Dermatol Clin

Surgical revision

Ken K. Lee, MD*, Khosrow Mehrany, MD, Neil A. Swanson, MD*

Department of Dermatology, Oregon Health and Science University, 3181 SW Sam Jackson Park Road, Mailcode OP06,

Portland, OR 97201-3098, USA

Revisions are an inherent aspect of surgery just as

complications are an inevitable part of surgery.

Hematomas, infections, necrosis, dehiscence, im-

proper technique, or unknown factors can lead to

less than ideal surgical outcomes. Proper planning

and meticulous technique result in fewer complica-

tions and better surgical outcome—an optimally

appearing scar. The aesthetic appearance of a scar is

often the single most important criterion used by

patients and physicians alike in judging surgical

outcome. The ideal scar is a nearly imperceptible fine

line that is level with the skin and blends with the

natural creases and folds. Sometimes, the final out-

come falls short of these expectations. Scars with

poor cosmetic results include those that are wide,

raised, depressed, red, or pigmented, or those that

transect natural creases and junctions. Depending on

the type of abnormality, different techniques are used

to improve the overall cosmetic appearance. Derma-

tologic surgeons need to understand why unsatisfac-

tory scars result and how to manage them.

Basic surgical techniques

In most cases, proper surgical technique at the

time of the initial surgery eliminates the need for scar

revision. Therefore, whenever the surgical outcome is

less than ideal, the physician must critically analyze

the surgical technique. What could have been done

0733-8635/05/$ – see front matter D 2005 Elsevier Inc. All rights

doi:10.1016/j.det.2004.08.006

* Corresponding authors.

E-mail addresses: leeken@ohsu.edu (K.K. Lee);

swansonn@ohsu.edu (N.A. Swanson).

differently that would have resulted in a better scar?

As the physician gains experience, fewer revisions

should be needed; the lessons learned from previous

‘‘mistakes’’ are applied to the present surgeries. The

following sections discuss important components that

maximize the cosmetic outcome of surgical scars.

Suturing technique

Wound eversion, critical in creating a superior

scar, results from meticulous suture technique.

Everted wound edges eventuate in thinner and flatter

scars. Most wound eversion results from proper

placement of buried dermal sutures. The buried

vertical mattress suture can especially promote

wound eversion [1]. In specific regions that have a

tendency to form depressed scars, such as the

forehead creases, additional measures are used to

further evert the upper dermis. Such measures include

vertical mattress sutures placed in the cuticular suture

layer. A technique that ‘‘hypereverts’’ the incisions is

the running horizontal mattress; this technique is

particularly useful for creases. The current authors

recommend using fast-absorbing gut suture when

performing this technique because suture removal

may be difficult otherwise. This technique can be

used to revise depressed scars (Fig. 1).

Scars on the trunk and extremities often spread

with ‘‘track’’ marks when closed with cuticular

sutures. These suture track marks are very noticeable

and should be prevented by using running subcuti-

cular sutures at all sites prone to their development.

The use of this technique with a buried absorbable

suture may also reduce scar spread. Finally, steri-

strips are applied at the time of surgery to further

support the incision line.

23 (2005) 141 – 150

reserved.

Fig. 1. (A) Running horizontal mattress suture technique demonstrates profound eversion of the wound edges. (B) The 6-month

follow-up shows a flat and thin scar.

Fig. 2. Trapdoor or pincushion effect. This effect is more

prominent in rounded flaps.

lee et al142

Relaxed skin tension lines

Relaxed skin tension lines (RSTLs) are a series of

curvilinear lines that form naturally and predictably

on the skin. Scars that run parallel to the RSTLs

reduce the tension across the wound, resulting in a

thinner scar. RSTLs are readily visible when facial

expressions are accentuated and should be identified

with these maneuvers before surgery. This step is

especially important in younger patients in whom the

lines are not as apparent. Whenever possible,

incisions should be placed parallel to the RTSLs.

Even in complex flaps with geometric shapes, the

design should place tension vectors along the RSTLs

to minimize scar spread [2].

