You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > COSMETIC SURGERY Scar RevisionArticle Last Updated: Jun 14, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 8
  Author: Howard S Kotler, MD, FACS, Clinical Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Illinois at Chicago Howard S Kotler is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Cleft Palate/Craniofacial Association, American College of Physician Executives, American Medical Association, American Medical Informatics Association, Chicago Medical Society, and Illinois State Medical Society Editors: Jaime R Garza, MD, DDS, FACS, Consulting Staff, Private Practice; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Keith A LaFerriere, MD, Clinical Professor, Fellowship Director, Department of Surgery, Division of Otolaryngology, University of Missouri at Columbia; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: scar revision, cosmetic wound revision, scar repair, cosmetic skin repair, Z-plasty, classic Z-plasty, multiple Z-plasty, serial Z-plasty, W-plasty, running W-plasty, zig-zag plasty, M-plasty, geometric broken line closure, GBLC INTRODUCTIONSection 2 of 8
  Scar evaluation and revision techniques are chief among the most important skills in the facial plastic and reconstructive surgeon's armamentarium. Often minimized in importance, these techniques depend as much on a thorough understanding of facial anatomy and aesthetics, advanced principles of wound healing, and an appreciation of the overshadowing psychological trauma as they do on thorough technical analysis and execution. Scar revision is unique in the spectrum of facial plastic and reconstructive surgery because the initial traumatic event and its immediate treatment usually cannot be controlled. Patients who are candidates for scar revision procedures often present after significant loss of regional tissue, injury that crosses anatomically distinct facial aesthetic units, wound closure by personnel less experienced in plastic surgical technique, and poor postinjury wound management. An overview of scar revision is presented in this article. This overview addresses the complex preoperative considerations, basic plastic surgical techniques, wound healing biochemistry and biomechanics, preferred revision techniques based on anatomic site, and technical considerations in revisional wound closure. The author hopes that this information serves as the foundation upon which superior scar revision is learned through direct experience. ProblemTiming of scar revision The timing of scar revision depends on a variety of factors, including type and location of injury and the psychological readiness of the patient. One popular practice adopts a 6- to 12-month waiting period following initial injury, but experience shows that this waiting period must be individualized because an earlier approach may be undertaken. Before any revision procedure, a thorough assessment includes characteristics of the initial injury, relationships to anatomic location and relaxed skin tension lines (RSTLs), likelihood of pathologic healing (eg, hypertrophic scar, keloid), and any regional functional impairment by deformity (eg, oral or ocular impairment). Surgeons should also recognize that conservative nonsurgical methods may be applicable as a primary treatment method. Psychological and physical considerations Patients who desire scar revision after physical trauma have a different mind-set than those who desire cosmetic facial surgery in the absence of physical trauma. Patients who have been injured frequently bear psychological trauma induced by the initial event. This trauma often persists irrespective of the time between injury and surgical consultation. While the timing of scar revision usually is dictated by the interval following the initial event, a waiting period allows the patient sufficient time to adjust psychologically to the prospect of undergoing another facial surgical procedure and to make a more dispassionate consideration of the surgeon's treatment plan. Patients should have a realistic perspective of the lengthy healing time following revision procedures, likely outcomes given the injury characteristics, and the possibility of future adjunctive procedures such as dermabrasion, laser resurfacing, or multiple steroid injections. It may be in the best interests of both surgeon and patient to seek adjunctive consultation with a therapist well versed in the treatment of posttraumatic stress disorder (PTSD) for patients whose scar revision follows significant psychological trauma. Likewise, when the facial scars result from domestic violence, the surgeon may want to seek the services of a qualified psychotherapist or social worker. When facial scars are caused by domestic violence, the objective of scar revision is more than just beautification. Camouflaging the daily physical reminders of former domestic abuse with a scar revision procedure ultimately may serve as the avenue by which a person regains lost self-esteem. Finally, in the appropriate setting, the surgeon may want to inquire about the patient's social situation, because compliance with postoperative wound care may be impeded by adverse social settings. Moreover, the importance of the professional services of a licensed cosmetologist knowledgeable in the application of cosmetics to camouflage facial scars cannot be overstated. While the patient is waiting for the operative date, these professionals can provide a way for patients to acceptably cover their wounds. Cosmetologists also are helpful in the postoperative period, while revised scars undergo maturation and require camouflage, for cosmetic reasons and to prevent solar-induced cicatrix erythema. Finally, because some scars may not be amenable to revision surgery or for those that still are suboptimal after revision, a cosmetologist may be of great assistance. The timing of revision surgery is influenced primarily by the well-characterized biochemical and histologic events following injury. Scars mature or remodel over 12-18 months, resulting in a final scar that has a tensile strength of 70-80% of uninjured skin. Hence, the final visible outcome of a scar can best be assessed after this period of remodeling and collagen reorganization as type I collagen replaces type III collagen and overall scar dimension and erythema decrease. For this reason, scars that initially appear erythematous and elevated may be managed satisfactorily without surgery after 1 year if they have an initially favorable RSTL and regional aesthetic facial unit configuration. Scars considered unfavorable because of their relationship to facial anatomic units, RSTLs, angle of incision, or depth and type of injury may be revised on a much earlier schedule. Performing scar revision as early as 2 months following initial trauma is not entirely unreasonable. Early intervention may promote earlier maturation, redirect the aesthetic and functional outcome, and help alleviate the psychological tension patients often experience while waiting for definitive treatment. While awaiting the appropriate interval before the revision operation, patients may persist in their efforts to influence the surgeon toward an inappropriately timed revision. The surgeon