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Archive for the ‘scar revision’ Category

Temporal Scar Revisions

Saturday, September 9th, 2017

 

Incisions in the scalp run the risk of creating visible scars. Such visible scalp scars are almost always due the lack of hair with it. As a matter of fact scalp scars can be very narrow, but if hair is lost along the edges the scar will appear much bigger than the actual scarred skin itself. Thus maintaining follicle viability is of critical importance in making scalp incisions for elective surgery.

One other cause of wide scalp scars are incisions that are performed at a very young age. Due to the growth of the skull and the subsequent expansion of the overlying scalp, incisions in infants and children can stretch over time increasing the width of the scar. This is most manifest in the temporal scalp areas. Why scalp scars become wider on the sides of the head rather than across the top is not clear but it is a consistent finding on my experience. As a result coronal scalp scars made early in life often lead to wide temporal scars later.

Temporal scar revisions, in particular, must be done in a unique fashion. Simply cutting out the scar and closing it in a straight line rarely results in an improved scar appearance. The scar quickly expands and becomes a visible non-hair bearing line again. To avoid this problem the scar edges must be cut so they interdigitate like connecting fingers. Using a running w-plasty excision pattern the temporal scar is removed and put back together in an interdigitating fashion. This allows the tension of the closure pattern to be better distributed with a far greater chance of a less visible scar.

Temporal scars become visible from the anterior temporal line of the skull down to the ear. A ‘pinking shear’ pattern of excision and closure in a meticulous manner puts hair follicles closer together with less chance of widening again.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Injections as a Scar Treatment

Sunday, January 29th, 2017

 

Scars are created by the reparative mechanisms of the body to heal a wound. The amount of scar tissue created varies based on a variety of factors. While effective at sealing and healing the wounds, the scar tissue is not normal and is not an exact replica of the tissue that it replaces or that surrounds it.

The surgical approach to scars is one basic method…cut it out and hope that less scar tissuemforms in its place. Or is some cases of scar revision a new line of closure is done so that it lays differently in the skin so that it may be less visible using the natural skin lines.

A newer approach to the treatment of scars is that of fat injections. The concept is to introduce new healthy cells (adipocytes, fibroblasts and some stem cells) that could potentially create new tissue that is more soft and supple. By breaking up the scar tissue and doing a secondary scar excision/revision if needed the scarred wound environment is changed. While this approach is theoretically appealing and there is lots of anecdotal clinical experience/results that provide support for its treatment benefits, the actual cellular biology of his approach is not well understood.

In the January 5th 2017 issue of the journal Science, an article was published entitled ‘Regeneration of Fat Cells from Myofibroblasts in Wound Healing’. In mice studies it was discovered that during wound healing fat cells (adipocytes) were regenerated from myofibroblasts. This was striking because scar tissue does not contain fat (or hair follicles) and that myofibroblasts are thought to be fully differentiated and incapable of being transformed into other types of cells. The myofibroblast is the most common cell type found in scars. Such myofibroblast reprogramming required hair follicles to trigger BMP signaling and subsequent activation of adipocyte transcription factors. Fat cells formed from human keloid fibroblasts when treated with either BMP or when placed with human hair follicle. Thus, the myofibroblast is a cell type that can be manipulated to treat scars in humans.

The theoretical benefits of these findings is that wound healing may be capable of being manipulated to create actual skin regeneration rather than scar tissue. Hair follicles have to be regenerated first after which fat can be formed. Factors are released from the hair follicles which causes myofibroblasts to create fat rather than scar tissue. The fat will not form without the new hairs, but once it does, the newly created fat gives the healed wound a natural appearance instead of leaving a scar.

Could drugs and treatment strategies be developed to turn myofibroblasts into fat and help wounds to heal without scarring? This is certainly the direction that this research suggests. Does this have any relevance to injecting fat into and around scarred tissues? Not exactly but treating early scar tissue formation with fat injections, as is commonly done today, may have a biologic basis after all.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Trach Scar Revision with Dermal-Fat Graft

Monday, December 26th, 2016

 

Background: The placement and removal of a tracheostomy always results in some degree of neck scarring. The longer the tracheostomy is in place, the more significant this scarring will be. The characteristics of the trach scar are classic and include a wide and depressed scar that is often associated with a visible inward movement when swallowing.

