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Archive for the ‘scar revision’ Category

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

Surgical Scar Healing – Patient Education and Expectations

Tuesday, March 19th, 2013

 

Scars are by far and away the concern of most plastic surgery patients, either before or after surgery. They are keenly interested in how to diminish their appearance and or what specific preventative or treatment strategies would be most effective. Scars can also be a source of tremendous dissatisfaction if they become exaggerated due to poor healing or inadvertent misplacement for their ideal location when seen after surgery.

There are many variables that affect how well a scar heals and its subsequent appearance. All other factors beinjg equal, the most signfiicant one is skin color or the degree of natural pigmentation. The more pigment that is in the skin (thicker dermis) the higher the risk is for more reactive scarring appearing as hypertrophic or wide scarring and potentially even keloids. At the least, darker skin will almost always hyperpigment, and sometimes even hypopigment, even if the scar line is very narrow. One of the best indicators of how well any patient will scar is to look ar their previous scars, particularly those created by surgery. But don’t confuse how a traumatic leg scar looks with what their facelift scars will do. Location of scars is almost as important as skin pigmentation and thickness.

The single most effective method to minimize scars is what the plastic surgeon does…careful placement and a meticulous layered wound closure. Plastic surgery often takes longer because more attentioin is paid to getting the scar closed as well as possible. One of the great misconceptions is that the use of a laser to make an incision will result in a better scar. It makes for better marketing but not better scars. Lasers, as opposed to the cold steel of a scalpel blade, always increases the risk of adverse pigment changes due to its heat…and they also cause delayed wound healing .

Patient education on how scars heal is important as often they will look worse with a long time befoer they get better. The initial appearance of a scar will usually be slightly raised and this is always a concern for many patients. But because there is tension on the wound closure in the vast manjority of plastic surgery procedures, the raised scar line will settle in the first month or two after surgery. The other natural healing process of scars is they initially appear very fine and colorless and then start to turn red weeks after surgery. Patients often think that something is wrong but this just represents blood vessels growing into the scar to help it heal. This is also why scar redness fades naturally many months laters as the blood vessels recede once good healing has occurred.

While patients  can’t wait to see how their scars look after the dressings or tapes are removed, the initial appearance of a scar is just the beginning of a cycle. All scars go through a life cycle of healing and then maturation which is different for various body locations and procedures. In general, scars will usually look worse before they get better.

Dr. Barry Eppley

Indianapolis, Indiana

 

Postoperative Instructions for Scar Revision

Wednesday, February 6th, 2013

 

Scar revision is most commonly done by surgical excision of the scar and putting it back together as either a straight line or a geometric or broken line closure pattern. The type of scar revision used depends on the location of the scar, its size and dimensions and the patient’s skin characteristics.

The following postoperative instructions for scar revision are as follows:

1.  Most scar revision have little if any discomfort. Most patients only use Tylenol or Ibuprofen for just a few days after the procedure. You may also feel free to use ice packs on the scar revision area for discomfort relief if you desire as long as they do not directly contact the skin to avoid a thermal injury.

2. In most cases of scar revision, the area will be covered with glued-on flesh-colored tapes. These are to be left on until Dr. Eppley removes them during your first postoperative visit. Some spotting of blood may appear on the tapes and this is normal.

3. In some cases, the area will not be taped and left open. Antibiotic ointment may be used three times a day to keep the sutures soft and moist.

4. Whether you have tapes or visible sutures, it is also ok to have them get wet when you shower. You may shower as normal the following day.

5. If the scar revision is on your face, you may wash your face and get the tapes or suture lines wet. Shaving and make-up application may be done around the area.

6. Physical activities after scar revision depend on where the scar is located. If it is on your scalp, face or neck, you should be able to do any activity that feels comfortable afterwards. If it is on your body, then just think carefully about whatever you are planning does not put undue stress or pulling on the incision lines for up to a month after surgery.

7. You may eat and drink whatever you like right after surgery.

8.  The application of topical scar therapies such as ointments and tapes can begin three weeks after the procedure.

9.   Avoid extreme sun exposure or the risk of sunburn on the scar revision areas for up to six months after the procedure.

10. If any scar revision redness, increased tenderness, or drainage develops after the first week of surgery, call Dr. Eppley and have your pharmacy number ready.

Consent for Plastic Surgery: Scar Revision

Wednesday, February 6th, 2013

 

Every plastic surgery procedure has numerous issues that every patient who is undergoing a procedure should know. These explanations are always on a consent form that you should read in detail before surgery. This consent form, while many perceive as strictly a legal protection for the doctor, is actually more intended to improve the understanding of surgical scar revision. The following is what Dr. Eppley discusses with his patients for this procedure. This list includes many, but not all,of the different outcomes from surgery. It should generate both a better understanding of the procedure and should answer any remaining questions that one would have.

