Hi, my name is Dr. Andrew Vardanian.
I'm from the Division of Plastic Surgery at UCLA, and I'm here today to talk about scars and keloids,
2 very common problems that affect many, many people.
This is our address, if you would like to join in with Twitter. I
have no disclosures, and I have no commercial interests as well.
So, my purpose for giving this webinar today is to basically educate the public on
scars, which are something that, you know, affect all walks of life and all age groups, from little babies to elderly patients.
I'd like people to take away three sort of bullet points from this talk. One is
what causes a scar, a
second is what are the different types of scars and
sort of how the medical professionals look at scars and talk about them, and the third
main point is what can we do if we have a scar? What do I do?
So, these are kind of the things that I want to focus on today for the audience.
So what causes a scar? Well, you know, pretty much everyone has a scar from something that's happened. You know, a
childhood fight or a childhood game that resulted in a small injury that's left someone with a lifelong scar,
to a bicycle accident,
potentially surgery, and other things,
but scars are basically caused by many, many different things in many parts of the body, and
what the scar is, is the body's response to an injury, and it's the result of the body
trying to heal or regenerate an injured tissue.
So that's sort of how a scar is caused. A
scar can be caused by things such as trauma, so it could be as small or simple as a small bicycle accident on a
toddler to something much more extreme and serious, such as a patient that had a motor vehicle accident
and was brought to the hospital for that.
Other scars can be caused by burn injuries. These can be things like fire or flame
as well as scald injuries, which are very common in young children.
Scars can be the result of surgery as well, so
patients that come to the hospital for things such as minor procedures or biopsies, to very large
operations, also have resultant scars, which can be problematic as well, and
scars can occur from things such as acne or blistering, as well.
There are many, many causes of scarring, and hopefully, today we can talk about more,
more about these problems.
So, what are various types of scars? So,
the medical terminology and
characterization of scars is quite specific,
and we'll talk about some of the general types of scars that we know about in medical literature.
One type of scar is called a keloid scar.
So, this is a very abnormal scar type. The scar is very large and bulky.
It's characterized by a scar that actually grows beyond the boundaries of the original injury.
So, keloid scars can occur from things such as surgery, for example, an open-heart surgery,
but it can also occur from something as--what we would think is--minor as an ear piercing.
The keloid has a genetic
predilection for certain HLA types. We do see it very commonly in
African-American and Asian-American populations, but other populations can also be affected by it.
But the main characteristic is abnormal scar growth and
the growth of the lesion beyond the borders. It's hard to tell on a 2D image, but this is a, you know, a large,
elevated, and
extended growth of abnormal tissue or scar, and these can be quite symptomatic. Symptoms can include
pain, tightness, heaviness. If you can imagine a patient that has had an ear piercing
and then has developed a very large or bulky scar around that
injury to the skin, that can really affect someone's quality of life, and,
you know, that is definitely what I call a symptomatic scar.
This is another example of an abnormal type of scar. This is what is termed a hypertrophic scar, and again,
it's difficult to appreciate in a 2D image,
the 3D nature of it, but these arrows pointing to these areas or ridges in the tissue which are
hypertrophic or elevated,
this entire tissue is actually injured. This is an extremity of a patient that had a burn. A lot of it is flattened,
but there are areas of it which are raised and elevated, and these are what we term
hypertrophic. The difference from hypertrophic scars from keloids are that
the scar actually doesn't extend beyond the borders of the injured tissue,
so it doesn't actually grow outwards or onto the normal
skin that's nearby, but it's grown upwards, so to speak. But it is also characterized as an abnormal scar type.
This is a scar that I term a contracted scar. This is a hand of a patient that was burned, and there are areas of
elevation, which are hypertrophic,
but in addition, what I want to emphasize for this particular scar type
is that it is a contracted scar. This patient has an
inability to properly extend or straighten the fingers of the hand,
which has resulted from the abnormal scar tissue on the palmar surface of the hand and the fingers. This
significantly affects this patient's ability to properly use the hand, and this is what I term a contracted scar that is symptomatic.