One of the key anatomic features of the trach scar is the crater-like appearance to it. The pressure of a plastic tube against the tissues of the neck ultimately causes some loss of subcutaneous fat around the tube site. The longer the tracheostomy tube is in place the more significant this fat loss will be. Thus when the tube is removed the open wound will heal but the surrounding tissues will be depressed inward as a result of the fat loss.

The other anatomic feature of the trach scar is an inward contraction seen when swallowing. This occurs due to the loss of fat but also from the development of a scar that extends from the surface of the skin down to the actual trachea. When the trach tube is removed secondary healing creates this scar band. When one swallows the movement of the trachea is transmitted through the scar band up to the skin surface.

Case Study: This 21 year-old female had a central neck scar from a tracheostomy tube that was removed ten years earlier. It had been in place after having it for five years due to severe reactive airway disease as a child. This left her with a bothersome vertically-oriented central neck scar that was depressed inward, had surrounding hyperpigmentation and pulled inward when swallowing.

trach-scar-excision-design-dr-barry-eppley-indianapolisThe scar excision pattern was marked in a horizontal elliptical orientation to include as much of the hyperpigmented skin as possible.

trach-scar-excision-and-muscle-repair-dr-barry-eppley-indianapolistrach-scar-revision-with-dermal-fat-graft-dr-barry-eppley-indianapolisUnder general anesthesia the marked skin was excised. The scar was dissected down to the trachea where it was removed. The trachea was covered by doing a muscle repair over it. A small dermal-fat graft was placed between the muscle repair and the skin closure over it.

While all trach scars will always be a scar, a scar revision should end up making it look less noticeable. One of the key features of achieving that goal is to have a flat outer contour and a scar that remains stable with swallowing. The use of a dermal-fat graft recreates the principal missing element of a trach scar…lost fat. Replacing the lost fat improves the scar contour and acts as a buffer from the skin surface and the deeper underlying trachea.

Highlights:

1) Depressed and retracted trach scars require adequate release from the tracheal ring.

2) Interpositional fat grafting between the skin and the underlying trachea helps create a smooth outer skin contour and prevents visible skin retraction with swallowing.

3) Small dermal-fat grafts survive very well in the trach scar neck site.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Tracheostomy Scar Revision with Dermal-Fat Graft

Sunday, June 19th, 2016

 

Background: A tracheostomy is a life-saving airway procedure. Done from infancy to seniors it is the introduction of a breathing tube through the midline neck skin into airway to bypass whatever obstruction lies above it. The breathing may be left in a matter of days dependent on the medical condition it is treating. When it is removed, the open neck wound is left to heal in on its own.

While most tracheostomy scars will heal, the process of secondary intentional healing often leaves a wide scar which may have some degree of depression. The longer the breathing tube was left in place usually make for more of a depressed tracheostomy scar. This is due to the tissue loss between the skin and the trachea which has occurred due to compression and fat atrophy.

In some depressed tracheostomy scars, a very visible retraction of the neck skin is seen when swallowing. This is due to tethering of the overlying scarred and shortened neck tissues to the trachea. The trachea is moved upward due to contraction of the muscles at the base of the tongue. The skin edges of the tracheostomy scar can be seen to pull upward and into the depressed scar area as swallowing occurs.

Tracheostomy Neck ScarTracheostomy Neck Scar RetractionCase Study: This 24 year-old female had a depressed midline neck scar from a tracheostomy performed when she was an infant. She did not remember why she had the tracheostomy placed or for how long it was in place. When she swallowed there was a dramatic upward retraction of the tracheostomy scar.

Dermal Fat Graft to Tracheostomy Scar Dr Barry Eppley IndianapolisUnder local anesthesia, the tracheostomy scar was excised and the deeper tissues released from the trachea. A small dermal-fat graft was harvested from the lower abdomen and inserted dermal side down into the defect. It was sutured into placed and the skin closed over it.

Tracheostomy Scar Revision with Dermal Fat Graft result Dr Barry Eppley IndianapolisTracheostomy Scar Revision with Dermal Fat Graft result obloque view Dr Barry Eppley IndianapolisThe change in the neck contour and the significant reduction in the scar retraction were immediately apparent at the end of the procedure.

While excising the neck scar and closing the skin over it seems like it would be a good scar treatment, it often is not. The very depressed trach scar is really missing subcutaneous tissue. An autologous dermal-fat graft is needed to replace what had been lost previously to both eliminate the depression and reduce the degree of tracheal retraction that is seen.

