Continuing Education Activity

Patients may want a scar revision for a multitude of reasons. They can cause function limitations, be a reminder of a traumatic event, or cause other emotional and psychological issues. Healthcare providers should be aware of the surgical and nonsurgical options available for scar revision. This activity describes the anatomy, indications, contraindications, technique, complications, and clinical significance of performing a scar revision and highlights the role of the interprofessional team in evaluating and treating this condition.

Objectives:

• Identify the indications, and contraindications for scar revision.
• Describe the equipment and personnel required for scar revision.
• Outline appropriate evaluation of the potential complications of scar revision.
• Explain interprofessional team strategies for enhancing care coordination and communication to advance scar revision and improve outcomes.

Introduction

After an injury, the skin attempts to restore its normal blood flow and function: this occurs through a very orderly three-phase process known as wound healing. The three steps or phases of wound healing are inflammation, proliferation, and maturation. A study by Dunkin et al. found permanent scars occur when the reticular dermis has been violated. Scars are a natural and normal part of healing following an injury to the integumentary system. Ideally, scars should be flat, narrow, and color-matched. Several factors can contribute to poor wound healing. These include but are not limited to infection, poor blood flow, ischemia, and trauma. Proliferative, hyperpigmented, or contracted scars can cause serious problems with both function and emotional well-being.[1][2][3] 

Anatomy and Physiology

The skin is a vital organ providing barrier protection as well as thermal regulation. The three layers, starting with external, are the epidermis, dermis, and subcutaneous fat. The dermal layer accounts for about 90% of the integumentary system. The dermis is composed of fibroblasts, blood vessels, nerve endings, hair follicles, and sweat glands.[4]

The injury immediately initiates the first process of wound healing, the inflammatory phase. The inflammatory phase lasts about 2 to 5 days.[5] The proliferative phase starts about 3 days after the injury and can last for weeks. The proliferative phase lays a framework for repair. The proliferative phase encompasses angiogenesis, fibroplasia, and epithelialization. The final step is maturation. Wound contraction occurs during the maturation phase and is due to myofibroblasts.[5][6]

Scar assessment is usually by vascularity, pigmentation, pliability, area, and height.[7] Immature scars are generally red to pink, may be itchy or occasionally painful. Immature scars are typically still in the remodeling phase. Mature scars are usually flat and light.[8] Keloids and hypertrophic scars are believed to be a result of chronic inflammation in the reticular dermis. Pro-inflammatory factors have also been shown to undergo up-regulation in keloid tissue as well as fibroblasts.[8][9]

Indications

A patient will seek scar revision for a variety of reasons. There are both physical and emotional reasons a patient may want their scar revised. Scars can have functional limitations on areas of mobility or that lack tissue laxity, causing contractions. If scar revision is for limitation in range of motion, then restoring function is the primary goal of the procedure. Scars can also be extremely painful, especially if a neuroma is present. The scar can also be a reminder of the trauma a patient has faced in the past. They may simply wish to erase these memories. And, finally, it can cause social embarrassment. All these reasons are indications for scar revision. The physician should be sensitive to the emotional and physical aspects of these patients.[8][10][11] It is important to note that scars take about 12 to 18 months to mature. Immature scars lead to poor results after a revision.[12]

Contraindications

Patients should receive counseling on scar revision expectations. The purpose of scar revision is to create a more acceptable and diminished scar; it is not to eliminate a scar altogether. Contraindications include any situation in which the new scar will be worse or limit function.

Anticoagulants should be held prior to the procedure. Patients that cannot be off anticoagulation should not undergo elective scar revision.

It is important to note patient factors that lead to suboptimal healing. A balanced diet is crucial for protein building, which is necessary for healing. Vitamins and minerals, notably vitamins A, C, and E, and zinc are integral to wound healing. Medical conditions can also hinder wound healing. Most notably, is diabetes mellitus. Additionally, patients taking immunosuppressive medications are at increased risk of suboptimal healing. Tobacco use also limits wound healing.[12][13]

Equipment

Equipment includes a functional and staffed operating room with basic general surgery equipment.

Personnel

Personnel needed includes a staffed operating room with a surgeon that is well versed in scar revisions.

Preparation

Smoking is associated with an increased risk of surgical site infection and poor wound healing. All patients should undergo smoking cessation education and be smoke-free for at least 30 days before scar revision. Patients should have their glucose under control with blood glucose levels less than 180 mg/dL.[12][13]

The patient should remain NPO after midnight if any sedation or general anesthesia is planned for the operation. Patients can take most, if not all, of their normal medications the morning of the procedure. Aseptic practice and sterile technique are necessary for all procedures.