must be steadfast during this time and not schedule the procedure until the wound has attained an acceptable degree of primary healing and the patient possesses a more realistic expectation of the likely result. EtiologyUnfavorable facial scars result from a variety of influences, over which the reconstructive surgeon often has little initial control. Patients who present with unaesthetic facial scars typically have wounds that (1) exhibit an unfavorable configuration with respect to length and direction of RSTLs, (2) have undergone pathologic healing processes, (3) unfavorably cross anatomic regions, (4) are subjected to constant deforming contractile forces because of underlying anatomy, and (5) are deeply traumatic. Each of these processes is discussed in detail because they inform the precise planning of scar revision. These processes also suggest how the reconstructive procedure heals. Scar length, pattern, and relationship to relaxed skin tension lines A lengthy linear scar often is more unaesthetic than a scar that is shorter or has multiple segments and covers less area. While it seems counterintuitive that more incisions actually can be less visible, a basic understanding of scar dynamic tension and of how linearity is perceived visually proves this fact. Scars of shorter length and those that are more multiple have 2 advantages over more lengthy counterparts. First, multiplicity tends to cause the wound to be irregular, thus the eye has more difficulty perceiving the entire length of the wound from end to end because of the intervening uninvolved tissue. Moreover, lengthier linear scars have more of a tendency to bowstring over surfaces, thus creating a more noticeable scar. Although this phenomenon is more likely to occur over concave surfaces (eg, medial canthus, inferior border of mandible to neck), it also may present over convex surfaces (eg, malar eminence, cheek) as a well-defined depressed scar. Furthermore, the motion of underlying musculature contracts linear scars and tends to depress the overlying tissue. In the case of a large U-shaped scar, this produces the well-known trapdoor deformity. However, with these considerations in mind, situations exist in which a truly linear or curvilinear and lengthy scar produces a superior aesthetic result. This is observed in certain facial scars lying in close approximation to or within an RSTL. Depth and angle of injury The depth of the initial injury has profound implications in scar revision. Injury that traverses the deeper tissues produces a much greater degree of scar contracture than superficial injury alone. This occurs as the scar in the deeper layers combines with the more superficial scar and retracts the less-fixed surface, producing a pronounced visible depression. However, deep scar tissue actually may be used as autogenous filler in future revision to prevent scar depression. Related to the depth of injury and resultant scar formation is the angle, single or multiple, at which the injured tissue is incised. Because of inherent tissue loss, stellate, avulsive, and crushing injuries amplify the degree of scarring following injury. Similarly, the angle of injury also influences the final appearance of a scar. Relative to its more perpendicular counterpart, an angled incision likely causes a greater degree of dermal injury. The oblique contracture of the dermal layer has a tendency to slide to one side of the wound, up and over the other, resulting in a heaped-up or pincushioned wound appearance. When revising this type of scar, the reconstructive surgeon faces the dilemma of 2 reconstructive options. The surgeon may subdermally debulk the raised portion of the scar and place deep dermal bolster sutures that pull the surface epidermis down, or the surgeon may entirely excise the scar and reapproximate the wound margins at right angles to each other. Clearly, this latter technique applies only when the cosmetic result far outweighs the loss of additional excised tissue. A notable exception to the above is the utility of a beveled incision in a hair-bearing area. Since the follicles usually are oriented in an angled direction, a beveled incision is less likely to injure the follicle germinal center. These incisions ultimately result in less loss of hair at the scar margin (see Image 29). Relaxed skin tension lines The decision regarding the location and type of incision used during any scar revision is based primarily on the concept of orienting all incisions perpendicular (as much as possible) to the direction of maximal underlying tension. Incisions made perpendicular (or nearly so) to this direction are better camouflaged and heal more favorably than those made parallel because these contractile forces tend to approximate the wound margins, rather than distract them apart. Understanding this concept is critical because it determines the difference between a long-term mediocre or superior scar revision. The elastic properties of skin allow it to be contracted or stretched under an applied tensioning force. Contracting the skin invariably produces lines (ie, wrinkles, creases) that generally lie perpendicular to the underlying muscular vector force. However, skin creases formed during a state of repose often do not follow this direction and are designated RSTLs. Thus, RSTLs are formed by the natural tension on the skin from underlying soft tissue and rigid bony or cartilaginous substructure. Superior results in scar revision arise from making incisions parallel or nearly parallel to RSTLs. The position of RSTLs may be appreciated easily from any of the well-described texts on the subject or from a glance at the mirror or a colleague's face. Moreover, a study of the most obvious wrinkle lines in elderly individuals alludes to the likely position of RSTLs. However, remember that wrinkle lines do not always accurately reflect the positions of RSTLs. A working knowledge of facial RSTLs is paramount to the conceptualization and execution of any well-planned scar revision. While RSTLs generally are oriented perpendicular to the tensioning direction of the underlying muscle, this is not always true. Thus, assuming that visible skin lines produced under tension (ie, wrinkles, creases) always lie perpendicular to the underlying direction of muscle contraction is erroneous. This is exemplified in regional facial anatomy, in which a circular band of muscle contraction exists. In the case of the orbicularis oris, skin wrinkles found between the mentum and lower red lip closely approximate the direction of the orbicularis oris fibers, whereas the opposite is true upon examining the tissue of the upper white lip. Periorbital skin is slightly more complex where creases extend radially from the lateral canthus, crossing alternately perpendicular and oblique to the underlying circumferentially arranged orbicularis oculi. The cosmetically inferior nasal dorsal transverse incision is another example that follows RSTLs more closely than its better-camouflaged vertical midline counterpart. Thus, determining the direction of the underlying contractile forces and RSTLs is primary to any scar revision procedure. A useful adjunct to understanding the position of RSTLs is to conceptualize the facial model as parallel