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Oral Maxillofacial Surg Clin N Am 17 (2005) 173 189

Secondary Procedures in Maxillofacial Dermatology


James M. Henderson, DDS, MDa,b,c,*, Bruce B. Horswell, DDS, MD, FACSa,b,c,d
Department of Surgery, West Virginia University School of Medicine-Charleston Campus, 3110 MacCorkle Avenue, Charleston, WV 25304, USA b Department of Oral and Maxillofacial Surgery, West Virginia University School of Dentistry, Morgantown, WV 26506, USA c Private Practice, Facial Surgery Center/FACES, 415 Morris Street, Suite 309 Charleston, WV 25302, USA d First Appalachian Craniofacial Deformity Specialists, 830 Pennsylvania Avenue, Suite 302, Charleston, WV 25302, USA
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The main surgical goal in managing cutaneous carcinomas is eradication of the primary lesion with disease-free margins. Once this goal has been achieved, attention can be turned to reconstruction of the surgical defect with favorable esthetic results. Many of the factors that ultimately lead to an esthetically favorable outcome begin with a critical evaluation of the anatomic subunit involved, primary repair versus secondary repair, choice of flap used for reconstruction, tissue handling, and various host factors (ie, tobacco use, comorbid disease). Some of these factors have been discussed in previous articles and receive only cursory review in this article. This article focuses on secondary procedures used to improve the esthetic outcome of surgical resection. Management of flaps and scars is discussed, including the immediate postoperative period and the late (secondary) period. Various adjunctive measures are discussed, including scar revision, resurfacing procedures, silicone, dressings, and topical agents. Numerous treatments are available for the management of facial scars. Each modality can partially improve the outcome in various ways, and a combination of treatments is often required to achieve optimal results. It is imperative to evaluate patient expectations before excision of facial lesions and

throughout the postoperative period, because patients often have unrealistic expectations about the resolution of their wound and the eventual esthetic outcome. Physicians must emphasize that no therapeutic modality can bring about complete resolution of scarring and that multiple treatments and treatment modalities are often required [1].

Wound healing To fully appreciate the role of secondary procedures in improving the esthetic outcome of surgical resection, one first must have a basic understanding of wound healing. This understanding helps guide the reconstructive surgeon in choosing a mode of therapy best suited to achieve the desired result. Wound healing represents a complex series of events that until recently have been understood poorly. The complex interaction of events in wound healing has been divided into phases, including inflammation, migration, proliferation, and remodeling (contraction). Inflammation begins when a site is injured (surgical incision) and results in a cascade of events that involves vasoconstriction, platelet activation, and eventual clot formation [2 9]. Exaggeration of the inflammatory phase increases the concentration of various growth factors, including transforming growth factor beta, platelet-derived growth factor, interleukin-1, and insulin-like growth factor. Neutrophils predominate initially, followed by macrophages several days later. In the migratory phase, angiogenic factors and fibroblasts increase, while excess amounts

* Corresponding author. FACES/Facial Surgery Center, 830 Pennsylvania Avenue, Suite 302, Charleston, WV 25302. E-mail address: james.henderson@camc.org (J.M. Henderson).

1042-3699/05/$ see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.coms.2005.02.006

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of collagen and extracellular matrix are produced [8,10]. The proliferative phase is characterized by an increase in collagen production and epithelial cell migration and regeneration. Granulation tissue also becomes evident during this phase. Scar contracture and collagen reorganization are observed in the remodeling (late) phase of wound healing. Wound contraction is characterized by a decrease in fibroblasts, macrophages, and wound vascularity and is believed to be the result of myofibroblasts [8]. Collagen cross-linking and alignment characterize the mature wound; epithelial architecture is stable, although it never returns to its preinjured state [11]. The phases of wound healing seem to act in concert to various degrees. As a result, any disruption of a specific component leads to an imbalance in the process that may lead to excessive wound contracture, hypertrophic scar formation, keloids, or pigmentary changes, which lead to a compromised esthetic result. Numerous factors can affect the delicate balance of wound healing and lead to scar formation, including infection, foreign body, systemic toxins, hematoma, tissue hypoxia, prolonged healing by secondary intention, improper tissue handling, and wound tension (traction) [11]. Various growth, hormonal, immunologic, and genetic factors also may be altered during the phases of wound healing, contributing to an imbalance in the process and eventual scar formation. Any of the agents typically used to improve healing, including topical and systemic agents, can be used inappropriately and disrupt the normal mechanism of wound healing. Ultimately, any of the factors listed previously increase metabolic and cellular activity within the wound leading to an excessive deposition of tissue collagen, water, fibronectin, and glycosaminoglycans [2 9,12]. With regard to scar management, numerous techniques and therapies have been advocated in the literature. Many therapies have been shown to be effective in small-scale studies and anecdotal reports; however, few of these modalities have been supported by prospective studies with adequate control groups and long-term follow-up. Care must be exercised when applying information from these studies and extrapolating it to the treatment of facial scars, because many studies are based on dermatologic wound healing in other body regions. Facial skin is thinner, has more appendages, and may be affected adversely by some scar treatment modalities [1]. Mustoe et al [13] gathered international recommendations on prevention and management of abnormal scarring and provided evidence-based recommendations for treatment. The consensus of this

international group of experts emphasizes the primary role of silicone gel sheeting and intralesional corticosteroids in scar management, and it is based on largescale, prospective, evidence-based trials. Throughout the remainder of this article, the authors attempt to highlight treatments supported by large-scale, prospective studies and point out therapies based on small-scale reviews or anecdotal reports.

