Scar Revision


Article Author:
Jessica Tullington


Article Editor:
Rick Gemma


Editors In Chief:
Amanda Oakley
Jules Lipoff
Shyam Verma


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
5/17/2019 7:27:45 AM

Introduction

After an injury, the skin attempts to restore its normal blood flow and function: this occurs through a very orderly three-phase process known as wound healing. The three steps or phases of wound healing are inflammation, proliferation, and maturation. A study by Dunkin et al. found permanent scars occur when the reticular dermis has been violated. Scars are a natural and normal part of healing following an injury to the integumentary system. Ideally, scars should be flat, narrow, and color matched. Several factors can contribute to poor wound healing. These include but are not limited to infection, poor blood flow, ischemia, and trauma. Proliferative, hyper-pigmented, or contracted scars can cause serious problems with both function and emotional well-being.[1][2][3] 

Anatomy

The skin is a vital organ providing barrier protection as well as thermal regulation. The three layers, starting with external, are the epidermis, dermis, and subcutaneous fat. The dermal layer accounts for about 90% of the integumentary system. The dermis is composed of fibroblasts, blood vessels, nerve endings, hair follicles, and sweat glands.[4]

The injury immediately initiates the first process of wound healing, inflammatory phase. The inflammatory phase lasts about 2 to 5 days.[5] The proliferative phase starts about 3 days after the injury and can last for weeks. The proliferative phase lays a framework for repair. The proliferative phase encompasses angiogenesis, fibroplasia, and epithelialization. The final step is maturation. Wound contraction occurs during the maturation phase and is due to myofibroblasts.[5][6]

Scar assessment is usually by vascularity, pigmentation, pliability, area, and height.[7] Immature scars are generally red to pink, may be itchy or occasionally painful. Immature scars are typically still in the remodeling phase. Mature scars are usually flat and light.[8] Keloids and hypertrophic scars are believed to be a result of chronic inflammation in the reticular dermis. Pro-inflammatory factors have also been shown to undergo up-regulation in keloid tissue as well as fibroblasts.[8][9]

Indications

A patient will seek scar revision for a variety of reasons. There are both physical and emotional reasons a patient may want their scar revised. Scars can have functional limitations on areas of mobility or that lack tissue laxity, causing contractions. If scar revision is for limitation in range of motion, then restoring function is the primary goal of the procedure. Scars can also be extremely painful, especially if a neuroma is present. The scar can also be a reminder of the trauma a patient has faced in the past. They may simply wish to erase these memories. And, finally, it can cause social embarrassment. All these reasons are indications for scar revision. The physician should be sensitive to the emotional and physical aspects of these patients.[8][10][11] It is important to note that scars take about 12 to 18 months to mature. Immature scars lead to poor results after a revision.[12]

Contraindications

Patients should receive counseling on scar revision expectations. The purpose of scar revision is to create a more acceptable and diminished scar; it is not to eliminate a scar altogether. Contraindications include any situation in which the new scar will be worse or limit function.

Anticoagulants should be held prior to the procedure. Patients that cannot be off anticoagulation should not undergo elective scar revision.

It is important to note patient factors that lead to suboptimal healing. A balanced diet is crucial for protein building, which is necessary for healing. Vitamins and minerals, notably vitamins A, C, and E, and zinc are integral to wound healing. Medical conditions can also hinder wound healing. Most notably, is diabetes mellitus. Additionally, patients taking immunosuppressive medications are at increased risk of suboptimal healing. Tobacco use also limits wound healing.[12][13]

Equipment

Equipment includes a functional and staffed operating room with basic general surgery equipment.

Personnel

Personnel needs include a staffed operating room with a surgeon that is versed in scar revisions.

Preparation

Smoking is associated with an increased risk of surgical site infection and poor wound healing. All patients should undergo smoking cessation education and be smoke-free for at least 30 days before scar revision. Patients should have their glucose under control with blood glucose levels less than 180 mg/dL.[12][13]

The patient should remain NPO after midnight if any sedation or general anesthesia is planned for the operation. Patients can take most, if not all, their normal medications the morning of the procedure. Aseptic practice and sterile technique are necessary for all procedures.

It is essential to carefully plan the incision before making a cut. The surgeon should identify relaxed skin lines or the desired orientation of the scar. Preoperative marking should be placed appropriately to correspond with these lines and ensure the skin edges will be closed successfully without tension.[14]

Technique

There are surgical and nonsurgical options for scar treatments. The initial assessment should focus on starting with the most straightforward option first and progressing from there. There are nonsurgical and surgical options for scars.

