Scar Revision Surgery

Scar evaluation and revision techniques are chief among the most important skills in the facial plastic and reconstructive surgeon's armamentarium. Often minimized in importance, these techniques depend as much on a thorough understanding of facial anatomy and aesthetics, advanced principles of wound healing, and an appreciation of the overshadowing psychological trauma as they do on thorough technical analysis and execution.
Scar revision is unique in the spectrum of facial plastic and reconstructive surgery because the initial traumatic event and its immediate treatment usually cannot be controlled. Patients who are candidates for scar revision procedures often present after significant loss of regional tissue, injury that crosses anatomically distinct facial aesthetic units, wound closure by personnel less experienced in plastic surgical technique, and poor postinjury wound management.
An overview of scar revision is presented in this article. This overview addresses the complex preoperative considerations, basic plastic surgical techniques, wound healing biochemistry and biomechanics, preferred revision techniques based on anatomic site, and technical considerations in revisional wound closure. The author hopes that this information serves as the foundation upon which superior scar revision is learned through direct experience.

Surgery of Facial Scars
When the skin is in the process of recovering from an injury, whether the result of an accident, surgery, a burn, or acne, scarring will occur wherever multiple layers of the skin have been affected. Once a scar forms, it is permanent but may be made less visible or relocated surgically.

With very few exceptions most people are self-conscious about facial scars. Some people may also experience diminished functioning of the eyes, mouth, or nose due to scarring. If you've wondered how facial scar revision could improve your appearance, your self-confidence, or your level of facial functioning, you need to know how scar revision works and what you can expect from this procedure. This pamphlet can address many of your and provide you the information to begin considering facial scar revision surgery.
Successful facial plastic surgery is a result of good rapport between patient and surgeon. Trust, based on realistic expectations and exacting medical expertise, develops in the consulting stages before surgery is performed. Your surgeon can answer specific questions about your specific needs.
Is Facial Scar Treatment For You?
The most basic requirement for all surgery is good health. Other requirements are more subtle and should be carefully considered in discussion with your surgeon. Expectations of the surgery and of the surgeon must be realistic. A person considering facial scar revision must understand that there is no way to remove scars completely. The goal is to improve the appearance of the scar either by disguising it, relocating it, or minimizing its prominence. Skin color and type, age, and the type of scarring, are all important factors that must be part of the discussion prior to surgery.
Different types of scars respond to different plastic surgery techniques. Timing of surgery is another important choice. Some surgeons advise against any scar revision in cases of injury for a period that might extend up to a year after the injury. This interval allows the body enough time to heal fully.
Making The Decision For Scar Treatment
Whether the surgery is desired for functional or cosmetic reasons, your choice of a facial plastic surgeon is of paramount importance. Your surgeon will examine the scar in order to decide upon the proper treatment and inform you of outcomes that can be expected from facial scar revision surgery.
Different scars require different treatments. For example, severe burns that destroy large sections of skin cause the skin to heal in a puckered way. As the skin heals, muscles and tendons may be affected in this "contracting" movement. Keloid scars are a result of the skin's overproduction of collagen after a wound has healed. These scars generally appear as growths in the scar site. Hypertrophic scars, unlike keloids, do not grow out of the boundaries of the scar area, but because of their thick, raised texture, can be unsightly and may also restrict the natural movement of muscles and tendons.
Some facial scars are unattractive simply because of where they appear on the face, while others affect facial expressions. All surgical possibilities will be discussed in the initial consultation along with risks involved for each type of scarring. The agreement between you and your surgeon on how to proceed is a prerequisite for successful surgery. After you both decide to proceed with scar revision, your surgeon will inform you about the anesthesia, the surgical facility, any supportive surgery options, and costs.
Because scars are highly individualistic and the patient's attitude toward scars is so personal, maximum improvement in facial scars may require more than one procedure, and more than one technique may be employed.
Understanding The Surgery
When a scar is of the contracture type, surgery generally involves removing the scar tissue entirely. Skin flaps, composed of adjacent healthy, unscarred skin, are then lifted and moved to form a new incision line. Where a flap is not possible, a skin graft may be used. A graft involves taking a section of skin tissue from one area and attaching it to another, and time must be allowed following surgery for new blood vessels and soft tissue to form. Z-plasty is a method to move a scar from one area to another, usually into a natural fold or crease in the skin to minimize its visibility. While Z-plasty does not remove all signs of a scar, it does make it less noticeable.
Dermabrasion and laser resurfacing are methods a surgeon uses to make "rough or elevated" scars less prominent, by removing part of the upper layers of skin with an abrading tool or laser light. Clearly, the scar will remain, but it will be smoother and less visible.
Keloid or hypertropic scars are often treated first with injections of steroids to reduce size. If this is not satisfactory, the scars can be removed surgically, and the incisions closed with fine stitches, often resulting in less prominent scars.
What To Expect After The Surgery
You can expect to feel some discomfort after facial scar revision surgery. Some swelling, bruising and redness are generally unavoidable. It is important for you to follow your surgeon's after care recommendations to the letter. Though the sutures will be removed within days after the surgery, your skin needs time to heal. Surgeons generally insist on decreased activity after surgery and instruct the patient to keep the head elevated when lying down, to use cold compresses to reduce swelling, and to avoid any activity that places undue stress on the area of the incision. Depending on the surgery performed and the site of the scar, the facial plastic surgeon will explain the types of activities to avoid. No medication should be taken without first consulting the surgeon. It is important to remember that scar tissues require a year or more to fully heal and achieve maximum improved appearance.
Facial plastic surgery makes it possible to correct facial flaws that can undermine self-confidence. Changing how your scar looks can help?change how you feel about yourself.
Insurance does not generally cover surgery that is purely for cosmetic reasons. Surgery to correct or improve scars caused by injury may be reimbursable in whole or in part. It is the patient's responsibility to check with the insurance carrier for information on the degree of coverage.

