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

Secondary Procedures in Maxillofacial DermatologyJames M. Henderson, DDS, MDa,b,c,*, Bruce B. Horswell, DDS, MD, FACSa,b,c,dDepartment 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, USAa

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 b