Highlights:

1) Depressed tracheostomy scars that retract on swallowing have a severe shortage of tissue.

2) To eliminate the soft tissue depression and decrease the visible tracheostomy scar retraction, a tissue graft is needed to fill in the space after scar excision and release.

3) The best tissue graft for any depressed scar is a dermal-fat graft.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Scar Revision Study

Sunday, April 24th, 2016

 

Scar revision is an important technique and part of plastic surgery. Many traumatic and sometimes surgical scars do not heal as desired and may benefit from a scar revision procedure. While much ado is made of laser resurfacing of scars for improvement, the reality is that many poorly formed scars will benefit by actual excision and not just superficial laser treatments.

Z plasty scar revisionIn performing surgical scar revision, there are numerous basic concepts that are used to result in an improved appearance. One of these is the interruption of a straight scar line into a non-linear closure. The most historic method to do is that of a Z-plasty. A Z-plasty scar revision breaks up a straight line scar into a Z pattern. This is most commonly used to break up a scar that has a contracture component of it, crosses a joint line or runs perpendicular to the relaxed skin tension line.

In the April 2016 edition of the JAMA Facial Plastic Surgery journal, an article entitled ‘Perceptions of Aesthetic Outcome of Linear vs Multiple Z-plasty Scars in a National Survey’ was published. In this study the perception of the cosmetic appearance of linear scars vs zigzag scars by the general public. A computer-generated image of a mature scar was created in both straight line and a Z configuration and overlaid on photographs of Caucasian faces. Side-by-side comparisons were on an Internet-based survey to be rated on a10 point assessment scale. (1 = best appearance, 10 = worst appearance)

Over 800 participant ratings were gathered with significantly lower scores and better appearances for linear scars compared with zigzag scars in every assessed group of images. The authors conclude that the lay public has a significantly better perception of the appearance of linear scars compared with zigzag scars in 3 facial locations. (temple, cheek, and forehead)

Neck Z Plasty Scar Revision Dr Barry Eppley IndianapolisWhile this study is interesting, it needs to be out into clinical context. A Z-plasty is the least commonly performed non-linear scar revision that I perform. Most facial scar revisions are done using a broken line or irregular closure pattern. By contrast a Z-plasty often creates a a more pronounced change in the scar line that I often find aesthetically objectionable. A Z-plasty has its role in scar revision but should be used in very specific scar problems such as obvious contracture problems or scar deformities around moving facial structures such as the mouth or eyes.

Dr. Barry Eppley

Indianapolis, Indiana

Early Fractional Laser Treatment Of Surgical Scars

Tuesday, February 17th, 2015

 

Early treatment of scars by some method is certainly preferred by patients whether the scars  are from traumatic injury or elective aesthetic surgery. A variety of such scar strategies exist from topical gels and tapes to pulsed dye and ablative laser treatments. All of these methods have shown long-term scar appearance benefit with topical treatments being the most economical. But whether similar benefits are seen with fractional laser resurfacing has not been similarly studied.

Fractional Laser Resurfacing of scars Dr Barry Eppley IndianapolisFractional laser resurfacing would seem to offer scar benefits, at least theoretically, because it stimulates collagen creation in the deeper dermis with deeply cut channels. This is the location which causes many scars to widen or become depressed due to loss of collagen structures deep in the dermis. Stimulation of deeper dermal collagen formation during the early healing phase could prove to help prevent these adverse dermal changes and improve the final appearance of the scar.

In the January 2015 issue of Lasers in Medicine and Surgery journal, a study was published entitled ‘Early Postoperative Single Treatment Ablative Fractional Lasing of Mohs Micrographic Surgery Facial Scars: A Split-Scar, Evaluator-Blinded Study’. In this study, a prospective randomized split scar study was done on twenty (20) patients between the ages of 20 to 90 years old. The scars created were from Mohs surgery for facial skin cancers. Studied scars had a linear length of 4 cms or more. On the day of suture removal half of the scar was treated with a fractional laser. (spot 7mm, 10% density  at 10mJ) The other half of the scar was left untreated to serve as a control. Three months laters the scars were evaluated and graded by both the patients and an independent observer. While all portions of the scars improved with healing time, the laser treated scar halfs were seen to be improved by patient assessments but not so much by independent assessment. No adverse effects of the laser treatments were seen.

