Scar revision surgery improves scars that are wide, raised, tight, sunken or badly placed after injury, surgery, burns or acne. We combine excision, Z-plasty, grafts and fat grafting with steroid injections, silicone, fractional laser and, for keloids, radiotherapy after surgery. A scar cannot be erased, but it can become a fine, flat line. At Biruni Hospital in Istanbul, our plastic surgery team plans each revision from your photographs.
About This Department
Plastic Surgery
Every scar is permanent, but no scar has to stay as it is. Revision makes it flatter, narrower, softer and better placed.
Scar revision surgery improves scars that are wide, raised, tight, depressed, discolored or badly placed after injury, surgery, burns or acne. It combines surgical techniques, cutting out the scar and closing it in a better line, Z-plasty, grafts and flaps, with injections, silicone, lasers and, for keloids, radiotherapy. A scar becomes less noticeable and more comfortable with treatment, though it cannot be erased. Each plan is built around the type, age and location of the scar, the patient's skin and any history of keloids, and the result that matters most to the patient, whether comfort, movement or appearance. Keloids return frequently after surgery alone. In a meta-analysis of 9,048 keloids, recurrence after surgery followed by radiotherapy was 22 percent, falling to 15 percent with brachytherapy (Mankowski and colleagues, Annals of Plastic Surgery, 2017). For burn scars, fractional CO2 laser improved patient-rated scar scores by 14 points on average across 20 studies (Peng and colleagues, Burns, 2021). This page explains scar types, timing, assessment, surgical techniques, keloids, nonsurgical treatment, lasers, contractures, risks, recovery, and how patients from abroad arrange scar revision at Biruni Hospital in Istanbul.
22
Percent keloid recurrence after surgery with radiotherapy, across 9,048 keloids
15
Percent recurrence when the radiotherapy after surgery was brachytherapy
14
Points of improvement in patient-rated burn scar scores after fractional CO2 laser
Free
Review of your scar photos by our plastic surgery team
Scar revision changes a scar's width, height, color, texture, direction or tightness so that it draws less attention and moves more freely. A single scar may need several of these steps.
The aim is a fine, flat line that lies in a natural crease and matches the surrounding skin as closely as possible.
Improve, rarely erase
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What surgery can do
Surgery replaces a poor scar with a new, better one. The new scar goes through its own healing and needs a year to settle.
Small scars need only nonsurgical treatment such as steroid injections, silicone or lasers in many cases, while larger, tight or badly placed scars need surgery combined with these treatments.
The best result usually comes from a sequence of treatments planned together, rather than from one operation.
Types of scar
Recognizing the scar
Common types of scar
Type
What it looks like
Usual approach
Widened scar
Flat but stretched
Excision and layered closure
Hypertrophic scar
Raised, red, within the wound
Silicone, steroid injection, laser, sometimes excision
Keloid
Grows beyond the wound, firm, itchy
Steroid, excision with radiotherapy
Atrophic or acne scar
Sunken pits
Subcision, fillers, fat, laser
Contracture
Tight band limiting movement
Z-plasty, graft, flap
Misaligned scar
Crosses natural lines
Z-plasty or W-plasty
Burn scar
Large, thick, discolored
Laser, release, grafts, fat grafting
Hypertrophic scars and keloids look alike at first. A hypertrophic scar stays within the original wound and often softens over time, while a keloid spreads into normal skin and rarely improves on its own.
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Where scars form badly
The chest, shoulders, upper back and earlobes form raised scars most readily, and scars across joints and crossing skin tension lines widen most.
Scars mature slowly
A scar takes a year or more to finish healing.
Red, raised and itchy in the first months, most surgical scars flatten, soften and fade between six and eighteen months, and treating them too early with surgery can make them worse, because the fresh scar tissue is still active and answers a new wound by laying down even more collagen than before. Waiting, with silicone and sun protection in the meantime, spares many patients an operation altogether. Children, burns and keloids follow different rules, and there we start early.
Patience is part of the treatment.
Timing and assessment
When to revise
Surgical revision is planned once the scar has matured, at twelve to eighteen months. Contractures that limit movement, scars around the eyes or mouth that pull features out of place and growing keloids are treated earlier.
What we assess
Factors we assess in a scar
Factor
Why it matters
How measured
Height and thickness
Raised scars need flattening
Inspection, ultrasound
Color
Red or dark scars need different lasers
Photographs
Width and direction
Determine excision and reorientation
Measurement against skin lines
Tightness
Contractures limit movement
Range of motion
Symptoms
Itch and pain guide treatment
Patient and observer scar scale
Previous keloids, family history and skin type change the plan, since excision alone can trigger a larger keloid.
