ABSTRACT

Patients frequently seek cosmetic improvement for existing scars. While no scar can be completely erased, dermatologic surgeons can employ a variety of approaches to achieve more esthetically pleasing scars. Classification of a scar abnormality guides the choice of treatment technique. Lasers and injectables are useful tools; however, for certain scar abnormalities, scalpel-based surgery remains the mainstay. This review focuses on common incisional surgical methods for scar revision.

Key Words:
scars, excision, scar revision

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.

Fusiform/Elliptical Excision

Indications:

• Elevated scars
• Hypertrophic scars or Keloids
• Depressed scars
• Widened scars

Regardless of width and depth, complete removal of scar tissue is the goal. The scar is removed as the center of an ellipse with opposing angles of 30 degrees or less. Adequate undermining is necessary to produce wound edges in an even and tension-free manner. Buried vertical mattress sutures are critical for wound edge eversion, especially for deep defects.³

For keloids, avoid areas of high tension since they have a high rate of recurrence. All potential sources of persistent inflammation should be excised, including epithelial cysts, sinus tracts, or trapped hair follicles.⁴ The overlying uninvolved epidermis and upper dermis can be used as a flap or graft by dissecting out the underlying keloidal collagen and replacing the upper dermis and epidermis over the site. With this technique, only epidermal sutures are used and subcutaneous sutures are avoided to prevent a subsequent inflammatory reaction.⁴

Serial Partial Excision

Indications:

• Large scars with insufficient surrounding tissue laxity for a single excision

This technique is helpful when the size, location, and elasticity of the scar and surrounding skin prevent primary closure or when closure will yield distortion of nearby structures. Using conventional excision methods, the scar is partially excised and the adjacent skin advanced by undermining sufficiently. If more than two procedures are required, consider tissue expansion as a complementary tool to reduce the number of necessary excisions.⁵

Scar Irregularization

Z-Plasty
Indications:

• Long linear scars
• Contracted or webbed scars
• AVOID in keloid revision as the keloid may recur along the lengthened scar

Figure 1: Z-Plasty 1=Scar oriented A-B; 2=Scar excised and creation of flaps with two limbs parallel to RSTLs; 3=Movement of the flaps; 4=Resultant scar with reorientation of A-B

This technique diffuses tension by transposing triangular skin flaps, changing the direction of an abnormal scar to lie within RSTLs. The lateral limb lengths are marked before excising the scar. Removal of the main portion of the scar creates the central limb, and the triangular flaps are cut to the same length as the central limb, although they may need to be lengthened depending on skin laxity. The final position of the central limb on the new “Z” can be predicted by connecting the two free ends of the original Z (Figure 1).6,7 The final scar will be approximately three times longer than the original scar, and multiple Z-plasties can be combined in series to reduce tissue contraction. The surrounding tissue is undermined, and the two triangles are then transposed. It is important to release the flaps adequately to allow the tips to have little tension and avoid tip necrosis.

W-Plasty
Indications:

• Long linear scars
• Contracted scars
• Scar perpendicular to RSTLs

Figure 2: W-Plasty 1=Straight line scar oriented perpendicularly to RSTLs; 2=Excision of scar with pattern of interdigitating W’s on either side; 3=Resultant zig-zag line with interposition of the W’s after scar excision

This technique does not lengthen the scar. Careful preplanning is essential, as a series of small interdigitating triangular skin flaps (several small “Ws”) are positioned on either side of the original scar so that the two sides will interpose after scar excision and local undermining.1,3,8 Triangle limbs should be 3-5mm long and ends should be less than 30 degrees in order to avoid a standing cone or “dog ear” effect. Components should parallel RSTLs as much as possible to yield optimal camouflage (Figure 2).

Geometric Broken Line Closure (GBLC)
Indications:

• Long linear scars
• Scars perpendicular to RSTLs

Rather than employing “w’s”, the GBLC involves a series of varying geometric shapes designed to interlock precisely with their mirror images on the other side of the wound. The irregularly irregular pattern camouflages the scar to an observer.^1,3 Geometric shapes should vary irregularly and be 3-7mm in size placed 3-6mm from the scar margin.⁸ As with the W-plasty, wide undermining is essential for a tension-free closure and ends should be less than 30 degrees or an M-plasty employed to avoid dog ears.

Atrophic Scar Revision^4,9

Punch Excision
Indications:

• Icepick scars
• Deep boxcar scars

Depending on the size of the scar, a 1.5-3mm punch tool can be used to remove the entire defect. Outward traction perpendicular to RSTLs during the excision creates an ellipse and allows closure parallel to RSTLs.

