Scar Revision Surgery in Ukraine

A scar is the normal result of healing. If an injury goes deeper than the papillary layer of the dermis, the body closes the defect with connective tissue rather than restoring the skin as it was. The collagen fibres in a scar lie in parallel bundles, and it has no hair follicles, sebaceous glands or sweat glands, so a scar always remains different from the surrounding skin. It cannot be removed without a trace; only its appearance can be changed.

A normotrophic scar lies level with the skin, is pale and causes no functional problems. It is rarely operated on, mostly when it runs across the natural lines of skin tension or crosses the face or another visible area. An atrophic, or depressed, scar is the opposite: it sinks below the level of the skin because there is not enough tissue beneath it; typical examples are marks left by acne, chickenpox or poorly healed wounds.

A hypertrophic scar is raised above the skin and can be red and firm, but it stays within the boundaries of the original wound. This is a crucial detail: over time it partly flattens on its own, responds well to silicone, compression and injections, and after a properly performed tension-free excision it usually does not return in its previous form.

A keloid looks similar but behaves differently: it spreads beyond the boundaries of the wound, grows onto healthy skin, often itches and hurts, and does not regress on its own. This is where patients make the main mistake they bring to the consultation: they ask for the keloid simply to be cut out. Excision alone, without supportive therapy, leads to recurrence in most cases, and the scar comes back larger than the original, because a new incision is a new injury to tissue that is prone to excessive scarring.

A scar contracture is a separate matter, and the motive here is not cosmetic. The scar pulls the tissues together and limits movement: a finger will not straighten, an arm will not lift, an eyelid or the corner of the mouth is pulled. Such scars are operated on for functional reasons, sometimes without waiting for full maturation, because a long-standing contracture leads to a permanent restriction in the joint.

Surgery is not performed while the scar is fresh and still changing; while there is active inflammation, suppuration or unhealed areas in the zone; with uncontrolled diabetes or blood clotting disorders; during pregnancy and breastfeeding; or when the patient expects the scar to disappear rather than change in appearance. MediUkraine is a treatment search and coordination service, not a clinic: we select the surgeon and medical centre, arrange the dates and support you throughout, while the decision on surgery and its scope is made by the doctor after an in-person examination.

Excision with layered closure is the basic operation. The old scar is removed within healthy tissue, the wound edges are mobilised and stitched in several layers: the deep sutures take the tension off the edges, and the surface sutures simply bring the skin together. That is the whole point: a thin new scar only forms where there is no tension, because tension makes a scar wide, raised and red. So layered closure with absorbable sutures inside and fine monofilament on the surface is not an optional extra: the result depends on it. Simple excision suits narrow linear scars that lie along the natural lines of skin tension.

A Z-plasty is needed when the problem is not the width of the scar but its direction. The surgeon cuts two triangular flaps and swaps them, so the scar line turns through an angle of 45–90 degrees and settles into a natural crease, and the scar itself becomes longer; it is this lengthening that releases the pull on the tissues. It is the main solution for scar contractures: a single Z-shaped flap lengthens the scar by about 75%, and several consecutive flaps give more. The scar does not disappear: it becomes a broken line instead of a straight one, and the eye stops reading it as a continuous scar.

W-plasty and a geometric broken-line incision solve a similar problem in a different way. Instead of rotating the whole line, the scar is excised in small zigzags, and in place of one straight line there is a zigzag of short segments running in different directions. A straight line on the face is much more noticeable than a broken line of the same length, so these incisions are used on the forehead, cheek and chin. Unlike a Z-plasty, a W-plasty does not lengthen the scar, so it does not work for contractures.

For scar contractures, excision alone is not enough: once the tight band is cut, a defect forms that has to be closed with something. Local tissue repair is used most often: Z-shaped, rotation or transposition flaps from the neighbouring area. When the skin deficit is large, a free skin graft is considered, or preliminary stretching of the tissue with a balloon expander, which takes several months and is done in two stages. Such operations are planned together with a rehabilitation specialist, because afterwards you need exercises to restore movement and splinting, otherwise the contracture returns.

Serial, or staged, excision is used for wide scars that cannot be closed without tension in one go. In one operation part of the scar is excised and stitched, then you wait three to six months for the skin to stretch and the tissues to become more pliable, and the process is repeated. Over two or three stages a wide scar can be turned into a narrow line. This takes longer and costs more than a single operation, but trying to remove a wide scar in one go ends in tension and a new wide scar.