 Problems

The timing of scar revision depends on a variety of factors, including type and location of injury and the psychological readiness of the patient. One popular practice adopts a 6- to 12-month waiting period following initial injury, but experience shows that this waiting period must be individualized because an earlier approach may be undertaken. Before any revision procedure, a thorough assessment includes characteristics of the initial injury, relationships to anatomic location and relaxed skin tension lines (RSTLs), likelihood of pathologic healing (eg, hypertrophic scar, keloid), and any regional functional impairment by deformity (eg, oral or ocular impairment). Surgeons should also recognize that conservative nonsurgical methods may be applicable as a primary treatment method.

Scar length, pattern, and relationship to relaxed skin tension lines
A lengthy linear scar often is more unaesthetic than a scar that is shorter or has multiple segments and covers less area. While it seems counterintuitive that more incisions actually can be less visible, a basic understanding of scar dynamic tension and of how linearity is perceived visually proves this fact.
Scars of shorter length and those that are more multiple have 2 advantages over more lengthy counterparts. First, multiplicity tends to cause the wound to be irregular, thus the eye has more difficulty perceiving the entire length of the wound from end to end because of the intervening uninvolved tissue. Moreover, lengthier linear scars have more of a tendency to bowstring over surfaces, thus creating a more noticeable scar. Although this phenomenon is more likely to occur over concave surfaces (eg, medial canthus, inferior border of mandible to neck), it also may present over convex surfaces (eg, malar eminence, cheek) as a well-defined depressed scar.
Furthermore, the motion of underlying musculature contracts linear scars and tends to depress the overlying tissue. In the case of a large U-shaped scar, this produces the well-known trapdoor deformity. However, with these considerations in mind, situations exist in which a truly linear or curvilinear and lengthy scar produces a superior aesthetic result. This is observed in certain facial scars lying in close approximation to or within an RSTL.
Depth and angle of injury
The depth of the initial injury has profound implications in scar revision. Injury that traverses the deeper tissues produces a much greater degree of scar contracture than superficial injury alone. This occurs as the scar in the deeper layers combines with the more superficial scar and retracts the less-fixed surface, producing a pronounced visible depression. However, deep scar tissue actually may be used as autogenous filler in future revision to prevent scar depression.
Related to the depth of injury and resultant scar formation is the angle, single or multiple, at which the injured tissue is incised. Because of inherent tissue loss, stellate, avulsive, and crushing injuries amplify the degree of scarring following injury. Similarly, the angle of injury also influences the final appearance of a scar. Relative to its more perpendicular counterpart, an angled incision likely causes a greater degree of dermal injury.
The oblique contracture of the dermal layer has a tendency to slide to one side of the wound, up and over the other, resulting in a heaped-up or pincushioned wound appearance. When revising this type of scar, the reconstructive surgeon faces the dilemma of 2 reconstructive options. The surgeon may subdermally debulk the raised portion of the scar and place deep dermal bolster sutures that pull the surface epidermis down, or the surgeon may entirely excise the scar and reapproximate the wound margins at right angles to each other. Clearly, this latter technique applies only when the cosmetic result far outweighs the loss of additional excised tissue.
A notable exception to the above is the utility of a beveled incision in a hair-bearing area. Since the follicles usually are oriented in an angled direction, a beveled incision is less likely to injure the follicle germinal center. These incisions ultimately result in less loss of hair at the scar margin (see image below).