Host and local factors Systemic health of the patient who undergoes surgery or dermatologic corrective measures has long been recognized as a key component in achieving a good result. Numerous host factors play a critical role in normal wound healing, including nutrition, oxygenation, coexisting disease, and existing dermatologic disease [14]. This is particularly relevant in oncologic patients who also may have undergone radiation treatment for their disease. The healthier a patient, the more accelerated and predictable the healing process and the less susceptible a wound is to adverse microbial and local environmental influences. Numerous studies have shown that scarring is minimized when a patients health status has been optimized. A review of the literature indicates that two or more comorbid systemic diseases significantly affect surgical outcome, which is compounded by increasing age, poor nutritional status, and substance abuse [11,14,15]. Patient selection for a particular procedure is paramount (some patients may not be good candidates for revision surgery, unless there are adverse functional concerns). Reducing or controlling smoking (particularly in the perioperative period), improving nutritional status if malnourishment is suspected, and optimizing the general medical condition improve outcomes after surgery for even minor procedures [11]. Nutrition should be optimized to provide an intact immune system and the building blocks needed for normal healing. Vitamins A and C and ferrous iron are needed for normal collagen synthesis. Reduced levels of zinc lead to decreased protein production and delayed epithelialization. Local host factors also play a key role in normal healing. The more involved the planned procedure (ie, deeper and more extensive flaps or grafts), the more one can anticipate problemsand possibly failurein a compromised patient. Surgeons should consider options carefully for dermatologic revision or correction, with patients and their health in mind. A wide and deep excision to bone or scar that necessitates local flap advancement in a smoker with poorly controlled diabetes may invite disaster and

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more problems. Scars located over convex surfaces can be difficult to revise because of unfavorable forces and high surface tension. Surgical defects located in areas of function may be prone to widened and deformed scars for similar reasons. Tissue type is also critical, with thick sebaceous skin being more prone to milia formation, acneiform eruption, and prolonged inflammation [16 19]. In the postablative patient, it is critical to review any history of radiation therapy. For patients who are otherwise healthy and have received less than 50 Gy, successful secondary procedures can be performed in an effort to reduce scarring. Regions of the head and neck that have received more than 50 Gy generally have compromised cutaneous characteristics of basilar fibrosis, dermal plexus obliteration, atrophy of the subcutaneous and surface epithelium, and some loss of dermal appendages. These conditions lead to delayed healing and an increased risk of wound complications that may contribute to a poor esthetic outcome [15]. Sun exposure is another host factor that is often overlooked when discussing postoperative secondary procedures and the prevention of scarring. Many patients who have undergone resection of skin malignancies have had an extensive sun exposure history and may continue to work outdoors or engage in outdoor recreational activities. Not only can continued sun exposure lead to further solar damage to the skin and risk of malignancy but it also can lead to significant pigmentary changes in postsurgical scars [16]. Even minimal sun exposure within the first 60 days of repair can lead to hyperpigmentation. A broad-brimmed hat and sunblock should be recommended to every patient to prevent these changes [14].

Fig. 1. Hyperpigmentation of scars in Fitzpatrick V individual.

is controlled or in remission [18,19]. A patient with active acne lesions in the midst of a wound have worse wound healing and increased scarring (Fig. 2). Active acne is usually treated with a combination of antibiotics, surface exfoliating adjuncts (eg, salicylic and azeleic acids, benzoyl peroxide), and, in severe cases, retinoic acid derivatives [19]. Preoperative mechanical or chemical resurfacing procedures may need to be planned before more extensive dermatologic surgery to optimize local skin conditions.

Surgical management The most critical time to prevent scar formation is at the time of injury or surgical resection. It is important to briefly review several factors involved in the surgical planning and resection of skin lesions and scars that have a profound impact on the eventual esthetic result. Skin preparation

Dermatologic conditions Inherent ethnic and skin characteristics affect results. Darkly pigmented individuals (Fitzpatrick IV, V, and VI) are prone to prolonged, unpredictable, and often less desirable results (Fig. 1) [16]. Persons with darker skin have a tendency to unpredictable dyschromia caused by melanocytic dysfunction that results in either hypo- or hyperpigmentation. This situation must be discussed carefully with patients before treatment. Judicious use of perioperative steroids and 4% hydroquinone may assist in modulating abnormal melanocytic responses [17]. Patients with active acne, rosacea, eczema, or other inflammatory dermatoses should have secondary revision surgery deferred until the condition Optimizing a patients skin condition is paramount for revision surgery success. Preoperative adjuncts include resurfacing procedures (eg, chemical, laser, or dermabrasion techniques) that improve skin metabolism, vasularity, orderliness of skin cell maturation, and collagen or elastin components in the dermis [20]. Generally, the skin should be prepared approximately 4 weeks before revision surgery to allow some maturation of the skin layers, especially the epidermis. The more extensive the resurfacing procedure, the longer the healing period until final secondary procedures can be performed. Some clinicians believe that preoperative administration of multivitamins, particularly vitamins C and E, one or two weeks before surgery enhances healing and