Flap refinements

Although there are many different categorizations

of local cutaneous flaps, they may be more simply

divided into two categories based on their principal

motions: sliding and lifting. Sliding flaps include

advancement, island pedicle, and rotation flaps

because local tissue slides into the defect to be

closed. Lifting flaps include transposition, interpola-

tion, and bilobed flaps because the designed flap is

lifted over adjacent tissue into the defect. The primary

defect is the defect that is to be closed, and the

secondary defect is what is created from the creation

of the flap. Typically, in a sliding flap, the primary

defect is closed first; in a lifting flap, the secondary

defect is closed first. The primary motion of a flap is

the movement of the flap into the defect. The

secondary motion is the movement of the surround-

ing skin that results from the flap being placed into

the defect. These motions need to be understood to

avoid complications that arise from errant flap design

near free margins, including the eye, nasal ala, and

oral commissure [3].

Bulkiness or thickening is a commonly seen flap

complication where the flap becomes raised above

the level of the surrounding skin. This complication

usually results from a flap that was cut too thick or

from a trapdoor effect. The trapdoor or pincushion

effect is a ‘‘quiltlike’’ deformity more commonly seen

in lifting flaps and results from contraction of the flap

wound bed during healing, which causes the flap to

buckle upward (Fig. 2) [4,5]. Flaps should generally

lay flat or slightly inset with the surrounding skin at

the time of surgery. To inset the flap, its subcutaneous

tissue may be thinned with care, guarding against

aggressive defatting, which may compromise vascu-

larity. In addition, the defect can be deepened to

receive and accommodate an inset flap. Many flaps

that are set in flat at the conclusion of the surgery can

become bulky as the scar matures. This type of

trapdooring is accentuated in rounded or U-shaped

flaps. The trapdoor effect can be minimized by

widely undermining the defect so that the flap and

the surrounding skin contract together during the

surgical revision 143

wound healing process. Last, flaps may be designed

with squared edges to reduce the trapdoor effect.

Cosmetic units

Respecting cosmetic units is an important aspect

of facial dermatologic surgery. These units divide the

face into distinct regions and are divided by land-

marks, contours, lines, and skin texture differences.

Occasionally, defects are enlarged so that a graft or

flap can be designed to encompass an entire cosmetic

unit, thus leading to a less apparent scar. Scars in the

middle of a cosmetic unit are more noticeable; hence,

placing incision lines at the cosmetic unit junctions

can optimize scar appearance.

Timing of scar revisions

Scars can take 1 year to mature because collagen

continues to remodel during this period. Although

most healing is complete by 1 year, the final ap-

pearance of a scar can improve even beyond this

period. It is therefore imperative to give adequate

time for the natural healing and remodeling process

and not to institute invasive revision procedures

prematurely. Occasional situations may arise where

early scar revision is necessary to avoid a functional

impairment, however [6]. Patients can actively

participate in the healing process of their scars by

gently massaging the scar beginning at approximately

1 month postoperatively. This procedure can hasten

resolution of the firm texture associated with newly

healing wounds.

Revision techniques

Intralesional steroids

Hypertrophic linear scars, and bulky grafts and

flaps, can be treated with intralesional corticosteroids

[7]. Injections can be instituted at approximately

1 month postoperatively. A small amount (as little as

0.1 mL) of low-dose triamcinolone acetonide (Kena-

log) at 5 to 10 mg/mL is injected into the scar; this

dosage can be repeated monthly until the scar has

flattened. This treatment will not affect the width of

the scar, however. The injection is placed into the

bulkiest region of the scar, at the level of the deep

dermis or subcutaneous fat. The physician must be

cautious not to be overly aggressive with the quantity,

frequency, or strength of Kenalog injections, because

significant atrophy may occur, especially if the

injection leaks out into healthy skin.