variations of the 4 main facial lines, ie, the facial median, nasolabial, facial marginal, and palpebral lines (see Image 1). Because most RSTLs are parallel variations of these lines, the proper positioning of any RSTL often can be predicted reliably from them. The facial median line begins at the alar facial junction and closely follows this contour medially to the junction of the columella and upper white lip. The line then begins a median vertical descent toward the mentum (crossing the upper vermilion and lower lip complex) and terminates at the inferior border of the mandible. The nasolabial line originates at the superior-most aspect of the alar facial junction and descends inferiorly, overlying the cheek-lip fold (ie, nasolabial sulcus, nasolabial fold). The line then crosses lateral to the lateral oral commissure and extends inferiorly to perpendicularly meet the facial median line inferiorly overlying the mandibular symphysis. The facial marginal line assumes a starting point at the hairline, anterior to the root of the helix, and descends vertically anterior to the tragus. At the inferior-most aspect of the lobule-facial junction, the facial marginal line continues its inferior descent, closely following the posterior margin of the mandible to its angle. Crossing over the submandibular triangle, it then proceeds toward the midline, nearly overlying the position of the hyoid bone. The palpebral line begins on the superior lateral aspect of the dorsum and then ascends superiorly in an oblique direction to meet the medial canthus. The line continues from the lateral canthus downward over the cheek, inferiorly over the mandibular border toward the submentum. As the palpebral line crosses the mandibular border, its course roughly parallels the nasolabial and facial marginal lines. Note that this RSTL is not continuous with the well-defined crease in the midline that lies horizontal at the rhinion, (see Image 1) nor is it oriented like this crease. Nearly all RSTLs follow one or the other of the lines described above. A thorough working knowledge of their courses over the facial contours ensures that the surgeon can preoperatively plan scar revision excisions and incisions that are most accurate. PathophysiologyBesides the initial trauma and closure technique, many other factors ultimately influence the scar revision result. Even if techniques of judicious undermining, dissection in an avascular plane, and antitension closure are followed rigorously, other factors may influence the result, including the patient's concurrent medical history, nutritional status, history of cigarette smoking, and ethnicity. Nonsurgical treatment of scars following primary closure Nonsurgical alternatives following injury or primary excision have historically been recommended as an adjunct to minimize visible normal scar formation and to reduce or prevent aberrant scar formation, including hypertrophic and keloid scars. A large volume of published experimental data from various scientific disciplines uses these alternative methods of steroid injection, application of silicone or polyurethane sheets, or pressure dressings, yet none equivocally demonstrates a superior advantage. Although these secondary means to treat or prevent scarring may have individual efficacy in differing practitioners' experiences, the scientific literature lends little support to their regular and predictable use (de Olivera, 2001; Schmidt, 2001; Klopp, 2000). Keloids The ethnicity of the patient considering scar revision is given paramount importance. While no differences have been documented concerning relative healing ability among races, more darkly pigmented individuals are commonly accepted to have a higher incidence of keloid formation. The differences in appearance and clinical behavior between keloid and hypertrophic scars are well known to most surgeons, and recent biochemical and electron microscopic characterizations have been able to differentiate the two. Hypertrophic scars are considered to be those exhibiting an excessive abundance of incision site cicatrices that usually recede or remain stable over time. However, the classic definition of keloid scars describes scars that grow in abundance and that actually may overgrow the original margins of incision to involve adjacent tissue. Ultrastructural histologic differences between hypertrophic and keloid scars relate primarily to orientation of collagen bundles in the skin surface's substratum. Hypertrophic scars have parallel flat bundles of arranged collagen sheets, while keloids have disarrayed collagen sheets rather than discrete bundles. Hypertrophic scars and keloids also may be immunochemically and biochemically differentiated. Keloids immunochemically demonstrate a greater tissue concentration of immunoglobulin G (IgG) relative to their hypertrophic scar and normal skin counterparts. When compared to uninjured skin, relative concentrations of the collagen metabolic enzymes collagenase and proline hydroxylase are 3-4 times higher in hypertrophic scars and 15-20 times higher in keloids. Traditional approaches to the treatment of keloids have included serial excision, primary excision with postoperative triamcinolone injection, carbon dioxide laser excision, and application of full-thickness skin grafts. All methods have varying degrees of success. Perhaps the most commonly used modality is primary excision with serial postoperative triamcinolone injection. With this approach, excise the keloid at the interface of keloid and uninvolved tissue and close primarily without tension. Inspect at weekly intervals, and, beginning at the second postoperative week, if the wound demonstrates a palpable or visual keloid appearance, inject it with 40 mg/mL of triamcinolone. Subsequently, evaluate the wound at bimonthly intervals, and re-inject as needed. Patients with a history of concurrent diabetes mellitus or other conditions of impaired microvascular circulation are at particular risk following revision procedures. Patients with a history of cigarette smoking particularly are prone to flap margin necrosis, complete loss of free grafts, and superficial epidermal slough. Carefully counsel patients who smoke that reconstructive procedures are severely compromised by ongoing cigarette smoking and that the failure rate is significantly higher if they continue to smoke. No smoking for 2 weeks before and after surgery and the assistance of a professional well versed in biobehavioral and pharmacologic antismoking therapies increase the probability of future reconstructive success. The patient's nutritional and immunologic status often is overlooked in scar revision preoperative planning. While only patients who exhibit severe vitamin or protein deficiency likely demonstrate visibly impaired healing, it still is important for the surgeon to maximize all nutritional factors that favorably influence healing and to counsel patients accordingly. As more patients undertake self-directed programs of nutritional and dietary modifications, the surgeon must inquire about any nontraditional dietary or nutritional regimens practiced by the patient. Chief among the vitamins involved in wound healing are vitamins C, A, and E. Vitamin C is an essential cofactor in the healing process, directly affecting the synthesis of collagen and neutrophil function. Acting as a cofactor in the hydroxylation of proline and lysine, vitamin C allows the cross-linking of collagen. Without adequate supply of vitamin C, skin breakdown and impaired wound healing occur. As an immunodefense cofactor, vitamin C acts as a reducing agent in toxic superoxide radical formation. Body stores of vitamin C last 4-5 months, and severe deficiency is unlikely to be observed in a person consuming the average Western diet. Vitamin A deficiency impairs wound healing by decreasing synthesis of collagen and its cross-linking and by decreasing wound epithelialization and tensile strength. RELEVANT ANATOMYSection 3 of 8