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need to be revised much sooner than anticipated. Scars in regions that restrict function, such as the eyelid, neck, and oral cavity, may need earlier intervention. Factors such as harassment and social alienation by other children and parental anxieties also may lead to earlier intervention [24]. Scar location It is important to understand that the goal of scar modification surgery is not to eliminate scars but to hide them and make them as inconspicuous as possible [15,25]. One also must take into account how the scar appears and may be accentuated during animation. A scar with favorable characteristics is flat (level with surrounding tissue), has similar color and texture to the surrounding tissues, is oriented within or along resting skin tension lines (RSTLs), and may have a geometric design that is less detectable to the naked eye [12,15,28]. Incorporation and deformation of normal surrounding tissue must be minimized as much as possible. The practicality of this concept is limited by scar maturity, width, and location. Wide, hypertrophied scars may be better suited to intralesional excision or resurfacing [24,29]. Scars ideally should lie within the relaxed skin tension lines (Fig. 3). Planning for scar or defect revision with local flaps should incorporate this objective so that healing proceeds without excessive

Fig. 2. Active acne and increased inflammation in scars.

improves surgical results, although this has not been proven [21,22].

Scar revision Several types of excisional designs are available to the surgeon. Limbergs excellent treatise on scar revision is foundational to our understanding and practice in dermatologic surgery [23]. He designed many flaps based on mathematical configurations, which are useful for reconstructing defects with local tissue. These flaps are discussed later; however, several factors must be considered before planning reexcision of scar tissue or lesions. Timing It is never too late to perform a scar revision; however, scar revision can be done too early [24]. As a general rule, scar modification surgery should be deferred 6 to 12 months. This is the time when mature collagen makes up most of the wound bed. Wounds in the inflammatory and proliferative phases of healing are more prone to exaggerated and prolonged inflammation and, consequently, increased scarring [1,15,24,25]. Adults typically have less wound healing vigor, and planning for surgery may take place earlier. For wounds with poor scar orientation or wound alignment, surgery can be considered earlier [26]. Children heal quickly but with longer periods of vascularity and more collagen depot; deferment for 1 or 2 years may be prudent [27]. This time period results in some improvement in appearance of the scar and diminution of scar size and bulk. No amount of time improves a scar or defect that has resulted in tissue mismatch in the vermilion border or eyelid margins or in a disfiguring avulsion defect with foreign body inflammation. These scars may

Fig. 3. RSTLs of the facial region with lines of maximal extensibility that run perpendicular.

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tension [28]. Scars that cross RSTLs typically widen and become hypertrophic, particularly over convex surfaces [30]. Earlier reorientation of the scar or placement of a free graft (not as ideal as local tissue) to avoid tension may be indicated. Nature of injury or procedure Areas of tissue loss, such as those seen after Mohs surgery or excision of facial skin lesions, are at high risk for widened scar formation [24,29]. Tissue loss connotes increased skin tension during primary and secondary closure. Normal skin texture is not obtained with re-epithelialization, and the resultant dermis is characteristically thin and atrophic [24]. Meticulous handling of the tissues, evacuation of blood from the wound, accurate wound alignment, and careful suture placement reduce inflammation and subsequent scarring [8,9,15,24,31]. Avulsive wounds and heavily contaminated wounds require judicious management to preserve viability and reduce bacterial load to prepare the bed for reconstruction. Some surgeons culture the tissue to confirm reduced bacterial load (<105 organisms/ gram of tissue) before repair [11]. Wound healing history (hypertrophic scars, keloids) Patients with a history of keloid formation should be approached with caution. Time usually does not improve a keloid, and use of adjunctive preoperative agents is important before revision surgery (Table 1) [29]. Preoperative triamcinolone injection two or three times before planned excision helps prepare

Fig. 4. Triamcinolone injection of keloid before revision surgery.

a keloid for more ordered and controlled healing (Fig. 4). A frank, honest discussion with patients before surgery is mandatory, with the expectation that some amount of keloid scarring will recur.

Scar morphology Scars that are raised and high profile are more difficult to camouflage than depressed scars hidden in RSTLs or under anatomic borders (eg, the ala or lower lip) [30,31]. More staged revision is required for the former type of scar, and patients must be informed of possible protracted treatment. Selection of excisional and reconstructive techniques follows a simple to more complex design algorithm. Fig. 5 (an algorithm for dermatologic secondary procedures) represents a decision-making tree on which the surgeon can add or modify adjunctive treatments, such as skin preparation, resurfacing, and postoperative modalities.

Table 1 Dosage of Kenalog (triamcinalone acetonide) for adults and children Adults Lesion size (cm2) 12 26 6 10 >10 Children Age (y) 12 35 6 10 Dosage (mg) 20 40 40 80 80 100 100 120

Simple excision Fusiform and Z-plasty techniques Unsightly scars can be re-excised with a fusiform or geometric design (Fig. 6). Generally, fusiform excision is performed for smaller scars or lesions that lie parallel to the RSTLs, which places the repair in a favorable and esthetic position after healing (Fig. 7). Scars that run across RSTLs need some reorientation, which can be achieved through Z-plasties of varying lengths, number, and angles. Typically, the more acute the angle of the limb, the less the gain in length of repair and reorientation of the scar [31,32].