We photograph the scar under standard lighting at each visit, so that progress can be compared over months.
Surgical techniques
Options
Surgical scar revision techniques
Technique
How it works
Best for
Excision and layered closure
Scar cut out, wound closed without tension
Widened or irregular scars
Z-plasty
Two triangular flaps swapped
Contractures, scars crossing creases
W-plasty, geometric broken line
Zigzag line that breaks up the scar
Long straight scars on the face
Skin graft
Healthy skin covers the released area
Large contractures, burns
Local flap
Neighboring skin moved in
Scars near joints or features
Fat grafting
Fat injected under the scar
Depressed, tethered or painful scars
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Z-plasty
Changing the direction of a scar so that it lies along natural skin creases makes it harder to see, and lengthening a tight scar releases a contracture. A single Z-plasty can lengthen a scar by up to 75 percent.
Tension is the enemy of a fine scar. Deep stitches take the strain so that the skin edges meet without pulling.
Keloids
Keloid recurrence after radiotherapy, 9,048 keloids
Treatment
Recurrence
Note
Radiotherapy alone
37 percent
Without excision
Surgery followed by radiotherapy
22 percent
Standard combined treatment
Surgery followed by brachytherapy
15 percent
Lowest recurrence
Surgery followed by electron beam or X-ray
23 percent
Widely available
Keloids recur in most people after excision alone. Radiotherapy started within a day or two of surgery prevents the excess collagen from forming, and chest keloids carry the highest recurrence rate (Mankowski and colleagues, 2017). Steroid injections before and after surgery and pressure earrings for earlobe keloids lower recurrence further.
Radiotherapy at our hospital
Postoperative radiotherapy for keloids is delivered on our Elekta Versa HD linear accelerator with electron beams, which treat only the surface of the skin.
Skin type and keloid risk
Keloids run in families and appear more frequently in darker skin.
People of African, Asian and Middle Eastern descent form keloids more readily than those with fair skin, and a personal or family history of keloids is the strongest warning sign we know of. We ask about both before any revision, and patients prone to keloids receive preventive steroid injections, silicone and close follow-up after every operation, including unrelated surgery.
Prevention starts with the first stitch. Every time.
Larger scars and flaps
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Tissue expansion
For large scars of the scalp, face or trunk, a balloon expander placed under nearby healthy skin is filled gradually over weeks, growing extra skin that then replaces the scar.
Serial excision
Wide scars that cannot be removed at once are removed in two or three stages several months apart, each time stretching the surrounding skin a little more.
Treatment without surgery
Nonsurgical scar treatments
Treatment
How it works
Best for
Silicone gel or sheets
Hydrates and calms scar tissue
Prevention, raised scars
Steroid injection
Breaks down excess collagen, reduces itch
Hypertrophic scars, keloids
5-fluorouracil injection
Slows scar-forming cells
Resistant keloids
Pressure garments
Flatten developing scars
Burns, earlobe keloids
Massage and moisturizers
Soften and mobilize
All maturing scars
A Cochrane review of 20 trials with 873 people found weak evidence that silicone sheeting prevents raised scars in people prone to them, and improvements in thickness and color in treatment trials, but noted that the trials were of poor quality (O'Brien and Jones, Cochrane Database of Systematic Reviews, 2013).
Steroid injections every four to six weeks flatten raised scars and ease itching. Thinning of the skin and lighter color around the scar can occur, and we space injections to limit them.
Sun protection for at least a year keeps new scars from darkening.
Silicone for twelve hours or more a day for two to three months.
Gentle massage once the wound has healed.
High-factor sunscreen on scars exposed to light.
Laser treatment
Lasers treat color, texture and thickness without cutting.
Fractional CO2 laser makes tiny columns of injury that trigger remodeling of the scar. In a meta-analysis of 20 studies on burn scars, it improved the Vancouver Scar Scale by 3.2 points and patient-rated scar scores by 14 points, with mild side effects (Peng and colleagues, 2021). Pulsed dye laser reduces redness in young scars.
How many laser sessions will I need?
Most scars need three to five sessions, four to eight weeks apart. Each session takes minutes to an hour under numbing cream or local anesthesia, with redness for a few days. Lasers combine well with steroid delivered through the laser channels and with surgery.
Contractures and burn scars
A contracture across a joint limits movement and can worsen as children grow. Releasing it restores function first.