Each anatomic facial region has its characteristic RSTL direction, soft tissue consistency and thickness, extent of mimetic activity, and relative degree of proximity to hair-bearing surface. While these characteristics largely determine the preferred revision procedure, surgeons must understand that a combination of revision methods may best serve the desired functional and cosmetic objectives. With this in mind, a summary of scar revision techniques that may be suited best to specific facial anatomic sites follows. Cheek The cheek represents a unique anatomic site in scar revision because the RSTLs do not run straight but rather in a curvilinear fashion from the malar eminence to the inferior border of the mandible. Scars crossing the cheek in the direction of the RSTLs are best treated with a running W-plasty (see Image 30). The surgeon may use a lateral-end Z-plasty for superior cosmesis. However, scars often run perpendicular (or nearly so) to the RSTL curvature mentioned above. In these cases, better camouflage is achieved by dividing the scar into multiple Z-plasties. Nasolabial fold The pronounced sulcus of the nasolabial fold (ie, cheek-lip fold) is well suited to scar camouflage. Understanding the proper use of Z-plasty is critical in this area where Z-plasty may be used, either singly or in conjunction with a running W-plasty, for scars extending from the cheek and crossing the nasolabial fold. Of critical importance are the orientation of the lateral limbs and the angle at which they subtend the Z-plasty central limb. In designing the lateral limbs of the Z-plasty, only one combination yields the best cosmetic result and places the lateral limbs nearest the direction of the RSTL. Any other combination results in the lateral limbs lying nearly perpendicular to the RSTL (see Image 10). Mentum Scars crossing horizontally over the mentum generally follow RSTLs and therefore are best treated with a running W-plasty (see Image 31). Laterally based and more obliquely directed scars are good candidates for Z-plasty because the primary objective here is to redirect the scar in the RSTL direction. Often, these scars cross from an oblique lateral to a more horizontal orientation and require a combination of lateral Z-plasty and running W-plasty over the mentum. Forehead The underlying frontalis muscle creates unusually prominent forehead RSTLs. These well-defined lines run horizontally in the central forehead with their lateral ends projecting obliquely inferior over the temple region. Pay particular attention to the junction of the glabella and forehead. The vertical RSTLs of the glabella meet those of the forehead in a nearly perpendicular orientation. Correction of scars that cross both of these regions probably requires incorporation of differing revision techniques that redirect by Z-plasty and cause irregularity by W-plasty or that use simple fusiform excision (see Image 32). Eyebrow The prominence of the supraorbital rim renders it a probable site of injury in frontal facial trauma. Lacerations frequently cross the forehead to include the eyebrow and are a revision challenge because of their visibility and because they require special techniques to camouflage the scar within the brow hair. Important concepts in eyebrow revision procedures include creating irregularity within the scar and beveling incisions parallel to the hair shaft. W-plasty is the revision procedure of choice and requires particular attention in aligning the superior and inferior borders of the brow (see Images 33-34). Moreover, brow width ultimately determines the absolute numbers of angles in the W. The central thicker brow requires a greater number of angles than the medial and lateral aspects of the brow. Before making any incisions, carefully inspect the brow hair to determine the predominant hair-shaft direction. This direction governs the beveled incision angle required to maintain the viability of the underlying hair follicles (see Image 29). CONTRAINDICATIONSSection 4 of 8
Contraindications to scar revision can be divided into those that limit a favorable visible outcome and instances in which the patient is not psychologically prepared for or has unrealistic expectations of what the revision procedure is capable of providing. As discussed previously, patients who have a history of hypertrophic or keloid scarring are at higher risk of a poor aesthetic result, which must be weighed against the expectation of a cosmetically superior revision. Moreover, patients with traumatically thickened or discolored skin are likely poor candidates for scar revision because the less compliant skin ultimately may compromise the revised scar. Finally, patients seeking scar revision must have realistic expectations of potential results before undertaking the often multiple surgical and medical procedures required to achieve superior results. For excellent patient education resources, visit eMedicine's Procedures Center. Also, see eMedicine's patient education article Suture Care. TREATMENTSection 5 of 8
Surgical therapyThe following will present the most common surgical techniques in scar revision, and includes discussion of their advantages and applications, conceptualization and methodology. Although the primary focus of this article is on surgical techniques, the nonsurgical treatment to minimize scar formation or to reduce problematic scarring after primary closure is also mentioned. Z-plasty Z-plasty is one of the most versatile scar revision techniques available. As a transposition flap, Z-plasty allows for 2 adjacent undermined triangular flaps, constructed from the same central axis, to transpose over each other and to lie in the other's originating bed. In essence, these 2 triangular flaps are transposed from areas of relative excess into areas of relative deficiency and eventually lie at near right angles to the original central axis. The usefulness of Z-plasty in scar revision rests in its ability to (1) reorient a scar to lie more favorably in the direction of RSTLs; (2) reorient the scar or anatomic landmark into a more favorable location or position; (3) break up the length of the scar, thereby rendering it less visible; (4) increase the scar length (ie, lengthen a contracted scar), thereby decreasing the prevailing scar contractile force and permitting better conformation to contoured surfaces; and (5) allow the surface-revised scar to run in a different angle to the deeper, more established scar, thus decreasing the tendency of the final scar to become depressed. Mastery