This is another scar entity that I've termed the red scar type,
and this is a patient that had an injury to an extremity, and the scar has resulted in a very red color.
This scar may not be painful,
it may not even cause symptoms such as contracture, itching, or tightness,
but it is very red, or hyperemic, in color, and this creates a really difficult
cosmetic situation. A patient may be very concerned about wearing shorts, wearing a short-sleeved t-shirt
with a red and prominent scar on their extremity with this. And we have various options for these types of scars as well.
So this is what I term the red scar.
A lesser appreciated scar is what I term or is termed an atrophic, or a sunken, scar, and again, on the
2D image, it's difficult to characterize on the 3D nature of this,
but this is a scar that occurred from a injury to an extremity on a patient, and the
surrounding or adjacent tissue is quite normal, the scar itself blends in relatively reasonably with the normal skin
that's around, but there is a contoured deformity or
sunken appearance to the scar that was problematic for this patient, and that primarily occurred because of injury to the underlying fat,
which created the sunken nature of it.
Injuries that affect the underlying fat or even the underlying muscle can create these types of sunken deformities,
and this is another scar type that can be addressed.
So that's great, that we have all these different types of scars,
but, you know, what can I do if I have a scar? What, you know, what are my options?
So, there are options available for both
symptomatic and asymptomatic scars, and what I mean by that are,
symptomatic scars are those that there are actual symptoms related to it--these are things such as itching, tightness, pain, discomfort,
inability to do certain maneuvers,
inability to use an extremity or to use a hand or foot in the proper way,
and those are actual symptoms that were caused by the scars.
There are also asymptomatic scars, and these are more cosmetic.
These are scars that, you know, we just don't like the appearance of, and we wish we didn't have them. These are
different in the sense that they don't have pain or symptoms,
but nevertheless, they still affect a patient's quality of life, and a patient could be quite
self-conscious about these as well.
We offer very personalized and comprehensive care for patients, so each
person is individual, and the scar type and the actual cause of the scar is very unique for each patient,
and we really try to
tailor the care specifically for the patient in a
personalized way, and we work for scar revision,
revising the scar that actually exists as well as modulating the scar. So, some scars
may not be amenable to actual removal,
but there are ways to actually improve the scar and modulate or change the way the collagen is arranged,
and we'll talk about that briefly as well.
I've sort of divided up the treatment
availabilities into surgical and non-surgical.
Surgical are, you know, I would say more invasive. They require going to the operating room,
usually the outpatient procedure room, but they actually require, on some
level, anesthesia and surgery
for completion, versus non-surgical modalities,
which can be done in an office-based setting, such as in our Plastic Surgery Division
clinic offices, and
we'll go over a few of these. This is skin grafting. That is one surgical modality.
This was a patient that had an injury that had a resultant scar that was dark in color.
Obviously there was an aesthetic component to this that, you know, the patient
did not like the difference in the color
from the normal skin to the area of the scarred tissue, and skin grafting was performed for this
articular scar in order to resurface the area. So this was something the patient
had to go to the operating room for. An area of skin was harvested from
another part of the body, and the skin was then transplanted, and you know, it's a much better color match for this patient, and
improvement in terms of the aesthetic for the patient as well.
Fat grafting is another surgical treatment modality that isn't often considered for scars,
but many in the audience have heard of
injectables or fillers, such as hyaluronic acid, which are used for wrinkles of the face.
Fat grafting is a similar concept. It is a little bit more permanent,
and it involves harvesting fat from the part of the body and actually
processing that fat and injecting it into areas of depressed
scar or areas of contour deformity from scarring. It's a more longer-lasting option than
fillers are for scars and but it is a surgical option that is available for scar treatment.
It is done in an outpatient surgical setting.
Z Plasty. This is a medical term for a type of local tissue rearrangement that is done for different types of
hypertrophic and contracted scars. This was an
injury on a patient's foot that had areas of hypertrophic scarring as well as contractors.
