Scar Revision - Results with Surgical Therapy

Revision of scars of the face and neck is particularly important to patients. Scars can be aesthetically displeasing, but in some areas, form and function should be taken into consideration and should not be compromised. It requires a thorough understanding by the surgeon of the patient's dissatisfaction with the scar and a thorough understanding of the patient with regard to options in revision and realistic final results. As with other cosmetic procedures, the main goal is to make the patient more comfortable with his or her appearance, even though the deformity may not be completely alleviated. Teamwork between the physician and patient helps ensure the optimal result in scar revision. A successful scar revision can bring great satisfaction to both parties and improve the doctor-patient relationship.

Surgical interventions

For longer-term results when treating displeasing scars, surgical intervention is often a better option. Surgical treatments include fusiform scar excision, shave excision, partial or serial excisions, local flap coverage, skin grafting, and pedicled or free flaps. In all surgical closures in the skin, care should be taken to evert the skin edges slightly so that upon healing and wound contracture, the scar will be level with the surrounding skin. In closing the wounds, tension should be avoided and should not cross the joint line in linear fashion.

Fusiform excision involves incision around the scar in an elliptical pattern, and the ellipse is then removed. The resulting surgical scar should be thinner and more easily hidden. Care should be taken to reorient the scar if need be when using fusiform excision. In this manner, the scar can be brought to lie in the relaxed skin tension lines of the skin, placing the wound such that it is subject to forces primarily along its axis. Forces counter to the long axis of the wound serve to prolong healing time, widen the scar, and yield a less aesthetic final result.

Some patients may have scars that are too large to be excised in one sitting, and they may have insufficient available skin for local skin flap closure. An ellipse can be excised from the center of the scar, removing as much as possible while still allowing for primary closure. The sides of the wound are undermined in order to close the defect. After several consecutive operations, the scar tissue should have been nearly removed, so that in the final surgery, an ellipse can be designed to remove all scar tissue present. The result is a thin surgical scar where a wide scar had been. If scars are too wide, staged excision can be considered.

Tissue expanders can be placed around the scar to provide more skin and allow for greater excision of scar tissue while facilitating primary closure. Indications for tissue expansion in scar revision of the head and neck are an inadequate quantity and quality of surrounding skin or a determination by the surgeon that too great a morbidity would be associated with local flap revision of the scar. Because the skin of the head and neck is thinner than elsewhere on the body, the recommendation is that no larger than 400 mL be used in tissue expansion in these areas.

Another useful technique in scar revision is shave excision. Shave excision is especially useful in scars that are unsightly by virtue of their elevation relative to surrounding tissue. The elevated portion of the scar is shaved off in a parallel plane to the surrounding skin, and the wound is dressed to help prevent reoccurrence. Compressive-type dressings or silicone dressings are helpful in this regard.4

When normal tissue surrounds a scar in sufficient quantity, local flaps can be used to fill defects left after scar excision, to move scars into areas that are less noticeable, or to break up the lines of a scar. Local flaps should also be planned so that the scars come to lie in the relaxed skin tension lines of the body or lie along the borders of the aesthetic units of the face for optimal camouflage of the scar. Scars perpendicular to the relaxed skin tension lines or those crossing aesthetic units of the face are usually very noticeable. Local flaps are discussed in detail in Advancement Flaps, but 2 flaps deserve mention here. The Z-plasty and W-plasty can be used to break up a linear scar into smaller components and to change the orientation of a linear scar, making it less noticeable. The resulting scar is longer but more camouflaged than the original.

The Z-plasty is a double transposition flap and may be used in the revision of scars and scar contractions. The Z-plasty elongates the operated tissues. The design involves the exchange of 2 adjacent triangular flaps with a central limb and 2 limbs oriented to resemble a Z. The length of the central limb dictates the absolute gain in length after Z-plasty, while the angles chosen determine the percent of length increase. The typical Z-plasty has 60° angles, resulting in a gain in length of 70% relative to the central limb. The angles may range from 30-90°, providing gains in length of 25% and 120%, respectively. However, these gains are theoretical. Therefore, smaller gains are seen in practice, owing to restrictive skin factors.

Because the Z-plasty also requires normal adjacent skin, it is a poor choice for the correction of burn wound contractures. However, the gain in length provided by the Z-plasty is well suited to other scar contractures, and the changed axis of the final scar often provides a more aesthetic result in facial scar revision. In plotting a Z-plasty, the final position of the central limb is planned first. This portion of the new scar is perpendicular to the original central limb incision and should lie parallel to relaxed skin tension lines. Consecutive Z-plasties result in further transposition of skin and obliteration of straight-line scars. Sequential Z-plasties create transverse shortening and lateral tension on the wound.

The W-plasty is also used to change the orientation of portions of a linear scar, although many smaller triangular flaps are interposed among one another. The base of each triangle is adjacent to the base of the triangle opposed to it. Unlike the Z-plasty, the W-plasty does not confer any gain in length to the contracted scar line. The W-plasty increases rather than decreases lateral tension, and skin must be sacrificed in its construction. Therefore, the procedure should only be undertaken in areas of scar with excess adjacent skin. At the ends of the scar to be revised, the triangles should sequentially diminish in amplitude.

Z-plasties and W-plasties are creative techniques for breaking up a scar and making it less noticeable. Other so-called geometric broken-line closures often result in a geometric scar that looks unnatural and confers little or no improvement in the scar and should therefore be avoided in favor of easier, more effective closures such as Z-plasty, W-plasty, or local flaps.

Another type of unaesthetic scar is the trap-door deformity, or pincushioning. This phenomenon may occur in instances of a healed curvilinear wound. The center of the tissue becomes elevated relative to the surrounding skin. Correction of the pincushion deformity should not be performed until the maturation of the scar is complete. Techniques for revision of this deformity are excision of the old scar, defatting of the flap, and closure with Z- or W-plasty to provide a more cosmetic result.

Complications

The complications of scar revision are dehiscence, infection, and local effects such as erythema. The complication patients are most concerned with is recurrence of the original unaesthetic scar.

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