Scar Revision & Camouflage

Michael E. Decherd, MD

Faculty Advisor: Karen H. Calhoun, MD

The University of Texas Medical Branch

Department of Otolaryngology

Grand Rounds Presentation

April 24, 2002

2

Introduction

• Scarring

– Dorland’s: a “mark remaining after the healing of a wound or other

morbid process”

• Mechanism

– Trauma

– Surgical

• Location & orientation

– Cosmesis

– Function

Scarring is a result of the normal healing process. Many factors influence

the final appearance of this process including the mechanism of injury,

location of the injury, the initial management of the wound and any

complications that occur during the healing process.

3

Ideal Scar

• Flat

• Narrow

• Good color match

• Parallel to or within skin crease

The ideal scar is level with the surrounding tissues, has a favorable color match, is

narrow, parallel to or lying within a RSTL, and sinuous without long straight

unbroken lines. Not all scars are able to be improved by revision techniques and

those that are already optimal may be made much worse if a poorly thought out

attempt at revision is undertaken. Patients should be carefully counseled to assure

that their expectations are realistic – if they expect the scar to be completely gone -

I.e invisible – they need education or they are likely to be displeased with the

outcome.

4

Strategies • Prevention

– Incision planning

• Relaxed skin tension lines

• Facial subunits

– Careful surgical technique

– Postop

• Wound care

• Steroid injection

• Antitension taping

• Excision

– Irregularization

– Reorientation

• Camouflage

– Cosmetics

– Dermabrasion

We will discuss several strategies that assist the surgeon faced with treating a previously formed scar, treating a

wound that is likely to scar, or when contemplating inducing a wound on the face that is likely to scar. The most

basic of these principles is careful planning of surgical incisions to minimize the cosmetic impact. Secondly,

appropriate care of a traumatic wound or a post operative wound may lessen the scar formation. When a

cosmetically unpleasant scar results and is mature, several options are available to render the scar less noticeable.

While not elegant or involved, consultation with a cosmetics specialist may be all that is needed to achieve a

pleasing result, and should not be forgotten as an option in the camouflage of facial scars.

5

Timing

• Traditionally 6 to 12 months

• Perhaps earlier for those perpendicular to

tension lines

• Dermabrasion 6 to 9 weeks

– High fibroblast activity

The timing of scar revision has traditionally been after the scar has had a period of maturation of 6 to 12

months. This allows time for scar maturation and better defines what needs to be accomplished in the revision.

Patients often need to be counseled and reassured during this waiting period that the outcome is likely to be

improved if appropriate time is taken for the scar to mature and the proper treatment selected.

Many would argue that scars lying outside RSTLs and especially those perpendicular to RSTLs are likely to

have a poor cosmetic outcome and early revision and reorientation can be considered.

Dermabrasion is frequently performed at 6-9 weeks post injury utilizing the high fibroblastic activity in the

wound at that time to aid in favorable wound healing.

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Wound Care • Steri-strips

• Wound cleansing

• Occlusive dressing

• Topical antibiotics

• Steri-strips add strength to the wound during the critical time of deposition of collagen by fibroblasts in the first several days after wounding. Initially there is no inherent

strength to the wound due to the absence of collagen extending across the wound. Suture material provides some apposition of the wound edges, but only at the site of each

suture. Between sutures, there may be microscopic dehiscences of the wounds edges, thereby delaying healing and predisposing to a wide scar. Steri-strips applied to the

wound serve to minimize this. Appropriately applied Steri-strips remove tension from the wound by sticking and pulling the skin distal to the wound margins. In general, they

rarely last longer than 3-4 days at which point they should be removed and re-applied. When removing the strip, the two ends should be grasped and both sides removed

toward the wound to avoid distracting the edges.