Dosage (mg) 20 40 80

Adapted from Chowdri NA, Mattoo MM, Darzi MA. Keloids and hypertrophic scars: results with intra-operative and serial postoperative corticosteroid injection therapy. Aust N Z J Surg 1999;69:656.

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horswell Fig. 5. Algorithm for decision making in dermatologic revision surgery. (From Horswell BB. Scar modification: techniques for revision and camouflage. Atlas Oral Maxillofac Surg Clin North Am 1998;6:55 72; with permission.)

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Fig. 8 illustrates a Z-plasty design for a scar band in the cheek that runs perpendicular to the RSTLs. It correctly reorients the incision and limbs in the direction of the RSTL and allows the retracted lip and cheek to displace inferiorly. Multiple Z-plasties also may be constructed to lengthen scar and decrease tension across the revised tissue plane [28,32,33]. Vigorous, yet judicious, undermining of the triangle bases must be performed to effect ease in transposition. A variant of Z-plasty is an S-plasty design, which results in a softer, less obvious linear arrangement. The S-plasty is indicated in higher profile or convex surfaces, as in over-the-cheek, nasal tip, and chin

Fig. 7. Diagram of closed scar excisions of Fig. 6. (Image n Bill Winn; with permission.)

areas. Because of a broader tip, there is less distal ischemia and necrosis than in Z-plasty [33]. Geometric designs A long linear scar over the cheek, upper jaw line, or forehead can be improved through incorporating multiple segmental Z-plasties or a W-plasty configuration (Fig. 9) [32,34]. This design favorably realigns the scar that runs across RSTLs into one that is more parallel or more easily hidden. The tips can be designed with pointed, round, or squared ends to help break up the scar profile. Often, the tips become edematous and may heal with some element of hypertrophy, which can be dermabraded for a final smooth appearance after initial healing. For U-shaped scars on a convex surface, the inner arch of W-plasties

Fig. 6. Diagram of various facial scar excisions. (A ) Fusiform. (B ) H-flap. (C ) W-plasty. (D ) Z-plasty. (E ) Elliptical and Z-plasty combined. (F ) geometric design. Stippled areas of (E ) and (F ) represent simultaneous dermabrasion. (Image n Bill Winn; with permission.)

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Fig. 8. Release of retracted lip and cheek with Z-plasty technique. (A ) Preoperative. X indicates subcutaneous scar band. (B ) Intraoperative Z-plasty incision. (C ) Postoperative closure of Z-plasty with inferior rotation of lip.

should have less length and angle (approximately 45) than the outer W-plasties (approximately 60), so that the advanced tissue runs radially in direction with and easily incorporate into the outer arc of tissue (Fig. 10) [35].

Flaps After excision of scar or a lesion, the defect may be too large for simple closure. Larger local flaps may need to be designed that can move tissue from the

Fig. 9. W-plasty revision of cheek and lip scar followed by postoperative dermabrasion. (A ) Preoperative. (B ) Postoperative.

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Fig. 10. U-shaped W-plasty excision of scar. (A ) W-plasty excision (white lines indicate radial advancement of arc). (B ) Closure of W-plasty excision.

surrounding region into the defect. These flaps have various geometric designs, most notably the rhomboid flap. Rhomboid flaps are the workhorse facial flaps for reconstructing defects not amenable to local closure [36,37]. They are particularly useful over the cheek and in nasal sidewalls, where the incision limbs can align with anatomic margins or RSTLs. Every defect has four possible rhomboid flaps, of which one is more ideal for tissue transfer and final limb orientation (Fig. 11) [37]. Final closure should provide a limb that aligns with the RSTLs, and allows tissue to rotate easily as the flap extends from lax tissue (perpendicular to the RSTLs). Surgeons should remember that greatest tension is at the leading edge of the flap; secure, permanent subcuticular sutures may be helpful in this area [38]. A variation of rhomboid flaps is the lobed flap, which may have several lobed components. The less

the lobed flap must rotate (less arc of rotation), the less tissue distortion and vascular compromise will occur [38]. Lobed flaps are useful for smaller defects or lesions in the nasal region. Rotation flaps may be used to reconstruct large defects or lesions. Larger cheek or lower eyelid defects can be closed with a random-pattern cheek flap that is rotated anteriorly (Fig. 12). Flaps also can be raised on a vascular pedicle (axial-pattern) and rotated to a defect. Flaps based on the infratrochlear (glabellar), supratrochlear (forehead), and superior labial (nasolabial) vascular branches are useful for reconstructing nasal region defects (Fig. 13).

Tissue expansion At times, large avulsion or resection defects may require reconstruction through tissue recruitment via expansion. This technique is particularly useful for scalp, forehead, and some cheek and neck defects (Fig. 14) [39]. The area to be reconstructed must be mature, with no recent incisions, dehiscence, or inflammation. The tissue reservoir to be expanded also should be uninvolved and distant enough to allow generous expansion without defect distortion; however, it should be close enough to afford local tissue matching and ease of transfer. Temporary distortion of cosmetic units may occur; care should be taken to avoid overexpansion and tissue transfer, which move the ears, brows, and lips [40]. Semi-rigid (reinforced) expander bases can be used in areas of underlying soft tissue (eg, cheeks, neck) to ensure overlying skin expansion without deeper structure distortion. Tissue expansion requires good knowledge of tissue mechanics, expander instrumenta-

Fig. 11. Four possible rhomboid flaps for a nasal lesion, one (X ) of which is ideal because of final position of the incisional limbs and direction of tissue transfer.