Nonablative lasers

Ablative techniques, such as dermabrasion and

carbon dioxide laser ablation, have been widely used

for scar improvement, but these techniques carry a

higher risk (see later). Nonablative lasers are used to

treat scars and have the advantage of improving scars

without incision or wounding, thereby minimizing

downtime. Multiple lasers have been used to refine

scars, and practically any nonablative laser that heats

collagen can effectively improve the appearance of a

scar. The flashlamp-pumped pulsed dye laser, how-

ever, has been used most extensively. The pulsed dye

laser works through absorption by oxyhemoglobin,

causing direct destruction of the blood vessels and

an indirect effect on the surrounding collagen. This

vascular laser improves the overall redness caused by

the scar’s vascularity and promotes collagen remod-

eling and scar softening. The collagen remodeling is

most effective at lower subpurpuric fluences where

collagen is believed to be stimulated rather than

injured [8–10]. It is probably best suited for red

hypertrophic scars or for telangiectases surrounding

scars, which typically are not noticed for at least

1 month postoperatively. Recent reports, however,

have shown improvement of the final scar appearance

when the laser treatment is initiated at the time

of suture removal [11]. Newer nonablative lasers

with wavelengths of 532 nm, 1064 nm, 1390 nm, and

1450 nm are also being used to promote collagen

remodeling. Further advancements in technology

should continue to enhance the ability to treat scars

in a minimally invasive fashion.

Fusiform elliptic excision

One of the simplest methods of surgical scar

revision is the re-excision of the scar in a linear or

slightly curvilinear fashion. This technique is best

suited for spread or depressed scars that usually result

from excess tension or poor wound eversion at the

time of the initial surgery. The scar should ideally be

designed to run parallel to RSTLs. Re-excision is best

performed on a mature scar, not a newly placed scar

under tension. This allows for reapproximation with

less resultant scar spreading and better wound ever-

sion. A fusiform ellipse is outlined around the scar

with the ideal 30� at the tips to promote blending. The

scar is excised and the surrounding skin appropriately

undermined to relieve surrounding tension (Fig. 3). In

sebaceous skin, scarring can be minimized by

beveling one edge and counterbeveling the other,

creating a ‘‘tongue-and-groove’’ effect when sutured.

Proper placement of deep and superficial sutures will

Fig. 3. (A) Large split-thickness skin graft used to close an aggressive cancer. The scar has contracted. A fusiform ellipse is

outlined around the scar. (B) Immediate postoperative result. (C) Follow-up at 2 months shows a narrower linear scar.

lee et al144

again allow for wound eversion. In areas such as the

trunk where suture track marks are more likely to

appear, running subcuticular sutures should be used.

A re-excised scar will always be longer than the

original scar. This is an important point to discuss

with patients before the re-excision.

In larger scars, fusiform elliptic excisions are

frequently performed serially in stages to minimize

tension on the wound. For example, split-thickness

skin grafts are sometimes used as a temporary closure

because of large defect size or for tumor surveillance.

If the scar is cosmetically unacceptable to the patient

after it has fully matured, it may be serially excised.

By waiting for the wound tension to subside and

elasticity to return, the final scar length can be made

shorter compared with that of a single-staged

excision. The fusiform ellipse is oriented within the

width of a broad scar (intramarginal excision),

resulting in an increasingly narrowed scar width with

each stage [12]. Serial excisions in tight hair-bearing

areas, such as the scalp vertex, can be performed by

triangulation, which is a modification of a fusiform

ellipse. This procedure allows for the intramarginal

containment of the scar, minimizing the excision of

healthy hair-bearing scalp (Fig. 4).

W-plasty

Both the W-plasty and geometric broken-line

closure (GBLC; mentioned later) techniques rely on

the similar principle that an irregular line is less

visible than a straight line. These techniques are

especially advantageous when the scar is not placed

in the RSTLs, which would cause it to be more

visible and spread. W-plasty is performed by out-

lining a zigzagging line on one side of the scar then a

mirror image line on the opposite side. The ‘‘points’’

of the ‘‘W’’ should run parallel to the RSTL or a skin

fold, whereas the length of the scar runs perpendic-

ular to it. The scar is excised along these lines then

reapproximated so that the mirror images dovetail

and form a single zigzagging line. The width of each

triangular cutout should be approximately 5 mm to

achieve a visibly irregular line. The incision is care-

fully reapproximated using a combination of dermal

3-point tip sutures and cuticular sutures. Not all of a

linear scar needs to be fashioned with a W-plasty;

there is less of an advantage of the W-plasty with

longer scars because the regularity of the zigzags

makes it more noticeable (Fig. 5). In longer scars, the

GBLC is preferable [13,14].