• The wound should be cleansed in order to prevent the formation of crusts. The formation of crusts allows the colonization of accumulated serum or blood with bacteria thereby

putting the wound at risk for infection. Antiseptics have not been shown to have any therapeutic benefit on the treatment of either clean or contaminated wounds. Anti-septics

were designed to be used on intact skin and their effectiveness in this regard cannot be translated into effectiveness when used on open wounds. In fact, many are quite

detrimental in the wound healing process causing an increase in the intensity and duration of the inflammatory response, gross and histologic evidence of tissue necrosis, and

endothelial damage and thrombosis in an animal model. Special mention should be made of H2O2, a cleanser commonly used on wounds to reduce crusting and espoused

by many authors. It is falsely believed that the effervescent bubbling of the solution is evidence of its antibacterial activity. It has been shown however, that its antibacterial

potency is minimal at best. In addition, it can cause disruption of re-epithelialization by producing bullae under the new epithelium. It is also interesting that even a dilute 1:100

solution of H2O2 may be toxic to fibroblasts and impairs the microcirculation of wounds. It has been shown to delay wound healing in both humans and animals. ( Branemark

etal, J Bone Joint Surg, 49A:48, 1967). Given these adverse effects, it is perhaps most prudent to have the patient cleanse the wound with either sterile saline for plain tap

water to remove any crusts that form.

• The plane of migration of epithelial cells from the wound margin is determined in part by the water content of the wound bed. The epithelium seeks a plane of migration with a

critical humidity. Open, dessicated wounds epithelialize much more slowly than moist, occluded or semi-occluded wounds. As demonstrated in this figure, migrating

epidermal cells in air-exposed wounds moved beneath the crust scab and devitalized dermis to seek a plane with a critical moisture level. This route was a circuitous one

taken with significant metabolic expenditure by the keratinocyte and consequently delayed wound re-epithelialization. In constrast, wounds that were kept moist had a level of

adequate tissue humidity essentially at the wound base, thereby allowing for a more direct and speedier route of epithelialization. The practical message is that occlusive or

semi-occlusive dressings optimally promote re-epithelialization.

• The application of an occlusive dressing is useful, but may be difficult with many wounds of the head or neck. In addition, the dressing is only able to stay in place for several

days due to the need for wound care. In our warm climate, where one cannot help but perspire approximately 11.5 months out of the year, these bodily secretions may

accumulate under the dressing and along the wound edges to become an ideal environment for skin flora. Even if invasive infection is not the result, an increase in wound

inflammation may result.

• A good alternative is the “open” technique of wound care. The wound is covered with a generous amount of antibiotic ointment. This provides not only a moist wound

environment, but also a barrier to dust and dirt contamination, as well as protecting the wound from contamination with skin oils and bacteria. The antibiotic ointment also

provides some effect at the point at which the suture material pierces the skin, reducing the likelihood of the formation of stitch abscesses. For best effect, the antibiotic

ointment should be replaced every 3-4 hours after a gentle cleansing and crust removal using sterile saline or tap water.

• It may be difficult to employ both Steri-strips and antibiotic dressings. Many authors favor the open antibiotic dressing for fresh, primary wounds and steri-strips for scar

revision or reconstructive wounds. 7

8

Wound Healing

• Inflammatory phase – hours

• Proliferative phase – days

• Remodeling phase – months

9

Wound Healing

10

It is generally agreed that there are at least 3 phases of wound healing: inflammatory or exudative phase,

proliferative or granulation phase and wound contraction or remodeling phase.

Inflammatory or Exudative Phase – 0-3 days (begins immediately upon injury) disruption of blood vessels -

influx of blood, serum proteins, platelets and clotting factors as well as collagen platelets initiate coagulation and

release substances such as growth factors,fibrinogen, and fibronectin, all of which promote cell migration into the

wound. 5-6 hours – neutrophils – fight bacterial contamination 24-48 hours – monocytes or macrophages –

phagocytose bacteria and neutrophils releasing platelet derived growth factor and transforming growth factor beta

needed to initiate granulation tissue formation

Proliferative or Granulation Phase – 3-4 days to 30 days post injury rapid increase in fibroblast and epithelial

cell mitoses, and increase in synthesis of extracellular collagen and proteoglycans re-epithelialization begins

within hours but intensifies with rapid mitosis and new epithelial cells migrate along a bridge of fibrin when cells

contact one another, migration ceases due to contact inhibition and keratinization begins most sutured wounds

have epithelial coverage by 4 days post-injury angiogenesis follows fibroblast proliferation (begins at about 48

hours post injury) granulation tissue made up of fibroblasts, macrophages and new capillaries is the result

collagen synthesis extremely active at 5-7 days

Wound Contraction (Matrix Formation) or Remodeling Phase – begins approx 4 weeks and continues for 6-

