The field of scar revision is not just about cosmetic improvement; it involves a comprehensive approach that includes patient assessment, detailed planning, and selection of the most appropriate technique tailored to the individual’s needs and scar characteristics. Understanding the biology of scar formation and maturation, the factors influencing scar development, and the psychological aspects of living with a scar are crucial for practitioners to provide effective treatments and manage patient expectations.
Indications
Types of Scars
Keloid Scars
Keloid scars result from an overly aggressive healing process, extending beyond the original wound boundaries. They form thick, puckered, and itchy clusters of scar tissue, which can grow much larger than the initial injury. Keloids are more common in individuals with darker skin tones and can recur after removal, often requiring multiple treatment strategies for improvement. They occur most often on the ears, chest, and shoulders.
Hypertrophic Scars
Hypertrophic scars are raised, often red scars that stay within the boundaries of the original wound but may be thick and uncomfortable. Unlike keloids, hypertrophic scars may improve on their own over time or respond well to nonsurgical treatments aimed at reducing their prominence.
Widened Scars
Widened scars usually result from wound separation during the healing process. This is usually due to the presence of tension perpendicular to the suture line. Closure of an incision without the presence of deep sutures, especially in an area that is under tension, increases the chance of the incision widening once the superficial sutures are removed or dissolved. Widened scars may appear flat or depressed relative to the adjacent tissue.
Atrophic Scars
Atrophic scars are characterized by a loss of tissue, resulting in a depressed area on the skin surface. These scars are often the result of acne or chickenpox, leaving pits or dents in the skin that can be particularly challenging to treat due to the loss of underlying support structures. Such scars may also arise from steroid injections into the skin, aimed at treating hypertrophic processes.
Stretch Marks
Stretch marks represent a form of skin scarring marked by an off-color hue, caused by tearing of the dermis during periods of rapid growth or changes in body size. These scars can be particularly distressing for individuals, as they often appear on visible areas of the body such as the abdomen, thighs, and breasts.
Technique
Patient Assessment
A thorough patient assessment is paramount in scar revision. This process involves not only a detailed examination of the scar itself but also an understanding of the patient’s overall health, skin type, and healing history. Psychological readiness and realistic expectations play a critical role in the selection process for scar revision procedures. Patients should be assessed for their ability to undergo the treatment process, which may involve multiple procedures and a commitment to postoperative care.
Patient Preparation
Effective patient preparation is a cornerstone of successful scar revision. This includes a comprehensive review of the patient’s medical history, lifestyle factors such as smoking and sun exposure, and any medications that could affect healing or bleeding. Detailed photographic documentation of the scar from multiple angles and in different lighting conditions is essential for planning the treatment strategy and assessing its effectiveness over time. A comprehensive discussion about expectations in terms of new scar positioning and the need for additional care (gels, creams, steroid and chemotherapy agent use, and radiation therapy), if appropriate, should be brought up before initiating any treatment plans.
Anesthesia
The choice of anesthesia is a critical component of the scar revision process, ensuring patient comfort and optimizing conditions for the best possible outcome. Local anesthesia is suitable for most scar revision procedures, allowing patients to recover quickly and with minimal discomfort. For more extensive revisions, or in a pediatric population, sedation or general anesthesia may be necessary, requiring a more significant recovery period but providing a pain-free experience during the procedure.
Treatment Options
Excision and Closure
Excision and closure represent the foundational approach to scar revision, involving surgical removal of the scar, followed by careful suturing of the incision ( Fig. 36.1A and B ). This technique is particularly effective for wide or irregular scars, where the goal is to create a new, thinner, and less noticeable scar. The key to successful excision and closure lies in meticulous surgical technique, including skin incision at a 90-degree angle through the epidermis and dermis, precise alignment of skin edges, appropriate undermining in the subcutaneous plane, and the use of sutures that minimize tension on the wound. In the facial region, excision and closure are particularly applicable to areas in which the final scar can be positioned along borders, facial subunits, or inside creases.
(A) Patient with large widened scar/keloid on the left cheek prior to scar revision. Complete surgical excision is required to reapproximate normal adjacent tissue. (B) Immediately status post scar revision with scar carefully positioned to fall into nasolabial fold. Slight lateralization of the left oral commissure is noted. Patients may be reassured that this typically resolves by 3 weeks post op.
Geometric Broken Line Closure, W-Plasty, and Z-Plasty
These techniques reorient and break up the linear pattern of scars, making them less noticeable. Z-plasty modifies the tension direction of the scar, often improving its functionality and appearance ( Fig. 36.2A – C ). It also allows the introduction of adjacent tissue and lengthening of contracted areas, with increasing internal Z angles recruiting more tissue into the area. This can be particularly beneficial when managing contracted scars around lips and eyelids. Geometric broken line closure (GBLC) and W-plasty are utilized to disrupt the straight lines of a scar, blending it more seamlessly with the surrounding skin texture and making scar lines deliberately inconspicuous ( Fig. 36.3A – C ). It is important to include excision of the apical triangles at either end of the planned GBLC to avoid creating a dog ear deformity. For the remainder of the design, the two limbs should mirror each other in design in a lock-and-key fashion.
