Scar Revision

The treatment of aesthetically displeasing scars of the head and neck is challenging at times, although not without options. While removing one scar without leaving another is not possible, replacing an unfavorable scar with a more camouflaged one, or rendering an existing scar less noticeable, is possible.

By the time scar revision patients present to a physician, they have exhausted every means at their disposal to disguise the scar. These attempts at concealing the scar typically involve the use of cosmetics, clothing, and hairstyle modifications. While various treatments exist, none is perfect, and the cornerstone of any scar revision is a thorough understanding of the patients' dissatisfaction with their appearance and their expectations following treatment. Patients must understand that the best result may require multiple treatments and that initially, little improvement may be noticeable relative to the preexisting deformity.

Other considerations of paramount importance when considering scar revision include (1) whether the scar is in a position that compromises function and (2) if any revision might result in decreased function. As with any skin defect, the quality and availability of surrounding tissue must be assessed.

History of Scar Revision Procedures

According to ancient Egyptian writing, scarification for aesthetic reasons dates back to 1700 BCE. Throughout history, different cultures have used scarring as a depiction of one's affiliation with a particular group, its exploits, or stature. In most cultures now however, scars on the head and neck are perceived as undesirable, and patients often present to their physician requesting revision to render their scars less noticeable.

Problem

In general, scar revision techniques are either operative or nonoperative in nature. More aesthetically pleasing scars are those that are less noticeable. Intuitively, this includes matching the surrounding skin in color, texture, distensibility, and elevation. The characteristics of scars are important relative to their surroundings. For example, scars often have fewer dermal appendages or lack them altogether. In areas of hair-bearing skin, a scar's lack of hair follicles is particularly noticeable. In other areas with sparse hair follicles, this is a desirable attribute of scars.

Patient characteristics also play a large factor in scarring, as does the quality of closure and the cleanliness of the wound. Patients at the extremes of age often scar to a greater degree. Young patients are more prone to excessive scar formation, while elderly persons are more prone to poor healing, owing to diminished fibroblast activity. Individuals with connective-tissue disease, diabetes mellitus, or vitamin deficiencies or those who return to activity too early may experience healing complications that result in greater scarring upon final closure.

Wounds that are poorly closed, undergo dehiscence, have necrosis of the skin edges, or have edges that are poorly approximated are more likely to heal with unsightly scarring. Likewise, wounds that become infected or undergo foreign body reactions to sutures more frequently yield poor cosmetic results. Proper screening of patients prior to surgery, proper nutrition, good technique, and conscientious wound care dramatically favor faster wound healing and more aesthetic results.

Etiology

Before considering scar revision, the treating physician must have an understanding of wound healing and how scar tissue forms. Wound healing progresses in 3 phases: an inflammatory phase, a granulation phase, and the final, remodeling phase.

Inflammation is an immediate physiologic response to any injury to the body. In the skin, it serves the additional role of helping to contain and repel any organisms or foreign materials introduced into the tissues by a variety of traumas, including surgical incisions. The various mediators of inflammation are the first materials released in the wound, including activated complement, transforming growth factor-beta, circulating monocytes, tissue macrophages, neutrophils, platelets, clotting factors, and serum proteins, among others. Damaged collagen fibers promote platelet aggregation in the wound. Later, collagen provides the scaffold for wound healing as the major constituent of the extracellular matrix. This primary phase of wound healing typically lasts for 1-2 days.

The granulation or proliferative phase involves fibroblast proliferation within the wound bed. These cells are responsible for the production of the collagen extracellular matrix. Cytokines present in the wound bed at this time also promote the process of angiogenesis and the appearance of granulation tissue, a characteristic of the healing wound. Once collagen is laid down as an extracellular matrix and cells have grown on this scaffold, the wound enters the remodeling phase of wound healing.

The remodeling phase involves the reassortment of collagen fibers laid down in the preceding proliferative phase. Remodeling is the longest period of the wound healing process; it may continue for up to a year. However, 2-3 weeks is a more common interval for this final phase of wound healing. During this time, the net amount of collagen does not increase, but the formation of a more orderly arrangement of fibers helps to greatly increase the wound's tensile strength. When healed properly, the final wound strength reaches 70-80% of prewound strength.

