eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Cosmetic Surgery
Scar Revision: Treatment
Updated: Jun 30, 2009
Treatment
Surgical Therapy
The following will present the most common surgical techniques in scar revision, and includes discussion of their advantages and applications, conceptualization and methodology. Although the primary focus of this article is on surgical techniques, the nonsurgical treatment to minimize scar formation or to reduce problematic scarring after primary closure is also mentioned.2,3
Z-plasty
Z-plasty is one of the most versatile scar revision techniques available. As a transposition flap, Z-plasty allows for 2 adjacent undermined triangular flaps, constructed from the same central axis, to transpose over each other and to lie in the other's originating bed. In essence, these 2 triangular flaps are transposed from areas of relative excess into areas of relative deficiency and eventually lie at near right angles to the original central axis.4
The usefulness of Z-plasty in scar revision rests in its ability to (1) reorient a scar to lie more favorably in the direction of RSTLs; (2) reorient the scar or anatomic landmark into a more favorable location or position; (3) break up the length of the scar, thereby rendering it less visible; (4) increase the scar length (ie, lengthen a contracted scar), thereby decreasing the prevailing scar contractile force and permitting better conformation to contoured surfaces; and (5) allow the surface-revised scar to run in a different angle to the deeper, more established scar, thus decreasing the tendency of the final scar to become depressed.
Mastery of the Z-plasty concept is essential for anyone practicing head and neck surgery because the technique is used in a variety of primary incisions and reconstructive excisions. The following describes the technique of Z-plasty and covers the usefulness and construction of the classic, multiple, and adjunct Z-plasties.
The classic Z-plasty is composed of 3 limbs (ie, a central and 2 parallel lateral limbs) of equal length with the 2 lateral limbs aligned to the central limb at identical 60° angles (see Image 2). Elevate, widely undermine, and then transpose the triangular flaps into the other's donor bed (see Image 3). In the result, the central limb is oriented nearly perpendicular to its original direction, lengthening the linear dimension of the scar (see Image 4). However, note that the lengthening in one axis mirrors the shortening in the other axis and results in corresponding tissue distortion. Images 5-7 demonstrate the relative degree of lateral tissue distortion in an elastic model of a classic 60°-angle Z-plasty.
Scar revision. Classic Z-plasty composed of two 60° angles.
Scar revision. Transposition of flaps in Z-plasty.
Scar revision. Completion of 60° Z-plasty. Note lengthening of the scar and how the central limb now lies nearly perpendicular to original orientation in Image 3.
Scar revision. Elastic model demonstrating Z-plasty before flap transposition.
Scar revision. Transposition of flaps in 60° Z-plasty. Note beginning of lateral tissue distortion as the central limb lengthens.
Scar revision. Final closure of elastic model in 60° Z-plasty. Note directional change of the central limb and extreme lateral tissue distortion.
The angle that the lateral limbs subtend with the central limb directly influences the final length of scar; the greater the angle the lateral limbs subtend with the central limb, the greater the lengthening of the scar. Moreover, the inherent elasticity of the surrounding tissue also influences the gain in length. Thus, a 60°-angle Z-plasty yields a 75% length increase; a 45° angle, a 50% length increase; and a 30° angle, a 25% length increase (see Image 8). While most surgeons opt for lateral limb angles that approximate 60° and thereby balance scar lengthening and adjacent tissue distortion, a higher degree of lengthening may be achieved by greater lateral limb angles. Lateral limb angles less than 30° are more likely to result in flap tip necrosis; those greater than 75° are more likely to result in standing cone deformities.
Scar revision. Relationship between angle and central limb lengthening in Z-plasty. Note how the larger angle corresponds to a greater increase in length.
For every potential Z-plasty, 2 possible lateral limb designs exist, but only 1 optimally places the final scar within or nearly within the RSTL. Selection of the optimal orientation of the lateral limbs requires careful planning. Collectively consider the original scar orientation, the resultant excised central limb, and the direction of prevailing RSTLs. Choosing lateral limbs that originally lie parallel to RSTLs ultimately creates transposed lateral limbs that also are likely to lie parallel to RSTLs.