18 months

characterized by reduction in fibroblasts, macrophages and wound vascularity Fibronectin eliminated as type I

collagen accumulates later type III collagen forms with fibronectin myofibroblasts cause wound contraction (0.6

to 0.75mm per day) scar size is a function of wound tension, patient age, O2 supply to the area –mechanical stress

promotes collagen synthesis and deposition leading to hypertrophic scarring hypoxia stimulates collagen

deposition as well Contracts 0.6-0.75 mm/day

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Cellular Activity in Wound

Healing

12

Wound Healing

13

Hypertrophic Scar / Keloid

Hypertrophic scar Keloid

Can regress Does not regress

Oriented collagen Random eosinophilic

collagen

Confined to wound Not confined

Scant mucin Mucinous stroma

No myofibroblasts Myofibroblasts

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Hypertrophic Scarring

15

Keloid

• Pressure can lead to resolution

16

Keloids

17

Keloids

• Described 1700 BC

• Chele – Greek for crablike

• More common in darker-skinned persons

• Most common age 10-30

• Usually after trauma

• Usually within a year

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Keloids – Treatment

• Steroids

• Excision – Laser vs. cold

• Pressure

• Interferon

• Low-dose radiation

• Silicone Gel sheeting (hydrocolloid dressing)

• Combination

19

Patient Encounter

• Common reaction to scar is ANGER

• Counseling regarding expectations

• Counseling regarding timecourse

– Cannot rush healing

– Possible touch-ups later

• Photodocumentation

– Consistent exposure and lighting

20

Scar Photography

Flat Lighting Side Lighting

21

Scar Revision?

22

Good Candidate Scars

• Longer than 20 mm

• Wider than 1-2 mm

• Disturbing function

• Poor match to surrounding tissue

– Color

– Depth

• Against RSTLs

23

Hidden Incisions

• Hide incision in orifice

– Transconjunctival, sublabial, intranasal, etc.

• Hide incision in hair

– Bevel edges, be aware of future balding

• Hide behind anatomic prominence

– Ex: retroauricular, submental

• Hide in junction of aesthetic subunits

• Hide in Relaxed Skin Tension Lines (RSTLs)

24

Relaxed Skin Tension Lines

25

Lines of Maximum Extensibility

• Lines of Maximum

Extensibility (LMEs)

are perpendicular to

RSTLs

26

Relaxed Skin Tension Lines

• Somewhat mirrored by lines of aging

27

Relaxed Skin Tension Lines

28

Facial Subunits

Incisions may be camouflaged

primarily by placing them at

the junction of aesthetic

subunits of the face. These

occur where there is a contour

change on the face or at the

junction of non-hair bearing

and hair-bearing skin. The

shadows that are cast from the

changes in contour tend to

hide the scars well.

29

Facial Subunits – Example

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Surgical Technique

• Adequate anesthesia

• Proper instruments

• Suture materials

• Closure of dead space

• Careful handling of tissue

• Precise closure of dermal layer

31

Technique

• Perpendicular

incision – unless

in hair-bearing

area

32

Technique

Improper Proper – everts

33

Depressed Scars

• Excision

• Injection

– Fat

– Collagen

• Bovine

• Human

Collagen allergy

34

Surgical Options • Simple excision (fusiform)

– Best for small scars that are wide or depressed

– Ex: trach scar

– Angle needs to be less than 30 degrees

• Serial excision

– Based upon ability of skin to stretch over time

– Can move scar to better anatomic location

– Also good for reducing grafted areas

– Alternatively, tissue expansion

• Shave – best for small raised scars

35

Serial Excision

• Scar could be moved

via serial excision to

hairline

36

Intramarginal Excision

• Hypertrophic scars

– Incisions within scar may heal better

– May be better than total excision

37

Intramarginal Excision

38

Z-Plasty

• Lengthens

• Reorients The well-known Z-plasty technique of scar manipulation both lengthens

and reorients the scar. It is especially useful in dealing with scars that

cross important RSTLs, distort anatomic features, or create webs or bands

across cncavities. By spreading the forces acting on a given point over

several directions, the Z-plasty helps to minimize distortions created by the

strong contractile forces during wound healing. Thus, the Z-plasty may

perform a cosmetic role by effacing a scar and may effect a functional

improvement by the lengthening it provides.

