Summary

Cutaneous scars are results of earlier surgery trauma, or inflammatory processes, e.g., acne. The injury may be cosmetically distressing or may distort functional anatomy. Thus, the aim of scar revision is the achievement of an aesthetically pleasing or less visible scar. Scars can be categorized by various descriptive characteristics, including contour, shape, length, width, color, and function. Recognition and analysis of these unique characteristics, along with the scars’ location and place, will aid in determining the proper technique or combination of procedures in revising a given scar. The improvement of scars of either cosmetic or functional impairment is the goal of scars revision. Numerous revision procedures are available to correct the various types of injuries. No one treatment or procedure is effective in correcting all types of scars. Therefore, knowledge, understanding, and experience in using a variety of techniques are vital to do acceptable results.

Cutaneous scars are results of earlier surgery trauma, or inflammatory processes, e.g., acne. The scar may be cosmetically distressing or may distort functional anatomy. Thus, the aim of scar revision is the achievement of an aesthetically pleasing or less visible scar. Various techniques, both surgical and nonsurgical, are available for the correction of cutaneous scars. Knowledge and experience in the use of these techniques are necessary to do desirable results. Scars can be categorized by various descriptive characteristics, including contour, shape, length, width, color, and function. Recognition and analysis of these unique characteristics, along with the scars’ location and place, will aid in determining the proper technique or combination of procedures in revising a given scar. Scar revision is aimed at the improvement of scars of either cosmetic or functional impairment. Numerous revision procedures are available for the correction of the various types of injuries. No one treatment or procedure is effective in correcting all types of scars. Therefore, knowledge and understanding, and experience in the use of a variety of techniques are vital to do acceptable results.

The Elevated Scar Treatment (revision)

Elevated scars can be caused by the closure of wounds under tension or due to the opposition of wound edges at varying levels, creating a step-off deformity. Full-thickness grafts may also leave an elevated scar in the reconstruction site. Dermabrasion is a highly effective procedure in the effacement of higher scars. It is advisable to let the patient know even before the first surgery that I may need dermabrasion.  The best time for performing the procedure is eight weeks post-surgery. These scars usually respond well to injections of intralesional steroids. Triamcinolone acetonide at a dosage of 10-40mg/cc is injected directly into the scars at intervals of 3-4 weeks. It would be best if you took care not to inject beyond the injury with resulting dermal atrophy, telangiectasias, and hypopigmentation. In some instances, improvement can be achieved by excision of the scar in fusiform fashion with care to reduce undue tension by placing the excision in the direction of relaxed skin tension lines, undermining, placement of buried absorbable intradermal sutures, as well as precise apposition of wound edges.  Additionally, the planning of the higher scar with a scalpel or razor blade has been used for flattening more elevated scars.

The Depressed Scar Treatment (revision)

Depressed or indented scars may result from performing a deep shave biopsy, curettage and electrodesiccation, suturing wounds with deficient wound eversion, or healing wounds complicated by the formation of hematomas or infection. A simple fusiform excision with attention to wound eversion can correct the indentation in most of these cases. Wound eversion can be carried out using buried vertical mattress intradermal sutures. Cutaneous sutures placed 90 degrees to the skin surface with eversion of opposing skin edges with skin hook or forceps. Dermal vertical mattress sutures can also help in achieving good wound eversion. However, they may leave unsightly suture marks. Soft tissue augmentation employing injectable autologous fat or other above-mentioned dermal fillers can elevate depressed scars.

The Widened Scar Treatment (revision)

Widened or spread scars occur with time in wounds closed under tension. They often form on the back, chest, or scalp areas. If possible, the injury can be excised parallel to the direction of the relaxed skin tension lines, widely undermined, and sutured with buried intra-dermal sutures. Some advocate the placement of nonabsorbable buried sutures such as nylon or polypropylene. Permanent anchoring or tethering sutures placed to the underlying periosteum or perichondrium may also decrease the chance of later scar spreading.

The Long Linear Scar Treatment (revision)

Several techniques have been used to break up the appearance of a long unsightly linear scar. The rationale behind these techniques is that a scar formed of multiple small scars is less perceptible than one long scar. W-plasty or geometric broken line closures are designed as a series of “W” s or unpredictable geometric figures advanced to interdigitate with a similar pattern on the opposite side of the scar. These procedures, however, are time-consuming to build and execute with proper wound approximation and can worsen the appearance of a scar. Dermabrasion may be a more straightforward technique to implement that gives better and more consistent results. At times a re-excision should be performed, followed by dermabrasion.