Fig. 4. (A) Staged excision of large kerion scar on vertex of the scalp. A modification of the fusiform ellipse with ‘‘three arms’’ is

outlined to contain the incisions within the circular scar (intramarginal excision). This triangulation allows for maximal removal

of the scar. (B) Immediate postoperative result following the second stage. Notice that after two excisions, the incisions have not

extended into the normal hair-bearing scalp.

surgical revision 145

Geometric broken-line closure

The GBLC is a more elaborate version of the

W-plasty [15]. It is the preferred technique for use

with longer scars to provide a less predictable ir-

regularity to the incision line. An outline is made

along one side of the scar using geometric designs,

such as semicircles, triangles, and squares, and the

mirror image is made on the opposite side. The

pattern should appear random (Fig. 6). The scar is

excised along the drawn outline and adequately

undermined to loosen up the adhesions from the

previous scar. It is then carefully reapproximated

using dermal and cuticular sutures so that the mirror

images coincide. The various random twists and turns

camouflage the scar. Both the W-plasty and GBLC

are better suited for scar revisions than primary

excisions and closures, and the wound may need to

Fig. 5. W-plasty. There is a zigzagging line on the superior

aspect of the incision where the horizontal forehead creases

become visible.

be enlarged to accommodate the various inward and

outward projections.

V -Y and Y -V advancement

V-Y and Y-V advancement repairs are helpful in

lengthening the scar and elevating or depressing a

free margin. When confronted with a contracted scar,

the V-Y repair is used to lengthen a scar. It is par-

ticularly useful near free margins such as around the

eyes and mouth when a scar has caused an ectropion

or eclabion, respectively.

The technique is performed by making a V-shaped

incision along the length of the contracted scar. The

wound is then widely undermined to loosen the scar.

The V-shaped flap is then pushed away from the

incision to relieve the tension and simultaneously

Fig. 6. Geometric broken-line closure. A random geometric

pattern is applied to a linear scar, making it appear less pre-

dictable than a zigzagging line.

lee et al146

lengthen the scar or push a free margin. The tension

should now be released in the ‘‘open’’ part of the

‘‘V.’’ The newly created defect is then closed such

that the two sides of the defect are brought together to

form a straight line along the initial scar line (Fig. 7).

Although this technique may theoretically seem to

move tissue significantly, in practice the V to Y repair

is helpful for relatively smaller contractions. The

immediate postoperative result should be exaggerated

because much of the initial movement is reversed

when the repair heals and contracts.

Just as the V to Y repair can raise an anatomic

point, a Y to V repair can be used to lower it. The

initial incision is made in a Y-shaped fashion and

similarly converted to form a V. Again, the wound

margins should be widely undermined so that the

wound base contracts evenly [16].

Z-plasty

Z-plasty is a versatile technique for revising scars.

First, it is used to create irregular zigzagging lines,

which make the scar less visible. Second, it is used to

change the direction of scar conspicuously perpen-

dicular to the RSTL, converting it parallel to the

RSTL. Third, it has the distinct advantage of length-

ening a contracted scar. This point is particularly

important with visible deformation of free margins,

Fig. 7. (A) V-Y advancement. A V-shaped incision is made

and, after wide undermining, is pulled in the direction of the

open end of the ‘‘V,’’ releasing tension/contracture in this

area. The remaining defect is closed side to side to form the

‘‘Y.’’ (B) Y-V advancement. A Y-shaped incision is made

and, after wide undermining, is pushed and contracted into

a ‘‘V.’’

including the eyelid, nasal alar rim, and lip. Finally,

this technique is used to change a displaced ana-

tomic point, raising or lowering it. It is therefore an

essential technique for scar revision and should be

mastered. Moreover, understanding the Z-plasty

concept helps the surgeon with many other aspects

of designing and implementing cutaneous flaps.

