scar revision , z plasty

SCAR REVISIONSCAR REVISION

Dr Dr Sumer YadavSumer Yadav Mch plastic surgeonMch plastic surgeon

dr sumer yadav, mch pastic dr sumer yadav, mch pastic surgery, surgery,

[email protected]@gmail.com

ScarScar is a fault or blemish remaining as a is a fault or blemish remaining as a trace of a healed wound, sore or burntrace of a healed wound, sore or burn

As, scar is a mark of..As, scar is a mark of.. IdentityIdentity FashionFashion CultureCulture Braveness…. it is a subject of interest !Braveness…. it is a subject of interest !



Anatomy of the SkinAnatomy of the Skin

Skin is composed of two layersSkin is composed of two layers EpidermisEpidermis Dermis Dermis

papillary dermis (thin, loose collagen, blood vessels, papillary dermis (thin, loose collagen, blood vessels, fibrocytes)fibrocytes)

reticular dermis (thick, compact collagen, sebaceous glands, reticular dermis (thick, compact collagen, sebaceous glands, and fibrocytes)and fibrocytes)

At the dermal-epidermal junction there are rete At the dermal-epidermal junction there are rete pegs which anchor the epidermis to the dermispegs which anchor the epidermis to the dermis

Rete pegs are lost in scar formationRete pegs are lost in scar formationdr sumer yadav, mch pastic dr sumer yadav, mch pastic

surgery, surgery, [email protected]@gmail.com

Wound HealingWound Healing

Vascular Phase (occurs immediately)Vascular Phase (occurs immediately) Early vasoconstriction (5 – 10 minutes)Early vasoconstriction (5 – 10 minutes) Vasodilation (can occur over hours to days)Vasodilation (can occur over hours to days)

Release of numerous cellular and acellular Release of numerous cellular and acellular products in the bloodproducts in the blood



Proliferative PhaseProliferative Phase ReepithelializationReepithelialization Granulation tissue/fibroplasia Granulation tissue/fibroplasia

inflammatory cells, fibroblasts, and inflammatory cells, fibroblasts, and neovasculature in a matrix of fibronectin and neovasculature in a matrix of fibronectin and other glycoproteinsother glycoproteins

Wound contractionWound contraction



Remodeling PhaseRemodeling Phase Collagen is remodeled and reorientedCollagen is remodeled and reoriented Process continues for approximately 6 months or Process continues for approximately 6 months or

moremore Decrease bulk and improve tensile strength Decrease bulk and improve tensile strength

through the realignment of the collagen fibersthrough the realignment of the collagen fibers



Fetal Wound HealingFetal Wound Healing

No fibrosis or scar formation in contrast to adult No fibrosis or scar formation in contrast to adult wound healing wound healing Extracellular matrix rich in hyaluronic acid (HA)Extracellular matrix rich in hyaluronic acid (HA) Fewer neutrophils and more monocytes during the Fewer neutrophils and more monocytes during the

inflammatory periodinflammatory period different concentrations of cytokines different concentrations of cytokines Greater proportion of type III collagenGreater proportion of type III collagen Low PDGF and high epidermal growth factor (a Low PDGF and high epidermal growth factor (a

mitogen for epithelializationmitogen for epithelializationdr sumer yadav, mch pastic dr sumer yadav, mch pastic


Causes for abnormal scar formation Causes for abnormal scar formation

Wound healing by secondary intention Wound healing by secondary intention (prolonged inflammatory response)(prolonged inflammatory response)

Foreign body reaction and bacterial infections Foreign body reaction and bacterial infections Skin tension (anterior chest, shoulders, and Skin tension (anterior chest, shoulders, and

upper back )upper back ) AnoxiaAnoxia Wound orientation Wound orientation



PathogenesisPathogenesis

Unique to humans Unique to humans No uniformly accepted theory or explanation No uniformly accepted theory or explanation Excessive accumulation of collagen, decreased Excessive accumulation of collagen, decreased

collagen degradationcollagen degradation Collagenase inhibitor alpha-2 macroglobulin Collagenase inhibitor alpha-2 macroglobulin

have been shown to be increased have been shown to be increased TGF- TGF- ββ, , specifically, low levels of TGF-specifically, low levels of TGF-ββ1 and 1 and

TGF- TGF- ββ2 and high levels of TGF- 2 and high levels of TGF- ββ3—probably 3—probably has a central role in scar formationhas a central role in scar formation



Clinical classification of scarsClinical classification of scars

Mature scarMature scar Immature scarImmature scar Linear hypertrophic scarLinear hypertrophic scar Widened hypertrophic scarWidened hypertrophic scar Minor keloidMinor keloid Major keloidMajor keloid