In Images 9-10, 2 different possible Z-plasty configurations are demonstrated in revising a scar that traverses the nasolabial (cheek-lip) fold. Only one of these produces the best possible result (see Image 9). By orienting the lateral limbs as close as possible to the prevailing RSTL, the final limb orientation aligns more favorably to the RSTL of the upper white lip and nasolabial fold. Compare this to the undesirable design illustrated in Image 10, in which the lateral limbs lie perpendicular to the RSTL of the white lip.
Scar revision. Properly oriented Z-plasty for a scar traversing the cheek-lip groove with lateral limbs directed nearly parallel to relaxed skin tension lines (RSTLs).
Scar revision. Improperly oriented Z-plasty with lateral limbs directed perpendicular to relaxed skin tension lines (RSTLs). Note how inferior the lateral limb lies perpendicular to RSTLs of the white lip.
Transposing large amounts of tissue theoretically could be achieved by constructing a Z-plasty with angles larger than 60°. While the construction of a single Z-plasty produces a greater gain in length than its smaller multiple-angle counterparts, a larger-angled Z-plasty is more likely to create unacceptable deformity. This results from adjacent standing cone deformity and incisions that noticeably cross boundaries of adjacent facial aesthetic units. Moreover, even though a scar may be revised by a single larger-angled Z-plasty, the creation of multiple or compound lesser-angled Z plasties acceptably lengthens the scar, results in less tissue distortion, and has the added benefit of better camouflage by increased scar irregularity. Therefore, a more reasonable alternative is to construct multiple or compound lesser-angled Z-plasties rather than a single Z-plasty with an angle approximating 60°.
Variants of the multiple Z-plasty include compound and serial types. These variations on the classic Z-plasty often are useful in closing ovoid defects, such as those resulting from excision of a widened scar. While both are useful, the compound Z-plasty has the advantage over the multiple serial variant because it requires fewer incisions. The compound type is constructed by creating 2 separate flaps at each end of the central limb, oriented at 45° to each other (see Images 11-12).
Scar revision. Compound 4-flap 45° Z-plasty.
Scar revision. Completion of compound 4-flap 45° Z-plasty. Note significant tissue distortion at ends of wound.
Construct the serial Z-plasty by transposing flaps created by laterally incising the margins of the defect (see Images 13-15). The serial Z-plasty creates minimal tissue distortion and is particularly useful near areas where this may result in functional and cosmetic impairment, such as near the ophthalmic or oral commissure. However, in practice, the surgeon must weigh the advantage of lesser tissue distortion against the multiplicity of incisions required in this type of Z-plasty.
Scar revision. Serial Z-plasty applied to ovoid defect.
Scar revision. Serial Z-plasty applied to ovoid defect.
Scar revision. Serial Z-plasty applied to ovoid defect.
Finally, the Z-plasty is effective as an adjunct to the excision of widened fusiform or ovoid defects in which skin margins cannot be reapproximated or can be closed only under excessive tension. In this case, a single Z-plasty lies lateral to the excised scar, and, by transposing its 2 flaps, tissue is mobilized toward the closure of the defect, thereby minimizing the tension on the final closure and distortion of adjacent aesthetic units.
W-plasty
The primary utility of the W-plasty (also termed the running W-plasty or zig-zag plasty) is in rendering a lengthy linear scar irregular. In addition to linear scar revision, the W-plasty is useful in the closure of semicircular incisions in which the sweeping unbroken curvilinear scar is more noticeable and under greater tension and, thus, over time more likely to become depressed or pincushioned. Note that while the W-plasty makes irregular a linear scar and spares unwanted lengthening that may arise from using small multiple Z-plasties, the final result is often readily visible because the eye easily can follow the predictable zig-zag configuration. Finally, in its basic execution, this technique incorporates neither transposition nor rotation of adjacent flaps; therefore, the final scar is not elongated but only increased in the final total length.
The basic W-plasty consists of creating consecutive small triangular flaps on opposite sides of the wound, with sides not more than 6 mm and corner angles of 90° or less. Important considerations for the basic W-plasty involve its use in curvilinear wounds and its orientation with respect to RSTLs. When using the W-plasty on curving wound margins, the outer triangles must be larger in both side length and angle than their counterparts on the inner curve (see Image 16).
