What are the different types of scars that can occur on the chest and how are they treated?

Types of Scars on the Chest and Their Treatment

The main types of scars that can occur on the chest include sternotomy scars, thoracotomy scars, hypertrophic scars, keloid scars, atrophic scars, and pleural plaques, each requiring specific treatment approaches based on their characteristics and underlying causes. 1

Types of Chest Scars

1. Surgical Scars

• Sternotomy scars: Result from cardiac surgeries where a vertical incision is made along the sternum. These appear as vertical midline scars on the chest 1
• Thoracotomy scars: Result from lateral chest surgeries and appear on the side of the chest 1

2. Pathological Scars

• Hypertrophic scars: Raised, red scars that remain within the boundaries of the original wound

  • Characteristics: Firm, raised, red/pink, may be painful or itchy
  • Common on the chest due to tension forces across the sternum 2, 3

• Keloid scars: Overgrown scars that extend beyond the original wound boundaries

  • Characteristics: Shiny, smooth, hard growths that can be significantly larger than the original wound
  • The chest is a high-risk area for keloid formation 2, 3

• Atrophic scars: Depressed scars that sit below the surrounding skin

  • Subtypes include icepick, boxcar, and rolling scars
  • Often result from acne or chickenpox 4, 5

3. Disease-Related Scars

• Pleural plaques: While not traditional scars, these are circumscribed pleural thickenings that appear as scarring on the chest wall, typically associated with asbestos exposure

  • Characteristics: Bilateral but asymmetric lesions on the parietal pleura, often calcified 1
  • Usually found on the lower posterior thoracic wall following the ribs 1

• Apical scarring: Common in the lung apices, may have a nodular appearance, especially when viewed on transverse images 1

Treatment Approaches

1. For Hypertrophic Scars

• First-line treatment: Silicone gel sheets or ointments applied daily for 2-3 months 2, 3
• Steroid injections: Intralesional triamcinolone (10-40 mg/mL) every 4-6 weeks 3
• Pressure therapy: Custom-made pressure garments worn for at least 23 hours/day for 6-12 months 3
• Laser therapy: Pulsed-dye laser to reduce redness and flatten the scar 3

2. For Keloid Scars

• Combination therapy is most effective:
  • Surgical excision followed by radiation and steroid tape/plaster application 2
  • Intralesional steroid injections (triamcinolone 10-40 mg/mL) every 4-6 weeks 3
  • Cryotherapy for smaller lesions 3
  • 5-fluorouracil injections, often combined with steroids 3

3. For Atrophic Scars

• Resurfacing procedures:
  • Chemical peels (glycolic acid, salicylic acid, TCA) 4, 5
  • Microdermabrasion for superficial scars 4
  • Laser resurfacing (fractional, CO2, Er:YAG) 4, 5
• Dermal fillers: For deeper atrophic scars 5
• Subcision: Surgical procedure to break up fibrous bands beneath the scar 5
• Microneedling: Collagen induction therapy 5

4. For Surgical Scars (Sternotomy/Thoracotomy)

• Early intervention: Silicone sheets and massage therapy starting 2 weeks post-surgery 1
• Scar revision surgery: For problematic or cosmetically concerning scars 1
• Local scar recurrence management: Re-excision to appropriate margins if recurrence occurs after initial treatment 1

5. For Pleural Plaques

• Generally asymptomatic and don't require specific treatment
• Regular monitoring with chest radiographs if associated with asbestos exposure 1
• Treatment focuses on any underlying condition rather than the plaques themselves

Treatment Selection Algorithm

1. Assess scar type and characteristics:

   • Raised vs. depressed
   • Within vs. beyond original wound boundaries
   • Color, texture, and symptoms (pain, itching)

2. For fresh scars (< 6 months):

   • Silicone sheets/gel
   • Sun protection
   • Massage therapy
   • Early intervention to prevent pathological scarring

3. For established scars (> 6 months):

   • Hypertrophic: Steroid injections → pressure therapy → laser therapy
   • Keloid: Combination of surgery + radiation + steroid tape
   • Atrophic: Resurfacing → fillers → subcision based on depth and type

Important Considerations

• No single treatment can achieve complete resolution of scars 4
• Combination therapies often provide better results than monotherapy 5, 3
• Treatment should be tailored based on scar characteristics including color, texture, and morphology 4
• The best prevention is early treatment of underlying conditions (like acne) to minimize inflammation 4
• Chest scars are particularly prone to hypertrophic and keloid formation due to high tension across this area 3

Remember that early intervention is crucial for preventing severe scarring, and a proactive approach with combination therapies typically yields the best outcomes for chest scars.