Scar Classification

Scar formation is a necessary process for the healing of tissue after insult. However, abnormal or disturbed collagen production can cause poor restoration of the cutaneous surface and textural irregularities. A cosmetically acceptable scar is often level with the surrounding skin, a good color match, soft, and narrow. Favorable lines of closure are usually within or parallel to relaxed skin tension lines (RSTLs): lines due to dynamic action of the underlying musculature.1 Preoperative planning and prevention are critical to achieving scar cosmesis.²

Abnormal scars usually fall into four etiologic categories: traumatic, poorly designed, poorly healed, and disease-related (Table 1). It is important to keep in mind the original etiology of poor scar cosmesis as this may influence the result of any revision attempt.

The resulting scar abnormality will guide the choice of treatment technique. A summary of treatment approaches is presented in Table 2. The surgical strategy selected should be based on a thorough evaluation of the scar's characteristics: size, color, thickness, texture, position and orientation, type and timing of previous therapy, and quality of the surrounding skin. In addition, while any scar with a suboptimal appearance can be revised, greatest patient satisfaction is achieved with realistic expectations. Patients must be counseled preoperatively that a scar can never be completely removed but, exchanged for a more cosmetically pleasing one. 

Treatment Techniques

Excisional Techniques
Shave Excision
Indications:

• Elevated scars
• Hypertrophic scars or Keloids

The scar is tangentially shaved with a flexible razor blade/scalpel until it is level with the surrounding skin avoiding entry into the deep dermis. When using a scalpel, it is often helpful to score the periphery of the elevated scar initially to ensure there is no extension beyond the intended area. The wound is allowed to heal by secondary intention.

Category	Examples of Causes
Traumatic or irregular wound creation	Burn Debris Laceration
Poorly designed	Not parallel or within RSTLs Lack of respect for facial landmarks Distortion of free margin e.g., lip or eyelid Long linear design Depressed scar from lack of evertional closure
Prior poor healing	Infection Excess tension Necrosis or slough
Disease-related	Acne Varicella Keloidal
Table 1:  Abnormal scars: etiologic categories Adapted from Choi JM, Rohrer T, Kaminer M, Batra RS. Surgical approaches to patients with scarring. In: Arndt, KA, ed. Scar Revision—Procedures in Cosmetic Dermatology. East Sussex: Elsevier Science. In press.

Scar Abnormality	Possible Causes	Surgical Techniques	Other Therapies
Elevated	Wound closure under tension Inadequate apposition of edges Full-thickness grafts (oversized)	Shave excision Fusiform excision	Intralesional corticosteroids Dermabrasion Laser Resurfacing
Hypertrophic scars/ Keloids	Genetic predisposition Area of motion or tension Nidus of prolonged inflammation (e.g., infection or foreign body reaction)	Shave excision Fusiform excision	Intralesional immunomodulators Radiation Cryosurgery Lasers Compression therapy
Depressed scar	Deep shave biopsy Electrodesiccation/curettage Deficient wound eversion Prior hematoma or infection	Fusiform excision Subcision/ subdermal undermining	Fillers Lasers
Widened scars	Wound closed under tension	Excision & suture with buried vertical mattress intradermal sutures	Lasers
Long linear scar	Laceration Preoperative poor planning	W-plasty Geometric broken line closure (GBLC)	Dermabrasion
Contracted/webbed	Traverse concavities	Z-plasties	Intralesional corticosteroids
Ice pick/pitted	Prior acne Trauma	Punch excision	Punch grafting Dermal pocket grafting Dermabrasion
Boxcar scars	Prior acne Varicella	Punch excision Punch elevation	Lasers
Rolling scars	Prior acne	Subcision	Fillers Lasers

Table 2:   Scar abnormalities and treatment approaches
Adapted from Choi JM, Rohrer T, Kaminer M, Batra RS. Surgical approaches to patients with scarring. In: Arndt,
KA, ed. Scar Revision—Procedures in Cosmetic Dermatology. East Sussex: Elsevier Science. In press.

How to prepare pre-operatively for surgical Scar Revision?

Prior hospitalization is not necessary for Scar Revision procedure. However, make sure that you inform your plastic surgeon about your health conditions and all the prescription and non-prescription medications that you are taking (including vitamin, mineral and herbal products). Stop smoking at least 2 weeks before the surgery and do not smoke for at least 2 weeks after the Scar Revision surgery.

What is the recovery period like after surgical Scar Revision?

Be sure to make arrangements for someone to drive you home as you will be sent home the same day after Scar Revision. You will heal gradually and be able to resume your daily activities within a week or so. The final results of your Scar Revision surgery will take a very long time to become completely apparent. The stitches will be removed within 3 - 5 days after Scar Revision surgery. 

Risks of Scar Revision

• Bleeding
• Infection
• Allergic reaction to anesthesia
• Numbness
• Recurrence of scar
• Risks of not having a Scar Revision
• There is no guarantee that surgery will improve the functional limitation that is most often seen from contractures. However, when performed by an experienced surgeon, Scar Revision can definitely change that and make your movements more comfortable.