Scar revision. Size and number differential between W-plasty triangles to ensure corresponding fit between inner and outer wound curvature.
This size discrepancy ensures that the number of outer and inner triangular flaps is the same. Careful preoperative planning must ensure numerical equality and must recognize the direction of the RSTLs. Unlike the Z-plasty, the W-plasty does not redirect the wound in a more favorable orientation to the RSTLs. Therefore, the sides of each triangle in the W may be oriented toward the RSTLs more than if they were constructed in an isosceles right triangular configuration (see Image 17). The corresponding contralateral wound margin then also must interdigitate this modification.
Scar revision. Modification of customary isosceles right triangular configuration to approximate more closely the prevailing relaxed skin tension line (RSTL). Lines with arrowheads indicate the direction of RSTL.
The precise nature of the W-plasty necessitates strict adherence to basic underlying plastic surgical technique. After carefully drawing the W-plasty (see Image 18), make incisions vertically and at right angles through the dermis with a No-11 scalpel blade (see Image 19). Use a deep dermal suture to reduce the tension on the superficial layers. A running locking configuration of rapidly absorbable suture may be used on the surface. All wound margins are imbricated precisely together (see Image 20).
Scar revision. W-plasty is drawn carefully.
Scar revision. W-plasty is excised while maintaining the blade perpendicular to the skin's surface.
Scar revision. A completed W-plasty. Note lack of lateral tissue deformation.
Finally, employ antitension taping to further reduce tension on the wound surface. As in all scar revision, remind patients that the final appearance of the wound cannot be evaluated fully until nearly 6 months postoperatively, as the erythema begins to subside. After this period, dermabrasion or laser resurfacing may be employed adjunctively as a further refinement.
Geometric broken line closure
A variant of the W-plasty, geometric broken line closure (GBLC) employs the same illusory principles as a W-plasty, seeking to maximally create irregularity in a linear scar and thus render it less visible than a procedure with a regular patterned unbroken configuration. GBLC can offer superior results to the W-plasty because the eye finds the greater scar irregularity even less perceptible in the final result. Like the basic W-plasty, GBLC does not lengthen the original scar.
Construction of GBLC follows from an exacting pattern of irregular geometric shapes on either side of the wound. Construct the geometric shapes of corresponding dimension squares, rectangles, and triangles that, when brought together in final closure, interlock into their opposite margin counterparts. The geometric shapes thus constructed should have their width randomized along the length of the scar with progressively lesser and then greater height near the ends and the mid region of the scar, respectively (see Image 21).
Direct special attention to the relative curvature of the wound margins. If the scar is curvilinear, the size of the geometric shapes is significantly smaller on the concave side than on the convex counterpart. Alternatively, a running W-plasty often can be used on the extreme curving aspect of curvilinear scars revised with GBLC. Remember that the outer triangles must be larger in both side length and angle than their inner curve counterparts.
Scar revision. Excision following design of geometric broken line.
Incisions made vertically and perpendicular to the skin surface using a No-11 scalpel blade ensure precise geometric shape interdigitation (see Image 21). Moreover, judicious use of preexisting scar in the underlying deep dermis or subcutaneous tissue as autoplastic filler, along with precise peripheral undermining, greatly enhances the final result by decreasing the likelihood of a depressed scar. Given these caveats, the length of any segment should be 3-6 mm, and all corner angles should be maintained at 90° or less. Perhaps the easiest method to construct this often confusing array of geometric shapes is to first create corresponding perpendicular lines on each side of the wound and then to create the corresponding geometric shapes that ultimately interlock in the final closure (see Image 22).
Scar revision. Closure of geometric broken line revision technique.
The geometric configuration and dimensions in GBLC are critical and depend on their relationship to the RSTLs and on their position along the scar length. Ideally, all incisions in GBLC should parallel prevailing RSTL direction as closely as possible. However, the scar often may run predominantly parallel or perpendicular to the planned revision. In either case, give special consideration to the sides or tops and bottoms, respectively, of any rectangles created when planning the initial incision.
