How Plastic Surgeons Assess Complex Scars

Treatment Planning

Complex scars, in addition to the marks on the skin surface, often present with redness, thickening, hardening, itching, pain, depression, adhesion, contracture, pigmentation abnormalities, recurrent ulceration, and functional limitations.

Different scars have various impacts; for example, facial scars may affect the appearance of facial features, hand scars may impact grip and fine motor skills, and scars near the neck or joints may restrict movement. Keloids may also continue to enlarge and recur.

When plastic surgeons assess complex scars, they use a comprehensive evaluation method that includes: scar type, color, thickness, hardness, area, volume, mobility, symptoms, functional impact, psychological impact, previous treatment history, and risk of recurrence. An ideal scar measurement tool should be non-invasive, objective, fast, and capable of collecting repeatable data to the greatest extent possible.

Step 1: Understanding the Source of the Scar

Doctors first inquire about the source of the scar. Common causes include burns, scalds, surgical incisions, trauma, infections, acne, animal bites, and radiation damage. The treatment approach varies significantly depending on the cause of the scar.

Burn scars are often accompanied by extensive proliferation, pigmentation changes, and contracture; surgical incision scars depend on the direction of the incision, suture tension, and postoperative care; acne scars often appear as depressions, ice-pick, or rolling changes; keloids frequently exhibit continuous proliferation beyond the original wound boundaries.

Additionally, it is important to understand the duration of wound healing, and whether there were any infections, exudate, dehiscence, secondary surgeries, or treatments such as laser, injections, radiotherapy, cryotherapy, surgical excision, silicone, or pressure therapy. Whether the scar recurred after treatment, how soon it recurred, and whether it became larger upon recurrence will also influence the next steps in the treatment plan.

Step Two: Determine the Type and Activity Level of the Scar

The foundation of complex scar assessment involves determining the type of scar. Hypertrophic scars are typically red, raised, and firm, but usually remain confined to the original wound area. Keloids extend beyond the original wound, spreading into the surrounding normal skin, and are commonly found on the earlobes, chest, shoulders, and jawline. Atrophic scars are sunken below the surrounding skin, while contracture scars can pull on joints or facial features.

Moreover, it is crucial to assess whether the scar is still in an active phase. Active scars often present with persistent erythema, increased thickness, itching, pain, and a firm texture upon palpation. Active phase scars are more suitable for initial control of proliferation and inflammation; stable phase scars are better candidates for morphological correction, release, or reconstruction.

Step Three: Evaluate Color, Vascularity, and Pigment Changes

Color is an important clue for doctors in assessing the state of a scar. A reddish hue usually indicates rich vascularity, inflammation, or active proliferation; dark or brownish discoloration is often related to post-inflammatory hyperpigmentation; a whitish appearance may suggest hypopigmentation, changes in blood supply, or a mature scar.

Traditional visual observation is easily influenced by light, skin color, and experience. Objective assessment tools can help doctors quantify color changes. In clinical practice, doctors can use colorimeters, spectrophotometers, laser Doppler, and dermatoscopes to assess scar color and blood flow status. Among these, dermatoscopes can observe dilated capillaries in the epidermis and superficial dermis, allowing for the assessment of scar maturity and proliferative activity based on color and vascular presentation.

For keloids or scars with subtle changes before and after treatment, doctors can also use three-dimensional skin imaging. For example, Antera 3D can evaluate the three-dimensional morphology of the scar surface, elevation degree, hemoglobin, and melanin levels, which are useful for observing changes in keloid treatment.

Step Four: Measure Thickness and Hardness

Thickness and hardness are directly related to the severity of the scar. Thick and hard scars often indicate significant collagen deposition, which may be accompanied by tightness, pain, itching, or restricted movement. In the past, doctors mainly relied on palpation and scale scoring, but now more assessments incorporate imaging tools.

High-frequency ultrasound can observe scar thickness, and shear wave elastography can quantify tissue hardness. A related study included 40 patients with hypertrophic scars after burns, with 77 scar sites, using VSS scoring, high-frequency ultrasound for thickness measurement, and SWE for hardness evaluation, compared with pathological results. The results showed that ultrasound assessment of thickness and hardness was more accurate than VSS. The study also indicated that ultrasound thickness measurements had good consistency with pathological measurements, and ultrasound hardness values were highly positively correlated with the proportion of collagen fiber areas in pathology.

