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Dr. Barry Eppley

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Archive for the ‘scar revision’ Category

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

Combination Scar Revision and Radiation for Earlobe Keloids

Tuesday, November 5th, 2013


Keloids are a notoriously difficult scar problem for which there is no match other than perhaps that of the broader-based burn scar. There are a wide variety of treatments used for keloids and that is a testament to their high recurrence rate despite what treatment method is done.

Keloids are well known to occur in the earlobe and just about everyone has seen someone with large ear keloids. Almost always the inciting event is an ear piercing that may or may not have gotten infected. Treatments for earlobe keloids have included everything from wide surgical excision, steroid injections, pressure therapy and low-dose radiation treatments. The classic approach is to try excision with steroid injections and if this fails to resort to surgery combined with immediate radiation.

How effective is earlobe keloid scar treatment, particularly when radiation is used? In the November 2013 issue of the journal Plastic and Reconstructive Surgery, an article entitled ‘Analysis of Surgical Treatments for Earlobe Keloids: Analysis of 174 Lesions in 145 Patients’. Over a five year period, earlobe keloids (85% primary, 15% recurrent) were treated by a variety of treatments including radiation. The postsurgical radiotherapy modalities were 15 Gy administered in three fractions over 3 days and 10 Gy administered in two fractions over 2 days. Recurrence over the following eighteen months was near 5% in the primary group and 0% in the recurrent earlobe keloid group. No differences were seen in those keloids treated with 15-Gy and 10-Gy postsurgical radiotherapy in terms of rate of recurrence.

What this study shows is that low-dose radiation may be the most effective form of earlobe keloid scar revision and may even be considered as an initial therapy with surgery as the first effort. Given that there appears to be no difference with the lower dose approach, postsurgical radiotherapy with 10 Gy of radiotherapy administered in two fractions over 2 days can be successfully used successfully to treat earlobe keloids.

Dr. Barry Eppley

Indianapolis, Indiana

Scar Revision Strategies in Hypertrophic vs Keloid Scars

Monday, October 28th, 2013


While scars have a negative connotation due to the imperfect appearance of the skin, they are a normal result of most injuries and surgeries. This is part of the wound healing process and their appearance (or perpetuation) is the expected result of this dynamic process. It is only deviations from normal wound healing, hypertrophic scars and keloids, that should be considered abnormal.

The differences between hypertrophic scars and keloids is a confusing one for most people. One is often thought of as the other, most commonly hypertrophic scars being confused as keloid scarring. But they are in both appearance and biology distinctly different. Hypertrophic scars appear raised but stay within the confines of the original wound. They are more likely to occur in wounds that cross the so-called relaxed skin tension lines or in wounds that have been left open to heal on their own or have become infected.

Conversely, keloids extend beyond the confines of the original wound (mushrooming from the wound edges) and are often associated with ongoing growth. They may stop growing but many do not. It is this progression in size that is the hallmark of their behavior. They often cause pain and other symptoms such as itchiness. This is due to the tight scar tissue and a sign of ongoing growth. They may also be a family history of keloids due to a genetic inheritance. They are often associated with traumatic wounds such as ear piercings, tattoos and burns.

Just like their biology the treatments for hypertrophic scars and keloids is different. While hypertrophic scars may improve with time, significant improvement in their appearance is usually only going to come from excision and closure, with or without some form of geometric rearrangement.(e.g., z-plasty, running w-plasty) This almost always solves this particular scar problem or, at the least, provides significant in its appearance. While the same issue for improvement applies to keloids, careful consideration needs to be given to how recurrence is going to be prevented as the propensity for so occurring is remarkably high.

Combining some recurrence prevention strategy with keloid excision is standard and most commonly is the injection of steroids along the wound edges. This is best done before surgery to get some regression of the keloid and then the excision is performed.  At the time of excision the wound edges may be injected with steroid followed by repeat injections every several weeks after surgery for a few intervals. This is far more successful that just excising a keloid alone but is still associated with a near 50% recurrence rate.