Nonsurgical

Steroid injections have been used for years for keloids and hypertrophic scars. Typically triamcinolone is used. The steroid is diluted to a concentration of 2.5mg/mL. Approximately 0.1 mL is injected per 5 to 8 mm of a linear scar. Patients are instructed to massage the area for 24 hours after injection. Injections occur every 4 weeks. Care must be taken to not over- inject the area. Over-injection can cause adverse outcomes such as surrounding telangiectasia, dermal thinning, and fat atrophy causing dimpling.[10] There are reports of adverse effects in up to 63% of patients undergoing injections. Intralesional 5-fluorouracil has been shown to be effective in minimizing hypertrophic scars. Intralesional cryotherapy has also been shown to be effective. However, up to 75% of patients report adverse effects.[12]

Ablative laser resurfacing is effective at scar revision. Both the carbon dioxide and the erbium: YAG laser cause superficial scar ablation. The carbon dioxide laser causes collagen remodeling. The erbium YAG laser is also beneficial on multiple types of scars. Adverse effects include hyperpigmentation from the laser.[12]

Soft tissue fillers are a method for depressed scars. Depressed scars are typically caused by scarring in the deep tissue or tethering to the deeper tissue.[15] Bovine or human collagen, fat, hyaluronic acid, and synthetic fillers have been shown to have good cosmetic outcomes.[12]

Dermabrasion is useful for acne scars. It helps level textured skin and smoothes any irregularities. It uses a sterile sandpaper or wire brush to erode the skin evenly.[16] The ideal timing is within 6 to 8 weeks of the operation as it will disrupt the remodeling phase of scar healing. The effects are very user-dependent.

Surgical options

Scar revision should focus on returning anatomic structures to correct locations, a tension-free return, atraumatic technique, and hiding the scar in a resting skin line of tension. There are multiple strategies and techniques one can use for these revisions.

Elliptical excisions are appropriate if the existing scar is already in a resting skin line of tension. The ratio of length to width should be 3 to 1, and the angle of the ends should be no more than 30 degrees to prevent a dog tail from occurring.[12] The repair must be tension free and needs to keep anatomic structures in appropriate locations.

Z-plasty is a type of tissue rearrangement. It is the most commonly used technique for scar revisions.[12] Z-plasty is a good technique when one needs to elongate an incision. The horizontal incisions also lessen the tension on the vertical segments. Increased tension prolongs the inflammatory phase leading to hypertrophy. The original scar serves as the common limb. The angle degree can be adjusted to allow greater lengthening and adjusting the orientation of the scar to align it with resting skin lines of tension.  The flaps should not include scar as this increases the risk of wound ischemia and necrosis.[1][12] Z-plasty is good for the forehead and nasolabial area because it is easy to align a scar with natural skin creases.

W-plasty is another technique for scar revision. The scar is excised using a zigzag pattern, and the interdigitated limbs get approximated. The theory behind the W-plasty is that a broken line is harder for the eye to follow. One arm of the triangle should be parallel to a resting skin line of tension. The upper and lower triangles need to correspond to allow proper alignment for closure.[1][12][17]

Flaps and skin grafts have also been used for scar revisions. These are generally the choice when the scar location is in an area where it would be difficult to mobilize the adjacent tissue.[12] Split-thickness grafts can give a poorer cosmetic effect due to meshing. One must be mindful of color-matching in both split thickness and full thickness skin grafts. The donor areas limit full-thickness grafts.[8]

Complications

Complications are typically minimal in scar revision surgery. Early complications include bleeding from the surgical site, pain, reaction to the suture material, surgical site infection, or flap necrosis. Surgical site infections are most commonly due to methicillin-resistant coagulase-positive Staphylococcus (MRSA).[18]

Delayed problems include new or recurrent contracture, hypertrophic scar, changes in skin pigmentation, nerve injury, skin atrophy, or a trap door deformity.

It is crucial to educate patients on the fact complications could lead to a less desirable scar.

Clinical Significance

Scars can cause a wide range of problems for patients, including both physical and emotional. Luckily patients do not have to live with suboptimal scars forever. There are many options for scar revision. If a patient presents with a suboptimal scar, they are potential candidates for revision. Patients wishing to undergo elective surgery should have a healthy, balanced diet, be tobacco-free, and have their comorbid conditions under control.

If the scar is due to improper technique, there are functional limitations or mal-aligned landmarks; then the patient should undergo surgical scar revision. Immature scars should not be candidates for surgical correction. Immature scars are red, itchy, sometimes painful scars that elevate above the skin. Physical exams should be performed every few months to determine maturity. Treatment for immature scars is best with adjunct therapy or lasers. Scars less than six weeks should receive adjunct treatment such as intralesional injections.