Hypertrophic scar and KeloidHypertrophic scar and Keloid

Although both…Although both… heal overzealously above the skin surface heal overzealously above the skin surface can be red and raised can be red and raised are indistinguishable by plain H&E stainingare indistinguishable by plain H&E staining can recur after surgical excisioncan recur after surgical excision



Hypertrophic scarHypertrophic scarNo racial No racial

predisposition……..predisposition……..No genetic No genetic

predisposition…..predisposition…..Regress over Regress over

time…………….time…………….Confined to Confined to

wound……………wound……………Scant Scant

mucin……………………..mucin……………………..Occur within months of the Occur within months of the

initial trauma initial trauma

KeloidKeloidMore in blacksMore in blacksPresentPresentDoes not regressDoes not regressGrow beyond marginGrow beyond marginMucinous stromaMucinous stromaCan occur within a year Can occur within a year

after injury after injury



Hypertrophied scarsHypertrophied scars

Raised, erythematous, fibrotic lesions that Raised, erythematous, fibrotic lesions that usually remain confined within the borders of the usually remain confined within the borders of the original wound original wound

Occur in persons of any age or at any site Occur in persons of any age or at any site More common than keloids More common than keloids More responsive to treatment More responsive to treatment Self-limited, worse at 2 weeks to 2 months Self-limited, worse at 2 weeks to 2 months



KeloidKeloid

Benign dermal fibroproliferative lesions Benign dermal fibroproliferative lesions that that grows beyond the boundary of the original site of grows beyond the boundary of the original site of a skin injurya skin injury

KeloidKeloid, meaning "crab claw," illustrate the way , meaning "crab claw," illustrate the way the lesions expand laterally from the original the lesions expand laterally from the original scar into normal tissuescar into normal tissue

occur in 5-15% of wounds occur in 5-15% of wounds



KeloidKeloid

more prevalent in persons aged 10-30 years more prevalent in persons aged 10-30 years 5-15 times higher incidence in African 5-15 times higher incidence in African

Americans and darker pigmented people than in Americans and darker pigmented people than in whites (Incidence-16%) whites (Incidence-16%)

May have different incidences in different parts May have different incidences in different parts of the same personof the same person

Persons with only earlobe keloids should not be Persons with only earlobe keloids should not be considered keloid formersconsidered keloid formers

remain red, pruritic, and painful for many months remain red, pruritic, and painful for many months to years to years



Keloid-contributing factorsKeloid-contributing factors

Skin and/or muscle tension Skin and/or muscle tension Infection, repeated trauma, skin tension or a Infection, repeated trauma, skin tension or a

foreign body-other factorsforeign body-other factors accelerated growth during puberty or pregnancy accelerated growth during puberty or pregnancy

and tend to resolve with menopause and tend to resolve with menopause thyroid hormone and melanocyte-stimulating thyroid hormone and melanocyte-stimulating

hormones alterationshormones alterations Excision with intramarginal borders is Excision with intramarginal borders is

reserved for intractable keloidsreserved for intractable keloidsdr sumer yadav, mch pastic dr sumer yadav, mch pastic


Relaxed Skin Tension LinesRelaxed Skin Tension Lines

Lines that follow the furrows formed when skin is Lines that follow the furrows formed when skin is relaxedrelaxed

Not visible features of the skin (unlike wrinkles)Not visible features of the skin (unlike wrinkles) Although each person has his or her own Although each person has his or her own

blueprint for RSTL, the direction of tension lines blueprint for RSTL, the direction of tension lines between individuals is consistentbetween individuals is consistent



DupuytrenDupuytren first noted this property of skin first noted this property of skin Langer Langer - the ellipses formed by stabbing a - the ellipses formed by stabbing a

round-tipped awl into hundreds of cadavers round-tipped awl into hundreds of cadavers (which he called spaltbarkeit, meaning (which he called spaltbarkeit, meaning cleavage), occurred along the lines of tension cleavage), occurred along the lines of tension

KocherKocher - -recognized its surgical importance and recognized its surgical importance and advised that surgical incisions follow these linesadvised that surgical incisions follow these lines



Borges - Borges - Langer's lines represented lines of Langer's lines represented lines of cleavage in cadavers and not lines of relaxed cleavage in cadavers and not lines of relaxed skin tension for live humans. (described his lines skin tension for live humans. (described his lines in 1962, the most well-accepted guideline for in 1962, the most well-accepted guideline for incisions of the face)incisions of the face)