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Fig. 12. Advancement cheek flap (rotational) into infraorbital defect. (A ) Diagram of cheek advancement flap to repair infraorbital defect. (B ) Clinical photo of advanced cheek flap. (C ) Postoperative view.

tion, and skill with placement. Experience is the key to success.

Immediate postoperative wound management The incidence of hypertrophic scarring after surgery is approximately 40% to 70%. The rate is considerably higher in burn injuries [9]. Recent evidence from the literature suggests that hydration is the most important external factor responsible for optimal wound healing and an esthetically pleasing scar [7,11,12,27]. Wound support with microporous tape is also critical in the immediate postsurgical phase. By 3 weeks, wounds have attained only 20% of their final strength. Interventions too early in the healing process can weaken the closure and lead to an unaesthetic scar [12,41]. Scar support, however, is critical during this period to prevent increased tension across the scar, which can lead to exaggerated scarring. The vector of tension is also important. Excess tension along a single axis may result in a widened or stretched scar, whereas multidirectional

tension or intermittent tension leads to hypertrophic scarring [12,34,42]. With open wounds, an occlusive dressing is recommended in the immediate postoperative phase. Scab formation should be prevented. Scabs consist of necrotic cells, fibrin, and blood products that retard healing through inhibition of epithelial migration. Occlusive dressings prevent scab formation, allow rapid epithelialization, and reduce wound pain, fibrosis, and infection, which produce a better cosmetic result [11]. Appropriate dressings include polyurethane films, hydrogels, and perforated plastic films [14,41]. Antibiotic ointments may serve as effective topical dressings during the exudative postoperative period; however, cleaning the wound daily to remove the film and reapplying the ointment are imperative. Topical antibiotics are usually not necessary beyond day 5 for closed facial wounds. Dermatitis, allergy, and development of resistant organisms are all concerns associated with prolonged antibiotic ointment use. Neomycin is particularly prone to cause skin sensitivity. Ointments with multiple antibiotics are available to broaden the spectrum of coverage [14].

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Fig. 13. Forehead and nasolabial flaps for reconstruction of a large, full-thickness (skin, bone, mucosa) postradiation defect of the nasal-canthal region. (A ) Full-thickness defect of nasal-canthal area with forehead (F ) and nasolabial (N ) flaps outlined for incision. (B ) The nasolabial flap is de-epithelialized and advanced superiorly to line nasal cavity and the forehead flap is turned down over it (top right ). (C ) Final result 6 months after division of forehead flap.

The skin is exquisitely sensitive to adverse environmental influences, particularly during early wound healing. It is important to remove or reduce excessive wetting and drying and protect the skin in extreme climatic conditions. Patients whose employment or hobbies include exposure to potential biohazards, heat, smoke, dust, and other irritants should be care-

ful to protect surgical sites or defer surgery until such time that initial healing can be guaranteed. It is well known that potentially harmful biofilms colonize chronically exposed or challenged skin and render the revised wound more susceptible to inflammation, breakdown, infection, and increased scarring [11]. At least 2 weeks should be allowed for healing after

Fig. 14. Tissue expanders for scar excision and scalp reconstruction. (A ) Large scar and forehead defect. (B ) After expansion of tissue fields lateral to defect. Note: care must be taken not to encroach on the brow region or overexpand the scar defect.

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simple or local skin flap surgery, and up to 6 weeks should be allowed after advanced procedures that involve regional flaps, grafts, or tissue expansion in susceptible patients whose activities or work may compromise healing.

Late postoperative wound management The choice of treatment modality for the management of existing scars depends on a careful evaluation of scar characteristics, age of the scar, and healing properties of patients. It is important to assess how patients have healed previously and whether they have a propensity toward hypertrophic scar production or the development of keloids. Distinguishing between hypertrophic scars and keloid formation is critical in planning intervention and choosing an appropriate therapeutic modality. Clinical characteristics of hypertrophic scars include confinement to original wound, spontaneous regression, onset within 3 months of injury, and improvement with surgery. Keloids, however, extend beyond the original wound margins, persist over time, have an onset of months to years after injury, have a familial tendency, and may worsen with surgery [8,34,42]. Prolonged adjunctive therapy for keloid scar revision includes periodic steroid injectionsif not performed preoperatively and pressure therapy up to 1 year after revision. Several modalities are available to for surgeons to use in conjunction with, or after, scar revision procedures and are discussed in the following section. Preoperative management may include staged skin preparation with glycolic acid peels or microdermabrasion. Glycolic acid peels are a predictable way to prepare skin for revision procedures, but one must be careful not to overinflame the skin just before surgery. After initial healing (2 3 weeks), the revised scar and surrounding tissues can be re-treated with peels or microdermabrasion to enhance epithelial leveling, but one must ensure that no excessive inflammation or dehiscence is present. By relying on subcutaneous sutures and little surface sutures for tissue support and approximation, a surgeon can expect less surface irritation. One should defer greater depth peels until the skin has matured.