The Trap doored Scar Treatment (revision)

Trap dooring (or pincushioning) usually occurs after reconstructing severe defects with round-shaped or island pedicle flaps. Underlying wound contraction seems to cause elevation of the center and depression of flap edges. I can minimize the chances of trap dooring if the flap is thinned and placed flat in defect following extensive undermining. Treatment of trap dooring consists of injections of intralesional steroids and, if necessary, an incision along flap scar line and removal of underlying scar tissue with extensive undermining. Dermabrasion using a motor-driven abrader or performed by manual dermabrasion will achieve improved cosmesis as well.

The Contracted Scar Treatment (revision)

Scars transversion concavities may contract and result in painful, unsightly scars. I can usually prevent this by designing the incision to be sinuous rather than a straight line. Using multiple Z-plasties makes it possible to elongate, regularize, and flatten the contracted surgical scar. Z-plasty, one of the original techniques employed in scar revision, is a transposition flap in which equal-size triangular flaps (two or more) are transposed. The main indications for its use are: increasing scar length, effacing and elongating tight contracted scars, changing directions of scars, effacing webbed scars, or shifting malposition facial landmarks. When used to lengthen a contracted scar, the degree of lengthening can be controlled by the alteration of the angles of the transposition flaps. The higher the angle, the greater the degree of lengthening.

The Webbed Scar Treatment (revision)

As mentioned above, scars transversion concavities can contract to form a short straight line. When it occurs in the inner canthal area, the result is a tented or webbed deformity. Revision using one or more Z-plasties, as described above, can repair the defect by changing the direction of tension on the scar with the effacement of the webbing.

Distortion of Free Margins Treatment (revision)

Following reconstruction, with flaps or grafts, a resulting scar may contract against a free structure such as the vermillion border ensuing eclabium. The lower lid can also be pulled down by scar contracture, causing ectropion. Two or more small 60-degree Z-plasties are helpful to lengthen the scar and allow the pulled free vermillion border to return to its normal position. The repair of the ectropion of the lower lid is corrected with a full-thickness skin graft. The incision is made in the lower lid and placed as high as possible under the lash line. The graft is sutured into place, and traction is placed on the graft with inter-marginal sutures (or Frost sutures). These sutures are left in place for one week to heal graft in the maximally expanded state. In a few cases, skin grafting is combined with a horizontal tightening procedure as the skin replacement alone will not restore the lid to its original position.

The Notched Nostril Scar Treatment (revision)

I can use various techniques to repair pulling up or notching of the nostril or alar rim. Distortion or notching of the ala can follow nasal reconstruction. Time alone may allow enough scar relaxation for the ala to return to its normal position. Intralesional steroids can hasten the process. If, after 6-9 months, the ala has not resumed its normal position, I should consider one of the various revision techniques. A Z-plasty or the use of multiple convergent triangle flaps can shift the nostril base forward to the level of the alar margin. Convergent triangle flaps are equal to various Z-plasties but more natural to execute and suture. Notching can be corrected by using a composite graft harvested from the helix, anthelix, anterior crus, or tragus, trimmed, and sutured in place. For significant alar defects, a hinged flap can be created from the skin at once superior to the fault and serve as the inner lining over which a composite graft will be placed. A two-stage pedicle flap may be used from the nasolabial fold. The flap is turned on to supply an inner lining, and the pedicle is severed after three weeks.

Dermabrasion has many applications as a skin resurfacing technique and is used to treat fine perioral rhytids and fine wrinkles found in other regions of the face. Rhinophyma is another disease of the face often treated with dermabrasion. It is characterized by granulomatous infiltration of the nose, making it appear larger and bulbous. With dermabrasion, the nose is debulked, and rapid re-epithelialization follows. I can sometimes treat premalignant and superficial malignant lesions of the skin with dermabrasion. Actinic keratoses, basal cell carcinomas, and squamous cell carcinomas have been successfully treated using skin-resurfacing techniques. Dermabrasion may also be used to revise scars from trauma, skin grafts, acne, and surgical incisions.

Recently in a comeback for dermabrasion, various methods of derma-sanding have been added, using various carpentry tools such as drywall/plaster sanding screen or moistened silicon carbide sandpaper to manually dermabrader the skin. One of the most effective but operator-dependent therapies is dermabrasion. Its benefits include the removal of the skin surface and refined contouring of scars. Dermabrasion was the first significant advance in the treatment of atrophic and traumatic scarring. It is best to treat grade 3 rolling scars and tighten the skin in an older patient with scarring. The sharp edges of some acne scars cast a shadow that emphasizes the lesion’s contouring reduces these contrasts, lessening their visible impact. I can achieve the essential removal of superficial scars along with a reduction of deeper scars. In addition, it may be used as an adjunct to surgical procedures such as punch elevation or grafting. A few weeks before the performance of dermabrasion, patients can be pre-treated with tretinoin (Retin-A). This medication promotes wound healing by increasing collagen formation. For patients at risk of hyperpigmentation postoperatively, hydroquinone, a bleaching agent, may be prescribed before the procedure. Dermabrasion is performed in an office-based procedure room, surgery centers, and occasionally in the hospital. It is done under local anesthesia with the choice of sedation or general anesthesia. Regional blocks are effective, and added topical anesthetics might be used to freeze the skin. If sedation or general anesthesia is used, I must check patients appropriately. The surgical team must wear proper sterile attire, including a mask with a face shield. Protection from blood exposure and aerosolized particles during the procedure is essential, especially when treating patients with a history of HIV or hepatitis.