When the rectangular or square shapes have their sides lying perpendicular to the RSTL, 2 methods may be employed. Either the proportion of squares and rectangles to triangles may be decreased (thereby decreasing the absolute number of perpendicular lines), or these geometric shapes may be slanted (as with a W-plasty) to approximate more closely the prevailing RSTL.
In an instance where the scar runs predominantly perpendicular to the RSTL and the rectangles have their bases and tops likewise perpendicular, the surgeon may decrease the number of the lines perpendicular to the RSTL by creating triangular shapes from the rectangle bases and tops. Finally, to ensure precise interdigitation of flaps, geometric shapes should have greater height at the mid portion and lesser height at the lateral ends of the wound (see Image 23).
Scar revision. Geometric broken line closure (GBLC) on a curved wound, oriented differentially to relaxed skin tension line (RSTL). Note height differences of geometric figures at ends and middle of wound and relative increase of triangular shapes to rectangles.
After placement of antitensioning dermal sutures, the GBLC may be closed superficially with a running locking absorbable suture placed approximately 5 mm lateral to the wound margins.
M-plasty
Often, scar revision creates angles greater than 30° at the lateral wound margins. While a greater angle at the wound's ends maximally preserves normal surrounding tissue, revision efforts under these circumstances are more likely to create a standing cone (ie, dog-ear) deformity. Decreasing the likelihood of a standing cone deformity ultimately leads to greater loss of healthy surrounding tissue and vice versa. A useful technique to preserve healthy tissue and lessen the chance of secondary tissue deformity is the M-plasty. The M-plasty, by creating 2 separate 30° angles instead of one, decreases the loss of surrounding healthy tissue by nearly 50%.
Construct the M-plasty by halving the distance from the central vertical axis of the wound to the lateral apex of the wound (see Image 24). The proximal length then forms a side of one of the 30° triangles, with the other side of the triangle formed by a line that begins at this halfway point and ends at the most lateral edge of the scar (see Image 25).
Scar revision. Central scar with bilateral M-plasty.
Scar revision. A wound following excision of central scar. Note how M-plasty design conserves otherwise discarded healthy surrounding tissue.
Closure of the M-plasty is more than simple approximation of tissue edges. The triangular point of tissue at the wound ends may be centrally advanced into the wound to achieve more or less lengthening of the wound, depending on the degree of tissue advancement. As much as possible, advance the remaining triangle of tissue into the wound in a V-Y advancement maneuver, thereby effectively shortening the overall length of the wound (see Images 27-28).
Scar revision. Diagrammatic representation of M-plasty closure with advancement of the tip into the defect by horizontal mattress suture technique.
Scar revision. An alternative method of closing angulated flap by horizontal half-buried mattress suture. The flap tip may be advanced differentially into the wound apex to achieve a moderate degree of eversion and decreased tension.
Plastic surgical incision and closure techniques
Poor wound healing results from posttraumatic infection, inadequate or traumatic wound closure, excessive use of electrocautery, or inappropriate postoperative wound care. Wounds overlying sites of maximal tension or repeated motion or perpendicular to RSTLs also probably result in more visible or widened scars. Emergency medical personnel in the acute care setting often do not understand the importance of judicious debridement, tension-free wound closure, and wound margin eversion.
While the judicious excision of devitalized tissue from wound margins and removal of foreign body contamination cannot be overemphasized, excessive debridement creates an uneven closure and contributes greatly to an unfavorable cosmetic result. Aside from overzealous debridement, avulsion injuries, full-thickness burns,5 and gunshot wounds are important causes of wound site tissue loss.
Furthermore, in an effort to reapproximate these widened margins, wounds are more apt to be closed under a maximal degree of tension or are left to heal by secondary intention. These scars are perhaps the most difficult to revise because the deep tissue inflammatory response following their injury creates a rigid, nondistensible recipient bed. Finally, wounds that are not covered with an occlusive ointment and are allowed to desiccate further contribute to the likelihood of a cosmetically unacceptable scar.
A thorough understanding of plastic surgical wound closure techniques is critical to the application of scar revision concepts. While soft tissue techniques in facial plastic and reconstructive surgery follow the time-honored guidelines of any wound closure, devoting particular attention to certain technical refinements ensures superior results.