Resurfacing (dermabrasion, laser therapy) Dermabrasion may play a role in the management of postablative scarring and treatment of certain benign lesions, including actinic and seborrheic keratoses, epidermal nevi, syringomas, angiofibromas,

trichoepitheliomas, lentigines, cysts, milia, and molluscum. Dermabrasion can be performed safely with simultaneous scar revision procedures (Fig. 15) [43]. Potential complications of dermabrasion include milia formation, acne flares, viral and bacterial infections, pigmentary changes, and contact dermatitis. Acne flares are temporary and may persist for 6 to 12 weeks. These flares are treated the same as any other acne flare and usually do not lead to new acne scars. Most viral infections can be prevented with proper prophylaxis. Antiviral agents should be administered preoperatively and during the process of re-epithelialization (7 10 days). Patients with breakthrough viral infections or a predisposition to herpetic outbreaks should be treated with a zoster dose of antiviral medication. Prophylactic antibiotics are not typically warranted, except in patients with a history of rosacea or impetigo. The most common complication of dermabrasion is pigmentary alteration [16]. Permanent hypopigmentation can occur in 10% to 20% of patients and is more common in persons with Fitzpatrick skin types IV, V, and VI. Postinflammatory hyperpigmentation is the most common pigmentary alteration encountered after dermabrasion. Typically, changes begin 3 to 4 weeks after surgery and can be reversed with topical steroids, hydroquinone (4% 8%), and sun avoidance [17,43]. Late or persistent erythema heralds the onset of scar formation and must be aggressively diagnosed and managed. Topical steroids may be useful during the initial phase, but intralesional steroids are used once any papular quality or induration develops [43]. The flashlamp-pumped pulse-dye laser was developed as a means to obliterate underlying vasculature believed to play a role in blood-borne tissue factors and growth factors that stimulate fibroblast activity [41,42]. Scars treated with the pulse-dye laser have shown a decrease in erythema and improved scar texture, height, and pruritis [10,41]. Typical treatment regimens involve fluences of 6.5 to 7.5 J/cm2 using a spot size of 5 mm, with treatments repeated at 6- to 8-week intervals until the desired result is achieved or no further improvement is noted. The effects are not as effective in patients with Fitzpatrick types IV, V, and VI skin [41]. Laser resurfacing of new surgical scars 6 to 8 weeks postoperatively produces results similar to those achieved with dermabrasion [1,20]. One area that shows promise for using laser resurfacing immediately after Mohs surgery is the nose. The predictability of secondary intention healing of defects on convex nasal surfaces is not reliable. For surgical defects of concave nasal surfaces, however, secondary intention healing can equal or surpass surgical reconstruction. In a retrospective review by

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Fig. 15. Simultaneous scar revision and dermabrasion. (A ) Preoperative view of multiple uneven, hyperpigmented scars. (B ) Clinical photo of planned areas for excision and dermabrasion. (C ) Postoperative view at 6 months.

Ammirati et al [44], 74 patients underwent immediate postoperative laser resurfacing of convex nasal surfaces after Mohs surgery using a scanned carbon dioxide or long-pulsed Er:YAG laser. All of the patients in their series were satisfied with the result, and an independent panel of nine physicians who reviewed postoperative photographs of 30 patients in the series deemed the results acceptable or excellent.

Medications Steroids Steroid preparations commonly used in the management of hypertrophic scars and keloids include triamcinolone acetonide (Kenalog) and triamcinolone diacetate (Aristocort). Mechanisms of action include reduced angiogenesis, decreased fibroblast proliferation, decreased cytokine production, inhibition of collagen and extracellular matrix protein synthesis, and disruption of fibrosis [1,9,10,41,42]. Steroids can

be used at various times during therapy. For early preexcisional treatment and early postsurgical treatment, a low concentration is used (Kenalog, 10 20 mg/mL). After scar maturation and in persons with a predisposition to excessive scarring, higher concentrations are used (Kenalog, 40 mg/mL). Treatment is usually administered with multiple injections given 4 to 6 weeks apart (Table 1) [1,15,41]. Complications of steroid administration include skin atrophy, granulomas, pigmentary changes, and development of telangiectasias [1,9,41]. To reduce the risk of these complications, Grossman [1] recommends starting with lower concentrations and slowly increasing the dose over several sessions. For the treatment of facial lesions, he begins with a dose of 3 mg/mL and increases this to 10 mg/mL.

