Scar revision Flashcards
Fusiform elliptical excision is the simplest surgical technique for scar revision but the resultant scar is always longer than the original scar
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W-plasty, geometric broken-line closure and Z-plasty each use irregular lines, to give a less visible scar.
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Z-plasty, V-Y repair and Y-V repair are techniques to shorten scars.
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Lengthen.
Dermabrasion and ablative laser both can improve uneven scar edges and raised grafts and flaps.
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Scars with poor cosmetic results include those that are wide, raised, depressed, red or pigmented, or those that transect natural relaxed skin tension lines.
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Scars that run parallel to the relaxed skin tension lines reduce the tension across a wound, resulting in a thinner scar.
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Pin-cushioning occurs due to contraction of the flap wound bed during healing, causing the flap to buckle.
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is less noticable if a whole cosmetic unit has been replaced eg nasal tip
Square-edged flaps are more likely to pin-cushion.
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Rounded or U-shaped flaps.
Pin-cushioning can be minimised by widely undermining the defect so that the flap and the surrounding skin contract together during the wound healing process.
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and adequatley sizing and defatting the flap
Scars can take over 1 year to mature as collagen continues to remodel
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Scar massage should begin as soon as possible after any flap surgery.
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Should start approx. 1 month post surgery.
Intralesional steroid is ideal for hypertrophic linear scars, as well as bulky grafts and flaps.
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Intralesional steroid should be delayed until at least 2 months after surgery.
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at least 1 month. Often done at 6 wks
Can repeat monthly until scar flattened.
PDL reduces overall scar redness, as well as promoting collagen remodelling and scar softening
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PDL treatment of scars works best at higher fluences.
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Subpurpuric fluences.
PDL can be used for atrophic scars.
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1550nm fractional Erbium (fraxel)
Treatment of hypopigmented scars with fractional lasers is highly efficacious.
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Limited efficacy.
Fusiform elliptical surgery is best suited for spread, or depressed scars that usually result from excess tension and/or poor wound eversion at the time of the initial surgery.
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W-plasty and geometric broken-line closures rely on the principle that an irregular line is less visible than a straight one.
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For a W-plasty, the tips of the ‘W’ should run perpendicular to the relaxed skin tension lines.
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Parallel or within the RSTLs (assuming the original scar is perpendicualr to the RSTLs)
For a W-plasty, the width of each triangular cut out should be approximately 5mm to achieve a visibly regular line.
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to achieve the desired visibly irregular line.
The advantage of the W-plasty is reduced with longer scars because the regularity of hte zigzags makes it more noticeable
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A geometric broken-line closure is preferable for longer scars.
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pattern determined by surgeon but must be mirrored on opposite side of wound
The Z-plasty alters the direction of a prominent scar placed perpendicular to the RSTLs to be parallel to the RSTLs.
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The Z-plasty lengthens a contracted scar.
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The geometry of the Z-plasty consists of two zigzagging triangular flaps transposed into the shape of a Z.
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A rhombic transposition flap is an asymmetric Z-plasty.
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In scar revision using a z-plasty the central diagonal is the scar
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In a Z-plasty, the angle of the designed triangle does not affect the degree of tissue lengthening.
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Greater angles results in greater gains.
The length of the central diagonal in a Z-plasty is usually predetermined by the length of the scar.
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The classic 60 degree Z-plasty angle results in a 90 degree change in scar direction and a 75% gain in tissue length
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Multiple Z-plasty has the advantage of better hiding the ‘Z’ shapes along the scar line, as well as distributing the tension across multiple smaller transverse diagonals.
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The resultant scar from a z-plasty is usually well hidden
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It is quite noticeable due to the large “Z” configuration
V-Y repairs do not alter the scar length.
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Lengthen scar
similar to V-Y flap but incision is a true V shape below the point to be raised rather than the triangular complete incision of a V-Y island pedicle flap
Y-V repairs can be used to lower an anatomical point. The initial incision is made in a Y-shape and converted to form a V.
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opposite to the V-Y repair used to raise an anatomical point
Mild trapdoor deformities are usually be managed with intralesional steroids
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start 4-6 wls after surgery
A technical trick of a surgical trapdoor deformity repair is to use a no.69 Beaver blade which is rounded at the tip
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use to remove a disc of fibrofatty tissue from under flap after elevating one edge
In repairing an ectropion, scars should be oriented perpendicular to the lower lid margin.
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Even mild ectropion does not resolve spontaneously
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It can resolve over several weeks postoperatively
Grafts near the eyelid margin should be oversized up to double the defect size to compensate for the massive contraction that occurs with thinner grafts in this region.
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Periosteal tacking sutures should not be used near lid margins.
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Can prevent pull on the lower lid.
Canthoplasty can be performed by making a horizontal incision several millimetres lateral to the lateral canthus
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Exposing the lateral canthal ligament, then tracking down this ligament to the superior orbital rim, thereby resulting in a tightening of the lower lid skin
V-Y repairs are helpful for prominent ectropion
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Mild ectropia. Use FTSG if prominent.
The ideal donor site for a FTSG repair of an ectropion is the upper lid skin.
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Should be oversized up to double the defect size.
In severe ectropion, the lower lid can be tacked to the eyebrow in order to suspend the lower lid to an elevated position for approximately 3 weeks.
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The ideal timing for dermabrasion scar revision is 4 weeks post-operatively.
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6-12 weeks.
Dermabrasion abrades down to the level of the papillary dermis
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Margins along the scar undergoing dermabrasion should be extended and feathered into the normal surrounding skin, including an entire cosmetic unit or subunit.
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Small scars can be lightly dermabraded to the point of pinpoint bleeding using sterile 500-600grit sandpaper wrapped on dental roll
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300-400grit
CO2 laser is more precise than Er:YAG in ablating raised scar edges.
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Er;YAG is more precise
Er:YAG has a high affinity for water and so is more precise in ablating raised scar edges
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The Er:YAG laser causes more thermal necrosis and thus promotes more wound contraction and collagen remodelling than CO2 laser
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CO2 laser does
Er:YAG laser promotes more wound contraction and collagen remodelling.
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CO2 laser does
Using dermabrasion, you should treat down to the reticular dermis in order to achieve the best scar revision.
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Must not treat deeper than papillary dermis.
PDL can be used early post op (just after suture removal) to prevent keloids and hypertrophic scars
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The 532nm freq doubled Nd:YAG has been used for scar revision of keloids and hypertrophic scars
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1064nm Nd:YAG
Fractional ablative Er:YAG resurfacing lasers result in redness and swelling that lasts a mean of 3 days, whereas the fractional CO2 laser causes hemorrhagic crusting, swelling, and redness that lasts a mean of 1 week
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Atrophic scars can be treated with chemical peels, dermabrasion, tissue augmentation (fillers) or non-ablative fractional laser resurfacing
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In sebaceous skin, scarring can be minimized by beveling one edge and counterbeveling the other, creating a “tongue-in-groove” effect when sutured
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when doing staged revision a wide scar the first stage revision removes the entire original scar
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ellipse is oriented within the width of a broad scar, resulting in an increasingly narrowed scar width with each stage
All ablative procedures, including both dermabrasion or laser ablation, carry a slight risk of worsening a scar from overly aggressive treatment or from pigmentary alteration
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lower risk w/ fractional resurfacing
radiofrequency energy can be used in place of mechanical energy for subcision treatment of rolling acne scars
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radiofrequency energy subcision of rolling scars causes more haematoma formation to result in better elevation of depressed scars
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radiofrequency delivered by electrosurgery probe applied to sheathed cannula, in cutting mode –> less bleeding
