Scar Revision

Author Credentials 

Jared Christophel MD MPH
Associate Professor
Otolaryngology – Head and Neck Surgery
University of Virginia Health System
Charlottesville, VA

Module Summary

Scar revision remains a time-tested method for improving otherwise untoward surgical outcomes.  The surgeon must think about patients seeking scar revision in a sequence of two steps.  The first is assessing the patient candidacy, evaluating time since last surgery, medical factors that contribute to poor healing, and the overall readiness of the patient.  Regarding the last factor, surgeons must trust their instinct when patients are seeking scar revision.  There can be a higher prevalence of splitting or body dysmorphic disorder in patients seeking scar revision.  If, in your judgement, the scar is well-healed, don’t get talked into doing something you don’t want to.  If previously a bullet, knife, or another surgeon are responsible for the scar, after the revision you will be.  

The second step in evaluating the scar revision patient is to break the scar down into the elemental factors that make it unsightly.  Patients often think it just looks bad, but you need to identify which of the factors are causing it to be noticeable, and assess what can be done for that individual factor.  

Module Learning Objectives 
  1. Explain the three phases of wound healing and how they relate to interventions for scars.
  2. Distinguish between Langer’s lines and relaxed skin tension lines.
  3. Compare hypertrophic scars and keloids. 
  4. Describe non-surgical measures for scar treatment.
  5. Describe surgical measures for scar treatment.

 

Anatomy

Learning Objectives 
  1. Be familiar with the differences between Langer’s lines and relaxed skin tension lines.
  2. Understand the role of facial muscle contraction in formation of relaxed skin tension lines.

 

References 
  1. Carmichael SW. The tangled web of Langer's lines.Clin Anat. 2014 Mar;27(2):162-8. 

Pathogenesis

Learning Objectives 
  1. Explain the pathology of a scar including changes in the epidermis, dermis, and connective tissue layers. 
  2. Summarize the phases of wound healing and maturation of scar.  

 

References 
  1. Younai S, Venters G, Vu S, Nichter L, Nimni ME, Tuan TL. Role of growth factors in scar contraction: an in vitro analysis. Ann Plast Surg. 1996 May;36(5):495-501
  2. Eming SA, Wynn TA, Martin P. Inflammation and metabolism in tissue repair and regeneration. Science. 09 Jun 2017:Vol. 356, Issue 6342, p. 1026-1030

Basic Science

Learning Objectives 
  1. Recognize differences between keloid and hypertrophic scar.
  2. Explain the role of skin surface hydration in healing, including the role and timing of emollients, taping, and silicone.  

 

References 
  1. Atiyeh BS, Costagliola M,  Hayek SN. Kloid or hypertrophic scar? The controversy: review of the literature. Ann Plast Surg, 54:676-80. 
  2. Gold MH, Foster TD, Adair MA, Burlison K, Lewis T. Prevention of hypertrophic scars and keloids by the prophylactic use of topical silicone gel sheets following a surgical procedure in an office setting. Dermatol Surg, 27:641-44.     
  3. Sidgwick GP, McGeorge D, Bayat A. A comprehensive evidence-based review on the role of topicals and dressings in the management of skin scarring. Arch Dermatol Res. 2015;307(6):461–477. doi:10.1007/s00403-015-1572-0.

 

Incidence

Learning Objectives 
  1. Understand the incidence of both keloids and hypertrophic scars as well as the genetic disposition.
References 
  1. Gauglitz GG, Korting HC, Pavicic T, Ruzicka T, Jeschke MG. Hypertrophic scarring and keloids: pathomechanisms and current and emerging treatment strategies. Mol Med. 2011;17(1-2):113–125.

Patient Evaluation

Learning Objectives 
  1. Be familiar with the 6 independent components of a scar that contribute to its noticeability, and evaluate scar with respect to potential intervention for each component.
  • Too long
  • Too wide
  • Color
  • Depressed/Raised
  • Orientation (vs RSTL)
  • Tethering (preventing normal facial animation/motion)
References 
  1. Garg S, Dahiya N, Gupta S. Surgical scar revision: an overview. J Cutan Aesthet Surg. 2014;7(1):3–13. 

Measurement of Functional Status

Learning Objectives 
  1. Be familiar with various patient reported outcome measures as well as observer measures of scar outcomes.
References 
  1. Mundy LR, Miller HC, Klassen AF, Cano SJ, Pusic AL. Patient-Reported Outcome Instruments for Surgical and Traumatic Scars: A Systematic Review of their Development, Content, and Psychometric Validation. Aesthetic Plast Surg. 2016;40(5):792–800

Treatment

Learning Objectives 
  1. Describe the fundamental aspect of breaking down a scar into its components listed above in the evaluation section, and customizing the treatment approach based on the component required. 
References 
  1. Garg S, Dahiya N, Gupta S. Surgical scar revision: an overview. J Cutan Aesthet Surg. 2014;7(1):3–13. 

Medical Therapies

Learning Objectives 
  1. Non-surgical methods
  • Intralesional steroid, 5-flourouracil, and bleomycin
  • Pulsed dye laser (for erythema)
  • Dermabrasion
  • Laser resurfacing

 

References 
  1. Newberry CI, Thomas JR, Cerrati EW. Facial Scar Improvement Procedures. Facial Plast Surg. 2018 Oct;34(5):448-457

Surgical Therapies

Learning Objectives 
  1. Procedures:
  • Simple excision and closure
  • Excision and closure with geometric broken line or W-plasty
  • Single Z-plasty (for smaller scar)
  • Serial Z-plasty
  • Tissue grafts beneath the dermis during closure. 

 

References 
  1. Newberry CI, Thomas JR, Cerrati EW. Facial Scar Improvement Procedures. Facial Plast Surg. 2018 Oct;34(5):448-457.

Case Studies

A 15-year-old girl presents with a complaint of a central forehead scar.  It occurred after a motor vehicle accident.  She required cranialization of her frontal sinuses and is missing pericranium over her frontal bone.  The scar on her forehead was from a laceration sustained during the MVA.  The scar is oriented improperly relative to the RSTL, it is wide, slightly erythematous, atrophic, and notably depressed compared to the surrounding tissue causing it to reflect light.  Given the multitude of factors involved, this is best handled with a surgical revision.  Because of the amount of depression and lack of tissue under the scar (it was tethered to the frontal bone), the decision was made to place temporalis fascia beneath the skin at the same time as a geometric broken line. 

 

 

 

 

 

 

Review

Review Questions 
  1. What is an appropriate time period for performing dermabrasion or laser resurfacing?
  2. What is an appropriate time period for steroid injection?
  3. What is an appropriate time period for formal scar revision surgery?
  4. What are the main factors involved in assessing a scar?

 

References 
  1. Newberry CI, Thomas JR, Cerrati EW. Facial Scar Improvement Procedures. Facial Plast Surg. 2018 Oct;34(5):448-457. doi: 10.1055/s-0038-1669400
Resources 

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  1. Annual Meeting Webcast (AMW):