of the Z-plasty concept is essential for anyone practicing head and neck surgery because the technique is used in a variety of primary incisions and reconstructive excisions. The following describes the technique of Z-plasty and covers the usefulness and construction of the classic, multiple, and adjunct Z-plasties. The classic Z-plasty is composed of 3 limbs (ie, a central and 2 parallel lateral limbs) of equal length with the 2 lateral limbs aligned to the central limb at identical 60° angles (see Image 2). Elevate, widely undermine, and then transpose the triangular flaps into the other's donor bed (see Image 3). In the result, the central limb is oriented nearly perpendicular to its original direction, lengthening the linear dimension of the scar (see Image 4). However, note that the lengthening in one axis mirrors the shortening in the other axis and results in corresponding tissue distortion. Images 5-7 demonstrate the relative degree of lateral tissue distortion in an elastic model of a classic 60°-angle Z-plasty. The angle that the lateral limbs subtend with the central limb directly influences the final length of scar; the greater the angle the lateral limbs subtend with the central limb, the greater the lengthening of the scar. Moreover, the inherent elasticity of the surrounding tissue also influences the gain in length. Thus, a 60°-angle Z-plasty yields a 75% length increase; a 45° angle, a 50% length increase; and a 30° angle, a 25% length increase (see Image 8). While most surgeons opt for lateral limb angles that approximate 60° and thereby balance scar lengthening and adjacent tissue distortion, a higher degree of lengthening may be achieved by greater lateral limb angles. Lateral limb angles less than 30° are more likely to result in flap tip necrosis; those greater than 75° are more likely to result in standing cone deformities. For every potential Z-plasty, 2 possible lateral limb designs exist, but only 1 optimally places the final scar within or nearly within the RSTL. Selection of the optimal orientation of the lateral limbs requires careful planning. Collectively consider the original scar orientation, the resultant excised central limb, and the direction of prevailing RSTLs. Choosing lateral limbs that originally lie parallel to RSTLs ultimately creates transposed lateral limbs that also are likely to lie parallel to RSTLs. In Images 9-10, 2 different possible Z-plasty configurations are demonstrated in revising a scar that traverses the nasolabial (cheek-lip) fold. Only one of these produces the best possible result (see Image 9). By orienting the lateral limbs as close as possible to the prevailing RSTL, the final limb orientation aligns more favorably to the RSTL of the upper white lip and nasolabial fold. Compare this to the undesirable design illustrated in Image 10, in which the lateral limbs lie perpendicular to the RSTL of the white lip. Transposing large amounts of tissue theoretically could be achieved by constructing a Z-plasty with angles larger than 60°. While the construction of a single Z-plasty produces a greater gain in length than its smaller multiple-angle counterparts, a larger-angled Z-plasty is more likely to create unacceptable deformity. This results from adjacent standing cone deformity and incisions that noticeably cross boundaries of adjacent facial aesthetic units. Moreover, even though a scar may be revised by a single larger-angled Z-plasty, the creation of multiple or compound lesser-angled Z plasties acceptably lengthens the scar, results in less tissue distortion, and has the added benefit of better camouflage by increased scar irregularity. Therefore, a more reasonable alternative is to construct multiple or compound lesser-angled Z-plasties rather than a single Z-plasty with an angle approximating 60°. Variants of the multiple Z-plasty include compound and serial types. These variations on the classic Z-plasty often are useful in closing ovoid defects, such as those resulting from excision of a widened scar. While both are useful, the compound Z-plasty has the advantage over the multiple serial variant because it requires fewer incisions. The compound type is constructed by creating 2 separate flaps at each end of the central limb, oriented at 45° to each other (see Images 11-12). Construct the serial Z-plasty by transposing flaps created by laterally incising the margins of the defect (see Images 13-15). The serial Z-plasty creates minimal tissue distortion and is particularly useful near areas where this may result in functional and cosmetic impairment, such as near the ophthalmic or oral commissure. However, in practice, the surgeon must weigh the advantage of lesser tissue distortion against the multiplicity of incisions required in this type of Z-plasty. Finally, the Z-plasty is effective as an adjunct to the excision of widened fusiform or ovoid defects in which skin margins cannot be reapproximated or can be closed only under excessive tension. In this case, a single Z-plasty lies lateral to the excised scar, and, by transposing its 2 flaps, tissue is mobilized toward the closure of the defect, thereby minimizing the tension on the final closure and distortion of adjacent aesthetic units. W-plasty The primary utility of the W-plasty (also termed the running W-plasty or zig-zag plasty) is in rendering a lengthy linear scar irregular. In addition to linear scar revision, the W-plasty is useful in the closure of semicircular incisions in which the sweeping unbroken curvilinear scar is more noticeable and under greater tension and, thus, over time more likely to become depressed or pincushioned. Note that while the W-plasty makes irregular a linear scar and spares unwanted lengthening that may arise from using small multiple Z-plasties, the final result is often readily visible because the eye easily can follow the predictable zig-zag configuration. Finally, in its basic execution, this technique incorporates neither transposition nor rotation of adjacent flaps; therefore, the final scar is not elongated but only increased in the final total length. The basic W-plasty consists of creating consecutive small triangular flaps on opposite sides of the wound, with sides not more than 6 mm and corner angles of 90° or less. Important considerations for the basic W-plasty involve its use in curvilinear wounds and its orientation with respect to RSTLs. When using the W-plasty on curving wound margins, the outer triangles must be larger in both side length and angle than their counterparts on the inner curve (see Image 16). This size discrepancy ensures that the number of outer and inner triangular flaps is the same. Careful preoperative planning must ensure numerical equality and must recognize the direction of the RSTLs. Unlike the Z-plasty, the W-plasty does not redirect the wound in a more favorable orientation to the RSTLs. Therefore, the sides of each triangle in the W may be oriented toward the RSTLs more than if they were constructed in an isosceles right triangular configuration (see Image 17). The corresponding contralateral wound margin then also must interdigitate this modification. The precise nature of the W-plasty necessitates strict adherence to basic underlying plastic surgical