SCN: How do scars form?

Doctor: Scars, which are part of the body’s natural healing process, are formed when skin is deeply damaged by trauma, surgery or disease, such as burns and chicken pox. The more layers of skin destroyed, the more widely extensive the damage. Also, the longer a wound takes to heal, the greater the likelihood of developing a noticeable scar.

Acne is arguably the best known cause of scars, which may result from either the severity of the disease itself or undue delay in obtaining appropriate treatment. Acne scarring is estimated to affect, to a greater or lesser extent, some 95 percent of sufferers.

Abnormalities in color, shape, contour and texture are the reasons that scars are visible. Although each patient and each scar must be treated individually, it’s generally the type of scar and its location that mostly determine the specific treatment.

SCN: What kinds of scars exist?

Doctor: Broadly defined, scars fall into three main categories: elevated, depressed and atrophic. Hypertrophic scars and keloids, which result from an exaggerated healing response, are elevated scars that stand like mountains above the skin surface and cast broad, unsightly shadows.

Both are composed of an overabundance of dense fibrous tissue. Hypertrophic scars, also called "proud flesh," sometimes shrink on their own over time. Keloids, which develop in genetically predisposed individuals, typically don’t require treatment.

A depressed scar, as the name suggests, is sunken below the skin’s surface. It’s especially visible due to the "craters of the moon" effect, where wide shadows are cast across the base of the scar making it stand out from the rest of the skin. While generally level with the remainder of the surface, or only slightly depressed, atrophic scars have an ivory-colored or a crinkly, off-color, cigarette-paper-like appearance that stands in sharp contrast to its surroundings.

SCN: Do all scars require removal?

Doctor: Although all scars are permanent, many that are disfiguring at first become much less visible after several months and require no further treatment. For those that don’t, however, we’re fortunate to have a variety of minimally invasive office techniques for significantly improving their appearance.

SCN: What kinds of treatments are available?

Doctor: These techniques include intralesional injections, surgical scar revision and punch-excision or punch grafting, dermaspacing, microchanneling (microneedling), fillers, buffing (manual dermasanding), chemical peeling, microdermabrasion, lasers and intense pulsed light (IPL). All are non-invasive or minimally invasive lunchtime beauty fixes that require topical or local anesthesia and engender little or no downtime.

SCN: What’s the best treatment for hypertrophic scars and keloids?

Doctor: Intralesional injections of an anti-inflammatory corticosteroid remain the treatment of choice for both hypertrophic scars and keloids. Most hypertrophic scars respond quite rapidly and will shrink after a series of one to three treatments spaced at monthly intervals.

Keloids, on the other hand, may require higher doses and additional techniques, such as pretreatment with cryotherapy to soften the tissue and permit the injections to disperse better, surgical removal to debulk the scar and subsequent use of certain wound dressings and topical medications to suppress recurrence.

In most cases, large unsightly keloids can ultimately be reduced to barely visible, flat, off-white skin discolorations with these methods. Fees for intralesional injections typically range from $150-$300 per session.

SCN: What’s surgical scar revision?

Doctor: Surgical scar revision involves cutting out a scar and reorienting and restitching the resulting wound in such a way as to make the new surgical scar much less visible than the one removed. Fees for this procedure vary depending upon the size of the scar and the anatomic location and typically range from $350-$1,000. Punch excision, punch elevation or punch grafting are all variations of surgical scar revision used for treating icepick scars.

SCN: Please elaborate on these various types of surgical scar revision.

Doctor: The word "punch" refers to the razor sharp circular cutting instrument used by the dermasurgeons to core out the scar. In punch excision, the scar is extracted and the resulting wound is simply sutured, closed or, if small enough, allowed to heal on its own.

In punch elevation, the scar is freed up in the same manner but isn’t removed. Instead, it’s elevated to the surface to eliminate the depression and then allowed to heal on its own.

In punch grafting, a small piece of normal color-matching tissue, usually taken from skin overlying the bone directly behind the ear, is used to replace the cored out scar.