Preeminent in the discussion of scar revision techniques is the manner in which the tissue is handled. The extreme importance of using atraumatic tissue technique during any revision procedure cannot be overemphasized. Most revision techniques involve delicate skin margins that may undergo complete vascular compromise from poor handling technique alone. Tissue forceps should be of a toothed variety (eg, Adson, Brown-Adson) and should be used sparingly on wound margins. Alternatively, single-pronged or double-pronged skin hooks may be placed in the subdermal tissue and used as a traction device. When visualizing how a closure ultimately will appear, the wound may be temporarily closed by grasping the subcutaneous tissue instead of the epidermis and approximating together the wound margins. This minimizes the crushing trauma to the wound, yet allows an adequate preview of how the revision will appear when the epidermis finally is closed.
Often overlooked is the value of using saline-dampened sponges during scar revision procedures. Damp sponges maximize wound margin hydration, an important point in revision procedures that are time intensive or use geometric configurations that are more likely to be injured (eg, delicate margins in GBLC). Moreover, damp sponges allow, by virtue of their ability to destain the tissue, a better differentiation of important adjacent anatomic structures (ie, preferred planes of dissection and neurovascular anatomy).
Incisions
Proper incisions in scar revision are the foundation of superior results and must be precise. Either a No-11 or No-15 blade attached to a No-9 handle can accomplish the varying degree of vertical, beveled, straight, or curved incisions. While vertical incisions offer the greatest usefulness in scar revision, conditions exist where a slightly beveled incision is desirable. Hair follicles rarely are oriented perpendicular to the skin surface, and thus the hair shaft lies in the same direction. Incisions made perpendicular to the skin in hair-bearing areas are at greater risk of irreversibly damaging the follicle with resulting alopecia adjacent to the healing incision.
This type of iatrogenic scar is particularly visible as a well-defined hypopigmented line lying adjacent to or within a hair-bearing surface. This may be overcome by beveling the incision parallel to the hair shaft, thereby preserving hair growth in the tissue adjacent to the incision line (see Image 29).
Scar revision. Incision parallel to direction of hair follicle reduces likelihood of alopecia.
Beveling the incision also plays an important role in the formation of an everted wound closure. To fully understand the importance of this technical concept, remember that, as scars heal, forces of contracture pull the wound centripetally, including from a deep to superficial direction. Even if wounds are closed using deep subcutaneous suture technique to minimize tension across the margins, scar contracture probably causes retraction of these same margins, resulting in a depressed scar. Then, an easily visible shadow is cast as incident light falls across the healed wound. To minimize this problem, incision and suturing techniques have been developed to produce wound eversion that over time results in a less visible planar scar.
While it may appear less aesthetic to both physician and patient, the initial heaped-up wound flattens out remarkably over 6 months to a year as the forces of scar contracture pull the healing margins inward and downward. Preoperatively counsel patients that initial results will seem unsatisfactory but will improve dramatically over time. Invariably, this concept needs reinforcement during the ensuing months. Dermabrasion or laser resurfacing may be employed adjunctively if the scar appears unaesthetic and unlikely to improve to an acceptable state after 6 months.
An essential component of any scar revision technique is judicious subdermal undermining lateral to the wound margins. This technique permits a more tension-free closure on the epidermal surface, resulting in a superior revision. The amount of undermining in any particular revision is dictated by the surgeon's experience; however, studies demonstrate that undermining more than 1 cm may do little to decrease tension on the wound and may create further unnecessary dead space or compromise the subdermal vascular plexus. Skin flap undermining can be achieved with a No-15 blade or sharp scissors. Elevation of the flap during undermining is achieved atraumatically with skin hooks or toothed forceps.
Wound hemostasis
Adequate hemostasis is of paramount importance in all surgical wounds. Localized collections of blood under the flap or the coagulum that separates wound margins can predispose the wound to infection and more visible scar between approximated margins. After all preoperative precautions are undertaken to ensure hemostasis, proper planar tissue dissection and judicious electrocautery remain the mainstays of superior wound hemostasis. While monopolar cautery with a needle-tip attachment is probably the more popular instrument used, a strong supportive argument can be made for bipolar cautery. Bipolar cautery has the distinct advantage because the cauterizing electric current passes only between the instrument tips, thus minimizing any unintended lateral thermal trauma. This is particularly important if any cautery is performed near the dermal-epidermal junction, in the subdermal vascular plexus of a particularly thin flap, or near hair follicles.