Elasticity maintains the skin in a state of constant tensionElasticity maintains the skin in a state of constant tension Lagers lines are parallel to collagen & elastin fibers Lagers lines are parallel to collagen & elastin fibers Determined by the protrusion of underlying bone /tissue Determined by the protrusion of underlying bone /tissue

bulk and underlying facial musculature (contractile bulk and underlying facial musculature (contractile forces) forces)

Why called RSTL?- parallel scar is not subjected to Why called RSTL?- parallel scar is not subjected to intermittent muscle pullintermittent muscle pull

Difference- Difference- line of skin tension/cleavage/retractionline of skin tension/cleavage/retraction line of expressionline of expression line of relaxationline of relaxation



Scar AnalysisScar Analysis

Ideal ScarsIdeal Scars FlatFlat NarrowNarrow Good color match to surrounding skinGood color match to surrounding skin Lies parallel to relaxed skin tension lines Lies parallel to relaxed skin tension lines Should not have straight, unbroken lines that Should not have straight, unbroken lines that

can be easily followed with the eye.can be easily followed with the eye.



Timing of Scar RevisionTiming of Scar Revision

Improvement without revision for up to 1 – 3 Improvement without revision for up to 1 – 3 yearsyears

Wait 6 to 12 months- allows time for the scar to Wait 6 to 12 months- allows time for the scar to maturemature

Perhaps earlier for those poorly positioned Perhaps earlier for those poorly positioned (perpendicular to tension lines), markedly (perpendicular to tension lines), markedly uneven or contractureduneven or contractured



Indication of Scar RevisionIndication of Scar Revision

Interrupting an aesthetic unitInterrupting an aesthetic unit WebbedWebbed HypertrophiedHypertrophied

Longer than 20 mmLonger than 20 mm Wider than 1-2 mmWider than 1-2 mm Disturbing anatomic function or distorting facial featuresDisturbing anatomic function or distorting facial features Poor match to surrounding tissue Poor match to surrounding tissue Lies against RSTLLies against RSTL Lie adjacent to, but not in a favorable siteLie adjacent to, but not in a favorable site

Contractured scarContractured scar



PrinciplesPrinciples

Move themMove them Divide themDivide them Reorient themReorient them Camouflage themCamouflage them



Surgical TechniquesSurgical Techniques

ExcisionExcision Simple ExcisionSimple Excision Serial ExcisionSerial Excision Shave excisionShave excision

Z-plastyZ-plasty W-plastyW-plasty Geometric broken line closureGeometric broken line closure ResurfacingResurfacing



Simple/Fusiform ExcisionSimple/Fusiform Excision

Indications:Indications: Small Hypertrophic scars or Keloids that lie Small Hypertrophic scars or Keloids that lie close to RSTLs or depressed or Widened scarsclose to RSTLs or depressed or Widened scars

Lengths of each side of the incision should be Lengths of each side of the incision should be made equal to each othermade equal to each other

Angle at the end less than 30 degrees or M-Angle at the end less than 30 degrees or M-plasty can be made at the apex plasty can be made at the apex

Slight vertical bevel outward will help in everted Slight vertical bevel outward will help in everted closureclosure




Intramarginal ExcisionIntramarginal Excision Incisions within scar Incisions within scar

may heal bettermay heal better May be better than May be better than

total excisiontotal excision



Serial excisionSerial excision Based upon ability of skin to stretch over timeBased upon ability of skin to stretch over time Can be used to move a scar to better anatomic Can be used to move a scar to better anatomic

locationlocation Tissue expansion can be used in conjunction if > Tissue expansion can be used in conjunction if >

2 procedures are required2 procedures are required

Indications:Indications: Large scars when size, location, and elasticity of the Large scars when size, location, and elasticity of the

scar and surrounding skin prevent primary closurescar and surrounding skin prevent primary closure



Scar could be moved Scar could be moved via serial excision to via serial excision to hairlinehairline



Shave excisionShave excision

Best for small raised Best for small raised scarsscars

Tangentially shaved with Tangentially shaved with a flexible razor a flexible razor blade/scalpel until it is blade/scalpel until it is level with the surrounding level with the surrounding skin, avoiding entry into skin, avoiding entry into the deep dermis the deep dermis

Wound is allowed to heal Wound is allowed to heal by secondary intention. by secondary intention.