Pathophysiology

The ideal scar is narrow and fills but does not eclipse the original volume of the wound bed. In fact, the wound often decreases in size upon healing due to contractile forces involved in scar formation. Occasionally, scar formation may be exuberant, as in the cases of hypertrophic scarring or keloid formation.

Hypertrophic scars do not extend beyond the original boundaries of the wound laterally, but scar tissue may rise above the level of the surrounding skin. This commonly results in a very noticeable, irregularly contoured scar. A more extreme example of exuberant growth of scar tissue is the keloid. Keloid scars extend beyond the original borders of the wound, resulting in a raised and expanded scar relative to the original defect. These are often very noticeable, and they occur with increased frequency in persons with dark complexions. In both hypertrophic scars and keloids, components of the extracellular matrix are increased. Thus, while the number of fibroblasts present is normal, the cells present are apparently overactive in their wound healing response.

Indications

The indications for scar revision are often a matter of patient preference. Scars on the head and neck are distressing to most patients. However, certain aspects of a scar, such as the color or texture, may bother one patient more than another. Patients should be counseled that a scar-free revision is not realistic and that an optimal result is achieved only through cooperation between patient and physician.

Contraindications

Cigarette smoking, nonsteroidal anti-inflammatory drugs, vitamin E, and isotretinoin should be stopped at the appropriate time prior to revision. Noninvasive or minimally invasive measures such as microdermabrasion and intralesional steroid injection can be performed as early as 3 weeks after revision of the scar, but many practitioners prefer to wait 6 weeks. When undertaking a revision, subtle problems should be treated conservatively first, before more aggressive interventions are used. Patients should be informed that the final maturation of the scar may take up to a year after revision. Above all, stress to the patient that scar revision merely replaces one scar with another in an attempt to improve the aesthetics of the area.

Complete restoration to the preinjury state is not possible under any circumstances, but the revised scar may be less detectable. A patient with realistic expectations is more likely to be satisfied with the final results of the revision procedures than a patient with unrealistic expectations.

Nonsurgical interventions

Nonoperative techniques for scar revision include topical applications to the scar tissue, materials injected within the lesion, augmentation of soft tissues, cryotherapy, laser therapy, and coloring involving makeup or tattooing. Each of these modalities has its advantages and disadvantages, and often more than one technique is used to aid in obtaining a more aesthetically pleasing result. Topical applications include the use of products such as silicone gels or sheeting, creams or salves, vitamins E and A (retinoic acid), herbal remedies, and others. These are the most widely used approaches by patients because they are easy to use and are of low cost. Depressed scars can be filled with temporary or permanent filler materials.

Silicone gel or silicone sheeting may be applied over healing wounds to promote scar improvement. Although this is somewhat effective in reducing scarring, no clear mechanism has been proposed. The improvement in scarring is purportedly due to the water retention in tissues beneath the occlusive silicone dressings. This effect is apparently independent of any compressive forces exerted by the dressing, and silicone gel offers the added advantage of not needing to be taped over the wound as does silicone sheeting. In vitro experiments have shown that this hydration decreases the production of collagen by fibroblasts and the production of glycosaminoglycans.

Other petroleum-based ointments also provide this occlusive effect, promoting hydration and improving scar appearance. Creams and salves of different varieties are widely used in the treatment of scars. Topical applications including vitamin A have been shown to improve the aesthetic properties of scars. Vitamin A as applied to the skin is 0.05% retinoic acid and is an effective resurfacing agent. Scars exposed to retinoic acid are typically less irritated, less elevated, and softer. The topical route of administration is preferred because the systemic toxicity of vitamin A is more easily avoided than with oral intake of the vitamin.

Despite popular opinion, applications containing vitamin E have been shown in double-blinded studies to result in no improvement in the cosmetic appearance of surgical scars compared with placebo. Vitamin E penetrates deeply into the dermis and has an antioxidant effect. If applied to a wound in the early stages of healing, the recovery of tensile strength may be adversely affected. Lastly, creams or salves containing herbal remedies have been shown to be largely ineffective in changing the attributes of scars, or at best, are of unproven efficacy.

Intralesional injections allow for greater penetration of the scar by the therapeutic agent and for delivery of greater concentrations locally than with topical or systemic administrations. The 2 most common intralesional injections are corticosteroids and antimitotic agents. Intralesional corticosteroid injection has been extensively studied and proven to reduce the size of hypertrophic scars and keloids. Steroids exert several effects on healing scars, including reducing fibroblast populations, reducing the formation of new vasculature, and decreasing fibrosis.