For children, pain-sensitive patients, and those requiring long-term follow-up, painless, rapid, and repeatable examinations are particularly valuable. High-frequency ultrasound combined with shear wave elastography is considered capable of dynamically monitoring subtle changes in scar thickness and hardness, providing a basis for evaluating the efficacy of pressure therapy, laser treatment, and other interventions.

Step Five: Assessing Area, Volume, and Three-Dimensional Shape

Complex scars often have uneven surfaces, making simple measurements of length and width with a ruler inaccurate. It is also necessary to evaluate the scar's area, elevation height, volume, whether the edges are expanding outward, and whether there is a reduction after treatment.

Flat photography is suitable for relatively flat scars, but projecting three-dimensional scars onto two-dimensional images can introduce errors. Three-dimensional stereophotography and 3D scanning can more accurately assess irregular surfaces and calculate scar surface area and volume, reflecting treatment efficacy through pre- and post-treatment volume differences.

This type of assessment is commonly used for keloids, hypertrophic scars, large burn scars, and treatment follow-up. For example, after keloid injections or surgery, changes may not be visually apparent, but three-dimensional data can help determine if the volume has truly decreased.

Step Six: Evaluating Pain, Itching, and Patient Experience

In addition to the scar's appearance, doctors also need to consider the patient's itching, pain, tingling, burning, numbness, tightness, sleep disturbances, and psychological stress in their assessment.

Because psychological health is very important during scar recovery, patient-led care, continuity of care, self-management learning, and psychological assessment are also key topics in patient-centered scar evaluation.

A commonly used combined subjective and objective assessment tool in clinical practice is the Patient and Observer Scar Assessment Scale (POSAS 2.0), alongside the Vancouver Scar Scale (VSS). POSAS 2.0 integrates patient self-assessment with objective clinical observation: the Patient Scale evaluates pain, itching, color, stiffness, thickness, and surface irregularity; the Observer Scale systematically assesses vascularity, pigmentation, thickness, relief, pliability, and surface area.

Step Seven: Assess Functional Impact and Range of Motion

Functional assessment is a crucial part of complex scar evaluation. Doctors will check whether the scar restricts joint movement, causes facial tension, affects fine motor skills, or impacts walking, dressing, eating, closing the eyes, or opening the mouth.

Burn scars on the hands require particularly detailed assessment. Although the hand area is small, its functions are complex. Simply looking at the burn area and scar area can underestimate the severity. For example, hand burns can impair skin elasticity and mobility, reduce joint range of motion, and affect overall finger mobility and coordination.

Step Eight: Evaluate Pediatric Scars Separately

Complex scars in children cannot simply be assessed using adult standards, as children are in a growth and development phase. Scars may gradually become more pronounced with the growth of height, limbs, and facial features. Children's ability to express themselves is limited, and their cooperation with pain and examinations varies.

Step Nine: Assessing the Risk of Recurrence and Treatment Difficulty

When evaluating complex scars, doctors also assess the risk of recurrence. Keloids, scars on the chest and shoulders, high-tension incisions, multiple recurrent lesions, individuals with darker skin tones, younger patients, and those with a family history typically require a more cautious treatment plan.

How Assessment Results Affect the Treatment Plan

After the assessment is complete, doctors translate the information into a treatment plan.

For red, active scars, vascular-related lasers, silicone, pressure, or injections may be considered; thick, hard hypertrophic scars may require a combination of injections, lasers, pressure therapy, and tension management; for depressed scars, it is important to determine if there is subcutaneous adhesion, which may necessitate subcutaneous release, fillers, fractional laser, or surgical repair; if contracture scars affect function, rehabilitation, splints, scar release, skin grafting, or flap reconstruction should be considered. For keloids, it is essential to evaluate the suitability of surgery combined with radiotherapy, injections, pressure, and long-term follow-up.

The treatment outcomes of complex scars also require repeated assessment. Doctors will document pre-treatment photographs, scale scores, ultrasound thickness, hardness, three-dimensional volume, pain and itchiness scores, and functional changes. This is necessary to determine whether the treatment plan is effective and whether adjustments to treatment intervals, intensity, or surgical strategies are needed.