Wound Healing and Scar Formation

The body’s natural response to injury is a complex process, and while it effectively repairs wounds, it can also lead to scar formation. Many individuals seek methods to minimise or manage these scars, particularly after surgery, burns, or traumatic injuries, to improve cosmetic outcomes and enhance skin recovery. This blog post explores the stages of wound healing, factors influencing scar formation, and modern strategies for scar treatment, focusing on ways to achieve scar reduction.

Wound healing is a highly coordinated biological process that occurs in four overlapping stages: hemostasis, inflammation, proliferation, and remodeling. Understanding these phases provides insights into why scars form and how they can be managed effectively.

Hemostasis: The initial response to a wound is to stop bleeding. Blood vessels constrict, and platelets form a clot to seal the wound. Fibrin, a protein, reinforces the clot, creating a temporary barrier that prevents further blood loss.

Inflammation: This phase commences immediately after clot is established. White blood cells, including macrophages and neutrophils, migrate to the wound site to remove dead tissue, debris, and bacteria, thus preventing infection. Although essential for healing, prolonged or intense inflammation can predispose to hypertrophic or keloid scar formation by promoting excessive fibroblast activity and collagen accumulation.

Proliferation: The body begins to rebuild tissue during this phase. New blood vessels form through angiogenesis, and fibroblasts synthesise collagen, the main structural protein in skin, to close the wound. Keratinocytes facilitate re-epithelialisation by generating new skin cells. While crucial for healing, unregulated collagen synthesis and angiogenesis can result in thick, raised scars that are often red, tender, and itchy.

Remodeling (Maturation): As healing progresses, the newly formed collagen undergoes reorganisation to enhance tissue strength. The scar's appearance gradually improves, becoming more pliable and less conspicuous. However, scars generally achieve only about 70-80% of the original skin's tensile strength and may normalise in color unless subjected to excessive tension.

These insights into the wound healing process highlight why scars develop and underscore the importance of managing each phase carefully to optimise healing and minimise scarring.

Not all scars are the same, and several factors can affect how a wound heals and the type of scar that forms:

Wound Depth and Size: The depth and size of a wound significantly impact scar formation. Larger and deeper wounds, such as those from major injuries or extensive burns, generally lead to more noticeable scars, potentially resulting in hypertrophic or atrophic scars.

Location on the Body: Scarring can also vary depending on the body part affected. High-tension areas like the shoulders, chest, or joints are prone to more pronounced scarring due to constant movement stretching the healing tissue. Conversely, the face, despite its better blood supply which facilitates quicker healing, can still develop noticeable scars depending on wound severity and individual healing responses.

Age and Skin Type: Age and skin type play crucial roles in healing dynamics. Younger skin regenerates quicker but may show a tendency toward hypertrophic scars. Those with darker skin tones are at a higher risk of developing keloids or experiencing hyperpigmentation after skin injuries.

Genetics: Genetic predisposition is a significant factor in how scars develop. Some individuals have a higher likelihood of experiencing abnormal scarring, such as keloid formation.

Infection or Complications: Wounds that become infected or experience complications like prolonged inflammation due to factors such as burns, infections, or the presence of foreign bodies, are more likely to develop prominent scars. Extended inflammatory responses can exacerbate scar tissue formation, impacting the scar's final appearance.

The body produces different types of scars depending on how the wound heals. Understanding the type of scar helps in choosing the most appropriate treatment modality for scar reduction.

Hypertrophic Scars: These raised scars stay within the boundaries of the original wound and are often red or purple. Over time, they may flatten and fade, but some remain raised without intervention.

Keloid Scars: These thick, raised scars proliferate beyond the original wound’s boundaries and may continue to expand, stabilise, or reinitiate growth. These thick, raised scars extend beyond the boundaries of the original wound and can continue growing, stabilise, or resume growth. Their development is influenced by various endogenous and exogenous factors, including skin type, genetic predisposition, wound location, and environmental influences.

Atrophic Scars: These sunken or depressed scars result from a loss of tissue, causing indentations in the skin. While commonly linked to conditions like acne and chickenpox, they can also arise from other causes, including surgical procedures or injuries.

