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THE MILLER INSTITUTE
A SHELTER FOR VICTIMS OF SCARS
Psychology of scars
By Evelyne Llorente, MD
An estimated 70 million adults in the United States have some sort of scar.
Most people are not affected by their presence. However, in many cases, it is
not just the person who has the scar(s), but also their family and friends who
are affected.
A wide range of things influence how we feel about scars: location of the scar, our age and sex; how the scar occurred. Facial scars can be very distressing, but other less visible scars can be as disturbing.
We often feel that people react differently to us because we have a scar. This can cause embarrassment, loss of self-esteem as well as anger and isolation.
If you or someone you know is having problems coming to terms with a scar, then do not despair. There are people who can help and ways you can help yourself. There are treatments for scars, but be realistic about your expectations: no therapy can erase a scar completely. It may take years to come to terms with a scar, but keeping a positive outlook will help you accept your situation. After all, nobody is perfect and your scar is part of who you are.
What is a scar?
The skin is the largest organ of the body, with an average surface area of 19.3
square feet in adults. Our skin is a sophisticated organ. It helps to keep us
cool in hot weather and warm in cold weather. It also prevents us from dehydrating.
It constantly sheds old cells and creates new ones, enabling it to repair itself
if damaged. It is the repair process that can result in a scar.
A scar is an essential part of this natural healing process following injury either to the outer layer of skin (the epidermis) or to the thick layer of skin (the dermis). Damage to the outer layer of the skin is healed by rebuilding this tissue. In these instances, scarring is slight.
When the thick layer of tissue beneath the skin is damaged, rebuilding is more complicated. Our bodies lay down collagen fibers (proteins naturally produced by the body). This usually results in a noticeable scar.
After the wound has healed, a scar continues to change as new collagen is formed and blood vessels return to normal. This is the reason why most scars fade and improve over a period of two years. However, there may always be some visible evidence of the injury. Furthermore, hair follicles and sweat glands may not grow back.
A wound does not become a scar until the skin has healed completely. Skin conditions such as eczema and psoriasis and injuries such as minor burns or sunburn are not scars because the skin is broken or still being repaired. However, these conditions could lead to a minor scar if scratched before the outer layer of skin is healed.
Many things may cause scarring: accidents, surgery, skin disease, burns, acne, infection and crime. Yet, not all scars are the same. Below are some of the different types of scars.
1) Flat, Pale Scars: These are the most common type of scars resulting from the body's natural healing process. Initially, they may be red or dark and raised, but become paler and flatter over a period of two years. Note that there may always be some visible evidence of the original wound.
2) Hypertrophic Scars: (Red or Dark and Raised) When a normal wound heals, the body produces new collagen fibers at a rate which balances the breakdown of old collagen. Hypertrophic scars may be itchy or painful. They do not extend beyond the boundary of the original wound. They may continue to thicken for up to 6 months. They usually improve over the next one to two years, but may cause distress due to their appearance or the intensity of the itching. They may also restrict movement when located close to a joint. Hypertrophic scars are more common in the young and people with darker skin. Some people have an inherited tendency to this type of scarring. It is not possible to completely prevent hypertrophic scars.
3) Keloid Scars: (Red or Dark and Raised) Like hypertrophic scars, keloids are the result of an imbalance in the production of collagen in a healing wound. Unlike hypertrophic scars, keloids grow beyond the boundary of the original wound. They may be itchy or painful. They may continue to grow indefinitely and may not improve in appearance over time . Keloid scars can result from any type of injury to the skin, including scratches, injections, insect bites and tattoos. Anybody can get a keloid scar, which may develop anywhere on the body. They are more common on certain parts of the body e.g. ears, chest, shoulders and back. However, the young and people with darker skin are more prone to this type of scarring. As with hypertrophic scarring, people who have developed one keloid scar are likely to be prone to this condition in the future and should alert their doctor or surgeon if they are likely to need injections or to have any form of surgery.
4) Sunken Scars: Sunken scars are pitted or recessed into the skin. They may be due to the skin being attached to deeper structures (such as muscles) or to loss of underlying fat. Acne and Chicken Pox Scars are common causes of sunken scarring. However, it is important to note that acne scarring is not always sunken in appearance and can even become keloid.
5) Stretched Scars: Stretched scars occur when the skin around a healing wound is put under tension during the healing process. This type of scarring may follow injury or surgery. Initially, the scar may appear normal but can widen and thin over a period of weeks or months. This can occur where the skin is close to a joint and is stretched during movement or may be due to poor healing due to general ill health or malnutrition.
What should you do if you have a problem scar?
Scars usually take between twelve and eighteen months to flatten and fade after
injury, but can take up to twenty four months. While there will always be some
evidence of the injury some scars may cause more serious problems. It would
be worth seeking advice from your doctor, dermatologist, surgeon, nurse or pharmacist
if the scar,
Grows bigger
Remains red/dark and raised and does not fade
Causes discomfort, itching or pain
Restricts movement of a joint
Causes you distress because of its appearance
Treatment Options Available
It is important to realize that no scar can ever be removed completely. All scars are permanent, though they may improve naturally over a period of time. Sometimes it is possible to improve the appearance of a scar by surgical removal or other scar therapies. Listed below are the main recognized scar therapies that are used by the medical profession to improve the appearance of scars. More information is available from your doctor or dermatologist.