Punch Elevation
Indications:

• Wide boxcar scars (>3mm) without significant color or textural irregularities

The punch size is matched to the inner diameter of the crateriform scar. A quick, rotating punch motion is used to release the bound-down scar. The scar is then elevated with forceps so that it lies slightly higher than the surrounding skin. The plug is secured with Dermabond® (2-Octyl Cyanoacrylate, Ethicon) and paper tape such as Steri-Strips® (3M Pharmaceuticals).

Subcision
Indications:

• Rolling scars
• Depressed scars

This procedure releases subcutaneous fibrotic strands that tether the overlying tissue. The controlled trauma creates new connective tissue formation under the defect for additional support. A sterile 18-gauge, 11/2 inch NoKor™ Admix needle (Becton-Dickinson) on a 3cc syringe is inserted at a shallow angle, with the blade parallel to the skin surface into the superficial subcutaneous layer, and occasionally, the deep dermis. The free hand should be used to stabilize the site while the needle moves in a lancing and fanning motion to release the subcutaneous fibrotic strands. Multiple puncture sites are used. Firm pressure should be applied postoperatively to achieve hemostasis.

Conclusion

A successful scar revision can dramatically improve a patient’s quality of life. Dermatologists can employ a number of surgical scar revision techniques. While some are better suited to treat specific types of scars, they can be used in combination with each other or with adjunctive therapies to achieve optimal results.

References

1. Brodland D. Complex Closures. In: Ratz JL, ed. Textbook of Dermatologic Surgery. Philadelphia: Lippincott-Raven p183-200 (1998).
2. Schweinfurth JM, Fedok F. Avoiding pitfalls and unfavorable outcomes in scar revision. Facial Plast Surg 17(4):273-8 (2001 Nov).
3. Kaplan B, Potter T, Moy RL. Scar revision. Dermatol Surg 23(6):435-42 (1997 Jun).
4. Tsao SS, Dover JS, Arndt KA, Kaminer MS. Scar Management: Keloid, Hypertrophic, Atrophic and Acne Scars. In: Kaminer MS, Dover JS, Arndt, KA, editors. Atlas of Cosmetic Surgery. Philadelphia: WB Saunders Co. p433-459 (2002).
5. Mostafapour SP, Murakami CS. Tissue expansion and serial excision in scar revision. Facial Plast Surg 17(4):245-52 (2001 Nov).
6. McGillis ST, Lucas AR. Scar revision. Dermatol Clin 16(1):165-80 (1998 Jan).
7. Thomas JR, Prendiville S. Update in scar revision. Facial Plast Surg Clin North Am 10(1):103-11 (2002 Feb).
8. Rodgers BJ, Williams EF, Hove CR. W-Plasty and geometric broken line closure. Facial Plast Surg 17(4):239-44 (2001 Nov).
9. Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classification system and review of treatment options. J Am Acad Dermatol 45(1):109-17 (2001 Jul).

Department of Dermatology, Stanford University School of Medicine, Palo Alto, CA, USA University, Nashville, TN, USA

ABSTRACT

Wound care after laser skin resurfacing (LSR) is critical for achieving a successful result. The superficial thermal injury created by LSR heals more quickly and with a reduced risk of scarring under occlusion. While open and closed wound care regimens can be employed to expedite reepithelialization, closed methods with semi-occlusive dressings may decrease morbidity. Effective medications and management techniques can help to minimize expected effects of the procedure such as crusting, discomfort, pruritus, erythema, and swelling.
Key Words: laser skin resurfacing, wound care, postoperative care

Laser skin resurfacing (LSR) for the rejuvenation of facial skin remains a popular cosmetic procedure. Meticulous postoperative care is essential and is as important as intraoperative technique in achieving optimal results after laser ablation. Epidermal regeneration following the thermal injury of LSR is improved in a moist environment, since a dry crust or scab impedes keratinocyte migration.¹ Both open and closed wound care methods can be applied to minimize morbidity and expedite postoperative wound healing. Numerous studies indicate that closed wound care regimens utilizing occlusive dressings for 48-72 hours postoperatively may hasten reepithelialization and reduce crusting, discomfort, erythema, and swelling.^2-4 Appropriate medications and management techniques can also minimize the predictable effects of LSR.

