Other Scars Types and Their Treatment
Cutaneous scars are results of earlier surgery trauma, or inflammatory processes, e.g., acne. The scar may becosmetically distressing or may cause distortion of 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 revision of cutaneous scars. Knowledge and experience in 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 techniques in revising a given scar.
Scar revision is aimed at improvement of scars of either cosmetic or functional impairment. Numerous revision procedures are available for correction of the various types of scars. No one treatment or procedure is effective in correcting all types of scars. Therefore, knowledge and understanding as well as experience in use of the variety of techniques is vital to do acceptable results.
The Elevated Scar Treatment
Elevated scars can be caused by closure of wounds under tension or due to apposition of wound edges at varying levels causing a step-off deformity. Full-thickness grafts may also leave an elevated scar in the reconstruction site.
Dermabrasion is a highly effective procedure in effacement of higher scars. It is advisable to let know the patient even before original surgery that a dermabrasion may be needed. The best time for performing the procedure is 8 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. Care must be taken not to inject beyond the scar 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 meticulous apposition of wound edges. \
Additionally, planning of the higher scar with a scalpel or razor blade has been used for flattening of higher scars.
The Depressed Scar Treatment
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 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 by using buried vertical mattress intradermal sutures and cutaneous sutures placed 90 degrees to skin surface with eversion of opposing skin edges with the aid of skin hook or forceps. Cutaneous 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
Widened or spread scars occur with time in wounds closed under tension. They often form on the back, chest, or scalp areas. The scar can be excised, if possible parallel to direction of the relaxed skin tension lines, widely undermined, and sutured with buried intra-dermal sutures. Some advocate 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 for later scar spreading.
The Long Linear Scar Treatment
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 a scars appearance. Dermabrasion may be an easier technique to execute that gives better and more consistent results. At times a re-excision should be performed followed by dermabrasion.
The Trap doored Scar Treatment
Trap dooring (or pin cushioning) usually occurs following reconstruction of deep defects with round-shaped or island pedicle flaps. Underlying wound contraction seems to cause elevation of the center and depression of flap edges. The chances of trap dooring can be minimized if the flap is thinned and placed flat in defect following wide undermining. Treatment of trap dooring consists of injections of intralesional steroids and if necessary, incision along flap scar line and removal of underlying scar tissue with wide undermining. Dermabrasion using a motor-driven abrader or performed by manual dermabrasion will achieve improved cosmesis as well.
The Contracted Scar Treatment
Scars transversion concavities may contract and result in painful unsightly scars. This can be usually prevented by designing the incision to be sinuous rather than a straight line. By using multiple Z-plasties it is 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 greater the angle the greater the degree of lengthening.
The Webbed Scar Treatment
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 direct of tension on the scar with effacement of the webbing.
Distortion of Free Margins Treatment
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. Repair of ectropion of the lower lid is corrected with a full-thickness skin graft. Incision is made in 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 1 week to allow healing of graft in the maximally expanded state. In a few cases the 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
Various techniques can be used for repair of 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, one of the various revision techniques should be considered.
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 multiple Z-plasties but easier to execute and suture. Notching can also be corrected by using a composite graft, harvested from the helix, anthelix, anterior crus, or tragus, which is trimmed and sutured in place. For large alar defects a hinge flap can be created from the skin at once superior to the defect 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 itself to supply an inner lining and the pedicle is severed after 3 weeks.
Timing of Scar Treatment (Revision)
The best time for scar revision may differ from scar to scar and patient to patient. Often with time spontaneous softening, fading or flattening may occur yielding acceptable cosmetic results. During this period the patient needs to be encouraged that their scar will improve in time. Makeup can be used as an important adjunct to scar revision and camouflage and decrease levels of anxiety until the corrective revision is performed. Optimal time for performing dermabrasion is 8 weeks. Revision of scars with significant dermal components is usually delayed until 6-9 months after first surgery to allow for scar maturation.