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Introduction
CHAPTER 35 Surgical Scar Revision
Mary L. Stevenson John A. Carucci
SUMMARY
Cutaneous scars are a critical consideration for the dermatologic surgeon, as
patients often judge the ultimate success of their surgery based on the final appearance of the surgical scar.
Numerous techniques are available for surgical scar revision, ranging from
topical therapy to laser treatment to surgical intervention.
Timing of scar revision is usually planned several months following surgical
intervention to allow for the scar to improve naturally, though in some instances โsuch as cases of hypertrophic scarring and keloid formationโmore rapid intervention may be appropriate.
Minimally invasive approaches, such as topical and laser therapy, may be
considered sooner.
Beginner Pearls
The majority of favorable scars are produced within RSTLs.
Scars continue to mature and remodel for up to 12 months, and the appearance of scars
continues to improve even beyond one year.
Intralesional corticosteroids are the mainstay of treatment for hypertrophic and
keloidal scars.
Expert Tips
The 585-nm pulsed dye laser (PDL) was the first laser to gain wide acceptance for use
in treating scars postoperatively, though the 532-nm KTP laser or IPL may also be used for erythema in surgical scars.
Fusiform excision, Z-plasty, VโY advancement flaps, and subcision may all be used to
improve scar cosmesis as well.
Donโt Forget!
Patients who are pregnant or immunosuppressed should not be injected with 5-FU.
Fractional ablative and nonablative laser resurfacing has also been used for scar
revision.
Dermabrasion is often performed 4 to 8 weeks postoperatively when tissue
remodeling is taking place, though it may also be used significantly later.
Pitfalls and Cautions
Ultimately, tension is the greatest enemy of the surgeon, and excess tension is
responsible for many scar-related complications.
Therefore, meticulous surgical design coupled with outstanding suturing technique may
mitigate many scarring complications.
Patient Education Points
Explain to patients prior to any procedure that every surgical procedure results in a
scar.
Ideally, a preoperative explanation that every surgical procedure may ultimately
benefit from a staged approach helps patients understand that additional treatment may be beneficial, and helps them anticipate this eventuality rather than see it as a complication.
Billing Pearls
Z-plasty may be billed using the 140XX series codes and is often reimbursable from
insurance.
Most laser- and light-based treatments are excluded from insurance coverage.
CHAPTER 35 Surgical Scar Revision
INTRODUCTION
Cutaneous scars are a critical consideration for the dermatologic surgeon, as patients often judge the ultimate success of their surgery based on the final appearance of the surgical scar. Revision of surgical scars is sometimes necessary for functional reasons, aesthetic reasons, or both. Numerous techniques are available for surgical scar revision, ranging from topical therapy to laser treatment to surgical intervention. Consideration of the texture, contour, erythema, hypo- or hyperpigmentation, and quality of the scar will affect the revision technique employed. Knowledge of these techniques allows the surgeon to achieve the best results for their patient. An appreciation of relaxed skin tension lines (RSTLs) is essential to understanding scars and scar revisions, as the majority of favorable scars are produced within RSTLs. Scars continue to mature and remodel for up to 12 months, and the appearance of scars continues to improve even beyond 1 year.1 Timing of scar revision is usually planned several months following surgical intervention to allow for the scar to improve naturally, though in some instances โsuch as cases of hypertrophic scarring and keloid formationโmore rapid intervention may be appropriate. Minimally invasive approaches, such as topical and laser therapy, may be considered sooner.
In an effort to standardize treatment of scarring, the International Advisory Panel on Scar Management released a consensus statement on the management of scars in 2002 consolidating evidence-based medicine and expert opinion.2 In 2014, updated recommendations were published and since then further technologies and data have been released.3,4 These recommendations include topical therapies, intralesional agents, laser therapy, and radiation therapy for the treatment of scars. Surgical revision may also be employed.