For the refractory keloid, radiation therapy is the one known alternative approach that is often better than steroids. It is combined with scar revision and is started immediately, even on the day of surgery. It is known as low dose radiation and, while there is no standard dosing regimen, most patients receive between 1500 and 2000 rads over several sessions done daily for the first week after the surgery. This radiation-induced disruption of collagen synthesis at its inception has the best chance of preventing new keloid formation although it is not foolproof and recurrences have been known to recur .

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Mega Abdominal Scar Revision

Saturday, September 28th, 2013


Background: Abdominal wall disruptions and deformities occur from a wide variety of problems. But infection from traumatic injury, surgery or a bowel-related disease process can produce a devastating and life-threatening abdominal wound problem due to having to be packed open. Once the infection is cleared, the open abdominal wound can usually be secondarily closed once tissue inflammation has subsided but, in some cases, the open wound is better to be skin-grafted after developing a good bed of granulation tissue. This is an older school of surgical thought but a very safe one once the abdominal wall or intraperitoneal cavity has been infected.

A large abdominal wall deformity with a wide scar and underlying separation of the rectus muscles poses a daunting task for achieving a more normal looking abdominal wall. While the underlying hernia, or the potential for it, is difficult enough the scar width seems almost impossible that it can ever be significantly narrowed.

The key to repair of large secondary abdominal wall problems lies in the rectus muscles. Any hope of simultaneously fixing the hernia and narrowing the scar lies in their approximation. The muscles must be adequately mobilized and brought together in the midline, for by so doing it carries with it he overlying skin. Ideally, patients should be six months or more after their initial event to allow the surrounding tissues to become more lax. In some patients, weight loss can also be helpful to reduce the underlying pressure on the closure. (although many patients have actually gained weight from their pre-injury state due to less mobility and an inability to exercise)

Case Study: This 28 year-old male presented with a large lower abdominal wall deformity secondary to a history of a burst appendix. His post-appendectomy course was complicated by a life-threatening peritonitis and resulted in a packed abdominal wound. Once the infection was cleared, his open abdominal wound was skin grafted. He was seen at nine months after his abdominal wound had healed with a 17cm separation of the normal abdominal skin edges and a large protrusion due to rectus muscle separation. (with an adhered skin graft across the wound) The belly button was seemingly lost. (in reality the stalk of it was pulled way to the side in one of the skin flaps)

Under general anesthesia, the skin graft was initially removed from the peritoneal lining in a de-epithelized fashion between all normal abdominal skin edges. The rectus muscles were identified, dissection carried over the top of them, the outer fascia released, and they were sewed together in the midline fixing the hernia. The skin flaps were then brought together in the middle and closed in multiple layers over a drain. With this closure, the belly button was remade and put back in the midline.

He went on to heal without any problems or recurrent infection. When seen six months later there was a relatively narrow scar, elimination of the abdominal protrusion and some residual fat fullness particularly above the umbilicus. He is scheduled to undergo a ‘touch-up’ with further scar revision and some liposuction of the surrounding abdominal wall to get it flatter.

Case Highlights:

1) Large abdominal wounds that have been allowed to heal and skin grafted are associated with underlying hernias and can appear impossible to ever regain a more normal looking abdominal wall.

2) Large abdominal scars with a hernia can be successfully repaired with scar excision, rectus muscle reapproximation and abdominal skin flap mobilization.

3) Such midline tissue tension on the abdominal wall can be expected to result in some scar widening and surrounding abdominal tissue distortions that can benefit from a secondary scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

The Z-plasty Scar Revision Technique

Monday, August 26th, 2013


Scar revision techniques have a long history in plastic surgery and are used as much today as they were many decades ago. While many patients think of scar revision as being done with a laser, like a magic eraser, the reality is that surgical excision and rearrangement of adjacent tissues is often more effective. Such scar revision techniques often have names that visually describe how the scarred tissues are rearranged.

One of the most well known plastic surgery scar revision methods is the Z-plasty. Geometrically the Z-plasty is a transposition flap technique that allows two adjacent undermined triangular-shaped skin flaps along the same axis to be switched in position and lie at right angles to each other. Much like robbing Peter to pay Paul, the triangular flaps comes from areas of tissue excess and are placed into a zone of tissue deficiency.

