keloid scars will require surgical excision. An example of this is large ‘dumbell shaped’ keloids on the earlobes. These sometimes require surgical excision purely due to their size. However, surgical excision alone often results in recurrence of the scar. It is therefore combined with cortisone treatment and other medical methods to help reduce the chance of recurrence.
Surgical treatment for hypertrophic scarring may often be indicated, and in some cases, surgical revision can improve the appearance of hypertrophic scarring.
Treatment of indented (atrophic) scars
This type of scarring is commonly caused by acne, although there are a number of other causes. Unlike keloid and hypertrophic scarring, where the problem is an excess amount of collagen proliferation, these scars require stimulation of collagen to help lift or fill in the scar so that it is closer to the level of the normal skin. This is a process called ‘neo-collagenesis’. This can be
done with fractional
carbon dioxide lasers, skin
peels and other non-ablative
Why should I choose Victorian Cosmetic Institute as my provider of acne scarring treatments?
There are many factors when deciding what treatment to use when treating scarring. Our doctors are highly experienced in the treatment of scarring, and will be able to help you decide which treatment best suits you and your skin condition/type.
A consultation with one of our medical staff will help assist you in your decision about which treatment will best suit your goals and lifestyle. Due to the large number of treatments available, a consultation will help you decide which best treatment suits you.
The first step is simply contacting us for your initial skin consultation, where we will discuss with you what is a realistic and achievable outcome, and what to expect from your treatment
Making that first phone call about any cosmetic procedure can be a confronting task – many of our patients have preferred filling out our online enquiry form. We can then contact you with an understanding of the results you are hopeful of achieving and ensure the treatment is appropriate.