The treatment for this was actually a combination of laser with steroid and local tissue rearrangement with Z Plasty,
and what the Z Plasty means is an actual Z is designed, and the tissue is
rotated and moved in order to release
areas of tightness of scarring and
tethered areas, so this is a surgical modality that's available.
And another modality that is being used with more frequency for scars is
ablative fractional CO2 laser resurfacing.
This was a recent paper that was published by some individuals I had the opportunity to work with, and
it's using an ablative laser technology to modulate
scar tissue.
One device we use is a luminous UltraPulse laser.
The procedure is often done in an outpatient setting
or in the procedure room with very little downtime.
Local analgesia,
topical analgesic may be used, and the treatment is often done--
it doesn't take a very long period of time to administer the treatment.
Oftentimes, more than one session is necessary. However, there have been very nice results for the right patient with this treatment
modality.
Some other surgical options that I haven't yet discussed are direct scar revision--
direct scar revision involves actually removing the existing scar in its entirety and
reapproximating, or bringing together, the skin edges
to revise the scar.
The most important thing to note with that is anytime any type of a incision is made on a person,
scar will result, and a scar revision with an open approach
has the purpose or aim to reduce the scar.
But in essence, a new scar will develop, and so the patient would be trading an existing scar for a new scar.
We are very careful with the way the scar is
reapproximated and the edges are brought together, and that is a huge impact, in my opinion, on the results and scar.
However, we do note that there is always a resultant scar which may occur.
And for certain other patients, tissue expansion may be something that's important. Tissue expansion is a process in which an
expander is placed in a certain part of the body, and an expander is--if you think of a balloon
that holds fluid, the expander is like a pocket that's created in that way, and
through serial visits in the office, the expander is augmented with more volume, and that helps stretch the skin
in certain parts of the body, and that skin can be used to actually
resurface areas of scarring or contracture, so quite a powerful technique, but it does need to be done by a
plastic surgeon and in the appropriate context.
Some non-surgical options that we've briefly
spoken about are steroid injections--these are
used as an adjunct for treatment of keloids and many other types of scars--and also silicone sheeting and pressure therapy are
some mainstays, as well, of scar treatment. Pressure therapy has been used for a very long period of time, and it is also a very powerful
scar treatment modality that is used many different patient populations.
So, in summary, the UCLA Scar Treatment Program is a program
that is available through the Division of Plastic Surgery at UCLA.
Our contact number is above. We
accept all patient inquiries and referrals, and
I think it's a great opportunity for
patients who are, you know, really--
they're either self-conscious about a scar that they have, or they have real symptoms from their scar
and made like a medical opinion on what can be done about it.
I think this is a very worthwhile
opportunity for the right patient, and we want to, again,
thank you for tuning in and the opportunity to talk about scars and keloids today with the audience. So,
we had some questions from our web audience,
and I'll try to answer these for you now. One question is "Who is a good candidate for surgery?"
That's a really excellent question.
Surgery is an invasive procedure.
It's something where a new incision has to be made on the skin and therefore a new scar is created and additional
healing has to be made. The ideal candidates are those who are otherwise in good health,
patients who are not on
significant immunosuppression, patients who are not on
significant blood thinners, and patients who are in, generally, you know, eating a well-balanced diet and don't have any particular
nutritional deficiencies,
and patients who are non-smokers. And smoking
adversely impacts the whole process of wound healing and surgery.
Our second question is "Can you fix liver transplant scars?"
Well, UCLA is certainly one of the top
liver transplant centers in the nation, and no doubt there are many, many patients that have transplant-related scars.
Given the multiple medical issues that a
transplant patient may face, the most important thing would be to have a in-person
consultation to review the options that are available for the particular scar as well as the patient's goals of improvement.
And our office can be called on.
An appointment can be scheduled to discuss that in detail.
And the third question we have are "Are treatments covered by insurance?"
Certainly, some types of scars are covered under insurance.
It's, again, dependent on the insurance company and the patient's
symptoms and type of scar that they have, so that's something that can also be further assessed upon in a clinic consultation.
Thank you.