What Causes Scarring?
Our natural skin traits factor heavily into how we scar. Studies have shown that patients who fall within the Fitzpatrick Scale's Type III to VI categories (groups ranging from white/olive to very dark brown/black skin colouration) are much more likely to develop excessive or abnormal scarring. Patients with darker skin are more likely to suffer from keloids (large, painful marks), hyperpigmented (discoloured) scars and scars that are large in volume (hypertrophied). These factors lead to a scar that is more easily visible and unsightly.
Collagen is a substance that naturally helps to repair wounds. If a patient's genetics make them prone to collagen overproduction and insufficient collagen degradation, they are more likely to develop keloids and hypertrophied scars.
Younger patients may be more likely to suffer from widened scars due to the higher tensile strength of their skin. Older individuals typically scar better since aged skin isn't as tight and places less tension on the wound as it heals.
Iatrogenic factors, simply put, are injuries caused by doctors as part of a medical treatment. For example, the type of incision a surgeon creates during a procedure would be an iatrogenic factor of the scar left behind. Since scars are formed as the result of a wound's healing, Dr. Brown understands the importance of minimizing soft tissue trauma as much as possible during surgery. Improperly closing the edges of the wound can create unnecessary skin tension that leads to depressed scars. If the wound isn't properly supported deep within the tissue, too much tension can be placed on the site and an overly wide scar is created. In addition, if stitches are taken out too early or too late the resulting scar will be too wide or have a noticeable, cross-hatched appearance. If steroids or medications like Accutane (isotretinoin) are used too closely to surgery they may also cause problematic scarring. Patients who have taken Accutane or steroids should wait at least 12 to 18 months after completing the medication course before undergoing any type of facial surgery.
Achieving the Best Scar
Clinical studies have helped doctors learn how to improve their surgical techniques and avoid causing the kind of damage that leads to abnormal or excessive scarring. These studies have determined that skin does not run in straight lines and also changes structurally with time. It is also anisotropic, meaning that it possesses mechanical properties that change based on direction.
Understanding the anisotropic nature of skin has helped doctors identify lines of minimal tension within the operating area. If surgical incisions are made parallel to these relaxed skin tension lines (or RSTLs) undue stress can be avoided during the healing process. There are also areas of the skin that are better at extending. These are known as lines of maximal extensibility (or LMEs). If incisions are made parallel to the RSTLs and then closed in the direction of the LMEs, there will be very little tension on the operating site as it heals and the best possible scar is left behind.
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