What a Z-plasty does best is to break up a straight scar line and reorient part of it so that it lies parallel to more favorable relaxed skin tension lines. (RSTLs) By so doing, the scar may be harder to eventually see (not a straight line) and less prone to recurrent scar band contracture/tightening. It does at the expense of actually making the total scar length longer, which may be especially helpful across moveable body surface areas such as joints and bony prominences.

The Z-plasty is done in a variety of ways including the classic technique as well as multiple and adjunct z-plasty methods. The Z-plasty was originally described as being made up of three limbs, a central and two parallel side limbs with varying degrees of angulation (30 to 75 degrees, 60 degree most common) to the central axis. This angulation from the central axis affects how much scar lengthening is achieved. A 60 degree angulation creates a 75% scar length increase. Conversely, for example, a 30 degree angle results in only a 25% scar length increase.

Variations of the z-plasty scar revision technique include multiple serial and the compound technique. The serial z-plasty technique is obvious in its description and is used in longer scars where a single large z-plasty is not aesthetically beneficial. The compound z-plasty is done by making two separate flaps at the end of the scar oriented at 45 degrees to each other.

While the z-plasty is an historic and well known scar revision technique, it is not as useful for many facial scar revisions as one would think. Its role is limited to linear scar band contractures and scars near moveable structures such as the corners of the eye and mouth.

Dr. Barry Eppley

Indianapolis, Indiana

Dog Ear Correction Surgery

Sunday, June 16th, 2013


The dog ear deformity is a well known phenomenon in plastic surgery. It occurs when at the end of any face or body wound closure a puckering or excess tissue occurs. It is best thought of as a bunching or elevation of skin at the end of the incisional closure. Sometimes it is immediately apparent during the operation and other times it becomes more evident as healing is ongoing and the tissue swelling subsides. It is extremely common in such body contouring  procedures as tummy tucks and other long incisional body lifts as well as facial defect reconstructions by primary closure or flap rotations. Its association with the actual appearance of a dog’s ear is a little suspect.

Dog ear wound problems occur for a variety of reasons of which the design and geometry of the tissue excision and closure method is the major contributing factor. Because of its well recognized occurrence, a wide variety of surgical techniques have been devised to eliminate it. Patterns of dog ear excision include various triangles and ellipses of skin. While effective, they all lead to extension of the length of the scar. While for many body areas this may or may not be aesthetically important, it almost always is on the face.

In the May 2013 Archives of Plastic Surgery, a new and easy technique for dog ear correction without extending the length of the original wound is described in an article entitled ‘Aesthetic Refinement of the Dog Ear Correction: A 90 Degree Incision Technique and Review of the Literature’. In their technique, a skin hook is placed in the end of the wound to define the extent of the dog ear. The elevated dog ear is then excised by creating a 90 degree incision at the end of the wound where the dog ear appears. By so doing, a small triangular advancement flap can be raised and removed as desired. This flap is brought across the wound so that the skin excess can be cut in a straight line paralleling the incision line. When sutured closed the 90 degree incision created will disappear. This 90° incision technique enables correction of a dog ear without either lengthening the wound or creating new scars.

The dog ear problem can be corrected with this technique whether seen during surgery or anytime thereafter. The postoperative dogear problem is one patients are acutely aware of but any correct attempts should be deferred until the incision has settled so the full extent of the dog ear can be appreciated. Most dog ear corrections, which are just small scar revisions, can be done in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Product Review: Cimeosil and Gelzone Scar Treatments

Thursday, June 6th, 2013


Scars come in a wide variety of sizes and shapes and can be caused from surgery or injury. But regardless of their origin, many patients are concerned about their appearance and want to participate in methods that can help them heal and disappear as much as possible. While there are no magical potions that can make scars completely go away, there are a wide variety of topical home treatments that exist.

The vast majority of topical therapies are based on one ‘active’ ingredient, silicone. Whether it is in liquid, gel or sheet form, external scar therapies are based on this one element. Numerous studies have shown that topical silicone can help control the quality of the scar.  Despite its effectiveness, it is not precisely known how it works. Various theories exist on its mechanism of action from occlusion, maintained hydration, pressure, static electricity and oxygen tension. At the least, it is fair to say that silicone acts as a protective barrier and maintains moisture to the scar.