1) Surgery: Any surgical removal will always leave a new scar that will take up to two years to mature. Surgery will never remove a scar but can be used to alter its position, alignment or shape. In the case of hypertrophic and keloid scars, there is a very high risk of recurrence of excessive scarring following surgery.
2) Laser Surgery & Resurfacing: Like surgery, the role of laser surgery in the management of scars has been traditionally limited. The color of a red scar may be improved by management with a vascular laser. It has also been suggested that removing the surface layers of the skin with a carbon dioxide laser may help to flatten scars. The CO2 laser is a relatively unrefined, harsh instrument in terms of scar revision and in some cases may aggravate the original scar.
Dr. Evelyne Llorente's new technique, Mikro-Lase laser rejuvenation has been
highly effective in the treatment of acne scars, even scars induced by CO2 laser
resurfacing.
Mikro-lase is a laser treatment developed several years ago by Evelyne Llorente
M.D. to non-surgically rejuvenate the skin and facial structure by using laser
light to induce collagen formation and stimulate dermal proteins to improve
the appearance of the skin.
The benefits of each MIKRO-LASE treatment over all other skin rejuvenation procedures include:
*No Downtime
*Non-Surgical
*Little pain and discomfort
*Immediate results after 1 - 2 treatments
*Affordable
*Enhances your own collagen growth
*Produces more dermal proteins
*Treats all types of skin
Complications such as oozing, bleeding, infections and a long recovery time associated with the CO2 laser resurfacing are non-existent with Mikro-Lase. The benefits are astonishing after one treatment.
NOTE: In a complimentary consultation, Dr. Llorente can best design a treatment plan to meet your expectations.
3) Steroid Injections: A series of steroid injections can be repeated at 4 to 6 week intervals under medical supervision. They may help to soften and flatten a hypertrophic or keloid scar. The steroid is injected into the scar itself. Very little is absorbed into the blood stream, so side effects are minimal.
4) Pressure Garments: Pressure garments are only used under supervision by a medical professional. They are most often used for burn scars that cover a large area and are only effective on recent scars. Pressure garments are tight fitting and are usually custom-made from an elastic material. They work best when worn 24 hours a day for 6 to 12 months. How they work is not understood, though it may be that continuous pressure on the surface blood vessels plays a part. Over a period of months, the scars soften, flatten and become paler.
5) Radiotherapy:
Low-dose, superficial radiotherapy may reduce the recurrence rate of hypertrophic
and keloid scars after surgery. It is effective in about 70% of cases, but is
reserved for the most serious cases because of the possibility of long-term
side effects from radiation.
6) Cryotherapy: Cryotherapy is a technique that uses special equipment to freeze the scar tissue using liquid Nitrogen or carbon dioxide. Research suggests that this technique is only effective in around 30% of cases and it is mainly used to improve scars on the shoulders or back. It may be associated with a large risk of hypopigmentation in some cases.
7) Dermabrasion: Dermabrasion can be used to reduce irregularities in the skin surface associated with scarring. This involves the removal of the surface of the skin with special instrument, much like a drillbit. The procedure usually requires a general anesthetic. It may be helpful where the scar is raised above the level of the surrounding skin, but is less useful when the scar is sunken or pitted. There may be a recovery period of a few days to a couple of weeks.
8) Crystal or Diamond Microdermabrasion: Similar to dermabrasion, but gentler, milder and performed without anesthetics. Appreciable results are seen after multiple sessions (minimum of 10 to 20; probably an even greater number of treatments for more serious scars).
9) Liposuction: Liposuction involves the removal of normal fat from beneath the skin. This has a limited role in leveling out the contour around a sunken scar.
10) Collagen Injections: Collagen can be injected beneath a sunken scar in order to build up the level of the skin. However, the effect is temporary. Injections need to be repeated at regular intervals---every 3 - 4 months. Injections are expensive: approximately $ 350 per syringe. Furthermore, because of the risk of allergic reactions, all patients require a test patch.
11) Punch Grafts: A tiny instrument is used to punch a hole in the skin and remove the scar. The area is then filled in with a matching piece of unscarred skin, usually taken from the back of the earlobe. The "plugs" are taped into place for five to seven days as they heal. Even though the punch grafts form scars of their own, they provide a smooth skin surface which is far less visible than depressed scars.
12) Chemical Peels: Chemical peels remove the top layer of the skin with a chemical in order to smooth depressed scars and give the skin a more even color. This technique is helpful for superficial scars. Light peels require no healing time while deeper peels can require up to two weeks to heal. The amount of scarring and color change determines the type of peel selected. There is a risk of both hypo- and hyper-pigmentation with chemical peels even in fair complected people (Skin type I).
13) Silicone Gel Sheets: Widely used in the therapies of red and raised scars by moisturizing and covering the scar area. This helps by flattening, softening and fading red and raised scars. Silicone gel sheeting was developed in the 1980's and has been used by over 1 million people throughout the world. Tests indicate that the average improvement time should be between 2 - 4 months.
14) Vitamin E Cream: Although Vitamin E cream is sometimes recommended for the self-management of scars, there is no strong medical evidence to suggest that it has an effect.
15) Cosmetic Camouflage and/or Permanent make-up: can be a very effective way of disguising a scar, birth mark, 'port wine' stain, vitiligo (a condition which destroys pigment in the skin causing white patches).
Evelyne Llorente, MD
Tel. (714) 885-8980
www.ehyperbaric.com
www.llorente.com/hyperbaric
www.mikro-lase.com