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Oral Maxillofacial Surg C

Secondary Procedures in Maxillofacial Dermatology

James M. Henderson, DDS, MDa,b,c,*,

Bruce B. Horswell, DDS, MD, FACSa,b,c,d

aDepartment of Surgery, West Virginia University School of Medicine-Charleston Campus, 3110 MacCorkle Avenue,

Charleston, WV 25304, USAbDepartment of Oral and Maxillofacial Surgery, West Virginia University School of Dentistry, Morgantown, WV 26506, USA

cPrivate Practice, Facial Surgery Center/FACES, 415 Morris Street, Suite 309 Charleston, WV 25302, USAdFirst Appalachian Craniofacial Deformity Specialists, 830 Pennsylvania Avenue, Suite 302, Charleston, WV 25302, USA

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 es-

thetically 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 im-

prove the esthetic outcome of surgical resection. Man-

agement 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 proce-

dures, silicone, dressings, and topical agents.

Numerous treatments are available for the man-

agement of facial scars. Each modality can partially

improve the outcome in various ways, and a com-

bination of treatments is often required to achieve

optimal results. It is imperative to evaluate patient

expectations before excision of facial lesions and

1042-3699/05/$ – see front matter D 2005 Elsevier Inc. All rights

doi:10.1016/j.coms.2005.02.006

* Corresponding author. FACES/Facial Surgery Cen-

ter, 830 Pennsylvania Avenue, Suite 302, Charleston,

WV 25302.

E-mail address: [email protected]

(J.M. Henderson).

throughout the postoperative period, because patients

often have unrealistic expectations about the reso-

lution of their wound and the eventual esthetic out-

come. 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 proce-

dures 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 in-

flammation, 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 activa-

tion, 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. Neutro-

phils predominate initially, followed by macrophages

several days later. In the migratory phase, angiogenic

factors and fibroblasts increase, while excess amounts

lin N Am 17 (2005) 173 – 189

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oralmaxsurgery.theclinics.com

henderson & horswell174

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 fibro-

blasts, macrophages, and wound vascularity and is

believed to be the result of myofibroblasts [8]. Col-

lagen cross-linking and alignment characterize the

mature wound; epithelial architecture is stable, al-

though it never returns to its preinjured state [11].

The phases of wound healing seem to act in con-

cert 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 con-

tracture, hypertrophic scar formation, keloids, or pig-

mentary changes, which lead to a compromised

esthetic result. Numerous factors can affect the deli-

cate balance of wound healing and lead to scar for-

mation, including infection, foreign body, systemic

toxins, hematoma, tissue hypoxia, prolonged healing

by secondary intention, improper tissue handling, and

wound tension (traction) [11]. Various growth, hor-

monal, immunologic, and genetic factors also may

be altered during the phases of wound healing, con-

tributing 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 mecha-

nism 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 tech-

niques 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 sup-

ported by prospective studies with adequate control

groups and long-term follow-up. Care must be exer-

cised 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 recom-

mendations on prevention and management of

abnormal scarring and provided evidence-based rec-

ommendations for treatment. The consensus of this

international group of experts emphasizes the primary

role of silicone gel sheeting and intralesional cortico-

steroids in scar management, and it is based on large-

scale, prospective, evidence-based trials. Throughout

the remainder of this article, the authors attempt to

highlight treatments supported by large-scale, pro-

spective 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 derma-

tologic 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 influ-

ences. Numerous studies have shown that scarring is

minimized when a patient’s health status has been op-

timized. 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 con-

dition 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 problems—and possibly

failure—in 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 ne-

cessitates local flap advancement in a smoker with

poorly controlled diabetes may invite disaster and

Fig. 1. Hyperpigmentation of scars in Fitzpatrick

V individual.

secondary procedures in maxillofacial dermatology 175

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 pro-

longed 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 basi-

lar 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 com-

plications that may contribute to a poor esthetic out-

come [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 ma-

lignancies have had an extensive sun exposure

history and may continue to work outdoors or engage

in outdoor recreational activities. Not only can con-

tinued 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 recom-

mended to every patient to prevent these changes [14].

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 modu-

lating abnormal melanocytic responses [17].

Patients with active acne, rosacea, eczema, or

other inflammatory dermatoses should have secon-

dary revision surgery deferred until the condition

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 dermato-

logic 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

Optimizing a patient’s skin condition is paramount

for revision surgery success. Preoperative adjuncts

include resurfacing procedures (eg, chemical, laser, or

dermabrasion techniques) that improve skin metabo-

lism, vasularity, orderliness of skin cell maturation,

and collagen or elastin components in the dermis

[20]. Generally, the skin should be prepared approxi-

mately 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

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


improves surgical results, although this has not been

proven [21,22].

Fig. 3. RSTLs of the facial region with lines of maximal

extensibility that run perpendicular.

Scar revision

Several types of excisional designs are available

to the surgeon. Limberg’s 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, sev-

eral factors must be considered before planning re-

excision 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 heal-

ing are more prone to exaggerated and prolonged

inflammation and, consequently, increased scarring

[1,15,24,25]. Adults typically have less wound heal-

ing 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 pe-

riod 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

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 inter-

vention. 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 sur-

rounding tissue must be minimized as much as pos-

sible. The practicality of this concept is limited by

scar maturity, width, and location. Wide, hyper-

trophied 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. 4. Triamcinolone injection of keloid before revi-

sion surgery.


