scars

During the phases of wound repair of which there are three, the final phase, or remodeling phase healthy skin is replaced with a more fibrous type skin in an effort to bridge any defects seen in the skin. In the majority of instances the scar is probably not even visible nor does it have any impact on the affected area. The scar is usually flat and over time becomes less noticeable.

The degree of scar formation that may occur depends on a person's age, sex, heredity, nutritional status of the person and of course, the severity of the original wound. Scars tend to form more predominantly in younger individuals.

The other type of scar is a KELOID SCAR which are also raised, red but tend to cover skin beyond the boundaries of the original wound. More importantly these do not tend to fade over time. Even when surgically excised, they tend to recur. It is thought that keloids have a genetic disposition.

We should also mention that there is another type of scar that is seen typically as a result of burns. Burns cause a contracture type of scarring where the affected area becomes extremely inelastic and can be quite uncomfortable, depending on the size of the scar.

Of course scars can appear any where on the body, but this discussion will be limited to the foot and ankle. Excessive scarring particularly in an area over the front of the ankle or perhaps the big toe joint can result in a limitation of motion due to the inability of the scar to "stretch" like healthy skin. Many times this can be due to poor skin closure of the skin by a surgeon, sometimes trauma to that area will have a similar result.

One of the biggest problems we as foot surgeons face is surgical intervention on the bottom of the foot. The skin of the bottom of the foot is generally thicker than skin elsewhere plus it is prone to more tension as the result of bearing weight on the foot. Typically when planning a surgical procedure, great care is taken as to where the incisions are going to be placed in an effort to reduce the stress on the incision. It is not uncommon to keep our patients non-weight bearing for a few weeks after the procedure just to keep tension off the wound and reduce the chance of scarring. Many times additional sutures will be placed in the wound in an effort to reduce tension, however, the down side to that is if the patient has a reaction to the suture material itself, having excess sutures in the wound may actually exacerbate the scar problem.

Weight bearing sections of the foot, particularly the ball of the foot is very prone to scarring as a result of trauma or incision. When patient's have a benign growth on the ball of the foot, such as a warts or porokeratosis. they should not be too quick to allow their doctor to surgically excise or hyfrecate (burn them out) these lesions as an end result of scarring may ultimately be more uncomfortable than the actual growth itself. More conservative means should be used to eradicate the problem. If a suspected malignancy is present then there is really no choice, however, I would suggest something less traumatic like a needle biopsy for first assess malignancy before actually excising the whole lesion.

As time passes more and more treatments for scarring have come to marketplace. Not all the products available today have been adequately tested to really know their true effectiveness.

Surgical scar revision has been around for ages. Depending on the size and type of scar there are two different approaches. One is to excise the scar and re-suture the area. The surgical approach is to perform plastic surgery procedures on the area such as what is known as Z-plasty or W-plasty which are procedures that actually redirect the scar. This is usually done on scars that are limiting motion. There is however, a reasonably high incidence of recurrence somewhere near the fifty percent range.

Cortisone injections for the reduction of scars has been around for years. Used with other treatments such as surgical excision, the injections may be given every two weeks in an effort to reduce the inflammatory response of the wound healing phase.

Radiotherapy has been used for larger keloid scars but it is important that the patient knows there is some evidence that it may increase carcinogenic activity in the surrounding area.

Laser therapy and dermabrasion has been used to "smooth" down scars but in recent years seems to becoming a less attractive option due to the high recurrence rate and the fact that it can take months to finally heal and during this time period the scars can be painful, swollen and red.

Cryotherapy or the use of liquid nitrogen works by freezing the scar and thus causes cell damage which prevents an over production of fibrous cells. Treatment can be performed every three to four weeks until your doctor is satisfied with your progress. This procedure may also tend to be painful and in some cases cause a depigmentation (loss of color) in the skin.

There are a few skin creams on the market which claim to reduce scars. They can make a difference in the appearance of the scar but it is a cosmetic improvement, not an actual thinning of the scar.

Compression therapy, whereby continuous pressure on a scar may actually thin it out over time. It does so by suppressing the inflammatory phase. Treatment may take upwards of a year depending on the size and location of the scar.

Silicone gels have become popular in recent years. Their method of action is by being placed directly over the scar they create a moist, occluded environment which prohibits increased blood vessel growth which then reduces the inflammatory over response seen in scars. These gel pads are simply taped on the scar. The gel sheets may be washed, they happen to be impermeable to bacteria, but over time they will lose their efficacy and will have to be replaced.