SCAR REVISION SURGERY TECHNIQUES
Category: Plastic Surgery
Abstract : Z-PLASTY AND W-PLASTY. Z-plasty and W-plasty are surgical techniques used to treat contractures and to minimize the visibility of scars by repositioning them along the natural lines and creases in the patient’s skin. They are not usually used to treat keloids or hypertrophic scars. In Z-plasty, the surgeon makes a Z-shaped incision with the middle line of the Z running along the scar tissue.
Z-PLASTY AND W-PLASTY. Z-plasty and W-plasty are surgical techniques used to treat contractures and to minimize the visibility of scars by repositioning them along the natural lines and creases in the patient’s skin. They are not usually used to treat keloids or hypertrophic scars. In Z-plasty, the surgeon makes a Z-shaped incision with the middle line of the Z running along the scar tissue.
The flaps of skin formed by the other lines of the Z are rotated and sewn into a new position that reorients the scar about 90 degrees. In effect, the Z-plasty minimizes the appearance of the scar by breaking up the straight line of the scar into smaller units.
A W-plasty is similar to a Z-plasty in that the goal of the procedure is to minimize the visibility of a scar by turning a straight line into an irregular one. The surgeon makes a series of short incisions to form a zigzag pattern to replace the straight line of the scar. The primary difference between a Z-plasty and a W-plasty is that a Wplasty does not involve the formation and repositioning of skin flaps. A variation on the W-plasty is known as the geometric broken line closure, or GBLC.
LASER SKIN RESURFACING AND DERMABRASION.
Skin resurfacing and dermabrasion are techniques used to treat acne scars or to smooth down scars with raised or uneven surfaces. They are known as ablative skin treatments because they remove the top layer of skin, or the epidermis. In dermabrasion, the surgeon moves an instrument with a high-speed rotating wheel over the scar tissue and surrounding skin several times in order to smooth the skin surface down to the lowest level of scarring.
Laser skin resurfacing involves the use of a carbon dioxide or Er:YAG laser to evaporate the top layer of skin and tighten the underlying layer. Keloid or hypertrophic scars are treated with a pulsed dye laser. Dermabrasion or laser resurfacing can be used about five weeks after a scar excision to make the remaining scar less noticeable.
Laser skin resurfacing, however, is less popular than it was in the late 1990s because of increasing awareness of its potential complications. The skin of patients who have undergone laser skin resurfacing takes several months to heal, often with considerable discomfort as well as swelling and reddish discoloration of the skin. In addition, there is a 33–85% chance that changes in the color of the skin will be permanent; the risk of permanent discoloration is higher for patients with darker skin. As of 2003, some plastic surgeons are recommending laser resurfacing only for patients with deep wrinkles or extensive sun damage who are willing to accept the pain and permanent change in skin color.
Diagnosis / Preparation
Preparation for scar revision surgery includes the surgeon’s assessment of the patient’s psychological stability as well as the type and extent of potential scar tissue. Many patients respond to scarring following trauma with intense anger, particularly if the face is disfigured or their livelihood is related to their appearance. Some people are impatient to have the scars treated as quickly as possible, and may have the idea that revision surgery will restore their skin to its original condition.
During the initial interview, the surgeon must explain that scar revision may take months or years to complete; that some techniques essentially replace one scar with another, rather than remove all scar tissue; and that it is difficult to predict the final results in advance. Most plastic surgeons recommend waiting at least six months, preferably a full year, for a new scar to complete the maturation phase of development. Many scars will begin to fade during this period of time, and others may respond to more conservative forms of treatment.
Good candidates for scar revision surgery are people who have a realistic understanding of its risks as well as its benefits, and equally realistic expectations of its potential outcomes. On the other hand, the following are considered psychological warning signs:
• The patient is considering scar revision surgery to please someone else—most often a spouse or partner.
• The patient has a history of multiple cosmetic procedures and/or complaints about previous surgeons.
• The patient has an unrealistic notion of what scar revision surgery will accomplish.
• The patient seems otherwise emotionally unstable.