Contracture Scars: These scars develop from deeper injuries, such as burns, leading to skin tightening and restricted movement. They often result from extensive wound contraction and tension, necessitating a multimodal approach that can include surgical intervention, combined with laser therapy and other treatment modalities, to enhance both function and appearance.

Scar treatment options have advanced significantly in recent years, offering individuals various ways to improve the appearance and texture of scars. Treatments may focus on reducing redness, flattening raised scars, or improving skin flexibility, depending on the type and severity of the scar.

Silicone gels, sheets, and tapes are among the most popular non-invasive treatments for scar management. Silicone sheets are particularly effective for hypertrophic scarring such as rasied burn scars and post-surgery scars, as they help maintain moisture, reduce collagen production, and apply mild pressure to flatten the scar over time. Studies show that consistent use of silicone products can significantly improve the appearance of hypertrophic scars.

Laser therapy is a powerful tool for scar reduction, particularly for hypertrophic and keloid scars. Fractional lasers, including Fractional ablative CO2 lasers and the newst fractional ablative cold fibre laser, as well as vascular lasers such as Pulsed Dye Lasers (PDL), Nd:YAG, and Diode lasers, are commonly used to target scars. While fractional lasers create microscopic thermal injuries that stimulate collagen production and remodel the scar tissue, vascular lasers like PDL, Nd:YAG, and Diode target the blood vessels in red or inflamed scars, reducing redness and improving texture.

Numerous research studies have demonstrated the efficacy of laser procedures, particularly in burn scar treatment. These treatments penetrate the deeper layers of the skin to improve texture and pliability, which is crucial for enhancing mobility and reducing the appearance of contractures.

Corticosteroid injections or laser facilitated corticosteroid infiltrations are often used in combination with other treatments for hypertrophic or keloid scars. These infiltrations can help reduce inflammation and collagen production, which can lead to a flattening of raised scars.

Scar massage, combined with moisturisers or silicone-based products, can improve the flexibility of the scar and promote better healing by increasing blood flow and breaking down dense collagen fibres. Moisturising regularly helps prevent the skin from becoming dry and tight, which can worsen the appearance of scars. However, it's important to note that vigorously massaging a true keloid scar can exacerbate the condition, potentially leading to increased scar tissue formation.

Surgical revision may be necessary for scars that cause significant functional impairment or aesthetic concerns. Techniques such as Z-plasty can effectively improve the appearance and functionality of scars with contracture bands that often result from burns or traumatic injuries. For post-surgery scars, including those resulting from skin grafts, surgical revision can be considered if substantial scar formation adversely affects movement or results in discomfort. Treatments such as laser therapy or silicone sheeting are often recommended as synergistic adjunct therapies to optimise the outcome, enhance healing, and prevent the recurrence of problematic scarring.

Compression therapy is particularly beneficial for larger hypertrophic scars. Compression garments work by applying consistent pressure to the scar, which can flatten raised areas and reduce collagen buildup over time. This treatment is especially common in the management of burn scars, where controlling the thickness of the scar tissue is crucial.

While some level of scarring is inevitable after a significant injury, there are steps that individuals can take to minimise the risk of excessive scar formation:

Wound Care: Proper wound care is crucial in minimising scars. Keeping the wound clean and protected can reduce the chances of infection and excessive inflammation, both of which contribute to more prominent scars.

Sun Protection: UV exposure can darken scars, making them more noticeable. Scars are also more fragile and susceptible to sunburn. Wearing sunscreen or protective clothing over healing wounds is essential to prevent hyperpigmentation and protect the scar from further damage, improving the overall appearance of the scar.

Early Intervention: Starting scar treatment early, as soon as the wound has healed, can significantly reduce the risk of developing hypertrophic or keloid scars. Silicone tape and sheets, in particular, are most effective when applied during the early stages of healing.

Scar formation is a natural part of the healing process, and although it may result in permanent marks, understanding the mechanisms behind wound healing and the various scar treatment options available can help individuals manage and improve the appearance of scars, whether they result from surgery, burns, or traumatic injuries.

If you’re seeking advanced scar treatments, book a consultation with our team of scar specialists.

Every scar undergoes thorough evaluation, measurement, and analysis using advanced technologies. This assessment guides the creation of a personalised treatment plan tailored to the unique requirements of each scar.