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Posts Tagged ‘scar revision’

Technical Strategies – Cleft Lip Scar Hair Transplants

Sunday, July 12th, 2015

 

Despite the best efforts at cleft lip repair, whether done as an infant, teenager or as an adult cleft lip revision, the ability to detect the cleft lip scar usually persists. This is most manifest in men because the thickness of the upper lip beard skin on both sides of the cleft lip scar make the hairless scar that much more apparent.

While cleft lip scar revision is the best method to minimize the width of the cleft lip scar, it does not always work as well as one would like. It can be very difficult to get a cleft lip scar that is narrow as one would like, no matter how many efforts are made to revise the scar.

Cleft Lip Scar HairTransplant Grafts Dr Barry Eppley IndianapolisCleft Lip Scar Hair Transplants Dr Barry Eppley IndianapolisIt is important to recognize that the cleft lip scar in a male has two fundamental deficits…lack of hair follicles and skin that is thinner and more atrophic. One simple method to address one of the deficits of the cleft lip scar is that of hair transplants. Placing small hair transplants (follicular extraction units, FUE) into he cleft lip scar not only adds hair growth to the scar but the presence of a follicular unit also has a rejuvenative effect on the lip scar. Whether the man ends up with a fuller moustache that crosses the cleft lip scar or merely ends up shaving (microdermabrasion) the cleft lip scar on a daily basis, the hair transplant helps with cleft lip scar camouflage.

When placing hair transplant into the cleft lip scar it is important to orient the hairs in a completely downward orientation that is nearly parallel to the surface of the skin. This will allow them to grow downward in the same direction as the rest of the upper lip hairs.

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

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

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

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

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


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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