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

Table 1

Dosage of Kenalog (triamcinalone acetonide) for adults and

children

Adults

Lesion size (cm2) Dosage (mg)

1–2 20–40

2–6 40–80

6–10 80–100

>10 100–120

Children

Age (y) Dosage (mg)

1–2 20

3–5 40

6–10 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.

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 in-

formed 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 sur-

geon can add or modify adjunctive treatments, such

as skin preparation, resurfacing, and postopera-

tive modalities.

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 reorienta-

tion, 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].

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.)

henderson

&horswell

178


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 de-

crease 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. 6. Diagram of various facial scar excisions. (A) Fusi-

form. (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.)

Fig. 7. Diagram of closed scar excisions of Fig. 6. (Image nBill 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’’ con-

figuration (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. 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].

Fig. 9. W-plasty revision of cheek and lip scar followed by posto

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

perative dermabrasion. (A) Preoperative. (B) Postoperative.

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 rhom-

boid 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 orienta-

tion (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 re-

member 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

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.

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 de-

fects 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 ro-

tated 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 dis-

tortion 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 knowl-

edge of tissue mechanics, expander instrumenta-

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 sur-

gery 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 rec-

ommended 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 cos-

metic result [11]. Appropriate dressings include poly-

urethane films, hydrogels, and perforated plastic films

[14,41].

Antibiotic ointments may serve as effective topi-

cal dressings during the exudative postoperative pe-

riod; 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 con-

cerns 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].

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 envi-

ronmental 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-

Fig. 14. Tissue expanders for scar excision and scalp reconstruction

tissue fields lateral to defect. Note: care must be taken not to encr

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

. (A) Large scar and forehead defect. (B) After expansion of

oach on the brow region or overexpand the scar defect.


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 manage-

ment 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 produc-

tion or the development of keloids. Distinguishing

between hypertrophic scars and keloid formation is

critical in planning intervention and choosing an

appropriate therapeutic modality. Clinical character-

istics 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 injections—if 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 microderm-

abrasion. 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 be-

nign lesions, including actinic and seborrheic kera-

toses, epidermal nevi, syringomas, angiofibromas,

trichoepitheliomas, lentigines, cysts, milia, and mol-

luscum. 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 infec-

tions, 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 ad-

ministered preoperatively and during the process of

re-epithelialization (7–10 days). Patients with break-

through 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 compli-

cation 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. Postinflamma-

tory hyperpigmentation is the most common pig-

mentary alteration encountered after dermabrasion.

Typically, changes begin 3 to 4 weeks after surgery

and can be reversed with topical steroids, hydro-

quinone (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 devel-

oped 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 resur-

facing 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 sur-

gical reconstruction. In a retrospective review by

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 sur-

faces after Mohs’ surgery using a scanned carbon di-

oxide 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 man-

agement of hypertrophic scars and keloids include

triamcinolone acetonide (Kenalog) and triamcinolone

diacetate (Aristocort). Mechanisms of action include

reduced angiogenesis, decreased fibroblast prolifera-

tion, 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 pre-

excisional treatment and early postsurgical treatment,

a low concentration is used (Kenalog, 10–20 mg/mL).

After scar maturation and in persons with a predis-

position to excessive scarring, higher concentrations

are used (Kenalog, 40 mg/mL). Treatment is usu-

ally 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] recom-

mends 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

Fig. 16. Silicone gel sheets to reduce keloid tendencies

in scars.


vitamin E has been advocated by medical profes-

sionals 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 heal-

ing 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 be-

lieved to soften and flatten scars, decrease pruritus,

and prevent capillary leakage. Systemic use of vita-

min A has shown a modest improvement in the ap-

pearance of some hypertrophic scars and keloids [41].

Antimetabolites

Another scar treatment that shows promise is intra-

lesional 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 incorpo-

rated 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 lacta-

tion [1,9,46].

Other agents

Calcium channel blockers may play a role in the

management of existing hypertrophic scars by induc-

ing 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 topi-

cally. This application often can be alternated with ste-

roid 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 therapeu-

tic 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 glycosamino-

glycans by fibroblasts [41]. Silicone gel seems to

function like the stratum corneum by reducing water

loss and restoring homeostasis to the scar, which re-

sults in decreased capillary hyperemia, collagen de-

position, and hypertrophic scar formation [1,12,42].

Use should begin when the incision has epithe-

lialized 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


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].

Fig. 17. Subdermal placement of temporalis fascia to

‘‘plump’’ depressed scar at the commissure and cheek.

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].

Soft-tissue augmentation

Various materials can be used to augment atrophic

and depressed scars. These techniques are more suc-

cessful in scars that are distensible and not exces-

sively 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 lon-

gevity. Allogeneic collagen is derived from donated

human skin from donors who have been screened

carefully for infectious diseases, such as HIV, hepa-

titis 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 recur-

rence 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 advo-

cated for soft-tissue augmentation. Delicate tissue

handling is paramount to successful transfer of viable

cells. Large-bore, low-pressure harvesting and inject-

ing 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% over-

correction 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 pa-

tients 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 skin’s 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


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.

Summary

Secondary dermatologic procedures for revision

of scar or re-excising a lesion must take into account

many factors. A patient’s 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 second-

ary 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 predict-

able results. Surgeons also must consider which

surgical (eg, excision, flaps, dermabrasion) and non-

surgical (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.

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