Subcutaneous closure
Proper closure of the deeper subcutaneous layers is of critical importance in any scar revision. No amount of carefully planned and executed incisions or meticulous epidermal closure yields a superior result if the subcutaneous layer is not closed in the appropriate manner. Properly placed subcutaneous sutures perform the vital functions of decreasing the dead space under a wound, permitting a tension-free epidermal closure, and causing a moderate degree of epidermal eversion.
One method of placing subcutaneous sutures is as follows. While gently everting the deep subcutaneous tissues with either a skin hook or minimally traumatic toothed forceps, the needle is placed 5-10 mm distal to the wound margin. The suture passes through the dermis and the opposite side in the reverse order. This sequence of suturing places the knot deepest in the wound, decreasing the likelihood of future suture extrusion. Alternative means are used in closing triangular flaps such as in GBLC and M-plasty. In this instance, a horizontal mattress suture is placed midway through the full thickness of the flap, and then, by placing the suture at a corresponding similar level, the angulated tip is advanced into the wound. This advancement is critical because it closes the potential dead space between the flap and recipient site and everts the wound edges (see Image 28).
Scar revision. An alternative method of closing angulated flap by horizontal half-buried mattress suture. The flap tip may be advanced differentially into the wound apex to achieve a moderate degree of eversion and decreased tension.
Closure of the subcutaneous layer most often is performed with a synthetic absorbable suture. Although nonabsorbable sutures retain tensile strength over an extended period, many surgeons believe that these sutures have little utility in facial plastic surgery because of their higher likelihood of later rejection. However, nonabsorbable suture elicits significantly less inflammation than its absorbable counterpart. Absorbable sutures eventually dissolve, losing tensile strength according to known time parameters and wound characteristics. This can lead to a loss of support in the subcutaneous layer and greater tension across the overlying epidermal layer, with an increased likelihood of a more prominent scar. For these reasons, surgeons must employ judicious undermining to decrease wound tension and must choose the proper absorbable suture. This ensures that the wound is healed sufficiently by the time the absorbable suture has lost nearly all its tensile strength.
Synthetic sutures based on polyglycolic acid, such as Dexon or Vicryl, are well suited to close the subcutaneous layer. Polyglactin suture (eg, Vicryl) maintains 75% of its tensile strength at 2 weeks and 50% at 3 weeks; it is dissolved completely in 56-70 days. Sutures with a longer duration of tensile strength (eg, polydioxanone [PDS], Vicryl) have a prolonged ability to decrease wound tension but also have the disadvantage of creating a longer duration of inflammation over time. This type of suture may have its greatest use in rigid fixation to deeper structures of tissues such as cartilage and bone grafts. PDS suture has 50% of tensile strength at 1 month and is histologically undetectable at 6 months.
Epidermal closure
The purposes of epidermal closure are to precisely reapproximate and to slightly evert the wound margins and not to decrease tension across the wound. This concept is especially critical when fast-absorbing suture is used. In fact, before epidermal closure, the wound margins already should be nearly completely apposed by well-placed subcutaneous sutures.
Suture material for epidermal closure depends largely on the type of scar revision, anatomic location, age of the patient, and desired degree of wound margin eversion. Most surgeons prefer to use a 5-0 or 6-0 nylon or Prolene suture in facial plastic surgery because of their low tissue bioreactivity. Advantages of Prolene suture include the ability to stretch during knotting and the ability to precisely define the appositional tension across the wound. In the scalp and neck, 4-0 and 5-0 sutures, respectively, find greatest utility in minimizing the scar while maintaining support of the healing wound.
A disadvantage of these types of nonabsorbable sutures is that they often require laborious removal, an especially challenging endeavor in hair-bearing wounds or in pediatric patients. In these instances, the mild chromic, fast-absorbing gut or newer rapid polyglactin synthetic suture facilitates postoperative care because these sutures require no medical personnel for removal. Each of these sutures imparts a low degree of bioreactivity and dissolves over a relatively short period. Remember that these suture materials are fragile and must not be exposed to aqueous environments and petrolatum-based ointments because these may precipitate a much earlier suture dissolution and consequent compromise of integrity.