Tissue ExpansionTissue Expansion

PrinciplePrinciple:: ““All living tissues respond in a dynamic fashion to All living tissues respond in a dynamic fashion to

mechanical stresses placed on them”mechanical stresses placed on them” Skin expansion is more than merely stretching Skin expansion is more than merely stretching

the skin to cover a defect; during the process, the skin to cover a defect; during the process, with multiple changes, new skin is generated- with multiple changes, new skin is generated- net gain of tissue results (biological dividend)net gain of tissue results (biological dividend)



The three most commonly used expanders provide The three most commonly used expanders provide different amounts of expansiondifferent amounts of expansion Rectangular expanders generally provide the greatest Rectangular expanders generally provide the greatest

expansion (38%)expansion (38%) Crescent shaped expanders provide 32%Crescent shaped expanders provide 32% Round expanders provide 25%Round expanders provide 25%



ClassificationClassification

Manner of expansion – External saline fillingManner of expansion – External saline filling - Self expanding. - Self expanding. Site of insertion – InternalSite of insertion – Internal - External- External Type of inflation port – IntegratedType of inflation port – Integrated - Distal inflation port- Distal inflation port Duration – TemporaryDuration – Temporary - Permanent- Permanent



Distal inflation port typeDistal inflation port type



Integrated inflation port typeIntegrated inflation port type



Selection criteriaSelection criteria

Size of an implant should closely relate to size Size of an implant should closely relate to size and shape of donor surfaceand shape of donor surface

Implant should be equal to or slightly smaller Implant should be equal to or slightly smaller than donor area selectedthan donor area selected

Overall base size of the device more important Overall base size of the device more important than volumethan volume

Base of the expander should be 2.5 – 3.0 times Base of the expander should be 2.5 – 3.0 times as large as the area to be reconstructed as large as the area to be reconstructed



AdvantagesAdvantages

Replace lost or surgically excised tissue with Replace lost or surgically excised tissue with neighboring tissue of similar color, texture, neighboring tissue of similar color, texture, sensation, and thickness. sensation, and thickness.

Hair-bearing capability is retained. Hair-bearing capability is retained. Remote donor site is avoided. Remote donor site is avoided. Compression of underlying nerves, major blood Compression of underlying nerves, major blood

vessels and the trachea during the expansion vessels and the trachea during the expansion process has not proven to be a significant process has not proven to be a significant problem. problem.



Hydrogel (SETE)Hydrogel (SETE)((Methylmethacrylate & N-Vinylpyrrolidone)Methylmethacrylate & N-Vinylpyrrolidone)

Capable of achieving Capable of achieving expansion within weeks expansion within weeks rather than months. rather than months.

The Hydrogel Tissue The Hydrogel Tissue Expander is available as Expander is available as a sphere in three sizes - a sphere in three sizes - 2.0 ml, 3.0 ml and 4.0 ml. 2.0 ml, 3.0 ml and 4.0 ml.



Advantages (SETE - specific)Advantages (SETE - specific)

The size is about 10% of its final volume ~ The size is about 10% of its final volume ~ requires a smaller incision.requires a smaller incision.

No need for external fillings ~ minimal infection, No need for external fillings ~ minimal infection, fewer follow-ups, no painful inflations, good for fewer follow-ups, no painful inflations, good for kidskids

Minimizes patient discomfort with no periodic Minimizes patient discomfort with no periodic large volume fillinglarge volume filling

Small size ~ less tissue trauma ~ decreased Small size ~ less tissue trauma ~ decreased incidence of seroma, hematoma incidence of seroma, hematoma



Z- PLASTYZ- PLASTY

Transposition of two interdigitating triangular Transposition of two interdigitating triangular flapsflaps

Effects : Effects : - Gain in length along direction of common limb - Gain in length along direction of common limb - Direction of common limb changed- Direction of common limb changed - Breakup of straight line - Breakup of straight line - Move tissues from one area to another- Move tissues from one area to another - Create or obliterate a web or cleft - Create or obliterate a web or cleft AVOID in keloid revision as the keloid may recur along AVOID in keloid revision as the keloid may recur along

the lengthened scar the lengthened scar dr sumer yadav, mch pastic dr sumer yadav, mch pastic


IndicationsIndications

Anti-RSTL scar on eye lids, lips and nasolabial foldsAnti-RSTL scar on eye lids, lips and nasolabial folds Scar on forehead, temples, cheeks, nose & chin at angle Scar on forehead, temples, cheeks, nose & chin at angle

<35* to RSTL<35* to RSTL Small anti-RSTL scarSmall anti-RSTL scar Cross the border of a facial aesthetic unit (vermillion Cross the border of a facial aesthetic unit (vermillion

border) or cross a concave surface (medial canthus)border) or cross a concave surface (medial canthus) Repositioning malposed tissues (useful for "trapdoor" or Repositioning malposed tissues (useful for "trapdoor" or