The fractional laser settings used in this study were very conservative. Improved scar appearances would likely be obtained by more aggressive settings, particularly if a single laser treatment was going to be used. While the optimal laser settings for prophylactic scar treatment are unknown, I prefer to use a density of 22% at 50 mJ as a single pass to help the scars get better faster.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Injections For Scar Therapy

Monday, August 4th, 2014

 

Fat injections, also known as autologous lipofilling, continues to expand in usage in plastic surgery. While initially perceived as just a soft tissue filler, it has become known for improving the quality of the tissues into which it is injected. The precise mechanisms as to why this happens is not known but observations and anectodal reports have demonstrated better skin quality and appearance. This is particularly impressive in helping reverse the effects of radiation as is now commonly used as an adjunctive technqiue in breast reconstruction surgeries.

In the August 2014 issue of the Journal of Plastic, Reconstructive and Aesthetic Surgery,  a paper appeared entitled ‘Improvement of Facial Scar Appearance and Microcirculation by Autologous Lipofilling’. In this study over a four year period, 35 facial scars on 26 patients were treated by fat injections. The scars were assessed before and after treatment by photo documentation, laser dopper spectrometry, tissue oxygen saturation, hemoglobin levels and microcirculation at various periods over the first three months after surgery.

All fat-injected scars show visible improvement with high patient satisfaction. They showed improvements in reduced pain, better color, less stiffness, and improved pliability. Microcirculation was initially reduced but returned to normal at the end of the study period. This study demonstrates that fat injections have a useful in extensive or complicated facial scars.

The use of fat injections for scar treatment is a natural and logical extension of its use in other areas of reconstructive surgery. This would not be for many simple and uncomplicated cars that can be treated by conventional scar therapies such as excision and laser resurfacing. Its use would be for very difficult scars such as in burns, those that cross joints with established contracture and problematic scars that have failed to show improvement with other treatments. Its use would be particularly helpful in atrophic scars where the tissues are very thin.

Despite the popularity of fat injections, the actual mechanisms that produce tissue improvement are incompletely understood. It is presumed that the combination of growth factors and stem cells mixed in with the fat are what is responsible for its remodeling effects and improved tissue quality.

Dr. Barry Eppley

Indianapolis, Indiana

Botox Injections for Keloid Scars

Monday, January 6th, 2014

 

Keloid Scar Surgery Dr Barry Eppley IndianapolisKeloids represent the extreme of scar problems. As a tissue overgrowth response to an injury, and often progressive and unremitting, keloids are a true pathologic scar problem. Besides being an overly obvious scar problem, it is also highly refractory to conventional scar therapies. While many strategies have been used for difficult keloids after excision (e.g., steroid injections, radiation treatments), there still remains a very high recurrence rate. There remains a need to for new and novel approaches to see if lower recurrence can be achieved.

In the Summer 2013 issue of the Canadian Journal of Plastic Surgery, an article was published entitled ‘Eradication of Keloids: Surgical Excision Followed By A Single Injection of Intralesional 5-Fluorouracil and Botulinum Toxin’. This study involved eighty (80) patients with keloids of at least one-years’ duration. Following total surgical excision of the keloid, a single dose of 5-fluorouracil (5FU) was injected into the edges of the healing wound on postoperative day nine (9) together with botulinum toxin.

The concentration of 5-fluorouracil used was 50 mg/mL and approximately 0.4 mL was infiltrated per cm of wound tissue, with the total dose <500 mg. The concentration of botulinum toxin was 50 IU/mL with the total dose <140 IU. Patients were followed-up to two years and a recurrence rate of 3.75% was found.

The present study shows a very low recurrence rate by keloid scar standards that is comparable to other studies with post-excision radiation treatments. One has to assume that it is the Botox that has a significant pharmacologic effect as 5FU injections alone would not have such a low recurrence rate.

Botox Injections for KeloidsSince Botox has a known effect as a muscle weakener/paralyzer, how then does it work on scars? Several clinical studies and reviews have been done on the effects of Botox injections on scars. Besides the obvious benefit of preventing muscle pulling on the edges of a fresh wound or scar (which is really only a consideration in certain types of facial scars), its potential benefits are largely conjecture. Some have hypothesized that it inhibits fibroblast proliferation or the action of myofibroblasts, which makes theoretical sense, but that has never been scientifically proven or verified.

