When topical therapies fail and the scar is unfavorable, resorting to scar revision is necessary. There is a lot to be said about time for scar maturation, but scars that are depressed, raised or excessively wide do not substantially improve as they heal in many cases. Many scars do not need an elaborate revision procedure and often simple linear excision and closure will suffice. This is particularly true for many scars on the trunk and the extremities.
But many facial scars are not improved by simple linear scar revision. The visibility of the face has a lot to do with the need for heightened scar revision outcomes as well as the location of the variable patterns of the relaxed skin lines of the face. For these reasons, better scar camouflage can be obtained through what is known as geometric, or non-linear, scar rearrangement. (GSR) A variety of GSR methods are known and they carry names that start with a letter followed by –plasty. Whether it be the classic Z-plasty or W-plasty or other combinations of the alphabet, the concept is to convert a straight line scar to a non-linear or irregular one.
The Z-plasty is a well known scar revision method that is easy to visualize. With a Z pattern in the middle of the scar, it is easy for patients to understand. The beauty of the Z-plasty is that it not only makes the scar irregular but also makes it longer. This is of great value in scars that have created skin tethers or contractures as they cross moving surfaces and concavities. Examples would be vertical scars of the upper eyelid, the inner area of the eye near the nose, the nostril rim, and the armpit. This lengthening benefit is also useful for contracted scars along the upper lip philtrum and the corner of the mouth. Scars around an orifice can also be helped with z-plasties including the oval nostril, a tracheostomy stoma scar, or those scars around or in the umbilicus.
The W-plasty scar revision turns the whole scar into an irregular ‘pinking shear’ pattern.Instead of a one or two areas with a Z pattern in a scar, the W-plasty turns the entire scar into a continuous zigzag pattern. The scar essentially becomes a series of alternating triangles. The theory is that an irregular line is harder for the eye to follow than a straight line. This is of great value in facial scars of the cheek, side of the face, or forehead in which there is no discrete skin fold or wrinkle in which to ‘hide’ the scar. While this does break up a linear scar, it also creates a regular pattern which may work against the concept of decreased visibility by making a regular pattern for the eye to follow, even if it is irregular.
For this reason, w-plasties are rarely done alone or throughout the entire scar. They are usually combined other patterns in what is a more sophisticated scar revision method known as geometric broken line closure. (GBLC) This method employs the W-plasty but with the addition of other shapes besides just triangular flaps of the W-plasty. The different shapes may be Ms or other shapes interspersed between the Ws. This makes the closure irregularly irregular and offers the best potential for maximal scar camouflage.The resulting scar is “irregularly irregular,” with the maximum potential for camouflage. This scar closure pattern, combined with sanding or dermabrasion later (no sooner than 2 to 3 months after), is the best bet for many scars that are in difficult or unfavorable facial locations.
Dr. Barry Eppley
Indianapolis, Indiana