"pin-cushion" defects) "pin-cushion" defects) Bow-string scar contracturesBow-string scar contractures



Z-plasty maneuver Z-plasty maneuver

Central limb of Z is placed along the line of Central limb of Z is placed along the line of contracturecontracture

Lateral limbs should be parallel to RSTLLateral limbs should be parallel to RSTL Two other limbs drawn at 60 degree to it to Two other limbs drawn at 60 degree to it to

create two triangle-a typical compromise figure create two triangle-a typical compromise figure reached by experience reached by experience

Scarring across base should be avoidedScarring across base should be avoided This parallelogram having short contractural This parallelogram having short contractural

diagonal and long Transverse diagonaldiagonal and long Transverse diagonaldr sumer yadav, mch pastic dr sumer yadav, mch pastic surgery, surgery,


Z-plasty maneuverZ-plasty maneuver

Transposition results in change in shape of Transposition results in change in shape of parallelogram such that contractural parallelogram such that contractural diagonal=transverse diagonal beforediagonal=transverse diagonal before

Variables in construction are angle size and limb Variables in construction are angle size and limb lengthlength



Angle (degrees)Angle (degrees) Length IncreaseLength Increase3030 25%25%4545 50%50%6060 75%75%



TYPES OF Z- PLASTYTYPES OF Z- PLASTY

Stereometric Z plasty Stereometric Z plasty Planimetric Z plasty Planimetric Z plasty Four flap Z plasty Four flap Z plasty Five flap Z plasty (Five flap Z plasty (Jumping Man or Dancing man Jumping Man or Dancing man

Flap)Flap) Six flap Z plastySix flap Z plasty Multiple Z plasty Multiple Z plasty - parallel - parallel - skew - skew dr sumer yadav, mch pastic dr sumer yadav, mch pastic


STEREOMETRICSTEREOMETRIC Z PLASTY Z PLASTY



PLANIMETRIC Z PLASTY PLANIMETRIC Z PLASTY



Single versus multiple Single versus multiple z plasty z plasty



Multiple Z plasty Multiple Z plasty - - parallel and skewparallel and skew



FOUR FLAP Z PLASTY (at 60 FOUR FLAP Z PLASTY (at 60 degrees)degrees)



FOUR FLAP Z PLASTY (at 45 FOUR FLAP Z PLASTY (at 45 degrees)degrees)



Jumping Man or Dancing man FlapJumping Man or Dancing man Flap(five flap plasty )(five flap plasty )

This is a modification of This is a modification of the double opposing Z the double opposing Z plasty. The upper (red) plasty. The upper (red) flap is partially split to flap is partially split to allow Y-V advancement allow Y-V advancement of the inner (green) flap. of the inner (green) flap. Because this split Because this split narrows the vascular narrows the vascular pedicle to the lateral flap pedicle to the lateral flap tips, their angles are tips, their angles are planned more obtuse planned more obtuse (75°) than for a typical (75°) than for a typical double opposing Z plasty. double opposing Z plasty.



Alternate Jumping Alternate Jumping Man Flap 1Man Flap 1 This design allows for This design allows for greater Y-V greater Y-V advancement and advancement and lengthening. It lengthening. It requires supple skin requires supple skin other than the tight other than the tight band itself. band itself.



Alternate Jumping Alternate Jumping Man Flap 2Man Flap 2 This design places This design places greater emphasis on greater emphasis on the lateral Z plasties the lateral Z plasties and less on Y-V and less on Y-V advancement. It is advancement. It is more appropriate for more appropriate for use in a heavily use in a heavily scarred bed. scarred bed. dr sumer yadav, mch pastic dr sumer yadav, mch pastic


Modifications Modifications

Flap of Flap of scarred skinscarred skin should be designated a little should be designated a little longer than its fellow of normal skinlonger than its fellow of normal skin

On occasion, a line of scarring can limit the angle of one On occasion, a line of scarring can limit the angle of one flap and dissimilar angles may then have to be usedflap and dissimilar angles may then have to be used

Curvilinear form of Z-plastyCurvilinear form of Z-plasty (S-plasty) (S-plasty) when straight when straight lines may be particularly obvious (as in the lines may be particularly obvious (as in the neck)neck)

Z-plasty with unequel smaller triangle moves significantly Z-plasty with unequel smaller triangle moves significantly less with as little distortion as possible (e.g., near eyes, less with as little distortion as possible (e.g., near eyes, lips).lips).