The area to be dermabrader is marked and may be divided into sections when dealing with large surface areas to ensure uniformity. A good diamond fraise tip or a wire brush is chosen and attached to the headpiece. The skin is held taut with one hand or held by an assistant, and the dermabrader is moved across the skin with constant, gentle pressure. A back-and-forth motion is used for the diamond fraise tip, but the wire brush is moved in one direction. The borders of the treated area are feathered to prevent any noticeable transitions. The dermabrader’s depth of skin is one of the most critical factors that will determine the outcome. No bleeding is seen while treating the epidermis because of the lack of vasculature. Punctate bleeding is visualized when entering the papillary dermis. The papillary reticular junction is the ideal endpoint of dermabrasion and is found by increased, confluent bleeding. Dermabrasion beyond the reticular dermis can lead to significant scarring. Immediately following the procedure, you may temporarily place saline-soaked gauze moistened with dilute epinephrine on the open wounds to achieve hemostasis. A moist environment is necessary to promote wound healing. Multiple petroleum-based products are available to keep a moist environment and prevent desiccation, such as Aquaphor and Xeroform gauze. The wound is cleaned daily, and the ointment is applied as necessary. Re-epithelialization has been completed 7 to 14 days following the procedure.

Patients should minimize sun exposure or wear proper sunblock for 6 to 12 months following the procedure to avoid hyperpigmentation. Hydroquinone may be used to treat any hyperpigmentation seen after dermabrasion. Residual erythema and edema should be expected to last 1 to 2months, and non-allergenic makeup is worn during that time. Recovering from dermabrasion usually lasts 2 to 4 weeks. Patients can return to work within two weeks. Although dermabrasion is an effective skin resurfacing tool, there are associated complications that physicians and patients need to be made aware of. Abnormal scarring, including the formation of hypertrophic scars and keloids, can potentially occur if dermabrasion is performed beyond the reticular dermal layer. It is also seen in patients with a genetic predisposition, such as collagen disorders, and those taking certain medications. I can avoid hyperpigmentation and hypopigmentation with proper patient choice and perioperative care. Patients with Fitzpatrick skin types I and II are less likely to experience pigment changes. Patients are instructed to avoid excessive sun exposure; however, I can prescribe hydroquinone to treat unwanted hyperpigmentation. I can treat infectious complications with antibiotics and antiviral therapy. Patients with a history of a herpes outbreak are treated prophylactically with antivirals. Dermabrasion should be used with caution in patients with active acne and may need antibiotic treatment before undergoing the procedure. The formation of milia, small white keratin-filled cysts, may be seen the following dermabrasion and usually resolve spontaneously, but they can be treated with incision and drainage when necessary. Dermabrasion remained constant in technique for more than 100 years apart from some refinements in patient choice and end pieces. More recently, the literature on abrasive treatment has centered on adding cosmetic uses and proper anesthesia for this procedure.

Scars Treatment. Surgery. Medium-depth TCA Chemical Peel & CROSS

The medium-depth peels are primarily considered to be 10% to 40% TCA solutions. It is a safe and effective modality in dark-skinned patients for the treatment of post-acne scarring. It has also been combined with dermabrasion to increase efficacy and decrease postoperative pain and complications. As with any resurfacing procedure, a proportion of patients will develop post-inflammatory hyperpigmentation. Chemical peeling is cost-effective, and where expensive recurrent laser technologies do not exist or are not practical, it is an excellent alternative resurfacing technique. Application of TCA to the skin causes cellular necrosis of the epidermis and necrosis of collagen in the papillary and reticular dermis. A variation of chemical peeling involving the use of 60% to 100% trichloroacetic acid, termed the CROSS technique, has raised interest in treating the smaller ice pick and boxcar type scars, which have always been used proved a challenge. This modality scars the inside of the already cylindrical scar, making it cosmetically more appealing. A similar concept has been discussed with the use of high-energy CO2 lasers. After 3 to 6 treatments, 90% of patients showed good (50%-70%) improvement. The peels considered to be deep are often phenol (carbolic acid) or croton oil-based. These can certainly be more effective but carry an even more significant potential for side effects.