These are abnormal scars following any injury, including surgery, burns and earlobe piercing.

How do they form?

The skin has a microscopic surface layer, the epidermis and a deeper layer, the dermis.

The epidermis is uniform in thickness (except in the palm of the hand and the sole of the foot) while the dermis varies in thickness, ranging from 1 mm in the eyelid, 2mm on the cheek and
5mm on the back.

The dermis has an ExtraCellular Matrix (ECM) which is a scaffolding to give strength to the dermis.

To form a scar, there has to be damage to the ECM. The scar is part of the repair process following an injury and this gives strength to the repaired area.  Unfortunately, this process of repair can sometimes be too strong, resulting in a hypertrophic or keloid scar.

(The epidermis, with no ECM, does not form scars).

Management

Prophylaxis and prevention give the best results!.

The process of scar formation

Scar formation is part of the healing process , to help regain strength (tensile strength). There is an initial rapid phase, followed by a slower but longer phase, to make a total of three months, after which there is tissue maturation and remodelling for a further three months

Abnormal scar formation can happen in any phase of healing.

Prophylaxis involves good planning about the intended surgery, placement of scars and post-operative scar management including compression therapy.

Compression Therapy involves lower pressure, probably constant, compression. For larger areas, a compression garment is used. For smaller areas, custom-made compression splints work well, including custom made ear rings for earlobe keloids.

For other parts of the ear, silastic splints are made for an exact fit.

Silicon gel usage is also part of the treatment.

Treatment

These scars may cause pain and itchiness , in addition to the change in appearance.

Pain and itchiness are treated with regular steroid injections or with steroid impregnated tape.

In a keloid scar causing disfigurement, the scar is reduced to make the affected area look near-normal in contour, and this is followed up with compression splints.

For earlobe keloids, the ear rings are made before the surgery, using the unaffected other side as a template.

For other areas, like the helical (margin) part of the ear, a silicon splint is custom-made once the wound is healed

Treatment will be for at least three months, but may be for longer sometimes.

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The initial step in the treatment of a skin cancer is to confirm the diagnosis.

Quite often, this is a clinical decision made after examining the affected area with magnification and good lighting.

Sometimes, a biopsy is done, where a small section of the cancer is removed and sent for study by a Pathologist.

Appropriate treatment is then planned, and this may be with the Carbon Dioxide laser for superficial cancers, or excision (removal) with a knife for deeper cancers.

Reconstruction of the treated area, to leave it looking as near-normal as possible and to preserve function, is often necessary and is usually carried out at the same time as removal of the cancer.

Residual or Recurrent Skin Cancers

The treatment of residual skin cancers, where initial treatment was inadequate and where there is persistence of cancer, and recurrent cancers, where the cancer re occurs after previous treatment, is more difficult.

In a significant percentage of patients, surgery is done in a staged fashion, where excision is done to confirm adequacy of cancer removal and followed up by reconstruction with skin grafts or flaps (skin and fat) and sometimes with additional material such as cartilage from the ear or nose.

Occasionally, a frozen section examination is done, when a Pathologist examines the tissue removed while the patient is still having the surgery.

The need for comprehensive care in skin cancer treatment

There is a lot more to Skin Cancer treatment than just the actual removal of tumour. Accurate diagnosis, adequate removal, appropriate reconstruction, and proper long-term follow-up care is needed.

Preservation of function and appearance (form) takes a while to be established, due to the way tissue heals and matures, and hence scar management and long-term follow-up  are important parts of treatment.

There may also be a need for more treatment in the form of surgery, radiotherapy or chemotherapy.

The above expert care and management, including reconstruction to maintain function and form is available at the plastic cosmetic laser surgery centre with care provided by Dr Arianayagam and his team.

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Capsular contracture
As the breast implant has an outer silicon shell, a relatively inert material, the breast implant is not rejected, but the body responds by putting an outer layer around it called the capsule.
However, this protective capsule can undergo contracture and the problems it causes are well documented.

BIA-ALCL (Anaplastic Large Cell Lymphoma)
This is a more recently recognised problem, over the last 7 to 8 years.
While a proportion of women have swelling and pain of a breast a few years after augmentation, investigations have not shown any problems in most of them, and symptomatic treatment is all that is required.
However, in a very small proportion of patients, less than 1500 over the last 7 to 8 years, removal, and testing of the fluid collection around the enlarged breast has shown the presence of a CD 30 receptor protein, which is diagnostic for ALCL.
A peculiar feature is that this problem has only been seen in textured implants.
Textured implants help shaped implants to be held in the right position.
As a result of this problem, which needs surgical correction involving removal of the implant and surrounding capsule, there has been a rapid shift to using only round smooth implants.

BII (Breast Implant Illness)
Some patients with breast implants have, over the years, complained of difficult to explain, vague systemic symptoms, such as excessive tiredness, anxiety, depression, cognitive difficulties, myalgia, and skin rashes.
For quite a while, this problem was not well understood and women who exhibited these symptoms had difficulties conveying their concerns to their treating physicians.
After a lot of effort from patients and with the help of sympathetic surgeons who responded to the distress of their patients, a few women had their implants removed and in some the effect was a very impressive relief of symptoms!
Though the medical establishment took a while to be convinced, social media, with the instant access it provided, helped more women to get the treatment they deserved, with a good percentage showing significant relief of their symptoms
By 2019, the US Food and Drug Administration (FDA) and the major Plastic Surgery Societies accepted that there seemed to be an inflammatory or autoimmune response in some women with breast implants which was causing a range of symptoms that suggested BII (breast implant illness) and that a proportion of patients had relief with removal of the implants. The problem was the lack of well-documented studies to confirm this trend.

In March 2022, published online in EPlasty is a paper entitled “Breast Implant ilIlness: Treatment using Total Capsulectomy and Implant Removal” by Stephen E. Metzinger MD et al.
Dr Metzinger, the lead author is a Plastic Surgeon from the Division of Plastic and Reconstructive Surgery of the Tulane University School of Medicine in New Orleans.
This was a retrospective cohort study for the period 2016 to 2020, with a total of 200 patients who presented with mastodynia and capsular contracture, with or without extra mammary symptoms, after cosmetic breast implant surgery.
The surgical treatment was an enbloc removal of implant and capsule.
ESPECIALLY IMPORTANT WAS THE FACT THAT ALL SURGERY WAS DONE BY Dr METZINGER
96% of patients reported improved or complete resolution of their systemic symptoms!
A positive microbial culture was found in 68.5% of patients
Average follow-up time was five months.

CONCLUSION
Enbloc removal of implant and capsule dramatically improves symptoms of breast implant illness.

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