Running W-PlastyRunning W-Plasty W-plasty is regularly irregular modification of W-plasty is regularly irregular modification of

scarscar

Principle- Irregular scar can be camouflaged Principle- Irregular scar can be camouflaged better than a straight/linear scar better than a straight/linear scar

Advantages- shorter segments than Z plastyAdvantages- shorter segments than Z plasty does not lengthen scar does not lengthen scar

Disadvantages- excision of skin moreDisadvantages- excision of skin more no gain of tissueno gain of tissue



Indications: Indications: Long linear scars on Long linear scars on forehead, cheeks, chin forehead, cheeks, chin

and noseand nose Scar at angle >35* to RSTLs Scar at angle >35* to RSTLs



Careful preplanning is essentialCareful preplanning is essential Try and align some of the sides into RSTLs as much as Try and align some of the sides into RSTLs as much as

possiblepossible Triangle limbs should be 3-5mm long (Maximum Triangle limbs should be 3-5mm long (Maximum

segment length 6mm) segment length 6mm) Ends should be less than 30 degrees in order to avoid a Ends should be less than 30 degrees in order to avoid a

standing cone or "dog ear" effectstanding cone or "dog ear" effect Acute angles on inner aspect of curved scarAcute angles on inner aspect of curved scar Excise consecutive small triangles on each side of a Excise consecutive small triangles on each side of a

wound and interpose resultant triangular flapswound and interpose resultant triangular flaps Wide undermining essentialWide undermining essential



Straight line scar Straight line scar oriented oriented perpendicularly to perpendicularly to RSTLs RSTLs



M-PlastyM-Plasty

Typically a technique Typically a technique for the end of a scarfor the end of a scar

Prevents dog ear Prevents dog ear formationformation

Saves skinSaves skin Shortens scar along Shortens scar along

central axiscentral axis



Geometric Broken Line ClosureGeometric Broken Line Closure

Modification of W-plasty- irregularly irregular Modification of W-plasty- irregularly irregular patternpattern

Instead of just triangles, a cornucopia of shapes Instead of just triangles, a cornucopia of shapes is used to hide the linesis used to hide the lines

series of varying geometric shapes designed to series of varying geometric shapes designed to interlock precisely with their mirror images on interlock precisely with their mirror images on the other side of the wound the other side of the wound

Similar rules for W plasty-angles and sizesSimilar rules for W plasty-angles and sizesdr sumer yadav, mch pastic dr sumer yadav, mch pastic


Particularly well suited to scars that traverse Particularly well suited to scars that traverse broad flat surfaces such as the cheek, malar, broad flat surfaces such as the cheek, malar, and forehead regionsand forehead regions

The GBLC is time consuming to execute and, if The GBLC is time consuming to execute and, if improperly designed, can worsen a scarimproperly designed, can worsen a scar



ResurfacingResurfacing

For uneven, unattractive, tight sheet of For uneven, unattractive, tight sheet of hypertrophic scarringhypertrophic scarring

Should be planned in aesthetic unitsShould be planned in aesthetic units Excision of the scarred area just below Excision of the scarred area just below

scar, preserving a thin layer of dermisscar, preserving a thin layer of dermis Replaced by FTG/thick STG or skin Replaced by FTG/thick STG or skin

substitute (integra)substitute (integra)dr sumer yadav, mch pastic dr sumer yadav, mch pastic


Adjunctive ModalitiesAdjunctive Modalities

DermabrasionDermabrasion Laser ResurfacingLaser Resurfacing Intralesional steroidsIntralesional steroids Pressure garmentsPressure garments Silicon gelSilicon gel



DermabrasionDermabrasion

Procedure to "refinish" the skin's top layers through a Procedure to "refinish" the skin's top layers through a method of controlled surgical scraping method of controlled surgical scraping

Superficially abrades the scar and the surrounding skin Superficially abrades the scar and the surrounding skin to the level of the papillary dermis to the level of the papillary dermis

Dermo-epidermal regeneration soften the sharp edges of Dermo-epidermal regeneration soften the sharp edges of surface irregularities, giving the skin a smoother surface irregularities, giving the skin a smoother appearance appearance

Best candidates have lighter complexions because of Best candidates have lighter complexions because of risk of postabrasion dyspigmentationrisk of postabrasion dyspigmentation

Best done around 6 -12 weeks after surgical scar Best done around 6 -12 weeks after surgical scar revisionrevision



Indications:Indications: Traumatic, acne or pox/ varicella scar Traumatic, acne or pox/ varicella scar Fine wrinkles of the skin Fine wrinkles of the skin freckles or brown pigmentationfreckles or brown pigmentation Superficial dermal tattoosSuperficial dermal tattoos