The classic Z-plasty represented in this diagram has two 60 degree angles

and three limbs of equal length. Undermining the two flaps created by

incising these limbs and transposing them theoretically increases the

length of the scar by 75%. The actual amount of lengthening is critically

dependent on the elasticity and availability of the surrounding skin. In

addition, increases in length from the rotated Z-plasty triangles vary

depending on the angle between the central and peripheral limbs. Angles

of less than 30 degrees may result in flap tip necrosis, those greater than 75

degrees in redundant standing-cutaneous cones.

Every Z-plasty has four different possible designs for the lateral limbs.

The correctly designed Z-plasty uses lateral limbs that parallel the

RSTL of interest. In addition, the ends of the lateral limbs must lie

precisely in the line where the new central limb will be placed. The angles

can be varied and made unequal to ensure that the limbs will fall in the

desired position. Multiple Z-plasties may be used in tandem around the

curve of a trapdoor deformity, allowing interdigitation of flap and

surrounding skin and thus effecting excellent scar camouflage. Less lateral

distortion is obtained by using multiple Z-plasties instead of a single,

larger Z-plasty centered about the same scar. This is important around

critical areas such as the medial canthus, where millimeter changes can

have significant functional and cosmetic implications.

The surgeon must be ever aware and weigh the versatility and benefits of

the Z-plasty against the fact that it requires two extra incisions, and

subsequent scars, to correct a single scar.

39

Z-Plasty

• Keep angle > 30 degrees to avoid tip necrosis

40

Z-Plasty

41

Z-Plasty

• Angles greater

than 60 degrees

can be broken

into multiple

flaps

42

Z-Plasty

43

Z-Plasty

44

Z-Plasty

• Angle should be no less than 30 degrees

• Optimally between 45 and 60 degrees

• Long scars can do with a series of Z-plasties

• Careful technique to avoid tip necrosis

45

M-plasty

• With a large standing cone, reduces amount

of healthy skin excised

– Ex: Lip, forehead flap

46

M-plasty

47

M-Plasty

• Can advance

tip with

closure

48

W-Plasty

• Eye is drawn to straight lines

• Straight scars more likely to cause

contracture

• W-plasty is regularly irregular

• Maximum segment length 6mm

• No. 11 blade helpful

49

W-plasty

50

W-Plasty

• Try to place segments in RSTLs

51

W-Plasty

• Helpful in

curved scars

52

W-Plasty

• Can use small VY segment to gain length

53

W-Plasty

• Correcting a design error

54

W-Plasty

• Gillies corner

stitch may be

helpful

• Others prefer

simple stitch

55

W-plasty

• Note

exposure on

photos

56

Geometric Broken Line Closure

• Irregularly irregular

57

Geometric Broken Line Closure

58

Geometric Broken Line Closure

• After closing dermis can run with Fast-Sorb

59

Geometric Broken Line Closure

60

Adjunctive Measures

• Dermabrasion

• Laser

• Cosmetic camouflage

61

Dermabrasion

• Reduces surrounding

skin to level of scar

• Blends color/texture

• Laser resurfacing now

popular

• Best done around 6

weeks

62

Dermabrasion

63

Dermabrasion

64

Laser

• More control

• Good for pigment

• Minimizes particulate matter

• Optimum laser/combination under

investigation

65

Laser

66

Cosmetics

• Very safe

• Allows sooner return to function

• May instead of or in addition to surgery

67

Cosmetics

68

Cosmetics

69

70

Treatment Algorithm

71

Conclusion

• “an ounce of prevention”

– Surgical planning and technique

– Wound care

• Counseling

• Timing

• Careful analysis

• Appropriate technique

72

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