technique. After carefully drawing the W-plasty (see Image 18), make incisions vertically and at right angles through the dermis with a No-11 scalpel blade (see Image 19). Use a deep dermal suture to reduce the tension on the superficial layers. A running locking configuration of rapidly absorbable suture may be used on the surface. All wound margins are imbricated precisely together (see Image 20). Finally, employ antitension taping to further reduce tension on the wound surface. As in all scar revision, remind patients that the final appearance of the wound cannot be evaluated fully until nearly 6 months postoperatively, as the erythema begins to subside. After this period, dermabrasion or laser resurfacing may be employed adjunctively as a further refinement. Geometric broken line closure A variant of the W-plasty, geometric broken line closure (GBLC) employs the same illusory principles as a W-plasty, seeking to maximally create irregularity in a linear scar and thus render it less visible than a procedure with a regular patterned unbroken configuration. GBLC can offer superior results to the W-plasty because the eye finds the greater scar irregularity even less perceptible in the final result. Like the basic W-plasty, GBLC does not lengthen the original scar. Construction of GBLC follows from an exacting pattern of irregular geometric shapes on either side of the wound. Construct the geometric shapes of corresponding dimension squares, rectangles, and triangles that, when brought together in final closure, interlock into their opposite margin counterparts. The geometric shapes thus constructed should have their width randomized along the length of the scar with progressively lesser and then greater height near the ends and the mid region of the scar, respectively (see Image 21). Direct special attention to the relative curvature of the wound margins. If the scar is curvilinear, the size of the geometric shapes is significantly smaller on the concave side than on the convex counterpart. Alternatively, a running W-plasty often can be used on the extreme curving aspect of curvilinear scars revised with GBLC. Remember that the outer triangles must be larger in both side length and anglethantheir inner curve counterparts. Incisions made vertically and perpendicular to the skin surface using a No-11 scalpel blade ensure precise geometric shape interdigitation (see Image 21). Moreover, judicious use of preexisting scar in the underlying deep dermis or subcutaneous tissue as autoplastic filler, along with precise peripheral undermining, greatly enhances the final result by decreasing the likelihood of a depressed scar. Given these caveats, the length of any segment should be 3-6 mm, and all corner angles should be maintained at 90° or less. Perhaps the easiest method to construct this often confusing array of geometric shapes is to first create corresponding perpendicular lines on each side of the wound and then to create the corresponding geometric shapes that ultimately interlock in the final closure (see Image 22). The geometric configuration and dimensions in GBLC are critical and depend on their relationship to the RSTLs and on their position along the scar length. Ideally, all incisions in GBLC should parallel prevailing RSTL direction as closely as possible. However, the scar often may run predominantly parallel or perpendicular to the planned revision. In either case, give special consideration to the sides or tops and bottoms, respectively, of any rectangles created when planning the initial incision. When the rectangular or square shapes have their sides lying perpendicular to the RSTL, 2 methods may be employed. Either the proportion of squares and rectangles to triangles may be decreased (thereby decreasing the absolute number of perpendicular lines), or these geometric shapes may be slanted (as with a W-plasty) to approximate more closely the prevailing RSTL. In an instance where the scar runs predominantly perpendicular to the RSTL and the rectangles have their bases and tops likewise perpendicular, the surgeon may decrease the number of the lines perpendicular to the RSTL by creating triangular shapes from the rectangle bases and tops. Finally, to ensure precise interdigitation of flaps, geometric shapes should have greater height at the mid portion and lesser height at the lateral ends of the wound (see Image 23). After placement of antitensioning dermal sutures, the GBLC may be closed superficially with a running locking absorbable suture placed approximately 5 mm lateral to the wound margins. M-plasty Often, scar revision creates angles greater than 30° at the lateral wound margins. While a greater angle at the wound's ends maximally preserves normal surrounding tissue, revision efforts under these circumstances are more likely to create a standing cone (ie, dog-ear) deformity. Decreasing the likelihood of a standing cone deformity ultimately leads to greater loss of healthy surrounding tissue and vice versa. A useful technique to preserve healthy tissue and lessen the chance of secondary tissue deformity is the M-plasty. The M-plasty, by creating 2 separate 30° angles instead of one, decreases the loss of surrounding healthy tissue by nearly 50%. Construct the M-plasty by halving the distance from the central vertical axis of the wound to the lateral apex of the wound (see Image 24). The proximal length then forms a side of one of the 30° triangles, with the other side of the triangle formed by a line that begins at this halfway point and ends at the most lateral edge of the scar (see Image 25). Closure of the M-plasty is more than simple approximation of tissue edges. The triangular point of tissue at the wound ends may be centrally advanced into the wound to achieve more or less lengthening of the wound, depending on the degree of tissue advancement. As much as possible, advance the remaining triangle of tissue into the wound in a V-Y advancement maneuver, thereby effectively shortening the overall length of the wound (see Images 27-28). Plastic surgical incision and closure techniquesPoor wound healing results from posttraumatic infection, inadequate or traumatic wound closure, excessive use of electrocautery, or inappropriate postoperative wound care. Wounds overlying sites of maximal tension or repeated motion or perpendicular to RSTLs also probably result in more visible or widened scars. Emergency medical personnel in the acute care setting often do not understand the importance of judicious debridement, tension-free wound closure, and wound margin eversion. While the judicious excision of devitalized tissue from wound margins and removal of foreign body contamination cannot be overemphasized, excessive debridement creates an uneven closure and contributes greatly to an unfavorable cosmetic result. Aside from overzealous debridement, avulsion injuries, full-thickness burns, and gunshot wounds are important causes of wound site tissue loss. Furthermore, in an effort to reapproximate these widened margins, wounds are more apt to be closed under a maximal degree of tension or are left to heal by secondary intention. These scars are perhaps the most difficult to revise because the deep tissue inflammatory response following their injury creates a