Several factors need to be considered before undertaking scar revision. These include the age of the patient, history of previous bad scarring duration and location of the scar, and whether the scar is stationary as far as spontaneous improvement is concerned. Also, occasionally economic factors are involved.

As a general rule, avoid revising any scar less than one year’s duration. If the scar is still improving after one year, postpone any secondary surgery until spontaneous improvement ceases. Occasionally insurance limitations on coverage for secondary surgery require that the procedure be done within one year from the original injury. Fortunately, most scars of the face and neck are reasonably mature within that timeframe. Ideally, the best approach is that suggested previously but unfortunately compromised sometimes is necessary because of financial considerations.

Revision of most scars of the trunk and extremities, unless they are interfering with function, is nonproductive also, revising scars of the face and neck during the adolescent growth spurt is to be avoided. Postponing the surgery until age 16 or 17 will often lead to a better long-term result.

Some individuals tend to form hypertrophic scars but the scars often will flattened with time. This flattening is the best one can hope for under the circumstances. Scars of the trunk or extremities frequently require 3 to 4 years to achieve maximal spontaneous improvement.

It is important to distinguish between a hypertrophic scar and a key loyal scar. A keloid tends to get progressively worse as time passes whereas a hypertrophic scar usually is at its worst in terms of color match and contour within two or three months and then tends to slowly improve. Keloids are rare in Caucasians and are most prevalent in Afro-Americans and then Orientals. Surgery alone rarely is helpful as far as keloids are concerned. Excision combined with postoperative injection of triamcinolone may be efficacious. Triamcinolone injections alone will often flatten a key loyal scar and resolve the tenderness and dysesthesia.

It is important to inject the steroid deep to the keloid rather than directly into it. The steroid may persist as tiny droplets throughout the keloid if the injection is done directly into it. I limit the amount of triamcinolone to 20 to 40 mg per injection. Use lidocaine without preservatives to anesthetize the area prior to triamcinolone injection. Repeat the procedure at two-month intervals if the drug appears to be helping.

Scar revision in the elderly is apt to be much more rewarding than in the young, because of decreased skin tension.

Also scars that roughly parallel natural skin wrinkles are more likely to respond well to secondary surgery, everything else being equal. Also, if the original wound repair was done by another surgeon and intradermal clear nylon was not used, employing this technique in the revision may improve the long-term scar.

Knowing what scars are more likely to respond well to revision, when the carry out the surgery and how to counsel the patient and family properly comes with experience. Scar revision is always a matter of trading one scar for another, in the hope that the new scar will be significantly less conspicuous than its predecessor, rather than a matter of completely defacing the scar. Once a scar, always to scar-- it is just a matter of how noticeable it is. Many laypeople and some physicians think that a plastic surgeon can avoid scarring in a primary wound or was scar revision. To use the vernacular, “it ain’t so.”

In the chapter on Special Situations describes the techniques