Technique of dermabrationTechnique of dermabration

With a rough wire brush or diamond impregnated burrs With a rough wire brush or diamond impregnated burrs attached to a motorized handle attached to a motorized handle

For larger areas, a motorized dermabrader with a For larger areas, a motorized dermabrader with a diamond fraise tip allows for a more even and controlled diamond fraise tip allows for a more even and controlled depth of ablationdepth of ablation

Local anesthesia- nerve block and infiltration- (also Local anesthesia- nerve block and infiltration- (also cause distention of the skin, which aids in the technique)cause distention of the skin, which aids in the technique)

Important to determine the correct depth of skin to be Important to determine the correct depth of skin to be removed to achieve the desired cosmetic resultremoved to achieve the desired cosmetic result



Technique of dermabrationTechnique of dermabration

One will first encounter pinpoint bleeding at the level of One will first encounter pinpoint bleeding at the level of the superficial papillary dermisthe superficial papillary dermis

When white-colored collagen strands are observed, When white-colored collagen strands are observed, appropriate depth has been reachedappropriate depth has been reached

Use even and light pressure, keep moving and skin at Use even and light pressure, keep moving and skin at stretchstretch

Edges “feathered” at periphery Edges “feathered” at periphery lubricate face with topical antibiotic ointment, A & D lubricate face with topical antibiotic ointment, A & D

ointment until reepithelisationointment until reepithelisation



Dermabration-complicationsDermabration-complications

Prolonged erythema of skinProlonged erythema of skin MiliaMilia HyperpigmentationHyperpigmentation Hypertrophic scarringHypertrophic scarring Permanent darkening of the skin, usually caused by Permanent darkening of the skin, usually caused by

exposure to the sunexposure to the sun Too deep dermabration cause depression which is Too deep dermabration cause depression which is

difficult to repairdifficult to repair



Laser ResurfacingLaser Resurfacing

Ablative LasersAblative Lasers PrinciplePrinciple- Tissue vaporization with limited thermal - Tissue vaporization with limited thermal

conduction to non-targeted surrounding skinconduction to non-targeted surrounding skin Immediate collagen shrinkage with subsequent collagen Immediate collagen shrinkage with subsequent collagen

remodelingremodeling CO2 laser used for deeper scars, while the Erbium is CO2 laser used for deeper scars, while the Erbium is

used for superficial scars and deeper skin tones used for superficial scars and deeper skin tones Can be combined with scar revision- single stage or Can be combined with scar revision- single stage or

laser treatment to surrounding cosmetic unit, followed by laser treatment to surrounding cosmetic unit, followed by scar re-excisionscar re-excision



Precise tissue ablation and limited residual Precise tissue ablation and limited residual thermal damage with ER-YAG laser- improved thermal damage with ER-YAG laser- improved side-effect profileside-effect profile

Limited collagen contraction, and substantially Limited collagen contraction, and substantially less impressive clinical results than with CO2less impressive clinical results than with CO2

To overcome the limitations of To overcome the limitations of short-pulsed short-pulsed Er:YAG laserEr:YAG laser skin resurfacing, skin resurfacing, "dual-mode" "dual-mode" (short- and long-pulsed) Er:YAG(short- and long-pulsed) Er:YAG systems have systems have been developedbeen developed



Laser ResurfacingLaser Resurfacing

Nonablative laserNonablative laser Heats collagen and improve the appearance of a scarHeats collagen and improve the appearance of a scar The The flash lamp-pumped pulsed dye laserflash lamp-pumped pulsed dye laser has been has been

used most extensivelyused most extensively Selectively target water-containing tissue, thereby Selectively target water-containing tissue, thereby

creating a selective thermal injury in the dermis creating a selective thermal injury in the dermis without damage to the epidermiswithout damage to the epidermis



greatest clinical improvement noted between 3 greatest clinical improvement noted between 3 and 6 months after the final laser procedure.and 6 months after the final laser procedure.

Side-effects and complications of nonablative Side-effects and complications of nonablative laser treatment of atrophic facial scars are laser treatment of atrophic facial scars are generally mildgenerally mild

newest approach in the treatment of acne and newest approach in the treatment of acne and atrophic scarring includes the use of a atrophic scarring includes the use of a nonablative radiofrequency devicenonablative radiofrequency device