The geometry of the Z-plasty is often considered

to be complex, with flap dynamics that may be

difficult to conceptualize. In essence, a Z-plasty

comprises two zigzagging triangular flaps that are

transposed into the shape of a Z, or more simply, the

two triangles switch places. (For those more familiar

with flap surgery, a rhombic transposition flap is an

asymmetric Z-plasty.)

Two elements are critical in the understanding and

performance of the Z-plasty: the angle size and length

of the common diagonal (also referred to as the

common limb or the common member) [16–18]. In

revising a scar, the common diagonal is the scar

(Fig. 8). Two arms that are of the same length as the

common diagonal are extended from the ends in

opposite directions. The ‘‘angle’’ is determined by the

angle between arm and common limb. The angle of

the designed triangle determines the degree of tissue

lengthening, with larger angles resulting in greater

gains. The length of the central diagonal also de-

termines tissue gain, but this aspect is less variable

because it is usually predetermined by the length

of the scar. The classic 60� Z-plasty angle results in

a 90� change in scar direction and a 75% gain in

tissue length.

The Z-plasty is performed by making an incision

along or around the scar and the outlined arms. The

skin is widely undermined and the scar loosened. The

triangular flaps are then simultaneously lifted, then

transposed to change the direction of the common

diagonal into the new ‘‘transverse diagonal.’’ It is

important that the two triangular flaps are actually

transposed because it can be easy to place them back

in their original orientation. A helpful tip is to mark

one tip with a marking pen and make sure it changes

position during the transposition. Another indication

that the transposition has occurred is that there will

be significant tension along the newly formed trans-

verse diagonal. As the length of the common diagonal

and arms become longer, this tension increases, espe-

cially in inelastic skin, a distinct advantage of a large

Z-plasty. Furthermore, the resultant scar can be quite

noticeable because of the larger Z configuration.

When confronted with a longer scar or inelastic

skin, the multiple Z-plasty helps combat the previ-

ously mentioned problems. This technique has the

advantage of better hiding the Z shape by using

Fig. 8. (A) Webbed and contracted scar in the postauricular sulcus. A single Z-plasty is outlined on the scar. The center line is

the common diagonal, and the two lines that extend in opposite directions are the arms. All three limbs are the same length. The

angle between the common diagonal and the arms is approximately 45� in this case but can vary depending on the desired

lengthening and effect. The black dot shows the actual movement of the triangular flap. The inset diagram outlines the design

as if multiple Z-plasties are performed. (B) The Z-plasty set in place with dermal sutures. The common diagonal has flipped

approximately 90�, the webbing has improved, and the scar has lengthened. The inset diagram outlines the result of multiple

Z-plasty effect.

surgical revision 147

multiple smaller Zs along the scar line and distribut-

ing the tension across multiple smaller transverse

diagonals. Although the final appearance of the mul-

tiple Z-plasty is a zigzagging line, it is not the same

as a W-plasty. There is no gain in tissue length in a

W-plasty [19].

The Z-plasty is a simple method used to correct

contracted or asymmetric anatomic landmarks, such

as an elevated or depressed oral commissure or

eyebrow (Fig. 9). The anatomic point that needs to be

moved is one triangle and the point it moves to is the

other triangle. The two points are switched, thereby

either raising or lowering the anatomic landmark.

Fig. 9. (A) A Z-plasty is used to elevate a contracted and depresse

is a helpful guide that can be used to follow the actual movement

Surgical debulking

Mild trapdoor deformities can usually be managed

with intralesional steroids beginning at approximately

1 month postoperatively. If the flap incision lines

blend well with the surrounding skin, then the

flattening of the bulkiness with intralesional steroids

is all that is required. If the deformity is pronounced,

however, surgical debulking may be required. The

debulking is initiated with an incision made along

the curvature of the flap. It is important to choose the

most appropriate area on the scar line to incise. Most

bulky flaps have both good- and bad-appearing areas.

d eyebrow. (B) The brow has been elevated. The black dot

of the Z-plasty.

lee et al148

Because the entire flap does not need to be lifted, the

portion of the scar that is the most uneven, raised, or

spread is selected for placement of the incision. The

incised flap is lifted and reflected back (Fig. 10). The

anatomy is distorted compared with the initial surgery

because the entire base is a sheet of scar. The

undersurface of the lifted flap is thinned and the

resultant base is deepened. In smaller flaps, the use of

a 69 beaver blade, which is rounded at the tip,

facilitates the removal of a disc of fibrofatty tissue.