rigid, nondistensible recipient bed. Finally, wounds that are not covered with an occlusive ointment and are allowed to desiccate further contribute to the likelihood of a cosmetically unacceptable scar. A thorough understanding of plastic surgical wound closure techniques is critical to the application of scar revision concepts. While soft tissue techniques in facial plastic and reconstructive surgery follow the time-honored guidelines of any wound closure, devoting particular attention to certain technical refinements ensures superior results. Preeminent in the discussion of scar revision techniques is the manner in which the tissue is handled. The extreme importance of using atraumatic tissue technique during any revision procedure cannot be overemphasized. Most revision techniques involve delicate skin margins that may undergo complete vascular compromise from poor handling technique alone. Tissue forceps should be of a toothed variety (eg, Adson, Brown-Adson) and should be used sparingly on wound margins. Alternatively, single-pronged or double-pronged skin hooks may be placed in the subdermal tissue and used as a traction device. When visualizing how a closure ultimately will appear, the wound may be temporarily closed by grasping the subcutaneous tissue instead of the epidermis and approximating together the wound margins. This minimizes the crushing trauma to the wound, yet allows an adequate preview of how the revision will appear when the epidermis finally is closed. Often overlooked is the value of using saline-dampened sponges during scar revision procedures. Damp sponges maximize wound margin hydration, an important point in revision procedures that are time intensive or use geometric configurations that are more likely to be injured (eg, delicate margins in GBLC). Moreover, damp sponges allow, by virtue of their ability to destain the tissue, a better differentiation of important adjacent anatomic structures (ie, preferred planes of dissection and neurovascular anatomy). Incisions Proper incisions in scar revision are the foundation of superior results and must be precise. Either a No-11 or No-15 blade attached to a No-9 handle can accomplish the varying degree of vertical, beveled, straight, or curved incisions. While vertical incisions offer the greatest usefulness in scar revision, conditions exist where a slightly beveled incision is desirable. Hair follicles rarely are oriented perpendicular to the skin surface, and thus the hair shaft lies in the same direction. Incisions made perpendicular to the skin in hair-bearing areas are at greater risk of irreversibly damaging the follicle with resulting alopecia adjacent to the healing incision. Beveling the incision also plays an important role in the formation of an everted wound closure. To fully understand the importance of this technical concept, remember that, as scars heal, forces of contracture pull the wound centripetally, including from a deep to superficial direction. Even if wounds are closed using deep subcutaneous suture technique to minimize tension across the margins, scar contracture probably causes retraction of these same margins, resulting in a depressed scar. Then, an easily visible shadow is cast as incident light falls across the healed wound. To minimize this problem, incision and suturing techniques have been developed to produce wound eversion that over time results in a less visible planar scar. While it may appear less aesthetic to both physician and patient, the initial heaped-up wound flattens out remarkably over 6 months to a year as the forces of scar contracture pull the healing margins inward and downward. Preoperatively counsel patients that initial results will seem unsatisfactory but will improve dramatically over time. Invariably, this concept needs reinforcement during the ensuing months. Dermabrasion or laser resurfacing may be employed adjunctively if the scar appears unaesthetic and unlikely to improve to an acceptable state after 6 months. An essential component of any scar revision technique is judicious subdermal undermining lateral to the wound margins. This technique permits a more tension-free closure on the epidermal surface, resulting in a superior revision. The amount of undermining in any particular revision is dictated by the surgeon's experience; however, studies demonstrate that undermining more than 1 cm may do little to decrease tension on the wound and may create further unnecessary dead space or compromise the subdermal vascular plexus. Skin flap undermining can be achieved with a No-15 blade or sharp scissors. Elevation of the flap during undermining is achieved atraumatically with skin hooks or toothed forceps. Wound hemostasis Adequate hemostasis is of paramount importance in all surgical wounds. Localized collections of blood under the flap or the coagulum that separates wound margins can predispose the wound to infection and more visible scar between approximated margins. After all preoperative precautions are undertaken to ensure hemostasis, proper planar tissue dissection and judicious electrocautery remain the mainstays of superior wound hemostasis. While monopolar cautery with a needle-tip attachment is probably the more popular instrument used, a strong supportive argument can be made for bipolar cautery. Bipolar cautery has the distinct advantage because the cauterizing electric current passes only between the instrument tips, thus minimizing any unintended lateral thermal trauma. This is particularly important if any cautery is performed near the dermal-epidermal junction, in the subdermal vascular plexus of a particularly thin flap, or near hair follicles. Subcutaneous closure Proper closure of the deeper subcutaneous layers is of critical importance in any scar revision. No amount of carefully planned and executed incisions or meticulous epidermal closure yields a superior result if the subcutaneous layer is not closed in the appropriate manner. Properly placed subcutaneous sutures perform the vital functions of decreasing the dead space under a wound, permitting a tension-free epidermal closure, and causing a moderate degree of epidermal eversion. One method of placing subcutaneous sutures is as follows. While gently everting the deep subcutaneous tissues with either a skin hook or minimally traumatic toothed forceps, the needle is placed 5-10 mm distal to the wound margin. The suture passes through the dermis and the opposite side in the reverse order. This sequence of suturing places the knot deepest in the wound, decreasing the likelihood of future suture extrusion. Alternative means are used in closing triangular flaps such as in GBLC and M-plasty. In this instance, a horizontal mattress suture is placed midway through the full thickness of the flap, and then, by placing the suture at a corresponding similar level, the angulated tip is advanced into the wound. This advancement is critical because it closes the potential dead space between the flap and recipient site and everts the wound edges (see Image 28). Closure of the subcutaneous layer most often is performed with a synthetic absorbable suture. Although nonabsorbable sutures retain tensile strength over an extended period, many surgeons believe that these sutures