For hypertrophic scar and keloidsFor hypertrophic scar and keloids

585nm pulsed dye laser (PDL)585nm pulsed dye laser (PDL) Striking improvements in erythema, pliability, Striking improvements in erythema, pliability,

bulk, and dysesthesia with minimal side-effectsbulk, and dysesthesia with minimal side-effects Delivered at 6-8 week intervals, longer treatment Delivered at 6-8 week intervals, longer treatment

intervals necessary in darker skin phototypesintervals necessary in darker skin phototypes Thick keloids may require the simultaneous use Thick keloids may require the simultaneous use

of intralesional corticosteroid or 5-fluorouracil of intralesional corticosteroid or 5-fluorouracil injections to enhance clinical resultsinjections to enhance clinical results



Laser-side effectsLaser-side effects

Most common- purpura, which can persist for several Most common- purpura, which can persist for several daysdays

Blistering, crusting, and scarring Blistering, crusting, and scarring Swelling of treated skin may occur immediately after Swelling of treated skin may occur immediately after

laser irradiation- generally subsides within 48 hourslaser irradiation- generally subsides within 48 hours Post inflammatory hyperpigmentation particularly in Post inflammatory hyperpigmentation particularly in

darker-skinned patients typically within 3-4 weeks after darker-skinned patients typically within 3-4 weeks after treatmenttreatment

Strict sun precautions should be practiced between Strict sun precautions should be practiced between treatment sessionstreatment sessions



Injectable Steroids-TriamcinoloneInjectable Steroids-Triamcinolone

First-line therapy First-line therapy Mechanism- decreasing collagen synthesis and Mechanism- decreasing collagen synthesis and

mucinous ground substance, and inhibiting collagenase mucinous ground substance, and inhibiting collagenase inhibitors inhibitors

Dose vary from 10-120 mg depending on the size Dose vary from 10-120 mg depending on the size Use injection for thin-to-wide hypertrophied scars & Use injection for thin-to-wide hypertrophied scars &

silicone for very wide hypertrophied scars silicone for very wide hypertrophied scars Especially on body areas where adherence is poor, such Especially on body areas where adherence is poor, such

as the face, palms, and soles as the face, palms, and soles



Inject with a 25- to 27-gauge needle at 4- to 6-week Inject with a 25- to 27-gauge needle at 4- to 6-week intervals until the scar flattens intervals until the scar flattens

Should be injected into theShould be injected into the papillary dermis papillary dermis (where (where collagenase is produced)collagenase is produced)

Avoid injection into the subcutaneous tissues Avoid injection into the subcutaneous tissues Response rate of 50-80%Response rate of 50-80% When surgical excision is combined with steroid When surgical excision is combined with steroid

injection, the response rate increases to 85-100%injection, the response rate increases to 85-100%



Silicone GelSilicone Gel

Effects appear to be secondary to both occlusion and Effects appear to be secondary to both occlusion and hydration and pressure hydration and pressure

The silicone gel is applied to the wound for at least 12 The silicone gel is applied to the wound for at least 12 h/dh/d

response rate has been as high as 80% response rate has been as high as 80%



Pressure GarmentsPressure Garments

MechanismMechanism reducing the oxygen tension in the wound through reducing the oxygen tension in the wound through

occlusion of small vessels, subsequent reductions in occlusion of small vessels, subsequent reductions in tissue metabolism, fibroblast proliferation, and tissue metabolism, fibroblast proliferation, and collagen synthesis and increase collagen breakdowncollagen synthesis and increase collagen breakdown

Custom-fitted Isotoner-type garmentsCustom-fitted Isotoner-type garments Made of Dacron spandex bobbinet fabric, shaped Made of Dacron spandex bobbinet fabric, shaped

Tubigrip support bandages or zinc oxide adhesive Tubigrip support bandages or zinc oxide adhesive plasterplaster



Pressure to the more difficult areas, including the lower Pressure to the more difficult areas, including the lower neck and torsoneck and torso

Start wearing as soon as re-reepithelisation occurs and Start wearing as soon as re-reepithelisation occurs and continue wearing until scar maturation is evidentcontinue wearing until scar maturation is evident

Recommended level of pressure is 25 mm Hg, but good Recommended level of pressure is 25 mm Hg, but good results observed with pressures as low as 5-15 mm Hg results observed with pressures as low as 5-15 mm Hg



ConclusionsConclusions

Scarring is inevitable and necessary aspect of Scarring is inevitable and necessary aspect of healinghealing

scar can never be completely removed but, scar can never be completely removed but, exchanged for a more cosmetically pleasing oneexchanged for a more cosmetically pleasing one

There are many techniques that can be used for There are many techniques that can be used for scar revisionscar revision

Appropriate knowledge and careful planning can Appropriate knowledge and careful planning can minimize scarring or improve scars after scar minimize scarring or improve scars after scar formation has occurredformation has occurred



scar revision , z plasty

Health & Medicine