Treatment of Scarring 

Opinions are often requested as to whether or not revision or other treatment of scars is required. Significant surgical treatment of scarring relates mainly to relieving tightness and to improving surface contour defects. Tight thin longitudinal scars across joint flexures may be dealt with by excision and rearranged at the local skin, often by z-plasty, which transfers the tightness from a troublesome to a non-troublesome axis while broad tight scars and scarred areas require free skin grafts and flaps.

Assessment of Scarring

Assessment of liability for scarring relevant to a surgeon is usually straight forward as it usually relates to the effects of laceration, abrasion, burns or tissue loss, including repair by direct suture, (free) skin grafts and flaps (which retain functioning blood vessels including reconstructed bloood vessels). The end result of scarring due to dermatological conditions might occasionally be assessed by a surgeon but liability for scarring of dermatological cause should be assessed by a dermatologist and, of course, appropriate treatment of dermatological conditions is advised by a dermatologist.  Any loss of joint movement caused by scarring is assessed as explained under "hand injuries". Other effects of scarring are assessed according to influences upon activities of daily living and activities at work as set out in tables in the AMA Guides. As adding percentages of whole person impairment of different causes would be inappropriate: assessments for loss of movement are combined with other assessments according to the AMA Guides Combined Values Chart or a formula.  

Burn Scarring

The first priority of the initial treatment of burns is to preserve life and all body parts (when achievable). The second priority of initial treatment is to minimise scarring. Secondary surgery involves mainly revision of scars by free grafting, flaps and, these days, free flaps involving transfer of skin and subcutaneous tissue and sometimes deeper tissues or structures by microvascular anastomosis. Opinions are often sought concerning the need for further treatment and, once treatment has definitely finished and the burn scars have stabilised sufficiently, assessment of permanent impairment is requested. 

Keloids and Hypertrophic Scars

Keloids are extremely hypertrophic (overgrown) scars. Most scars go through a period of hypertrophy (overgrowth) - redness, slight irritation and firm swelling (induration) which usually subsides over a few weeks - when adjacent undamaged skin becomes affected by the hypertrophic process a keloid has formed.  A keloid may continue to increase for several to many years before eventually starting to resolve very slowly.   

Hypertrophic scars result from an excess of normal scar hypertrophy for longer than normal. Burning is particuarly likely to cause hypertrophic scars which take a long time to subside, probably because of the tension caused by scar contracture. Tight scars, espeically longitudinal scars over joint flexures commonly become hypertrophic (see above for treatment). People who have an inherited keloid tendency form hypertrophic scars, the extreme forms of which are keloids. 

Keloids follow trauma (sometimes just an insect bite to an especially keloid prone part of the body, e.g., the "spontaenous" butterfly pre-sternal keloid) in a person who has an inborn keloid tendency. A keloid is an elevated irritable red thick hard scar. Without additional treatment, simple excision of a keloid causes a larger keloid to form. Repeated intralesional steroid injections ordinarily result in keloids subsiding completely providing follow up is adequate. After they have subsided fully, scarring due to keloids is assessed in the same way as other scars. A person's keloid tendency becomes active a few months after birth, increases until shortly after puberty and then slowly decreases over the whole of a person's life.