have little utility in facial plastic surgery because of their higher likelihood of later rejection. However, nonabsorbable suture elicits significantly less inflammation than its absorbable counterpart. Absorbable sutures eventually dissolve, losing tensile strength according to known time parameters and wound characteristics. This can lead to a loss of support in the subcutaneous layer and greater tension across the overlying epidermal layer, with an increased likelihood of a more prominent scar. For these reasons, surgeons must employ judicious undermining to decrease wound tension and must choose the proper absorbable suture. This ensures that the wound is healed sufficiently by the time the absorbable suture has lost nearly all its tensile strength. Synthetic sutures based on polyglycolic acid, such as Dexon or Vicryl, are well suited to close the subcutaneous layer. Polyglactin suture (eg, Vicryl) maintains 75% of its tensile strength at 2 weeks and 50% at 3 weeks; it is dissolved completely in 56-70 days. Sutures with a longer duration of tensile strength (eg, polydioxanone [PDS], Vicryl) have a prolonged ability to decrease wound tension but also have the disadvantage of creating a longer duration of inflammation over time. This type of suture may have its greatest use in rigid fixation to deeper structures of tissues such as cartilage and bone grafts. PDS suture has 50% of tensile strength at 1 month and is histologically undetectable at 6 months. Epidermal closure The purposes of epidermal closure are to precisely reapproximate and to slightly evert the wound margins and not to decrease tension across the wound. This concept is especially critical when fast-absorbing suture is used. In fact, before epidermal closure, the wound margins already should be nearly completely apposed by well-placed subcutaneous sutures. Suture material for epidermal closure depends largely on the type of scar revision, anatomic location, age of the patient, and desired degree of wound margin eversion. Most surgeons prefer to use a 5-0 or 6-0 nylon or Prolene suture in facial plastic surgery because of their low tissue bioreactivity. Advantages of Prolene suture include the ability to stretch during knotting and the ability to precisely define the appositional tension across the wound. In the scalp and neck, 4-0 and 5-0 sutures, respectively, find greatest utility in minimizing the scar while maintaining support of the healing wound. A disadvantage of these types of nonabsorbable sutures is that they often require laborious removal, an especially challenging endeavor in hair-bearing wounds or in pediatric patients. In these instances, the mild chromic, fast-absorbing gut or newer rapid polyglactin synthetic suture facilitates postoperative care because these sutures require no medical personnel for removal. Each of these sutures imparts a low degree of bioreactivity and dissolves over a relatively short period. Remember that these suture materials are fragile and must not be exposed to aqueous environments and petrolatum-based ointments because these may precipitate a much earlier suture dissolution and consequent compromise of integrity. The suture materials above are used to close linear wounds by taking 1- to 2-mm bites of tissue on each side of the wound and placing the sutures approximately 3-5 mm apart. Epidermal suture placement is thus a balance between inadequate wound closure and placing too many sutures too close together, compromising flap vascular integrity. This concern is amplified when the geometric configuration of the wound edges is anything less than 180°, as with Z-plasty, W-plasty, or GBLC. In these instances, blood supply to the tip of the flaps may be compromised if more than a single suture is placed through the flap margins. For this reason (ie, to avoid constricting the dermal and subdermal blood supply), the author recommends that the suture be singular and encompass only the epidermal layer. An alternative method is to employ a horizontal mattress technique in which the suture is half-buried and includes both the flap tip and the sides of the defect (see Image 28). Both techniques work equally well, but, if improperly placed, both may compromise the vascular integrity of the flap. The suture technique used in scar revision closure may include simple interrupted, vertical mattress, or running locking configurations. Simple interrupted suturing affords the best protection for maintaining flap margin viability because of its spacing along the wound margin. This technique also may be employed to primarily create or supplement wound margin eversion. As a timesaving measure, the running locking suture technique allows the surgeon to close a wound with multiple edges, such as with complex GBLC or running W-plasty. To maintain a viable blood supply, do not cinch down the many running half-formed knots. The vertical mattress suturing technique allows for a superior eversion of wound margins and primarily is used in less angulated closures such as simple fusiform excision. Often overlooked is the importance of antitension skin taping, performed after epidermal closure. Like epidermal sutures, antitension taping is directed at further minimizing wound tension but is not used as a primary method for doing so. By preventing coagulum from intervening between wound margins, antitension taping ensures near complete wound apposition. After completing the epidermal closure, apply topical liquid adhesive to each side of the incision. Exercise great care not to contaminate the incision with the adhesive. Then, use Steri-Strips or other easily applied taping to decrease the tension across the wound. Leave these in place until the epidermal sutures are removed. When removing the tape, removing the strips by pulling the tape in a medial direction (ie, toward the wound margins) is essential because this minimizes any forces that otherwise may tend to distract the wound margins. Next, reapply the taping, and, ideally, leave it in place for at least 4 weeks. Darker, more flesh-colored tape that camouflages well is available for anatomic locations where visibility is a concern. Another method to further decrease wound tension after subcuticular suturing is the topical application of tissue adhesive. These newer acrylate-derived liquid adhesives provide superior wound apposition when applied as directed by the manufacturer, but do not allow them to enter directly into the wound. While their relative reactivity with epidermal nylon or other synthetic sutures is not fully described, they may find the greatest use in the adjunctive closure of wounds closed with subcuticular suturing techniques. FUTURE AND CONTROVERSIESSection 6 of 8
Scar revision techniques are directed toward camouflaging otherwise functional and aesthetically unacceptable wounds. Unlike any other cosmetic facial surgical procedure, scar revision retains a high emotional component that must be addressed by the surgeon. Superior scar revision begins with an understanding of the factors affecting scar formation and is linked to an applied knowledge of plastic surgical technique and specific revision procedures. MULTIMEDIASection 7 of 8
REFERENCESSection 8 of 8
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