Psychology Of Scars and A Look at New Treatment Options
By: Evelyne Llorente, M.D.

THE MILLER INSTITUTE
A SHELTER FOR VICTIMS OF SCARS

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 often affected as well.

We often perceive that people react differently to us because we have a scar. This perception can cause embarrassment, loss of self-esteem as well as anger and isolation.
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Translations

Coming to terms with a scar can be difficult, but do not despair. There are people who can help. There are effective treatments for scars. Realistic expectations are paramount because certain scars may not be removed completely. It may take years to come to terms with a scar. Nurturing a positive outlook will help you find some proactive level of acceptance so that you can move forward with courage and grace.

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. An ineffective repair process can result in scarring. However, please remember that a scar is NOT always the endpoint in the healing process. .

Damage to the outer layer of skin (the epidermis) is healed by rebuilding this tissue. Where the injury only involves the upper epidermis, scarring may be slight.

When the thick layer of tissue beneath the skin is damaged, rebuilding is more complicated. Our bodies lay down excess collagen fibers (proteins naturally produced by the body), often resulting in a more noticeable scar.

After the wound has healed, a scar continues to evolve as new collagen and blood are produced. Most scars fade and improve over a period of two years. However, there may always be some visible reminder of the injury.

Many things may cause scarring: accidents, surgery, skin disease (eg. psoriasis, eczema), burns, acne and infection. There are a number of 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.

2) Hypertrophic Scars: (Red or Dark and Raised): When a wound heals, the body produces new collagen fibers at a rate which balances the breakdown of old collagen. Excess production of collagen fibers may lead to the formation of hypertrophic scars, which may be itchy or painful. They frequently 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): these may develop anywhere on the body. They are more common on certain parts of the body e.g. ears, chest, shoulders and back. The young and people with darker skin are more prone to this type of scarring. Keloid scars can result from any type of injury to the skin, including scratches, injections, insect bites, acne, surgery, and tattoos. 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.

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 also be itchy or painful. They may continue to grow indefinitely and may not improve in appearance over time.

4) Sunken Scars: Sunken scars are pitted or recessed into the skin. The underlying skin may be attached to deeper structures (such as muscles) or there may be loss of fat at the site of the wound. Acne and Chicken Pox Scars are common causes of sunken scarring.

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 twenty-four months to flatten and fade after injury. While there will always be some evidence of the injury some scars may be the harbinger of more serious problems. You should seek advice from your doctor if the scar:
1. Grows bigger
2. Remains red/dark and raised and does not fade
3. Causes discomfort, itching or pain
4. Restricts movement of a joint or
5. Causes you distress because of its appearance

Treatment Options Available
Scars may improve naturally over a period of time. It is important to realize that a scar may not be removed completely. 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.

1) Surgery: most surgical procedures tend to leave a new scar which may take up to two years to mature. Surgery can be used to alter the position, alignment or shape of a scar. In the case of hypertrophic and keloid scars, surgical removal of a scar may be associated with a very high risk of recurrent problematic excessive scarring.

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. In my own experience, I prefer the Yag, diodes, green lasers and the alexandrite. The results are superior. Topical anesthesia is not necessary. There is no pain, or swelling. Minimal redness.

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. during an inspiring trip to Greece. This procedure enables us 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---by "rebuilding" 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. But even under the best of hands, there is a risk of tissue atrophy at the injection site such that the scar may become recessed or pitted months after treatment. Clusters of spider veins may also develop at the injection sites.

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,. This modality is mainly used to improve scars on the shoulders or back. It may be associated with a large risk of hypopigmentation (loss of pigment) in some cases.

7) Dermabrasion: 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 (significant pain, redness and swelling) period of a few days to a couple of weeks. This treatment may be associated with a large risk of hypopigmentation (loss of pigment) as well as hyperpigmentation.

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). The can be very costly and time consuming. Cost of one microdermabrasion: $ 100 - 250.

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: Bovine 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. Some patients require even more frequent injections if the scar is located in an area associated with a lot of muscular contractions like the mouth, nasolabial folds). Injections are expensive: approximately $ 350 per syringe. Furthermore, because of the risk of allergic reactions, all patients require a test patch.

11) Dermalogen: similar to bovine collagen in its application, but since it is of human origin, it does not require a test patch. It has also been reported to last 3 - 9 months. Cost: $ 350 - 600 per syringe. (In New York: reportedly $ 1000 - 1200 per syringe); FDA approved.

12) Adatosil: medical grade silicone was FDA approved for treatment of intra-occular hemorrhage in 1991 or 1994. It has not yet been FDA approved for correction of skin defects even though the FDA has not found support for the controversies associated with silicone breast implants. Adatosil is currently widely and openly administered in the United States by board certified dermatologists, plastic surgeons, cosmetic dermatologists and surgeons. Benefits of this therapy last for years. Hence they are more cost effective for patients/consumers. Small risk of granuloma formation ("lumps") if injected in large volumes. Cost: $ 200 - 400 per syringe.

13) Restylane: hyaluronic acid produced by Q-Med in Sweden. After injection, effects last 6 -12 months. No test patch necessary. Not FDA-approved yet. Clinical trials underway at UCLA. Cost in Canada: $ 500- 700 per syringe.

14) Artecoll: Not yet FDA approved for cosmetic applications. PNMA particles already approved in a variety of medical procedures like bone replacement of the jaw and hip. Effects last for YEARS after 1-2 injections. Cost $ 500 -1000 per treatment. Risk of granuloma formation ("lumps") at ijection site.

15) 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.

16) 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 little healing time while deeper peels can require up to several 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).

17) 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.

18) 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.

19) 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).

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