One manufacturer that offers a complete line of silicone-based scar products is Allied Biomedical and their Cimeosil and Gelzone products. Cimeosil scar gel comes in both 5 and 14 gram tubes and is offered in both regular and laser gel formulations. These are applied topically and allowed to dry to form an occlusive barrier.

Cimeosil silicone sheeting comes in a variety of self-adhesive sheets. Standard gel sheets are available in 4 x 5 inch sizes as well as long strips. A specific set of breast scar sheets are also available including areolar circles, vertical mastopexy (lollipop), and T-shaped breast reduction scar patterns.

The Gelzone wraps are a particularly interesting scar treatment product as it combines the benefits of silicone gel sheeting with compression and scar protection. These wraps are designed to be used for scars from tummy tucks,, arm lifts and c-sections. In addition to providing a scar treatment, the silicone provides a non-slip surface to hold the wrap in place as well as a non-irritating soft skin surface.

Allied Biomedical offers a complete line of silicone-based scar management products. Facial scars are treated by topical gels while larger body scars are treated by sheeting and specifically-shaped gel sheeting. (breasts) For post-surgical scars from plastic surgery, scar treatments are done twice a day between 3 weeks and 3 months after surgery. For those patients who want to make a concerted effort at optimal scar outcomes, this product line offers a complete scar management approach that reduce the future need for scar revisional surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Topical Silicone Gel and Sheeting for Scar Treatments

Monday, May 27th, 2013


Scars are an inevitable consequence of any elective surgical incision or traumatic injury. It is never a question of whether a scar will form, it is merely a question of how noticeable it will be. The natural history of scar healing is that the majority will improve over time, changing in color from red to white. Some scars, however, will get worse with time becoming wider, raised and evening worsening in color. Some scar worsening is predictable based on the nature of the injury (e.g., burns), its location on the face or the body and the patient’s skin type and degree of pigmentation.

The natural healing process in scars is done through the production of collagen. Collagen is made by the wound edges to fill in and close the gap in the wound. Collagen is a tough fiber-like protein that comprises a greater percent of scar tissue than it does in normal skin. The collagen fibers in scar tissue in addition to being more abundant are also irregularly arranged. This is why scar tissue feels more firm and inflexible than normal skin does as well as discolored or even raised. All of these factors combined contribute to what makes a scar visible and the degree to which it is so.

Despite the natural healing process, the outcome of scars can be managed in some cases by various topical therapies. Prevention or improving adverse scar formation can be challenging as not every phase of the process can be completely controlled. This has led to a wide variety of scar management strategies from topical to invasive therapies. But the prevention of adverse scar formation is preferred and the most accepted non-invasive approach is through the use of topical silicone.

There is substantial documentation that topical silicone has a favorable outcome on a scar’s appearance. This has consisted of either the application of a thin layer of silicone gel or the use of silicone gel sheeting. Its application should be done within a few weeks after the incision or laeration is made and to be used for up to three months of daily use. How the silicone favorably influences scar tissue is not fully understood. Multiple theories have been proposed including occlusion, hydration, pressure, oxygen tension and even static electricity mechanisms. But the most accepted belief is that it acts simply as a moisture barrier that keeps the scar’s surface hydrated.

The optimal topical scar treatment approach is a combination of both a gel and gel sheeting. The gel can be used during the day when the scar may be visible and the silicone sheets at night. In more hidden scars, such as the breasts, abdomen and arms, the gel sheets can be used exclusively. During the healing phase of new scars, gel sheets add an additional layer of protection. They appear to exert their effects very much like an occlusive bandage, providing surface support and reducing water loss from the scar’s surface.

Why is scar hydration or good moisture levels important? Keeping the protected and preventing evaporative water loss appears to reduce surface tension across the scar’s surface and deeper into the scar. Tension across scars, including surface tension, may prolong the inflammatory process and lead to stretched or hypertrophic scar appearances. Any method or prevention may avert poor scar outcomes and the potential for scar revision later.