The flap can be thinned to a greater degree than at the

time of the initial surgery because there is reduced

tension and better vascularity in that the flap base is

less disrupted. Any excessive flap tissue is trimmed,

and the wound edges are again widely undermined to

extend the scar base to minimize recurrence of the

bulkiness. The flap is then gently draped back and

placed slightly inset compared with the surrounding

skin [20,21]. Techniques, such as W-plasty, GBLC, or

multiple Z-plasties, can be used to further camouflage

the incision line. A subtle change in the shape of a

circular scar to a more square shape also reduces the

pincushion appearance.

Dermabrasion

Dermabrasion is a technique that can improve

textural abnormalities associated with scars. This

technique can be performed on a scar as the sole scar

revision technique or used in combination with a re-

excision. The ideal timing for dermabrasion is 6 to

12 weeks postoperatively.

Fig. 10. Flap debulking. A disc of fibrofatty scar is excised

from a paramedian forehead flap. The wound edges also

should be widely undermined to prevent recurrence of

the trapdoor/pincushion effect.

Dermabrasion superficially abrades the scar and

the surrounding skin to the level of the papillary

dermis in a precise and controlled manner. This

process results in a smoother texture and evens out

any irregularities along the scar surface. Dermabra-

sion can improve the appearance of uneven scar

edges and raised grafts and flaps by leveling the

irregular contours [22,23]. If there is a significant

trapdoor effect, surgical debulking should be per-

formed before dermabrasion. Even in aesthetically

acceptable scars, dermabrasion can help to blend the

scar into the surrounding skin. There are two main

techniques for dermabrasion. For larger areas, a

motorized dermabrader with a diamond fraise tip

allows for a more even and controlled depth of

ablation. A topical spray cryogen serves to anesthe-

tize the skin and harden it, making it more receptive

to dermabrasion. Smaller scars, however, can be

lightly dermabraded to the point of pinpoint bleeding

using sterile 300- to 400-grit sandpaper. The surgeon

must be cautious not to go too deeply into the dermis,

thus causing a depression that would be difficult to

repair. A second dermabrasion can always be

performed if the initial procedure is not enough.

The boundary of the dermabraded area should be

extended beyond the scar and feathered into normal

surrounding skin to include an entire cosmetic unit or

subunit. The pigmentation and texture may differ

between the treated and untreated areas, leading to a

more conspicuous treated area. The blending helps to

prevent this demarcation (Fig. 11).

Ablative laser resurfacing

Pulsed ablative lasers (eg, carbon dioxide and

erbium: YAG) can provide similar results as derm-

abrasion by superficially ablating the scar [24]. Each

laser has its distinct advantages. Erbium:YAG, with

its higher affinity for water, is more precise in

ablating raised scar edges. The carbon dioxide laser

causes more thermal necrosis, which promotes more

wound contraction and collagen remodeling. This

collagen remodeling is an important aspect of the

ablative procedures because it is not just the physical

leveling of the scar that enhances the appearance of

the scar. Surgical scar revision and laser resurfacing

can sometimes be combined into a single-step

procedure in which the cosmetic unit surrounding

the scar undergoes laser treatment first, immediately

followed by scar re-excision. This procedure allows

the entire area to re-epithelialize and remodel at the

same time.

All ablative procedures that include lasers and

dermabrasion may result in pigmentary alteration and

Fig. 11. Dermabrasion. (A) A raised and uneven scar on the nose. (B) The scar and the surrounding healthy skin is dermabraded

with decreasing depth of ablation on the periphery (feathering). (C) Postoperative result after 2 months.