ALTERNATIVES

Alternatives for improving the appearance of a scar could include more time for scar maturation, dermabrasion, laser resurfacing, injectable fillers, fat injections, collagen and stem cell injections and the use of make-up for camouflage.

GOALS

The goal of scar revision is to improve the appearance of the scar(s). This could include physical changes such as narrowing, correction of depressed or elevated surface contour, red or brown color reduction, or line of scar direction.

LIMITATIONS

The limitations of scar revision is in how much the appearance of the scar can be actually improved. Age of the scar, the scar pattern, where on the face or body the scar is located and the patient’s skin color and elasticity all play a factor in limiting how well the appearance of the scar can be improved.

EXPECTED OUTCOME

Expected outcomes include the following: temporary swelling and bruising around the scar revision site, temporary numbness of the surrounding skin, temporary increased redness or discoloration of the scar, elevation/firmness of the scar, and that it can take up to one year after scar revision to see the final result. It is important to understand that no scar can be completely removed and scar revision is about scar reduction not scar elimination.

RISKS

Significant complications from scar revision are very rare. More likely risks include infection, wound separation, suture reactions, worsening of the appearance of the scar, and failure of long-term scar improvement. Any of these risks may require revisional surgery for improvement.

ADDITIONAL SURGERY

Should additional surgery/therapies be required to do additional surgical scar revision, laser resurfacing, pulsed light treatments or topical scar therapies, these will generate additional costs

Treatment Options for Facial Acne Scars

Saturday, January 5th, 2013

 

Acne is a common skin condition that results in a wide variety of scars types and patterns. Even though there are a number of available treatments for acne scars, they are not always universally successful. Acne scars represent a difficult challenge for improvement and every option must be considered in each patient. Often different treatment approaches may be used on the same patient based on the type of acne scars that they have.

When evaluating acne scars, there are three main types based on their shapes. Ice pick scars are the most common acne scar and are semi-round in shape but narrow and deep. They occur most commonly on the nose and cheeks. Rolling hill scars are wide deep scars that roll into the skin. They often occur in bunches and are the result of large and deep cysts. Boxcar (atrophic) scars are somewhat similar to ice pick scars but are not as deep and are wider. The morphology of acne scars goes a long way in determining the correct treatment choice.

The options available for acne scar treatments include injectable fillers, subcutaneous incision/subcision, punch excision, punch elevation and fractional laser resurfacing. Which of these approaches is best? Again, the shape and depth of the acne scar is the determinant.

Hyaluronic acid injectable fillers work by lifting up the depth of the scar depression and trying to make it more level with the surrounding unscarred skin.  In essence, try and raise the valley to get closer to height of the surrounding mountains. Fillers may stimulate collagen regeneration in the skin but this is more theoretical than ever actually seen on a consistent basis. This acne scar technique works best for broad and shallow scars. Deep pitted scars are too fibrotic to be elevated by the push of a filler. While the improvement occurs immediately with injectable fillers, it is a temporary effect that will last as long as the composition of the filler.

Subcision is a technique that inflicts injury to the skin at the base of the scar. This causes the scar to release and accumulate blood underneath it. This is done by using the beveled edge of a small needle like a miniature scalpel. This will result in some bruising and swelling. The dermal collagen injury and bleeding may act as a stimulant for new collagen growth. This technique works best in rolling hill type scars. Multiple sessions are often needed for the best results.

Punch excision is a very well known acne scar technique that does exactly what it describes, it cuts the scar out in a circular pattern. This is done using punches which are small cooker-cutter tools with varying diameters. (1 to5mms) Once the scar is removed, the circular hole is then treated by one of two closure techniques, small suture closure or the hole is filled in with a full-thickness skin graft of the exact size usually cut with the same tool. (punch elevation) Once healed, laser treatments are often done for the smaller scars left behind from excision and closure or the raised scars from the punch graft.  Punch excision works best for ice pick and boxcar scars.

Laser resurfacing works best for the most number of acne scar types. The laser fundamentally works by removing the top layer of skin so that shallow scars may be eliminated and deeper scars appear more shallow. But in a 100% ablative laser, where top layers of skin are removed in even unscarred skin, no net gain may often be seen. The better technique for acne scars is fractional laser resurfacing where just a portion of the skin is treated but the penetration is much deeper. The deep skin channels cut by the fractional laser stimulates the skin to contract and get tighter, narrowing the diameter of the scar. Multiple fractional laser treatments are almost always needed.

The challenge of improving facial acne scars is met with a variety of treatment techniques. While perfectly smooth skin is never possible, mixing and matching  several of these treatment techniques almost always provides visible improvement for most patients.

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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