Resurfacing with carbon dioxide (CO2) or Erbium:YAG lasers results in ablation of the epidermis and upper papillary dermis. During reepithelialization, the wound produces copious serous discharge along with sloughing of denatured collagen. Resultant crusting may predispose the wound to secondary infection. Other immediate expected sequelae of LSR include discomfort, pruritus, erythema, and edema. Reepithelialization after resurfacing occurs at a mean of 8.5 days after CO2 and a mean of 5.5 days after Erbium:YAG lasers.⁵

Wound Care Methods

Open wound care techniques allow ongoing surveillance of resurfaced skin; as well they minimize the feeling of claustrophobia by the patient. These regimens, theoretically, would seem to be less likely to foster infection, since there is no dressing under which bacteria may be trapped.⁶ However, open methods may be more painful and inconvenient for the patient. Most open wound care regimens consist of frequent soaks with 0.25% acetic acid, normal saline, or cool tap water lasting 20 minutes every 2-4 hours, followed by gentle wiping of the skin. Cold compresses are immediately followed by the application of a bland emollient ointment. Popular ointments include Catrix®-10 (Lescarden) and Aquaphor® Healing Ointment (Beiersdorf AG). Patients are routinely seen on the first and third days postoperatively, and any excess crust is gently removed with saline. The frequency of soaks and ointment application decreases as reepithelialization progresses and is tapered off when reepithelialization is complete. Gentle cleansings begin a day or two later. The use of ointment is replaced during the day by use of a lighter moisturizer-sunscreen. At nighttime, ointment is more slowly replaced.

Dressings utilized in closed wound care techniques provide a semi-occlusive environment that may protect the wound from exogenous bacteria and foster exchange of oxygen and water vapor.⁷ Drainage of the wound exudates via the dressing may prevent excess crust and simplify wound management. Popular dressings include the composite foam Flexzan® (Dow Hickam Pharmaceuticals), the hydrogel product 2nd Skin® (Bionet), the plastic mesh N-terface® (Winfield Laboratories), and the polymer film Silon-TSR® (Bio Med Sciences).

After LSR, occlusive dressings are applied for 2-3 days postoperatively. Longer applications increase the risk of bacterial or fungal colonization and infection with subsequent scarring.

We prefer the Silon-TSR®, a silicone dressing with a polytetrafluorethylene inner polymer network. Immediately after the procedure, the face is blotted dry and the dressing is applied. The dressing comes in a transparent face mask design with perforations to allow excess fluid drainage. Drawstrings tied behind the head hold the mask in place. Openings are cut for the eyelids, nose, and central lips, and a smaller patch of dressing is applied to cover the nasal bridge. Gauze 4 x 4 dressings are applied over the mask to absorb exudates and are held in place by tube gauze.

Patients are seen on the first postoperative day and the tube gauze and 4 x 4 gauze are removed. The resurfaced area is inspected through the mask, and accumulated exudate or crust is removed from uncovered areas with saline. Patients are instructed to begin ice-water soaks through the mask for 20 minute periods at 2-4 hour intervals while awake. Patients return at the third postoperative day and the dressing is removed. Patients continue soaks at 3-4 hour intervals followed by application of Aquaphor® healing ointment. By 7-10 days after the procedure, soaks are replaced with gentle cleansing, and patients switch to the application of a moisturizer-sunscreen.

Antibiotic ointment should be avoided in both open and closed wound care regimens. Bacitracin contained in antibiotic ointments is a common cause of allergic contact dermatitis after resurfacing.⁸

Medications

Regardless of the wound care technique chosen, certain medications and principles of postoperative management can help to reduce morbidity. Postoperative infection can cause permanent scarring. Prophylactic antibiotics such as dicloxacillin or azithromycin are begun at least 24 hours before LSR and continued for a minimum of 5 days postoperatively. Antivirals such as acyclovir or valacyclovir are also begun 24 hours before LSR and continued until epithelialization is complete (10 days). Recovering patients are advised to avoid contact with anyone actively infected with herpes simplex virus. 

Patients often awaken after LSR with mild burning discomfort, and over 80% note pain in the immediate postoperative period.⁹ This can be minimized by intraoperative use of supplemental local anesthesia as well as ketorolac (Toradol®) 60mg IM.¹⁰  After the procedure, ice packs, cold compresses and acetaminophen help to alleviate pain. Approximately 85% of patients require pain medications for the first 3 days postoperatively,³ and those not relieved by acetaminophen often benefit from acetaminophen with codeine phosphate (Tylenol® with Codeine) or acetaminophen with hydrocodone bitartrate (Vicodin®) 1 to 2 tablets every 6 hours as needed.

