CHAPTER 21 Scar Revision and Camouflage

The head and neck is a prominent part of the human body and can frequently be injured as a result of trauma, burns, or surgery. With superficial injuries, most facial wounds will heal with little to no scar formation. However, once the reticular dermis has been violated, some amount of residual scarring is destined to occur. Several factors that are beyond the surgeon’s control can affect the final appearance of the scar, including the mechanism of injury, position of the wound, health status of the patient, the patient’s skin type, and the tendency to form robust scars. Factors that are under the surgeon’s control include proper realignment of wound edges, conservative débridement of injured tissues, meticulous handling of tissues during primary repair, and aesthetically favorable alignment of scars whenever possible.

After complete maturation and healing, an ideal scar should be flat and level with the surrounding skin, a good color match with the surrounding skin, narrow, parallel to the RSTLs (Fig. 21-1) or on the border of aesthetic facial subunits, and without straight, unbroken lines that can be easily followed with the eye (Fig. 21-2).¹ Scars with aesthetically unfavorable characteristics include those that are wide or misaligned with relaxed skin tension lines or aesthetic subunits, and those that are thickened, hypertrophied, or keloid (Fig. 21-3).¹ The facial plastic surgeon has many options to improve, but not eliminate, these aesthetically unfavorable scars. Successful application of various treatments requires an understanding of which techniques are best indicated when performing scar revision or treating hypertrophic and keloid scars.

Figure 21-1. Relaxed skin tension lines and creases can aid in scar camouflage. A, Nasolabial. B, Glabellar furrows. C, Horizontal forehead rhytids. D, Subunit junctions (ear and cheek).

(Adapted from Thomas JR, Holt GR. Facial Scars, Incisions, Revision & Camouflage. St. Louis: Mosby; 1989.)

Figure 21-2. A 4-cm-long incision placed in alignment with relaxed skin tension lines and closed with multilayered closure and vertical mattress sutures.

Figure 21-3. Scar on right cheek with unfavorable characteristics: depressed and not in alignment with relaxed skin tension lines.

Successful scar revision begins with a precise analysis of both the scar and the patient’s expectations. Patients often have the false perception that plastic surgery can make an existing scar invisible. The surgeon should educate the patient on the true realistic goal of surgery, which is to modify the scar to a point of maximized camouflage within the natural shadows, lines, and borders that exist within the head and neck.

Excision

A cardinal principle of surgery is that the best treatment of any complication is primary prevention. For scar revision, this translates into the use of proper technique when closing any wound primarily. When presented with wounds that were not closed properly, re-excision with meticulous closure may be all that is needed. Re-excision should be done by use of fusiform shape with 30-degree angled ends positioned within RSTLs when possible (Figs. 21-4 and 21-5). A slight vertical bevel outward from the original scar will prepare the wound edges for proper everted closure. Routine undermining of 1 to 2 cm around the periphery of the wound allows reapproximation of the skin edges with minimal tension. The use of buried subcutaneous sutures further decreases wound edge tension. Final eversion of the wound edges is achieved with properly placed monofilament interrupted sutures. Vertical mattress sutures can also prove helpful when wound edge eversion needs to be maximized.

Figure 21-4. Examples of proper placement of fusiform incisions with 30-degree angled ends aligned with relaxed skin tension lines and aesthetic unit boundaries.

(Adapted from Thomas JR, Holt GR. Facial Scars, Incisions, Revision & Camouflage. St. Louis: Mosby; 1989.)

Figure 21-5. A, Design of fusiform closure of Mohs defect. Note the design of a longer scar in parallel with relaxed skin tension lines to achieve 30-degree angles. B, Same patient 1 month postoperatively.

Expansion with Excision

Serial Excision

Wide scars, birthmarks, and skin grafts with poor match to surrounding tissues can all be candidates for serial excisions. In some ways, this is a variant of tissue expansion in that scarred skin is excised and adjacent normal skin brought into the defect area. Like tissue expansion, this technique relies on the skin’s biologic creep (ability to stretch over time) and is limited by the given amount of stretch attainable during each excision. Typically, older patients and those with increased skin laxity will require fewer excisions than younger patients with increased skin tone. As with all techniques of scar revision, the patient must be well informed as to the proposed number of excisions and must understand that serial excision can require months to years to complete.

Tissue Expansion

When treating larger scars, the best camouflage is afforded when abundant amounts of similar-appearing tissue can be brought into the repair. Tissue expansion can be a powerful tool to help create excess amounts of surrounding tissue. Tissue expanders are available in a variety of shapes and sizes. Studies on the gain of surface area afforded by the three most commonly shaped expanders have determined that rectangular expanders provide the greatest expansion at 38%, crescent-shaped expanders provide 32%, and round expanders provide only 25%.³ As a general rule, the base of an expander should be approximately 2.5 to 3 times as large as the area to be reconstructed.⁴

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