Why Scar Repair Is More Than Cutting Out a Scar

Reconstructive Strategies

Scar repair is often misunderstood as simply 'cutting out the scar,' but in plastic surgery, excision is just one part of the treatment.

Plastic surgeons need to focus on and address many other factors, such as the color, thickness, hardness, volume, tension, blood supply, skin defects, deep adhesions, pain and itching, movement restrictions, risk of recurrence, and the patient's needs regarding appearance and quality of life.

A new wound will form after excision.

After the scar is excised, a new wound or incision will appear locally. The new wound still needs to go through the processes of inflammation, proliferation, maturation, and remodeling. If there is high suture tension, inappropriate incision direction, or imprecise tissue alignment, a new scar may form later, which could be wider, harder, and more noticeable than the original.

Therefore, scar surgery is not as simple as just removing the lesion. In the precise repair of facial trauma, plastic surgeons will first assess the patient's condition, thoroughly irrigate the wound, remove devitalized tissue, debris, and blood clots, while protecting important nerves and blood vessels. For irregular wounds, they will also perform fine trimming of about 1 millimeter to create fresh wound edges, minimizing postoperative scar formation. Deeper wounds require layered suturing of the muscle layer, subcutaneous tissue, and skin.

Precise alignment determines appearance and function.

When scars are located on the eyelids, nasal alae, lips, corners of the mouth, eyebrow area, or fingers, the difficulty of repair increases. In these cases, the goal of repair is not only to close the skin but also to restore anatomical structure and function.

For example, if a lip scar does not align with the vermilion border, it can result in noticeable misalignment post-surgery; if a nasal scar does not properly restore the tip, alae, or columella, it may affect appearance or even breathing; if a periocular scar pulls on the eyelid, it may cause incomplete eye closure, ectropion, or tearing.

In precise facial repair, the periocular tissue layers are intricate, requiring careful differentiation and precise alignment during debridement; nasal soft tissue injuries need restoration of anatomical landmarks such as the tip, alae, and columella.

When there is tissue loss, forcibly pulling the skin together can lead to deformation.

In some cases, after scar excision, the local skin may become insufficient. If the doctor forcibly pulls the skin edges together for closure, it may appear closed in the short term, but later may result in local deformation, excessive tension on the incision, scar widening, organ displacement, or contracture recurrence.

For larger facial defects, it is crucial to consider organ shape, facial contour, skin color, and texture before choosing methods such as local flaps, free skin grafts, or composite tissue free transfers to close the wound. Postoperatively, pressure dressings, infection prevention, and early anti-scar treatments like silicone gel sheeting are necessary.

Scar treatment must address color, thickness, and hardness simultaneously.

Some scars, even after excision, leave the surrounding skin red, thickened, and hardened, indicating that the area remains active. Doctors will assess the scar's color, vascularity, thickness, and hardness to determine whether immediate surgery is appropriate or if initial control of proliferation with laser, injections, silicone, or pressure therapy is needed.

High-frequency ultrasound combined with shear wave elastography studies show that hypertrophic scars have significantly greater thickness and hardness compared to normal skin. Additionally, ultrasound measurements of scar thickness correlate well with pathological measurements, and ultrasound hardness values are highly positively correlated with the proportion of collagen fiber areas in pathology. For patients, this means that in addition to comparing photos before and after treatment, it is important to assess whether the scar has truly become thinner and softer internally.

Simple excision of keloids easily leads to recurrence.

Keloids are one of the most challenging types of scars to treat, as they grow beyond the original wound boundaries and are commonly found on the earlobes, chest, shoulders, and jawline. Simple excision creates a new wound, and without adjunctive measures such as injections, radiotherapy, pressure, silicone, or other anti-recurrence strategies post-surgery, the risk of recurrence is high.

Hypertrophic scars may also require minimally invasive debulking and regenerative repair.

Hypertrophic scars are usually confined to the original wound area, but if they are significantly raised, red, hardened, unresponsive to conservative treatment, or cause contracture and functional impairment due to contraction, surgical intervention may be necessary.

Traditional excision is not the only option; in some cases, a more minimally invasive approach involving volume reduction and tissue transplantation can be considered.

Burn scars require attention to skin quality and contracture.

Burn scars are often accompanied by extensive hypertrophy, decreased skin elasticity, itching, pain, and restricted joint movement. Simply excising large scar areas does not automatically restore normal skin; it is also necessary to consider wound coverage materials, dermal layer reconstruction, subsequent contraction, and functional rehabilitation.

Research on the Glyaderm acellular dermal regeneration template shows that simple autologous split-thickness skin grafts often lead to hypertrophic scars and scar contracture due to the lack of a dermal reticular layer. When Glyaderm is used in combination with autologous split-thickness skin grafts in the first stage, patients and observers report better scores on the scar assessment scale, and histological analysis suggests it promotes dermal regeneration, with elastin present up to 12 months.

For hand scars, it is important to include mobility in the treatment goals.

Hand scars are particularly prone to being underestimated. Although the hand is not large in area, the complex relationships between joints, tendons, nerves, and skin mobility make it intricate. If a scar affects finger flexion and extension, thumb abduction, fist formation, opposition, or fine motor skills, it requires careful evaluation, even if it appears small.

Postoperative care affects the final outcome

The treatment is not complete after scar repair surgery. Incision care, compression bandaging, infection prevention, pain management, silicone therapy, pressure therapy, sun protection, rehabilitation exercises, and regular follow-ups all influence the final result.

Patient perception should also be included in treatment decisions

Scars affect not only appearance but also sleep, exercise, dressing, social interactions, and psychological state.

Therefore, when doctors develop a treatment plan, they will ask patients what concerns them the most: whether it is noticeable color, raised and hard texture, pain and itching, depression and unevenness, restricted movement, or frequent recurrence. Different concerns correspond to different plans, and a combination of aesthetic repair, functional reconstruction, and symptom control is often required.

Therefore, scar repair is more than just excision because scars involve skin structure, collagen deposition, vascular changes, pigmentation changes, tension direction, tissue defects, deep adhesions, functional activity, and the risk of recurrence.

Simple excision can only remove existing scar tissue and cannot automatically resolve issues such as new wound healing, skin shortage, excessive tension, organ deformation, keloid recurrence, joint contracture, and postoperative care.