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Scar Revision & Camouflage

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Scar Revision & Camouflage Michael E. Decherd, MD Karen H. Calhoun, MD Introduction Scarring Dorland s: a mark remaining after the healing of a wound or other ... – PowerPoint PPT presentation

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Title: Scar Revision & Camouflage


1
Scar Revision Camouflage
  • Michael E. Decherd, MD
  • Karen H. Calhoun, MD

2
Introduction
  • Scarring
  • Dorlands a mark remaining after the healing of
    a wound or other morbid process
  • Mechanism
  • Trauma
  • Surgical
  • Location orientation
  • Cosmesis
  • Function

3
Ideal Scar
  • Flat
  • Narrow
  • Good color match
  • Parallel to or within skin crease

4
Strategies
  • Prevention
  • Incision planning
  • Relaxed skin tension lines
  • Facial subunits
  • Careful surgical technique
  • Postop
  • Wound care
  • Steroid injection
  • Antitension taping
  • Excision
  • Irregularization
  • Reorientation
  • Camouflage
  • Cosmetics
  • Dermabrasion

5
Timing
  • Traditionally 6 to 12 months
  • Perhaps earlier for those perpendicular to
    tension lines
  • Dermabrasion 6 to 9 weeks
  • High fibroblast activity

6
Wound Care
  • Steri-strips
  • Wound cleansing
  • Occlusive dressing
  • Topical antibiotics

7
Wound Healing
  • Inflammatory phase hours
  • Proliferative phase days
  • Remodeling phase months

8
Wound Healing
9
Cellular Activity in Wound Healing
10
Wound Healing
11
Hypertrophic Scar / Keloid
12
Hypertrophic Scarring
13
Keloid
  • Pressure can lead to resolution

14
Keloids
15
Keloids
  • Described 1700 BC
  • Chele Greek for crablike
  • More common in darker-skinned persons
  • Most common age 10-30
  • Usually after trauma
  • Usually within a year

16
Keloids Treatment
  • Steroids
  • Excision Laser vs. cold
  • Pressure
  • Interferon
  • Low-dose radiation
  • Silicone Gel sheeting (hydrocolloid dressing)
  • Combination

17
Patient Encounter
  • Common reaction to scar is ANGER
  • Counseling regarding expectations
  • Counseling regarding timecourse
  • Cannot rush healing
  • Possible touch-ups later
  • Photodocumentation
  • Consistent exposure and lighting

18
Scar Photography
Flat Lighting
Side Lighting
19
Scar Revision?
20
Good Candidate Scars
  • Longer than 20 mm
  • Wider than 1-2 mm
  • Disturbing function
  • Poor match to surrounding tissue
  • Color
  • Depth
  • Against RSTLs

21
Hidden Incisions
  • Hide incision in orifice
  • Transconjunctival, sublabial, intranasal, etc.
  • Hide incision in hair
  • Bevel edges, be aware of future balding
  • Hide behind anatomic prominence
  • Ex retroauricular, submental
  • Hide in junction of aesthetic subunits
  • Hide in Relaxed Skin Tension Lines (RSTLs)

22
Relaxed Skin Tension Lines
23
Lines of Maximum Extensibility
  • Lines of Maximum Extensibility (LMEs) are
    perpendicular to RSTLs

24
Relaxed Skin Tension Lines
  • Somewhat mirrored by lines of aging

25
Relaxed Skin Tension Lines
26
Facial Subunits
27
Facial Subunits Example
28
Surgical Technique
  • Adequate anesthesia
  • Proper instruments
  • Suture materials
  • Closure of dead space
  • Careful handling of tissue
  • Precise closure of dermal layer

29
Technique
  • Perpendicular incision unless in hair-bearing
    area

30
Technique
Improper
Proper everts
31
Depressed Scars
  • Excision
  • Injection
  • Fat
  • Collagen
  • Bovine
  • Human

Collagen allergy
32
Surgical Options
  • Simple excision (fusiform)
  • Best for small scars that are wide or depressed
  • Ex trach scar
  • Angle needs to be less than 30 degrees
  • Serial excision
  • Based upon ability of skin to stretch over time
  • Can move scar to better anatomic location
  • Also good for reducing grafted areas
  • Alternatively, tissue expansion
  • Shave best for small raised scars

33
Serial Excision
  • Scar could be moved via serial excision to
    hairline

34
Intramarginal Excision
  • Hypertrophic scars
  • Incisions within scar may heal better
  • May be better than total excision

35
Intramarginal Excision
36
Z-Plasty
  • Lengthens
  • Reorients

37
Z-Plasty
  • Keep angle gt 30 degrees to avoid tip necrosis

38
Z-Plasty
39
Z-Plasty
  • Angles greater than 60 degrees can be broken into
    multiple flaps

40
Z-Plasty
41
Z-Plasty
42
Z-Plasty
  • Angle should be no less than 30 degrees
  • Optimally between 45 and 60 degrees
  • Long scars can do with a series of Z-plasties
  • Careful technique to avoid tip necrosis

43
M-plasty
  • With a large standing cone, reduces amount of
    healthy skin excised
  • Ex Lip, forehead flap

44
M-plasty
45
M-Plasty
  • Can advance tip with closure

46
W-Plasty
  • Eye is drawn to straight lines
  • Straight scars more likely to cause contracture
  • W-plasty is regularly irregular
  • Maximum segment length 6mm
  • No. 11 blade helpful

47
W-plasty
48
W-Plasty
  • Try to place segments in RSTLs

49
W-Plasty
  • Helpful in curved scars

50
W-Plasty
  • Can use small V?Y segment to gain length

51
W-Plasty
  • Correcting a design error

52
W-Plasty
  • Gillies corner stitch may be helpful
  • Others prefer simple stitch

53
W-plasty
  • Note exposure on photos

54
Geometric Broken Line Closure
  • Irregularly irregular

55
Geometric Broken Line Closure
56
Geometric Broken Line Closure
  • After closing dermis can run with Fast-Sorb

57
Geometric Broken Line Closure
58
Adjunctive Measures
  • Dermabrasion
  • Laser
  • Cosmetic camouflage

59
Dermabrasion
  • Reduces surrounding skin to level of scar
  • Blends color/texture
  • Laser resurfacing now popular
  • Best done around 6 weeks

60
Dermabrasion
61
Dermabrasion
62
Laser
  • More control
  • Good for pigment
  • Minimizes particulate matter
  • Optimum laser/combination under investigation

63
Laser
64
Cosmetics
  • Very safe
  • Allows sooner return to function
  • May instead of or in addition to surgery

65
Cosmetics
66
Cosmetics
67
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68
Treatment Algorithm
69
Conclusion
  • an ounce of prevention
  • Surgical planning and technique
  • Wound care
  • Counseling
  • Timing
  • Careful analysis
  • Appropriate technique

70
Scar Revision Camouflage
  • Michael E. Decherd, MD
  • Karen H. Calhoun, MD

71
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Bibliography
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