Treatment of burn scar contractures
Situation
Option
Note
Narrow band
Z-plasty
Lengthens the scar
Broad tight area
Release and skin graft
Splinting afterward
Neck, axilla, elbow, hand
Local or free flap
Better long-term movement
Thick, red scars
Laser, pressure, silicone
Combined program
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Fat grafting
Fat injected under burn scars softens them, eases pain and improves texture in many patients.
Hand therapists and physiotherapists continue stretching and splinting for months after release.
Our microsurgery page describes the free flaps used when large areas need new skin.
Risks
Risks of scar revision
Risk
What happens
Management
Recurrence of raised scar
New scar thickens
Silicone, steroid, laser
Keloid recurrence
Keloid regrows
Radiotherapy, injections
Wound separation
Edges open under tension
Dressings, later revision
Color change
Lighter or darker area
Time, laser, sun protection
Infection
Redness, discharge
Antibiotics
Risk is highest in keloid-prone patients, in smokers and in scars under high tension.
After steroid injections
Thinning of the skin, small visible vessels and lighter skin color occur in some patients and fade over months.
Smoking
Smokers stop four weeks before and after surgery to protect healing.
Expectations
A successful revision makes a scar easy to overlook.
The best outcome turns a wide, raised or tight scar into a fine, flat, pale line that moves well and blends with the skin around it, while anyone who knows exactly where to look, including you, will still be able to find it.
We show typical results honestly. Lines remain.
The procedure and recovery
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The procedure
Most revisions take thirty minutes to two hours under local anesthesia as day surgery. Larger releases, flaps and grafts need general anesthesia.
Stitches come out after five to seven days on the face and ten to fourteen days elsewhere. Silicone starts once the wound has closed, and sun protection continues for a year.
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Activity
Avoid stretching the area for three to six weeks, especially across joints and on the back and chest.
The new scar looks its worst at six to twelve weeks. It then settles over a year.
For patients from abroad
The length of stay is five to ten days in Istanbul for most revisions, longer for grafts, flaps or keloid radiotherapy. Fitness to fly follows the wound check before departure.
A typical stay
Day
Step
Note
Day 1
Consultation, photographs, plan
Treatment agreed
Day 2
Surgery or first laser session
Day case in most
Days 3 to 4
Radiotherapy for keloids
Within two days of surgery
Day 7 to 10
Stitch removal
Cleared for travel
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What to send
Clear photographs of the scar in good light, its cause and age, earlier treatments and any history of keloids in you or your family.
After you return home, follow-up continues by video with photographs, and laser or injection sessions can continue with a local doctor following our plan. One coordinator from the international patients office handles arrangements from the first message through discharge and answers the same WhatsApp number after you return. The office works in English, Arabic, French, Russian, Serbian, Romanian and Spanish and books interpreters for other languages, and it arranges the visa invitation letter, airport transfers, daily transport and accommodation near the hospital. Halal, vegetarian and diabetic meals, a prayer room on site, and a female physician on request wherever the rota allows.
Cost
What a quote for scar revision covers
Item
Included
Priced separately
Surgery
Surgeon, anesthesia, operating room
Tissue expanders
Adjuncts
Steroid injection at surgery, silicone
Laser sessions, radiotherapy
Follow-up
Stitch removal, video follow-up
Further injections
The price depends on the size and location of the scar, the technique and any laser or radiotherapy.
Elements that change the price
Element
Effect
Note
Keloid with radiotherapy
Higher
Several sessions
Laser series
Per session
Three to five sessions
Graft or flap
Higher
Longer surgery
We quote after reviewing your photographs, before you travel.
Comparing quotes
Ask about
Why
Note
Whole plan
Revision is often a series
Not one session
Keloid prevention
Recurrence risk
Radiotherapy or injections
Follow-up
Scars need a year
Photographs and review
Compare quotes for the whole plan, including the steps after the first operation.
References
Mankowski P, Kanevsky J, Tomlinson J, Dyachenko A, Luc M. Optimizing radiotherapy for keloids. A meta-analysis systematic review comparing recurrence rates between different radiation modalities. Ann Plast Surg. 2017;78(4):403-411.
O'Brien L, Jones DJ. Silicone gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst Rev. 2013, issue 9, CD003826.
Peng W, Zhang X, Kong X, Shi K. The efficacy and safety of fractional CO2 laser therapy in the treatment of burn scars. A meta-analysis. Burns. 2021;47(7):1469-1477.
Editor's note
Written by the Biruni Hospital medical editorial team. Reviewed by Prof. Dr. Atilla ARINCI, Plastic, Reconstructive and Aesthetic Surgery.