Fig. 12. Ectropion repair. When the ectropion is more

severe, the scarring inferior to the lower eyelid margin is

incised and the surrounding area is widely undermined. A

suture originating from the lower eyelid margin is carried

through the upper eyelid and eyebrow and back down

through the lower eyelid where it is tied, suspending the

lower eyelid higher. Note the larger defect that results from

this maneuver. This technique allows a larger full-thickness

skin graft to be positioned to push up the lower eyelid.

surgical revision 149

carry the risk of worsening a scar from overaggres-

sive treatment. At a minimum, patients should be

warned of the prolonged recovery course, which

sometimes may be longer than the initial surgery.

Patients need to be fully informed and provide their

consent for these potential risks.

Ectropion repair

An ectropion is an infrequent complication

because most experienced dermatologic surgeons

are adept in its prevention. It deserves special

consideration, however, because, unlike most other

scars, it has implications beyond the cosmetic

appearance. Patients with an ectropion complain of

irritation, tearing, and conjunctival injection and,

depending on the severity, may demand immediate

attention. A mild ectropion frequently resolves spon-

taneously over several weeks postoperatively.

An ectropion can be difficult to repair; therefore,

its prevention through careful planning and surgical

technique is paramount at the time of the initial

surgery. The potential for an ectropion can be as-

sessed by having the patient open his or her mouth

and look up. This maneuver exaggerates the pull on

the lower eyelid. Scars should be oriented perpen-

dicular to the lower lid margin. Grafts should be

oversized up to double the defect size to compensate

for the massive contraction that occurs with thinner

grafts in this region. Flaps should be sized generously

to push the inferior lid up, such as in an inferiorly

based rhombic transposition flap. The flap’s tension

vector can also be designed to pull up on the lower lid

as is seen in a laterally based advancement flap that is

incised above the level of the lateral canthus.

Periosteal tacking sutures can also be placed to sus-

pend flaps to the bony orbit to prevent pull on the

lower lid. If excessive lid laxity is present, the lower

lid should be tightened preventatively by removing a

full-thickness triangular wedge of the lower lid [25].

In addition, canthoplasty/-pexy can be performed

by making a horizontal incision several millimeters

lateral to the lateral canthus, exposing the lateral

canthal tendon, then suturing this tendon to the lateral

orbital rim periosteum.

lee et al150

Once a severe ectropion has developed, however,

other techniques need to be performed to release the

contracture causing the ectropion. V-Y repair is

helpful for a mild ectropion only [26]. For more

prominent ectropia, a full-thickness skin graft is a

good option to restore the lower eyelid. The ideal

donor site is the upper lid skin. The graft should be

oversized up to double the defect size [27]. If the

original scar is present near the lower lid margin, then

an incision is made through the scar and undermined

to lift the lower lid into proper position, thus releasing

the ectropion (Fig. 12). The graft is then inserted into

the defect created by the release. If the original scar is

distant from the lid margin, then the incision is made

horizontally at the subciliary line. In severe cases, the

lower lid is tacked to the eyebrow to suspend the

lower lid in an elevated position for approximately

3 weeks. This maneuver can be performed alone

without a skin graft for a mild to moderate ectropion.

Summary

‘‘If you do enough surgeries, you’ll develop

complications’’ is a valid adage. Surgeons therefore

must learn from experience to reduce the chances of

complications. Meticulous planning and technique

will lead to superior results. Even the best surgeons,

however, must confront scars and complications that

are aesthetically unacceptable and need revision.

When to act and how to act is important in surgical

revision. Just waiting often may be the best treatment.

Sometimes, surgical intervention is needed to opti-

mize the appearance of the scar. With careful assess-

ment of the scar, various scar revision techniques can

be applied to create an aesthetically pleasing result.

References

[1] Zitelli JA, Moy RL. Buried vertical mattress suture.

J Dermatol Surg Oncol 1989;15:17–9.

[2] Borges AF. Relaxed skin tension lines (RSTL) versus

other skin lines. Plast Reconstr Surg 1984;73:144–50.

[3] Swanson NA. Classifications, definitions, and concepts

in flap surgery. In: Baker SB, Swanson NA, editors.