Dr. Barry Eppley

Indianapolis, Indiana

Mini-Mommy Makeover Procedures

Sunday, May 19th, 2013

The concept of a Mommy Makeover plastic surgery procedure is about combining abdominal and breast reshaping in one operation. The breast and abdominal components are not new and include many well known procedures such as tummy tucks, breast implants, liposuction and breast lifts in whatever combination each individual women needs. While the effects of a Mommy Makeover can be dramatic, breast and abdominal procedures are major surgery with significant recovery as well.

But there are numerous other procedures of lesser magnitude that could also be lumped into the Mommy Makeover category and consist of a variety of ‘nips, tucks and sticks’ that create effects that mothers would also like. Here are some of the most noteworthy.

BOTOX  For reduction of those facial expression lines that come from the stress of balancing mother and wife roles, Botox injections are probably the most common injectable Mommy procedure.

Vi/PERFECT PEELS With only a few days of redness and flaking, these medium-depth facial peels are essentially painless to go through and provide a real boost to one’s complexion. A few of these a year will keep a mother’s skin radiant and glowing.

C-SECTION SCAR REVISION For those women that don’t need a tummy tuck and have a noticeable c-section scar with just a little pooch above it, widely cutting out the scar can produce a flatter upper pubic area. This scar revision can be combined with some lower abdominal liposuction for an additional and wider flattening effect.

UPPER LIP PLUMPING Some well placed Restylane or Juvederm injections into the upper lip has an instant youthful volumizing effect. This is particularly evident if the cupid’s bow and philtral columns are accentuated.

NIPPLE REDUCTION Breast feeding can elongate the nipple which can be a source of embarrassment and out of proportion to the size of the areola. Under local anesthesia, the nipple length can be reduced by half or more.

EARLOBE REPAIR Fixing stretched out ear ring holes or complete tears through the lobe can allow old or new ear rings to be comfortably worn again.

BELLY BUTTON REPAIR (Umbilicoplasty) Pregnancies can change an innie belly button to an outie due to a small hernia through the umbilical stalk attachment. Tucking the peritoneal fat back through the hole and reattaching the stalk of the belly button back down to the abdominal wall will recreate that an old inne look again.

EXILIS For those stubborn fat areas that just won’t go away despite some diet and exercise, this non-surgical fat treatment can easily fit into a busy mom’s schedule. It takes a series of treatments to see the effects but there is no downtime with 30 minute in-office treatment sessions.

These mini-Mommy Makeovers provide changes that do not require major surgery or recovery and can fit into anyone’s hectic schedule.

Dr. Barry Eppley

Indianapolis, Indiana

Scar Revisions of Dogbite Injuries in Children

Monday, April 29th, 2013


One of the most common traumatic facial injuries to deal with in children as a plastic surgeon are dogbites. There are a lot more common than most people think and, fortunately, are usually minor and result in no significant scarring. They often are just ‘nips’ and don’t require any major reconstructive surgery.

But having been at a University for many years before entering private plastic surgery practice, I had the unfortunate opportunity to see more than my share of major dogbite injuries to the face…the vast majority being in children. I reported my pediatric dogbite experience in the March 2013 issue of the Journal of Craniofacial Surgery over a ten year period while covering a major children’s hospital. From 1995 to 2005, I treated over 100 major dogbites the face, scalp and neck in children that required surgical repair in the operating room. The average age of the patients was 6 years old and was fairly evenly split between boys and girls. In most cases the dog was known to the patient or family and was classified as ‘provoked’. The most common dog breeds were Pit Bull, Chow, German Shephard and Doberman Pinscher. Most injuries could be primarily closed but a few did need skin grafts or other reconstructive surgery.

Contrary to popular perception, only one patient developed an infection. Surprisingly, only one patients was left with a permanent facial nerve weakness. In more than three-fourths of the patients, scar revisions were needed and another third needed more than one scar revision.

More than one-third of these dogbite cases involved legal action, either against the dog’s owner or their insurance companies. Because of the high litigation rate and possible denial of insurance claims for subsequent reconstructive procedures, I would advise all plastic surgeons and the families to keep meticulous records, including photographs, of the dog bite injuries.

Like many traumatic injuries dog bites to the face often require repeated plastic surgery procedures to obtain the optimal aesthetic outcome. One should not try and be too clever at the time of initial injury repair with complex closure decisions as the tissue quality often precludes the optimal aesthetic result from the primary repair.

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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