R. S. Batra, MD, MSc, MPH

Skin Care Physicians of Chestnut Hill, Chesnut Hill, and Department of Dermatology,
Brigham and Women’s Hospital, Boston, MA, USA

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.

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.

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
Z-Plasty
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
W-Plasty
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 Revision4,9

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).