A depressed scar calls for the opposite logic: there is not enough volume beneath it, and the aim is to restore that volume. The fibrous bands that tether the scar to the deeper layers are cut from within with a needle (subcision), and the space under the scar is filled with your own fat; this is fat grafting. The fat is taken from the abdomen or thigh, processed and injected in micro-portions; some of it is absorbed, so two procedures are often needed. For isolated deep acne scars, each one is excised individually and stitched (punch excision), and the surface is then smoothed with laser resurfacing.

A keloid is a special case, and it needs to be said plainly: a keloid cannot simply be cut out. After excision alone it comes back in most patients and is usually larger than the original. So a keloid is managed with a combination: excision is combined with a scheduled course of corticosteroid injections into the scar bed over several months, constant compression, silicone dressings and, where indicated, cryotherapy or superficial radiotherapy in the first days after surgery. Some keloids do not need a scalpel at all: small and recent lesions are managed with injections alone. The decision to operate on a keloid is made very cautiously, and a surgeon who offers simply to cut it out in a single excision is a reason to get a second opinion.

Non-surgical methods are not an add-on to surgery but often a full alternative to it. Silicone sheets and gel are a first-line method with a broad evidence base for hypertrophic scars and keloids: they are worn for at least 12 hours a day for three to six months. Triamcinolone injections into the body of the scar reduce its height, firmness and itching; a course consists of several injections three to four weeks apart. Compression therapy works on large surfaces, including after burns. A vascular laser removes the redness of a young scar, a fractional laser smooths the texture, and microneedling and chemical peels help with superficial atrophic acne scars.

Surgery can usually be avoided when the scar is narrow, lies level with the skin, does not pull on the tissues and is bothersome only because of its colour; when it has not yet matured and has a chance of changing by itself; when it is a small keloid that responds well to injections; or when there are many acne scars and they are superficial, where laser and peels are more effective than a scalpel. Surgery is chosen when the scar is wide, deeply depressed, distorts anatomical landmarks such as the edge of the eyelid, the corner of the mouth or the nipple, or restricts movement.

The surgeon chooses the technique at the examination, not from a photograph. They assess the type of scar, its age, length and width, its direction relative to the lines of skin tension, the condition of the surrounding tissue, your skin phototype and any history of excessive scarring. One patient often receives a combination of solutions: part of the scar is excised simply, the contracture area is converted with a Z-plasty, and a laser is added at the final stage. No one can predict the result in exact figures in advance, so the surgeon outlines the expected range and shows their own photographs of patients with similar scars.

For the first two days the treated area may swell and be moderately painful; pain relief is usually limited to tablets. The dressing is changed on the schedule the surgeon gives you, and the wound is kept dry. Stitches are removed depending on the area: on the face on day 5–7, on the trunk and limbs on day 10–14, and in areas under tension sometimes later.

Then the maturation phase begins, and this is the part patients find hard. From about the third week until the third or fourth month the new scar turns red, becomes firmer and may look worse than immediately after the stitches came out. This is the expected course, not a complication: the blood vessels in a young scar are still dilated and the collagen is remodelling. It is during this period that the final appearance of the scar is decided.

That is why supportive therapy starts according to plan, not when you stop liking the result. From the second or third week, once the wound has closed, silicone sheets or gel are applied and worn for at least 12 hours a day for three to six months. Where indicated, the surgeon adds corticosteroid injections into the scar, compression, or a vascular or fractional laser from the fourth to sixth week.

Sun is a separate point. A young scar easily develops persistent hyperpigmentation, so the area is covered with clothing or SPF 50 sunscreen for at least a year, including on overcast days. Sunbeds, saunas, swimming pools and gym workouts are put off for the period the surgeon specifies, usually three to four weeks.

The final appearance of the scar is judged after 12 months, and after 18 for keloids and scars in areas under tension. Interim conclusions at the third month mean nothing: surgeons will not perform a planned repeat revision of a scar that has already formed earlier than 12 months afterwards. Acute situations are a different matter: if the wound edges have separated or there is an obvious complication, the surgeon intervenes straight away, revises the wound, re-stitches it or leaves it open to heal, and the discussion about aesthetic revision of the scar is put off for at least a year.

And the most important thing to hear before surgery: revision does not make a scar invisible. It makes it thinner, flatter, changes its direction or reduces its colour contrast, in other words makes it less noticeable. A complete absence of a scar is impossible in principle, because any new incision also heals with a scar. A patient who expects clear skin will be dissatisfied even after a technically flawless operation, and an honest conversation about this at the consultation matters more than the choice of technique.