Topical agents Many topical agents are available for use in the management of scars. Many of these agents are vitamin based or contain herbal extracts. Topical

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vitamin E has been advocated by medical professionals and lay people alike for the treatment of scars. The mechanism of action seems to be related to reduction of oxygen radicals, which alter collagen and glycosaminoglycan production and decrease healing by damaging DNA, cellular membranes, proteins, and lipids [41,45]. Systemic use of vitamin E seems to slow early wound healing by downregulating the inflammatory response and may lead to decreased tensile strength. Topical administration of vitamin E has shown mixed results in the literature [12,17, 22,45]. Despite having widespread anecdotal support, a double-blind study by Bauman and Spencer [45] using topical vitamin E showed no improvement in the cosmetic appearance of surgical scars [45]. Topical vitamin E also has been observed to have mild deleterious effects on the esthetic outcome of some wounds if administered too early in the healing process by reducing tensile strength of the wound [12,41]. Topical use of vitamin E later in the wound healing process (4 6 weeks) may contribute to a flatter scar but also may result in a stretched and weakened scar [12]. Topical vitamins A, C, and K also have been used in the perioperative management of dermatologic wounds [21,22]. Their antioxidant properties are believed to soften and flatten scars, decrease pruritus, and prevent capillary leakage. Systemic use of vitamin A has shown a modest improvement in the appearance of some hypertrophic scars and keloids [41]. Antimetabolites Another scar treatment that shows promise is intralesional injection of bleomycin and 5-fluorouracil [41]. Bleomycin is available in 15-U vials, and 5-fluorouracil is available in 50-mg/mL vials. Some authors recommend combining 5-fluorouracil with triamcinalone, 1 mg/mL, with frequent injections to maximize scar tissue resolution. 5-fluorouracil is converted into its active substrate, which is incorporated into DNA and inhibits DNA synthesis. Cells that synthesize increased amounts of DNA, such as fibroblasts, are targeted, which leads to decreased proliferation. A single application in the first few days after wound closure seems to be effective. Wound healing amid actinic conditions has been shown to be improved with limited use of 5-fluorouracil and glycolic acid peels in the perioperative period. One advantage of the use of antimitotic agents is that steroid atrophy can be avoided [1]. Contraindications to the use of 5-fluorouracil include existing bone marrow depression, infection, pregnancy, and lactation [1,9,46].

Other agents Calcium channel blockers may play a role in the management of existing hypertrophic scars by inducing collagenase production, which leads to scar tissue degradation. Verapamil or other calcium channel blockers can be injected into the lesions in a manner similar to that for corticosteroids. Alternatively, 4% to 5% verapamil in a cream base can be applied topically. This application often can be alternated with steroid injections to achieve a reasonable response [9].

Silicone gel sheeting Numerous randomized, controlled trials and a meta study of 27 trials have demonstrated that silicone gel sheeting is a safe and effective therapeutic technique in the prevention and management of hypertrophic scars and keloids (Fig. 16) [13]. Silicone gels have been shown to be effective in reducing scar size and erythema through steady-state oxygen and hydration maintenance. Hydration has been shown to inhibit the production of collagen and glycosaminoglycans by fibroblasts [41]. Silicone gel seems to function like the stratum corneum by reducing water loss and restoring homeostasis to the scar, which results in decreased capillary hyperemia, collagen deposition, and hypertrophic scar formation [1,12,42]. Use should begin when the incision has epithelialized fully. Silicone gel sheets should be worn 12 to 24 hours per day for at least a month; thereafter they should be continued on a weaning basis over the next 3 months until maturation is complete. Silicone ointments may be useful, particularly in the head and neck region; however, their use is not supported

Fig. 16. Silicone gel sheets to reduce keloid tendencies in scars.

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by controlled trials. When used, silicone gels are typically applied two times per day after the removal of sutures [1,10,12,13,41,42].

Pressure therapy Pressure therapy is often used as first-line therapy in the management and prevention of scarring and has been used since the 1970s. In general, pressure of 24 to 30 mm Hg must be maintained for several hours per day over a period of 6 to 12 months [10,13,14]. The beneficial effects of compression seem to be related to local tissue hypoxia, reduced scar blood flow, decreased protein deposition, decreased edema, and a reduction in the population of mast cells, which may affect fibroblast growth [10,41,42].

Fig. 17. Subdermal placement of temporalis fascia to plump depressed scar at the commissure and cheek.

Soft-tissue augmentation Various materials can be used to augment atrophic and depressed scars. These techniques are more successful in scars that are distensible and not excessively bound down [41]. The first material to become available for injection was bovine collagen. Several forms are available, with various studies showing degradation after 6 to 9 months. The major drawback to using bovine collagen injections is allergy. Three percent to 3.5% of the population have a localized hypersensitivity reaction. Other adverse reactions to bovine collagen injection include bruising, herpes reactivation, and bacterial superinfection [1,47]. Collagen should not be injected into patients with a history of autoimmune diseases or patients with hypersensitivity to lidocaine [1]. Allogeneic collagen has intact collagen fibers, which give it greater longevity. Allogeneic collagen is derived from donated human skin from donors who have been screened carefully for infectious diseases, such as HIV, hepatitis B, hepatitis C, and syphilis [41]. In addition to being used in an injectable form, Alloderm can be used to elevate depressed scars and prevent recurrence of the contracted scar tissue bands. After the scar is excised, Alloderm is cut to the shape of the defect and the wound edges are approximated and closed over the defect [48]. Autologous fat and fascia also have been advocated for soft-tissue augmentation. Delicate tissue handling is paramount to successful transfer of viable cells. Large-bore, low-pressure harvesting and injecting devices should be used to maintain cell integrity. Longevity of 6 months to years has been documented

when cells are atraumatically harvested and placed [41]. Sites for fat harvest include the abdomen, thighs, and buttocks. Fat is collected and centrifuged at 3000 rpm for 5 minutes. The lower layer of fat is used for transplantation. Cannulas 4 to 5 mm in diameter are used to transplant the autologous fat. The endpoint of injection is when the depressed scar is obliterated and approximately 20% to 30% overcorrection is achieved. The amount of fat needed for transplantation is approximately 3 cm3/cm of scar length [49]. Fascia similarly can be used to plump and fill depressed scars (Fig. 17). Fascia is easily harvested from the temporalis or fascia lata of the thigh and has no immune rejection phenomena.