The suture materials above are used to close linear wounds by taking 1- to 2-mm bites of tissue on each side of the wound and placing the sutures approximately 3-5 mm apart. Epidermal suture placement is thus a balance between inadequate wound closure and placing too many sutures too close together, compromising flap vascular integrity. This concern is amplified when the geometric configuration of the wound edges is anything less than 180°, as with Z-plasty, W-plasty, or GBLC. In these instances, blood supply to the tip of the flaps may be compromised if more than a single suture is placed through the flap margins. For this reason (ie, to avoid constricting the dermal and subdermal blood supply), the author recommends that the suture be singular and encompass only the epidermal layer.
An alternative method is to employ a horizontal mattress technique in which the suture is half-buried and includes both the flap tip and the sides of the defect (see Image 28). Both techniques work equally well, but, if improperly placed, both may compromise the vascular integrity of the flap.
Scar revision. An alternative method of closing angulated flap by horizontal half-buried mattress suture. The flap tip may be advanced differentially into the wound apex to achieve a moderate degree of eversion and decreased tension.
The suture technique used in scar revision closure may include simple interrupted, vertical mattress, or running locking configurations. Simple interrupted suturing affords the best protection for maintaining flap margin viability because of its spacing along the wound margin. This technique also may be employed to primarily create or supplement wound margin eversion. As a timesaving measure, the running locking suture technique allows the surgeon to close a wound with multiple edges, such as with complex GBLC or running W-plasty. To maintain a viable blood supply, do not cinch down the many running half-formed knots. The vertical mattress suturing technique allows for a superior eversion of wound margins and primarily is used in less angulated closures such as simple fusiform excision.
Often overlooked is the importance of antitension skin taping, performed after epidermal closure. Like epidermal sutures, antitension taping is directed at further minimizing wound tension but is not used as a primary method for doing so. By preventing coagulum from intervening between wound margins, antitension taping ensures near complete wound apposition.
After completing the epidermal closure, apply topical liquid adhesive to each side of the incision. Exercise great care not to contaminate the incision with the adhesive. Then, use Steri-Strips or other easily applied taping to decrease the tension across the wound. Leave these in place until the epidermal sutures are removed. When removing the tape, removing the strips by pulling the tape in a medial direction (ie, toward the wound margins) is essential because this minimizes any forces that otherwise may tend to distract the wound margins.
Next, reapply the taping, and, ideally, leave it in place for at least 4 weeks. Darker, more flesh-colored tape that camouflages well is available for anatomic locations where visibility is a concern.
Another method to further decrease wound tension after subcuticular suturing is the topical application of tissue adhesive. These newer acrylate-derived liquid adhesives provide superior wound apposition when applied as directed by the manufacturer, but do not allow them to enter directly into the wound. While their relative reactivity with epidermal nylon or other synthetic sutures is not fully described, they may find the greatest use in the adjunctive closure of wounds closed with subcuticular suturing techniques.
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Webster RC, Davidson TM, Smith RC, et al. M-plasty techniques. J Dermatol Surg. Nov 1976;2(5):393-6. [Medline].
Further Reading
Clinical guideline
Management of burns and scalds in primary care.
New Zealand Guidelines Group - Private Nonprofit Organization. 2007 June. 120 pages. NGC:005962
Clinical trials
Juvista in Scar Revision Surgery of Disfiguring Scars (Revise)
Exploratory Study of the Efficacy and Safety of Juvista 250ng When Administered Following Excision of Ear Lobe Keloids
Related eMedicine topics
Scar Revision (Dermatology)
Laser Revision of Scars
Z-Plasty
Facial Burns
Wound Healing, Nerve
Keloid and Hypertrophic Scar
Keywords
scar revision, cosmetic wound revision, scar repair, cosmetic skin repair, Z-plasty, classic Z-plasty, multiple Z-plasty, serial Z-plasty, W-plasty, running W-plasty, zig-zag plasty, M-plasty, geometric broken line closure, GBLC