Punch procedures often run between $250 and $500 per site.

SCN: How do you treat depressed scars?

Doctor: Depressed scars, such as those from chicken pox or acne, must be elevated. Dermaspacing, a technique that uses a small cutting needle to break up scar tissue, creates a pocket within the scar under the skin into which fresh collagen can be produced and laid down, thereby elevating the surface of the scar above. Fees for dermaspacing may range from $300-$500 per session.

Microchanneling (or microneedling) is another successful technique for permanently improving depressed scars. In this procedure, the scar is first anesthetized with topical or local anesthesia. Then, using an instrument called the Dermaroller — which is essentially a rolling pin to which numerous tiny, acupuncture-like spokes are affixed — the treatment area is criss-crossed multiple times to ensure complete coverage.

Numerous deep channels are created in the dermis that mechanically break up the scar tissue and stimulate the production of new collagen, a process known as collagen induction therapy or CIT. Occasionally, the patient may even feel the scar tissue giving way.

The "spokes" are so fine that they don’t damage the epidermis; in fact, often the displeasing off-white or ivory surface color of the scar is improved following treatment and blends better with the surrounding skin. Although the channels seal almost immediately, the skin may appear mildly sunburned for a few days, which is easily covered with makeup.

The procedure may be repeated as needed at six week intervals to achieve an optimum result. Generally two to four treatments are necessary. Fees range from $750-$800 per treatment.

The results of dermaspacing and microchanneling have the advantage of being permanent. If necessary, fillers such as Radiesse, Juvederm or Restylane may also be used, either alone or in combination with either technique to further raise the depressed areas.

SCN: What about icepick scars?

Doctor: Icepick scars, which are typically very narrow, often numerous and penetrate quite deeply, present perhaps the most difficult therapeutic challenge. In my experience, these are best treated by the Chemical Reconstruction of Skin Scar (CROSS) technique — a modification of a deep chemical peel in which 100 percent trichloroacetic acid is carefully placed deep within the pit (rather than applied to the whole face). The resulting wound closes the pit.

A series of four to six treatments may be necessary. Fees vary according to the number of areas treated, and may range from $500 to $750 per session.

SCN: What options are available for patients with irregular scars?

Doctor: When surface irregularities are a prominent feature of a scar, the following may be considered: buffing the skin (i.e. manually "sanding"), microchanneling (i.e. microneedling), chemical peels or light-based therapies such as intense pulsed light (IPL).

Buffing the skin with a medical grade, sandpaper-like material and chemical peeling agents abrade and remove the surface of the scar and level out the irregularities.

IPL penetrates the skin causing damage below that subsequently results in a thickening of the dermis via new collagen synthesis with a consequent smoothing out of the overlying upper layer of skin. Buffing generally costs about $500 a treatment, and IPL may range from $300-$400 per session.

SCN: What would you recommend in the following situation: "I recently fell from my bicycle and split my chin. The wound required eight stitches and has left a scar. Should I wait until the scar fully forms before seeking treatment?"

Doctor: In the old days, the conventional wisdom was to wait until a scar was fully matured before undertaking any treatment. Today, we suggest that the scar be treated by microneedling, manual dermasanding or by another form of skin abrasion somewhere between eight to 12 weeks after the injury — the latter known as scarabrasion. Early intervention in this fashion offers the best chance of significant scar improvement or even total clearing.

SCN: How about this one: "Several months ago, I developed a "proud flesh" scar over my shoulder at the site of the surgical excision of a suspicious mole. I’m not concerned about the appearance, but I’m bothered by persistent itching at the site. Is there anything I can do?"

Doctor: Your doctor can prescribe a number of topical corticosteroid creams or a variety of non-steroidal anti-itch medications. However, if this a hypertrophic scar, the intralesional injection of anti- inflammatory corticosteroid is the fastest and most effective method for eliminating symptoms and shrinking the scar.

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To learn more about cosmetic dermatologist Nelson Lee Novick, M.D., F.A.A.D., F.A.A.C.S., please visit his bio.