Camouflage therapy For patients who have local or systemic factors that contraindicate secondary procedures or for patients who do not wish to undergo any surgical revisions, camouflage therapy may represent a viable option for improved cosmesis. Camouflage therapy can conceal postoperative bruising and erythema and can normalize the skins appearance, providing a psychological lift to a patient. Camouflage also can be used as an interim measure to allow scars to mature or local/systemic factors to improve before definitive secondary procedures [50]. Water-based cosmetics can be applied as soon as sutures are removed (5 7 days) or after re-epithelialization is complete (10 14 days) [15,50]. Another form of camouflage therapy is placement of color by micropigmentation or cosmetic tattooing. White scars can be improved by placing skin-colored pigment into the mature scar tissue. The pigment

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horswell treatment of excessive dermal scarring. J Natl Med Assoc 2004;96(1):108 16. Demling R, DeSanti L. Scar management strategies in wound care. Rehab Manag 2001;14(6):26 30. Lawrence WT, Bevin AG, Sheldon GF. Acute wound care. In: Wilmore DW, Cheung LY, Harken AH, Holcroft JW, Meakins JL, Soper NJ, editors. ACS surgery: principles and practice. New York7 Web MD Corp.; 2002. p. 131 4. Widgerow AD, Chait LA, Stals R, et al. New innovations in scar management. Aesthetic Plast Surg 2000;24:227 34. Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar management. Plast Reconstr Surg 2002;110:560 71. Leach J. Proper handling of soft tissue in the acute phase. Facial Plast Surg 2001;17(4):227 38. Horswell BB. Scar modification: techniques for revision and camouflage. Atlas Oral Maxillofac Clin North Am 1998;6(2):55 72. Rendon MI. Melasma and postinflammatory hyperpigmentation. Cosmetic Dermatology 2003;16(4):917. Pandya AG. Pharmacological sgents in skin of color. Cosmetic Dermatology 2003;16(4):49 52. Koopmann Jr CF. Cutaneous wound healing. Otolaryngol Clin North Am 1995;28(5):83545. Thiboutot OM. Acne and rosacea: new and emerging therapies. Dermatol Clin 2000;18:63. Lowe NJ, Lask G, Griffin ME. Laser skin resurfacing: pre- and post-treatment guidelines. Dermatol Surg 1995;21:1017. Fitzpatrick RE, Roston EF. Double-blind, half-face study comparing topical vitamin C and vehicle for photodamage. Dermatol Surg 2002;28:231. Hayakawa R, Ueda H, Nozaki T, et al. Effects of combination treatment with vitamins E and C on chloasma and contact dermatitis: a double-blind controlled clinical trial. Acta Vitaminol Enzymol 1981; 3:31. Limberg AA. The planning of local plastic operations on the body surface: theory and practice. Lexington (MA)7 DC Heath and Co.; 1984. Schweinfurth JM, Fedok F. Avoiding pitfalls and unfavorable outcomes in scar revision. Facial Plast Surg 2001;17(4):273 7. Bradley DT, Park SS. Scar revision via resurfacing. Facial Plast Surg 2001;17(4):253 61. Borges AF. Timing of scar revision techniques. Clin Plast Surg 1990;17:71 6. Krummel TM, Blewett C. Wound healing. In: Ziegler MM, Azizkhan RG, Weber TR, editors. Operative pediatric surgery. New York7 McGraw-Hill; 2003. p. 179 80. Borges AF. Relaxed skin tension lines (RSTL) versus other skin lines. Plast Reconstr Surg 1984;73:144. Murray JC. Keloids and hypertrophic scars. Clin Dermatol 1994;12:27. Borges AF. Elective incisions and scar revision. Boston7 Little Brown and Co.; 1973. p. 1 14.

typically lasts 3 to 5 years. Several treatments may be required to obtain an optimal color match [1]. Consultation with an esthetician who is experienced in medical-grade pigmentation procedures can be a valuable asset to the reconstructive facial surgeon.

[10] [11]

Summary
[12]

Secondary dermatologic procedures for revision of scar or re-excising a lesion must take into account many factors. A patients health and habitus, local tissue characteristics and health, previous treatments to the area of concern, and location of the lesion are some factors that influence the outcome of secondary procedures. A thorough understanding of wound healing and how to intervene appropriately during healing, if necessary, is important for clinicians. It has become clear in the literature that proper preparation of the site through elimination of inflammatory conditions and increasing tissue integrity and health provide the foundation for satisfactory and predictable results. Surgeons also must consider which surgical (eg, excision, flaps, dermabrasion) and nonsurgical (eg, resurfacing techniques, medications, dressings, pressure therapy) modalities optimally will correct the condition and continue to improve on its healing state through the postoperative period until tissue maturity.

[13]

[14] [15]

[16] [17] [18] [19] [20]

[21]

[22]

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