This is a fairly large clinical series of keloid treatments and would thus indicate that there  is merit to the injection of Botox after their excision. The mechanism of action remains speculative but its use is certainly more convenient and less costly than post-excision radiation treatments.

Dr. Barry Eppley

Indianapolis, Indiana

Fractional Laser Treatments for Traumatic Burn Scars

Sunday, December 22nd, 2013

 

Many disfiguring and debilitating scars, particularly those of a burn origin, are often associated with pain and itching in addition to their appearance. The use of fractional laser resurfacing, which is now about a decade old, has become a very valuable treatment method for these types of traumatic scars. To those experienced in using it, its functional and cosmetic benefits have become viewed as a breakthrough scar treatment method.

Fractional Laser Resurfacing of scars Dr Barry Eppley IndianapolisIn the online first publication of the December 2013 issue of JAMA Dermatology, an article was published entitled ‘Laser Treatment of Traumatic Scars With an Emphasis on Ablative Fractional Laser Resurfacing – Consensus Report’. Eight independent, self-selected academic and military dermatology and plastic surgery physicians with extensive experience in the use of lasers for scar treatment assembled for a 2-day ad hoc meeting. Consensus was based largely on expert opinion and relevant medical literature reports.

The consensus of these eight experienced multidisciplinary practitioners is that laser treatments, particularly that of fractional laser resurfacing, deserves a prominent role in scar treatments, with the possible inclusion of early intervention for contracture avoidance and assistance with wound healing. Its results are not only very promising but is an underused tool in the multidisciplinary treatment of traumatic scars. Changes to existing scar treatment paradigms should include extensive integration of fractional resurfacing and other combination therapies guided by future research.

What is most important is this consensus report is that it speaks to the treatment of traumatic burn scars, one of the most challenging of all burn scar problems. Significant hypertrophy, contracture and pain are the hallmarks for these scars. A fractional laser approach, which ‘punches’ thousands of tiny slits in the scar, serves as a mechanism of scar release. When combined with immediate physical therapy to further release the contracture and increase range of motion, significant scar improvement occurs regardless of any appearance change.

This report of fractional laser treatments should not be confused with many other types of scars that are more favorable, albeit still distressing to many patients. The role of the fractional laser in fresh incisions and early traumatic non-burn scars is more speculative and not yet proven and needs further clinical study to determine potential effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Tracheostomy Scar Revision Using Fat Injections

Friday, November 8th, 2013

 

A tracheotomy is a life-saving operation but will usually leave a scar deformity when it is removed. This is due to the sustained pressure of the tube through the neck tissues and that, when the tracheostomy is removed, the wound is allowed to heal by secondary intention. Thus it is not surprise that wide and depressed neck scars often result. In addition because there is loss of fat tissue between the skin and the trachea, a direct adhesion can result creating a tracheal tug that is evident with swallowing. As one swallows the overlying indented skin can be seen to be pulled inward.

Lipofilling by fat injection grafting has become a popular method of treating many soft tissue defects. It can create a new soft tissue interface depending upon how much fat survives. Given that some trach scars are both wide and indented, fat grafting is often used in tracheostomy scar revisions. I often combine a dermal-fat graft with scar excision and closure to solve the soft tissue loss problem in the neck.

In the July 2013 issue of the Journal of Craniofacial Surgery, a paper entitled ‘Management of Tracheostomy Scar by Autologous Fat Transplantation: A Minimally Invasive New Approach’ was published. In a clinical study of ten patients with retracted and/or wide tracheostomy scars, fat injection treatments were done under local anesthesia or sedation. Before injecting the fat, the scar bands between the skin and the underlying tissue were released with a needle. (subcision) Most tracheostomy scars treated were done with two sessions six to twelve months apart.with an interval of 6 to 12 months. Injected fat volumes was between 3 and 10ccs during the treatment and an additional 3 to 5ccs during the second injection. In some cases (30%), scar excision was performed as a final procedure. All patients achieved an aesthetic improvement and were satisfied with the result at long-term follow-up. (near two years)

This study shows that fat grafting can be an effective treatment of the indented tracheostomy. But how does it compare to a one-time scar excision with dermal-fat grafting which can be done in one single session under local or sedation anesthesia as well? It is certainly no less invasive given that the scar size is very small and is inefficient in terms of getting to the final outcome. But if one is not bothered by scar width and the depression of the tracheostomy scar is the only issue, fat injection grafting would be a logical treatment choice.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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