Mild-to-moderate pruritus occurs during reepithelialization and typically lasts about 10 days. Recent evidence suggests that this symptom relates to a yeast infection or colonization in healing skin.¹¹ Pruritus is often relieved by cool compresses and emollients. Over half of all patients require antihistamines such as hydroxyzine hydrochloride (Atarax®) 25mg at night. Moderate pruritus is often controlled with diphenhydramine hydrochloride (Benadryl®) 25-50mg or hydroxyzine hydrochloride (Atarax®) 25mg 2-3 times daily.⁹ In cases of severe pruritus, medium-to-high potency topical steroids, more potent antihistamines such as doxepin 25-50mg at night, and very rarely, systemic corticosteroids may be required. Control of pruritus is essential since excoriation may result in scarring.

Immediate Predictable Effects of LSR

Erythema typically occurs for up to several months after LSR. The mean maximum severity is reduced, and the duration of noticeable erythema and the time until complete resolution of erythema are shorter in patients treated with closed as compared to open wound care techniques.³ Erythema can be camouflaged with make-up containing green foundation. In addition, sun protection and avoidance should be encouraged during the entire period of post-LSR erythema to minimize post-inflammatory hyperpigmentation. This is particularly important in patients with skin phototypes III through VI. Hyperpigmentation occurs in nearly a third of patients. Preoperative hydroquinone for at least 1 month prior to LSR may decrease this risk.¹²

Edema develops in the first 48 hours postoperatively. The severity can be controlled with ice packs and head elevation at night. In cases where marked edema develops during or immediately after the procedure, oral corticosteroids may be necessary. The time until complete resolution of edema is significantly less when closed dressings are utilized than with  open wound care postoperatively.³ 

Conclusion

In addition to explicit instructions to patients for postoperative care, careful physician follow-up is essential for at least several months after LSR to observe for side-effects and complications. In most cases, untoward effects can be completely reversed if treated promptly and effectively. In addition, ongoing follow-up care can help to reinforce shared, realistic expectations of the physician and patient regarding possible outcomes of the procedure and may influence patient satisfaction after LSR.¹³

Acknowledgement

Many thanks to Matthew H. Kanzler, MD, for his helpful comments and critical review of the manuscript.

References

1. Collawn SS. Occlusion following laser resurfacing promotes reepithelialization and wound healing. Plast Reconstr Surg 105(6):2180-9 (2000 May).
2. Goldman MP, Roberts TL 3rd, Skover G, Lettieri JT, Fitzpatrick RE. Optimizing wound healing in the face after laser ablation. J Am Acad Dermatol 46(3):399-407 (2002 Mar).
3. Batra RS, Ort RJ, Jacob C, Hobbs L, Arndt KA, Dover JS. Evaluation of a silicone occlusive dressing after laser skin resurfacing. Arch Dermatol 137(10):1317-21 (2001 Oct).
4. Newman JP, Koch RJ, Goode RL. Closed dressings after laser skin resurfacing. Arch Otolaryngol Head Neck Surg 124(7):751-7 (1998 Jul).
5. Alster TS, Lupton JR. Prevention and treatment of side effects and complications of cutaneous laser resurfacing. Plast Reconstr Surg 109(1):308-16 (2002 Jan).
6. Christian MM, Behroozan DS, Moy RL. Delayed infections following full-face CO2 laser resurfacing and occlusive dressing use. Dermatol Surg 26(1):32-6 (2000 Jan).
7. Newman JP, Fitzgerald P, Koch RJ. Review of closed dressings after laser resurfacing. Dermatol Surg 26(6):562-71 (2000 Jun).
8. Lowe NJ, Lask G, Griffin ME. Laser skin resurfacing. Pre- and posttreatment guidelines. Dermatol Surg 21(12):1017-9 (1995 Dec).
9. Batra RS, Dover JS, Hobbs L, Phillips TJ. Evaluation of the role of exogenous estrogen in postoperative progress after laser skin resurfacing. Dermatol Surg 29(1):43-8 (2003 Jan).
10. Dover, JS, Arndt, KA, Geronemus, RG, Alora, MBT, editors. Illustrated Cutaneous & Aesthetic Surgery, 2nd ed. Stamford, CT: Appleton & Lange (2000).
11. Alam M, Pantanowitz L, Harton AM, Arndt KA, Dover JS. A prospective trial of fungal colonization after laser resurfacing of the face: correlation between culture positivity and symptoms of pruritus. Dermatol Surg 29 (3):255-60 (2003 Mar).
12. Bernstein LJ, Kauvar AN, Crossman MC, Geronemus RG. The short- and long-term side effects of carbon dioxide laser resurfacing. Dermatol Surg 23(7):519-25 (1997 Jul).
13. Batra RS, Jacob CI, Hobbs L, Arndt KA, Dover JS. A prospective survey of patient experiences after laser skin resurfacing: results from 2 1/2 years of follow-up. Arch Dermatol 139(10):1295-9 (2003 Oct).