Local flaps in facial reconstruction. St. Louis, MO7

Mosby; 1995.

[4] Koranda FC, Webster RC. Trapdoor effect in nasola-

bial flaps. Arch Otolaryngol 1985;111:421.

[5] Webster RC, Benjamin RJ, Smith RC. Treatment of

‘‘trapdoor’’ deformity. Laryngoscope 1978;88:707.

[6] Borges AF. Principles of scar camouflage. Facial Plast

Surg 1984;1:181–90.

[7] Goslen JB. The role of steroids in preventing scar for-

mation. In: Thomas JR, Holt GR, editors. Facial scars:

incision, revision, and camouflage. St. Louis, MO7

Mosby; 1989. p. 88–9.

[8] Alster TS. Improvement of erythematous and hyper-

trophic scars by the 585 nm flashlamp pumped pulsed

dye laser. Ann Plast Surg 1994;32:186–90.

[9] Alster TS, Williams CM. Treatment of keloid stemotoy

scars with 585 nm flashlamp pumped pulsed dye laser.

Lancet 1995;345:1198–200.

[10] Manuskiatti W, Fitzpatrick R, Goldman M. Energy

density and numbers of treatment affect response

of keloidal and hypertrophic sternotomy scars to the

585 nm PDL. J Am Acad Dermatol 2001;45:557–65.

[11] Nouri K, Jimenez GP, Harrison-Balestra C, Elgart GW.

585nm pulsed dye laser in treatment of surgical scars

starting on the suture removal day. Dermatol Surg

2003;29:65–73.

[12] Thomas JR. Scar analysis. In: Thomas JR, Holt GR,

editors. Facial scars: incision, revision, and camou-

flage. St. Louis, MO7 Mosby; 1989. p. 103–22.

[13] Borges AF. Improvement of antitension lines scars by

the ‘‘W’’ plastic operation. Br J Plast Surg 1959;12:

29–43.

[14] Thomas JR, Frost TW. Scar revision and camouflage.

In: Baker SB, Swanson NA, editors. Local flaps in

facial reconstruction. St. Louis, MO7 Mosby; 1995.

p. 587–95.

[15] Webster RD, Davidson TM, Smith RC. Broken line

scar revision. Clin Plast Surg 1977;4(2):263–74.

[16] Swanson NA. Atlas of cutaneous surgery. Boston7

Little Brown; 1987.

[17] Borges AF. Z-plasty. In: Borges AF, editor. Elective

incisions and scar revision. Boston7 Little Brown; 1973.

[18] Frodel JL, Wang TD. Z-plasty. In: Baker SB, Swanson

NA, editors. Local flaps in facial reconstruction. St.

Louis, MO7 Mosby; 1995. p. 131–48.

[19] McGillis ST, Lucas AR. Scar revision. Dermatol Clin

1998;16:173.

[20] Hosokawa K, Susuki T, Kikui T, et al. Sheet of scar

deformity: a hypothesis. Ann Plast Surg 1990;25:134.

[21] Salache SJ. Complications of local flaps. In: Baker SB,

Swanson NA, editors. Local flaps in facial reconstruc-

tion. St. Louis, MO7 Mosby; 1995. p. 581.

[22] Hill TG. Enhancing the survival of full-thickness

grafts. J Dermatol Surg Oncol 1984;10:639.

[23] Robinson J. Improvement of the appearance of full-

thickness skin grafts with dermabrasion. Arch Derma-

tol 1987;123:1340.

[24] Wheeland RG. Revision of full-thickness skin grafts

using the carbon dioxide laser. J Dermatol Surg Oncol

1988;14:130.

[25] Young VL, Bartell TH. Burns of the face. In: Thomas

JR, Holt GR, editors. Facial scars: incision, revision,

and camouflage. St. Louis, MO7Mosby; 1989. p. 238–9.

[26] Tromovich TA, Stegman SJ, Glogau RG. Flaps and

grafts in dermatologic surgery. Chicago7 Year Book

Medical Publishers; 1989. p. 217.

[27] Skouge JW. Skin grafting. New York7 Churchill-

Livingstone; 1991.