Scar Revision & Camouflage

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Scar Revision Camouflage

• Michael E. Decherd, MD
• Karen H. Calhoun, MD

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Introduction

• Scarring
• Dorlands a mark remaining after the healing of
  a wound or other morbid process
• Mechanism
• Trauma
• Surgical
• Location orientation
• Cosmesis
• Function

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Ideal Scar

• Flat
• Narrow
• Good color match
• Parallel to or within skin crease

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Strategies

• Prevention
• Incision planning
• Relaxed skin tension lines
• Facial subunits
• Careful surgical technique
• Postop
• Wound care
• Steroid injection
• Antitension taping

• Excision
• Irregularization
• Reorientation
• Camouflage
• Cosmetics
• Dermabrasion

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Timing

• Traditionally 6 to 12 months
• Perhaps earlier for those perpendicular to
  tension lines
• Dermabrasion 6 to 9 weeks
• High fibroblast activity

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Wound Care

• Steri-strips
• Wound cleansing

• Occlusive dressing
• Topical antibiotics

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Wound Healing

• Inflammatory phase hours
• Proliferative phase days
• Remodeling phase months

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Wound Healing
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Cellular Activity in Wound Healing
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Wound Healing
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Hypertrophic Scar / Keloid
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Hypertrophic Scarring
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Keloid

• Pressure can lead to resolution

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Keloids
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Keloids

• Described 1700 BC
• Chele Greek for crablike
• More common in darker-skinned persons
• Most common age 10-30
• Usually after trauma
• Usually within a year

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Keloids Treatment

• Steroids
• Excision Laser vs. cold
• Pressure
• Interferon
• Low-dose radiation
• Silicone Gel sheeting (hydrocolloid dressing)
• Combination

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Patient Encounter

• Common reaction to scar is ANGER
• Counseling regarding expectations
• Counseling regarding timecourse
• Cannot rush healing
• Possible touch-ups later
• Photodocumentation
• Consistent exposure and lighting

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Scar Photography
Flat Lighting
Side Lighting
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Scar Revision?
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Good Candidate Scars

• Longer than 20 mm
• Wider than 1-2 mm
• Disturbing function
• Poor match to surrounding tissue
• Color
• Depth
• Against RSTLs

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Hidden Incisions

• Hide incision in orifice
• Transconjunctival, sublabial, intranasal, etc.
• Hide incision in hair
• Bevel edges, be aware of future balding
• Hide behind anatomic prominence
• Ex retroauricular, submental
• Hide in junction of aesthetic subunits
• Hide in Relaxed Skin Tension Lines (RSTLs)

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Relaxed Skin Tension Lines
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Lines of Maximum Extensibility

• Lines of Maximum Extensibility (LMEs) are
  perpendicular to RSTLs

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Relaxed Skin Tension Lines

• Somewhat mirrored by lines of aging

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Relaxed Skin Tension Lines
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Facial Subunits
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Facial Subunits Example
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Surgical Technique

• Adequate anesthesia
• Proper instruments
• Suture materials
• Closure of dead space
• Careful handling of tissue
• Precise closure of dermal layer

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Technique

• Perpendicular incision unless in hair-bearing
  area

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Technique
Improper
Proper everts
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Depressed Scars

• Excision
• Injection
• Fat
• Collagen
• Bovine
• Human

Collagen allergy
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Surgical Options

• Simple excision (fusiform)
• Best for small scars that are wide or depressed
• Ex trach scar
• Angle needs to be less than 30 degrees
• Serial excision
• Based upon ability of skin to stretch over time
• Can move scar to better anatomic location
• Also good for reducing grafted areas
• Alternatively, tissue expansion
• Shave best for small raised scars

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Serial Excision

• Scar could be moved via serial excision to
  hairline

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Intramarginal Excision

• Hypertrophic scars
• Incisions within scar may heal better
• May be better than total excision

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Intramarginal Excision
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Z-Plasty

• Lengthens
• Reorients

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Z-Plasty

• Keep angle gt 30 degrees to avoid tip necrosis

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Z-Plasty
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Z-Plasty

• Angles greater than 60 degrees can be broken into
  multiple flaps

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Z-Plasty
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Z-Plasty
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Z-Plasty

• Angle should be no less than 30 degrees
• Optimally between 45 and 60 degrees
• Long scars can do with a series of Z-plasties
• Careful technique to avoid tip necrosis

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M-plasty

• With a large standing cone, reduces amount of
  healthy skin excised
• Ex Lip, forehead flap

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M-plasty
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M-Plasty

• Can advance tip with closure

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W-Plasty

• Eye is drawn to straight lines
• Straight scars more likely to cause contracture
• W-plasty is regularly irregular
• Maximum segment length 6mm
• No. 11 blade helpful

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W-plasty
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W-Plasty

• Try to place segments in RSTLs

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W-Plasty

• Helpful in curved scars

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W-Plasty

• Can use small V?Y segment to gain length

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W-Plasty

• Correcting a design error

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W-Plasty

• Gillies corner stitch may be helpful
• Others prefer simple stitch

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W-plasty

• Note exposure on photos

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Geometric Broken Line Closure

• Irregularly irregular

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Geometric Broken Line Closure
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Geometric Broken Line Closure

• After closing dermis can run with Fast-Sorb

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Geometric Broken Line Closure
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Adjunctive Measures

• Dermabrasion
• Laser
• Cosmetic camouflage

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Dermabrasion

• Reduces surrounding skin to level of scar
• Blends color/texture
• Laser resurfacing now popular
• Best done around 6 weeks

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Dermabrasion
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Dermabrasion
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Laser

• More control
• Good for pigment
• Minimizes particulate matter
• Optimum laser/combination under investigation

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Laser
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Cosmetics

• Very safe
• Allows sooner return to function
• May instead of or in addition to surgery

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Cosmetics
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Cosmetics
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Treatment Algorithm
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Conclusion

• an ounce of prevention
• Surgical planning and technique
• Wound care
• Counseling
• Timing
• Careful analysis
• Appropriate technique

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Scar Revision Camouflage

• Michael E. Decherd, MD
• Karen H. Calhoun, MD

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