Mature scars can receive surgical treatment. The technique used is determined by the scar. Depressed scars respond best to fillers, especially autologous fat injections. Scars with minimal tissue loss can have treatment with elliptical excisions, z-plasty, and w-plasty. The option for scars with significant tissue loss is with skin grafting and flaps or serial excision using the techniques mentioned above.

Enhancing Healthcare Team Outcomes

All healthcare workers must be aware of the wound healing process. The complexity leads to multiple opportunities for chaos. Increased tension, ischemia, infection, poor nutrition, and tobacco use are among the factors that can lead to a suboptimal scar. Any injury to the reticular dermis can result in a scar. This is why the optimal approach to scar revision is with an interprofessional team, that includes physicians, surgeons, specialists, specialty-trained nurses, and when necessary, pharmacists, all collaborating across disciplinary boundaries to drive patient outcomes successfully. [Level V]


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Scar Revision - Questions

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A 23-year-old female presents to the clinic for a scar revision. She was shot in the leg two years ago, and the scar on her thigh is a constant reminder of the trauma she endured. What characteristic would lead one to believe her scar is mature for revision?



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Scar Revision - References

References

Ogawa R, Surgery for scar revision and reduction: from primary closure to flap surgery. Burns     [PubMed]
Newberry CI,Thomas JR,Cerrati EW, Facial Scar Improvement Procedures. Facial plastic surgery : FPS. 2018 Oct;     [PubMed]
Cerrati EW,Thomas JR, Scar Revision and Recontouring Post-Mohs Surgery. Facial plastic surgery clinics of North America. 2017 Aug;     [PubMed]
Nourian Dehkordi A,Mirahmadi Babaheydari F,Chehelgerdi M,Raeisi Dehkordi S, Skin tissue engineering: wound healing based on stem-cell-based therapeutic strategies. Stem cell research     [PubMed]
Lindholm C,Searle R, Wound management for the 21st century: combining effectiveness and efficiency. International wound journal. 2016 Jul;     [PubMed]
Broughton G 2nd,Janis JE,Attinger CE, The basic science of wound healing. Plastic and reconstructive surgery. 2006 Jun;     [PubMed]
Thompson CM,Sood RF,Honari S,Carrougher GJ,Gibran NS, What score on the Vancouver Scar Scale constitutes a hypertrophic scar? Results from a survey of North American burn-care providers. Burns : journal of the International Society for Burn Injuries. 2015 Nov;     [PubMed]
Sharma M,Wakure A, Scar revision. Indian journal of plastic surgery : official publication of the Association of Plastic Surgeons of India. 2013 May;     [PubMed]
Ogawa R, Keloid and Hypertrophic Scars Are the Result of Chronic Inflammation in the Reticular Dermis. International journal of molecular sciences. 2017 Mar 10;     [PubMed]
Mobley SR,Sjogren PP, Soft tissue trauma and scar revision. Facial plastic surgery clinics of North America. 2014 Nov;     [PubMed]
Moran ML, Scar revision. Otolaryngologic clinics of North America. 2001 Aug;     [PubMed]
Garg S,Dahiya N,Gupta S, Surgical scar revision: an overview. Journal of cutaneous and aesthetic surgery. 2014 Jan;     [PubMed]
Guo S,Dipietro LA, Factors affecting wound healing. Journal of dental research. 2010 Mar;     [PubMed]
Hussain SN,Goodman GJ,Rahman E, Treatment of a traumatic atrophic depressed scar with hyaluronic acid fillers: a case report. Clinical, cosmetic and investigational dermatology. 2017;     [PubMed]
Hession MT,Graber EM, Atrophic acne scarring: a review of treatment options. The Journal of clinical and aesthetic dermatology. 2015 Jan;     [PubMed]
Jáuregui EJ,Tummala N,Seth R,Arron S,Neuhaus I,Yu S,Grekin R,Knott PD, Comparison of W-Plasty vs Traditional Straight-Line Techniques for Primary Paramedian Forehead Flap Donor Site Closure. JAMA facial plastic surgery. 2016 Jul 1;     [PubMed]
Sillitoe AT,Platt A, The Z-plasty simulator. Annals of the Royal College of Surgeons of England. 2004 Jul;     [PubMed]
Ratner D, Skin grafting. Seminars in cutaneous medicine and surgery. 2003 Dec;     [PubMed]

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