Intralesional steroidal therapy every 4-6 weeks is often used following scar excision to prevent a reoccurrence of unsightly scarring. Intralesional corticosteroid injection is the common standard used in research to establish the relative effectiveness of new agents for scar revision. However, intralesional steroid injections are not without potential adverse effects, including changes in coloration of the scar tissue, the development of telangiectasis in the overlying skin, and the formation of granulomas.

Antimitotic agents such as 5-fluorouracil or bleomycin are used intralesionally to inhibit proliferation of scar tissue. These agents are contraindicated in pregnancy.

Cryotherapy involves the freezing of tissue with liquid nitrogen. The mechanisms of action are cell death and sloughing. Liquid nitrogen is applied either in spray form or directly with a cotton applicator. Immediately after application, the area becomes edematous, and cell death ensues. The resulting scar, if managed well, may provide a more aesthetic result.

Laser therapy has progressed significantly since it was first used to treat skin lesions. Laser is an acronym for light amplification by stimulated emission radiation. Laser light that is absorbed heats the tissue and coagulates or ablates it. Pulsed-dye laser systems are often used because they have been shown to result in long-term improvements in the appearance of scars, whereas continuous carbon dioxide lasers and Nd:YAG lasers have had shorter-term successes. The wavelength used is 585 nm, which is vasculature specific. This ablation within the scar tissue helps to decrease the height of the scar and to render the tissue of the scar softer. When performed correctly, the damage caused by the laser is limited to the underlying dermis; the epidermis is largely not affected. Because the skin barrier is not breached, infection rates are low. Hyperpigmentation can be reduced with laser therapy in some cases.

In scars that are significantly depressed relative to surrounding tissue, some filler material may be added to correct the contour deformity. For this method to be effective, the skin must be pliable. Consequently, soft tissue augmentation works poorly in heavily fibrotic areas. Collagen injections or fat transfers can be introduced into areas of depressed scar to elevate the skin and make the area less noticeable. These biologic tissues are derived from autologous or allogenic sources.

Collagen is obtained from processed dermis, while lipocytes needed for fat transfers are obtained via liposuction prior to augmentation. Bovine collagen is also used, with the peptide ends of the collagen molecules cleaved enzymatically to diminish their antigenicity. A disadvantage of this material is that skin testing is required before injecting bovine collagen because 1-4% of patients have hypersensitivity responses. Collagen preparations used in the skin include Zyderm I and Zyderm II. Zyderm I is a 35-mg/mL collagen used in areas of thin skin, and Zyderm II is 65-mg/mL collagen used in areas of thicker skin. Collagen and fat injections last only a few months, and repeated injections may be necessary for correction of scar contour deformity. Other filler materials such as hyaluronic acid derivatives (eg, Juvederm, Restylane, and Perlane) can be used and do not require any skin testing.

Other options in soft tissue augmentation are processed acellular dermal matrix materials. These are widely available. They are treated to remove cells; therefore, they carry a very low risk of prion-related disease transmission. The processed acellular dermal matrix materials last longer than collagen or fat injections, but the dermal matrix must be implanted.

All of these are temporizing measures and do not provide long-term correction of the depressed scar. Permanent implants consisting of Gore-Tex, Softform, or Silastic (polytetrafluoroethylene) are long-lasting options. Hyperemic scars can be treated with nonablated lasers (pulse light).

Dermabrasion is a good technique for slightly raised scars. Dermabrasion does not treat the scar itself; it planes-down the surrounding skin, which makes the raised scar less noticeable. The skin is planed or sanded with a dermobrader, stripping away layers of the superficial dermis and epidermis. Regeneration of these layers then proceeds from the dermal appendages. The effects of dermabrasion are very operator dependent. Variations in abrasion either more superficially or too deep produce either a suboptimal effect or greater scarring, respectively. Because portions of the dermis are removed and the skin barrier is breached, dermabrasion has an associated risk of infection. Patients must be questioned about a previous history of herpes simplex infection, isotretinoin use, or previous surgeries in the affected area. Ablative lasers (eg, carbon dioxide, erbium) can also be used to decrease raised scars.

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