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Dr. Barry Eppley

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Posts Tagged ‘facial scar revision’

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

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

Prevention Of Dogbite Injuries To The Face In Children

Sunday, May 22nd, 2011

Dogbites are an unfortunate risk to which all children are potentially exposed. Beyond the trauma of the experience, permanent scarring almost always occur which can leave lifelong marks to be seen by all if it occurs on the face. With millions of dog bites occurring per year, plastic surgeons are involved in a lot of repairs particularly when it has occurred on the face. Plastic surgery involvement is so significant that last week was Dogbite Prevention Week sponsored by the American Society of Plastic Surgery.

Having done many hundreds of facial dogbite repairs and secondary reconstruction, there are some very common trends. A disproportionate number occur in children from ages five to nine, the biting dog is rarely an unknown one, and many such injuries turn into legal and insurance issues. The common age of patient injury is a reflection of the naïve and innocent nature of that age and their view that dogs are playful and fun. Most dogbites occur in a family, neighbor or relative’s dog where the familiarity promotes unintentional behaviors that are predisposed to evoke their protective natures. Because many dogbites occur on the owner’s home, insurance battles are certain to ensue that frequently involve lawyers. It is not uncommon for me to see referrals from attorneys to evaluate dogbite scars and get an estimate on the cost of scar revision.

That being said, prevention of dogbite injuries can avoid many of these problems. These are the most significant ways to avoid a dogbite injury to a child. These are based on many of the reasons or circumstances I have heard that were given for what was going on when the injury happened.

1) Don’t play aggressive games with a dog. They may not see it as a game.

2) Don’t mess with a dog while eating or play keep away games with food. They are very protective of food and aggressive about getting it.

3) Do not jump on a sleeping dog or surprise it from behind. Give it plenty of warning that you are around.

4) Do not attempt to kiss a dog, particularly face-to-face. Dogs tend to strike defensively when confronted directly.

5) Do not hug, squeeze, or ‘pin’ a dog in any way. This is likely not to be interpreted as play to them.

6) Keep away from a dog with puppies or do not attempt to take a puppy away or get between a mother and her puppy.

7) Do not attempt to pet a dog, particularly an unfamiliar one, unless you let them sniff you first.

While some dogbites can just not be prevented or occur for no discernible reason, these behaviors which are common in children can unintentionally cause a defensive maneuver by a dog. Defensive maneuvers in dogs are usually a biting response and their nature is to go for the face and neck.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study: Revision of Extensive Facial Scars

Wednesday, June 9th, 2010

Background:  Scars are a common patient concern, whether they be slight or significantly disfiguring. While scar treatments and therapies abound, significant scarring requires some form of surgical scar revision. Lacerations and traumatic wounds are particularly prone to hypertrophic scar formation, the most common type of raised and disfiguring scars. While less commonly seen on the face, hypertrophic scars can develop under two healing situations. One is when a laceration crosses a facial transition zone, such as the jaw line. The other is when an open facial wound is allowed to or can only heal by secondary intention. Abrasions, burns and other partial thickness wounds are particularly prone to abnormal scar formation

This is a 22 year-old female who was originally involved in a motor vehicle accident in which she was thrown from the car. She sustained multiple long facial lacerations including a deep abrasion from the left side of her face down into the neck. Her original care was unclear although she may have received suturing of some of her facial wounds. She went on to heal and came in for scar revision 18 months after the accident. Besides the numerous persistent red and prominent scars, she had a large scar contracture across the left jaw line. It was painful and tight and limited her from turning her head to the right.

She underwent revision of all of her scars in a single operation. Some basic plastic surgery scar principles were used. Scar revision of most facial scars is best done by changing the line or orientation of the scars. While you can’t change the direction of scars, you can make them more narrow and not a perfectly straight line. This is the principle of the running w-plasty, it changes a straight line into more of a pinking shears pattern. This is useful if the scar runs obliquely or perpendicular to the natural lines of skin tension. This is known as geometric scar rearrangement. Z-plasties are done when the scar is contracted and needs lengthening. This is of particular need in many scars that cross the jaw line, a transition zone between the face and the neck which differs in both skin thickness and exposure to stretching.

Over 500 skin sutures were placed in doing these comprehensive facial scar revisions. They were removed one week later and replaced with topical glue to allow further healing. She was lost to follow-up  but reappeared nearly two years later. Her scars had adequately faded and the final results of the initial scar efforts could be seen. While I thought some further scar improvements could be obtained, she declined any further scar work.

Case Highlights:

1)      Traumatic facial lacerations and wounds are prone to develop hypertrophic scars. Such scars can only be improved by surgical treatment.

 2)      The use of a combination of straight line closure and geometric rearrangement for facial scar revision is used based on scar orientation to the relaxed skin tension lines.

3)      Most facial scar revisions will require some form of touch-up which can include laser resurfacing and/or treatment of persistent redness. Such considerations should wait at least six months after the initial scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Scar Revision by Geometric Rearrangement

Friday, January 23rd, 2009

Scars are a common concern for many people, particularly when they are on your face. Whether they have just happened or are years old, scars are unsightly reminders of a traumatic event. The desire to remove scars is evident by the many over-the-counter treatment products and the endless scar treatments touted on the internet. As a plastic surgeon, I not only create scars through surgery but see patients who would like their existing scars removed.

Despite the hype and marketing of many scar products and technologies, the reality is that scar excision remains the most effective treatment for many scar problems. Cutting out the scar and putting it back together is the most effective strategy for many scar problems. It is often not what patients want to hear and you can’t put it in a bottle and sell it on the internet. But more times than not, this is the really effective scar treatment strategy. Depending upon the scar type and its location (orientation), narrowing and geometric rearrangement are the best method for diminishing the scar’s appearance.

Geometric rearrangement of scars refers to changing the straight line of a scar to an irregular one. This is particularly advantageous if the scar violates the natural skin creases. (for example, a vertical scar on the forehead) Scars that run perpendicular or obliquely to these natural skin creases (otherwise known as RSTL, relaxed skin tension lines) are not only very visible to the eye but become more obvious with facial expressions as the natural wrinkles are noticeably distorted.

Scar line rearrangement can be done in a variety of geometric patterns known as z-plasty, running w-plasty, and a few other letters of the alphabet…..all which serve to break up a straight line and make it distort less with facial movements and wrinkling. Such scar techniques have been around for many decades and they are not new. They are tried and true techniques of plastic surgery. It is critical that the patient understand that the realistic objective is decreased scar appearance. There is no magic eraser that can make scars go away completely.

The biggest issue that any patient faces when considering scar excision and geometric rearrangment is that one must take a step back to eventually move forward. It is a committment of time and patience. The scar must be cut out and closed and go through many months of healing before the final result will be seen. As all scars go through a redness phase, this may mean up to a year to get to where you want to be. This process of scar maturation, however, is where some newer technologies such as pulsed light therapies may be beneficial. They are capable of making the scar mature and settle faster. Even if it is just a few months of shortening the process that would be considered a benefit by 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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