In addition to discussing the timing and nature of treatments, the surgeon will take a careful medical history, noting whether the patient is a heavy smoker or has a family history of keloids, as well as other disorders that may influence the healing of scar tissue. These disorders include diabetes, lupus, scleroderma, and other disorders that compromise body’s immune system.
Aftercare
Aftercare following Z-plasty or surgical removal of a scar is relatively uncomplicated. The patient is given pain medication, told to rest for a day or two at home, and advised to avoid any activities that might put tension or pressure on the new incision(s). Most patients can return to work on the third day after surgery. The most important aspect of long-term aftercare is protecting the affected area from the sun because the surgical scar will take about a year to mature and is only about 80% as strong as undamaged skin. Sunlight can cause burns, permanent redness, loss of pigment in the skin, and breakdown of the collagen that maintains the elasticity of the skin.
Aftercare following the use of skin grafts, flaps, or dermal regeneration templates begins in the hospital with standard postoperative patients care. If sutures have been used, they are usually removed three to four days after surgery on the face and five to seven days after surgery for incisions elsewhere on the body. Patients are usually asked to return to the hospital at regular intervals so that the graft sites can be monitored. If artificial skin has been used, the patients must keep the site absolutely dry, which may require special precautions or restrictions on bathing or showering.
Aftercare for some patients includes going for psychotherapy or joining a support group to deal with emotions related to disfigurement and scar treatment.
Risks
Scar revision surgery carries the same risks as other surgical procedures under anesthesia, such as bleeding, infection at the incision site, and an adverse reaction to the anesthetic. The chief risk specific to this type of surgery is that the scar may grow, change color, or otherwise become more noticeable. Some plastic surgeons use the “90–10 rule,” which means that there is a 90% chance that the scar will look better after surgery; a 9% chance that it will look about the same; and a 1% chance that it will look significantly worse.
Normal results
Normal results of scar revision surgery and associated nonsurgical treatments are a less noticeable scar.
Morbidity and mortality rates
Mortality rates for scar revision surgery are very low. Rates of complications depend on the specific technique that was used, the condition of the patient’s general health, and genetic factors affecting the condition of the patient’s skin.
Alternatives
There are a number of nonsurgical treatments that can be used before, after, or in place of scar revision surgery.
Drugs
Medications may be used during the initial inflammatory phase of scar formation, as well as therapy for such specific skin disorders as acne. Keloids are often treated by direct injections of corticosteroids to reduce itching, redness, and burning; steroid treatment may also cause the keloid to shrink. Corticosteroid injections, gels, or tapes impregnated with medication are also used after scar excisions and Z-plasty to prevent recurrence or formation of hypertrophic scars. Acne scars are treated with oral antibiotics or isotretinoin.
Massage, wraps, radiation, and nonablative treatments
The most conservative treatments of scar tissue include several techniques that help to minimize scar formation and improve the appearance of scars that existing already. The simplest approach is repeated massage of the scarred area with cocoa butter or vitamin E preparations. Burn scars are treated typically with the application of pressure dressings, which restrict movement of the affected area and provide insulation.
Another technique that is often used is silicone gel sheeting. The sheeting is applied to the scarred area, and remains for a minimum of 12 hours a day over a period of three to six months. It is effective in improving the appearance of keloids in about 85% of cases. Keloids that do not respond to any other form of treatment may be treated with low-dose radiation therapy.
Nonablative treatments, which do not remove the epidermal layer of skin, include microdermabrasion and superficial chemical peels. Microdermabrasion, the use of which has increased widely since 2000, is a technique for smoothing the skin. During this procedure, the physician uses a handheld instrument that buffs the skin with aluminum oxide crystals; skin flakes are removed through a vacuum tube.
Microdermabrasion does not remove deep wrinkles or extensive scar tissue, but can make scars somewhat less noticeable without the risk of serious side effects. Mild chemical peels, such as those made with alpha-hydroxy acid (AHA), are used sometimes to treat acne scars or uneven skin pigmentation resulting from other types of scar revision treatment.
Camouflage
Scars on the face and legs can often be covered with specially formulated cosmetics that even out the color of the surrounding skin and help to make the scar less noticeable. Some of these preparations are available in waterproof formulations for use during swimming and other athletic activities during which one perspires.
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