It is essential to carefully plan the incision before making a cut. The surgeon should identify relaxed skin lines or the desired orientation of the scar. Preoperative marking should be placed appropriately to correspond with these lines and ensure the skin edges will be closed successfully without tension.[14]

Technique or Treatment

There are surgical and nonsurgical options for scar treatments. The initial assessment should focus on starting with the most straightforward option first and progressing from there. There are non-surgical and surgical options for scars.

Nonsurgical

Steroid injections have been used for years for keloids and hypertrophic scars. Typically triamcinolone is used. The steroid is diluted to a concentration of 2.5mg/mL. Approximately 0.1 mL is injected per 5 to 8 mm of a linear scar. Patients are instructed to massage the area for 24 hours after injection. Injections occur every 4 weeks. Care must be taken to not over- inject the area. Over-injection can cause adverse outcomes such as surrounding telangiectasia, dermal thinning, and fat atrophy causing dimpling.[10] There are reports of adverse effects in up to 63% of patients undergoing injections. Intralesional 5-fluorouracil has been shown to be effective in minimizing hypertrophic scars. Intralesional cryotherapy has also been shown to be effective. However, up to 75% of patients report adverse effects.[12]

Ablative laser resurfacing is effective at scar revision. Both the carbon dioxide and the erbium: YAG laser cause superficial scar ablation. The carbon dioxide laser causes collagen remodeling. The erbium YAG laser is also beneficial for multiple types of scars. Adverse effects include hyperpigmentation from the laser.[12]

Soft tissue fillers are a method for depressed scars. Depressed scars are typically caused by scarring in the deep tissue or tethering to the deeper tissue.[15] Bovine or human collagen, fat, hyaluronic acid, and synthetic fillers have been shown to have good cosmetic outcomes.[12]

Dermabrasion is useful for acne scars. It helps level textured skin and smoothes any irregularities. It uses a sterile sandpaper or wire brush to erode the skin evenly.[16] The ideal timing is within 6 to 8 weeks of the operation as it will disrupt the remodeling phase of scar healing. The effects are very user-dependent.

Surgical Options

Scar revision should focus on returning anatomic structures to correct locations, a tension-free return, atraumatic technique, and hiding the scar in a resting skin line of tension. There are multiple strategies and techniques one can use for these revisions.

Elliptical excisions are appropriate if the existing scar is already in a resting skin line of tension. The ratio of length to width should be 3 to 1, and the angle of the ends should be no more than 30 degrees to prevent a dog tail from occurring.[12] The repair must be tension-free and needs to keep anatomic structures in appropriate locations.

Z-plasty is a type of tissue rearrangement. It is the most commonly used technique for scar revisions.[12] Z-plasty is a good technique when one needs to elongate an incision. The horizontal incisions also lessen the tension on the vertical segments. Increased tension prolongs the inflammatory phase leading to hypertrophy. The original scar serves as the common limb. The angle degree can be adjusted to allow greater lengthening and adjusting the orientation of the scar to align it with resting skin lines of tension.  The flaps should not include scar as this increases the risk of wound ischemia and necrosis.[1][12] Z-plasty is good for the forehead and nasolabial area because it is easy to align a scar with natural skin creases.

W-plasty is another technique for scar revision. The scar is excised using a zigzag pattern, and the interdigitated limbs get approximated. The theory behind the W-plasty is that a broken line is harder for the eye to follow. One arm of the triangle should be parallel to a resting skin line of tension. The upper and lower triangles need to correspond to allow proper alignment for closure.[1][12][17]

Flaps and skin grafts have also been used for scar revisions. These are generally the choice when the scar location is in an area where it would be difficult to mobilize the adjacent tissue.[12] Split-thickness grafts can give a poorer cosmetic effect due to meshing. One must be mindful of color-matching in both split-thickness and full-thickness skin grafts. The donor areas limit full-thickness grafts.[8]

Complications

Complications are typically minimal in scar revision surgery. Early complications include bleeding from the surgical site, pain, reaction to the suture material, surgical site infection, or flap necrosis. Surgical site infections are most commonly due to methicillin-resistant coagulase-positive Staphylococcus (MRSA).[18]

Delayed problems include new or recurrent contracture, hypertrophic scar, changes in skin pigmentation, nerve injury, skin atrophy, or trap-door deformity.

It is crucial to educate patients on the fact complications could lead to a less desirable scar.

Clinical Significance

Scars can cause a wide range of problems for patients, including both physical and emotional. Luckily patients do not have to live with suboptimal scars forever. There are many options for scar revision. If a patient presents with a suboptimal scar, they are potential candidates for revision. Patients wishing to undergo elective surgery should have a healthy, balanced diet, be tobacco-free, and have their comorbid conditions under control.

If the scar is due to improper technique, there are functional limitations or mal-aligned landmarks; then the patient should undergo surgical scar revision. Immature scars should not be candidates for surgical correction. Immature scars are red, itchy, sometimes painful scars that elevate above the skin. Physical exams should be performed every few months to determine maturity. Treatment for immature scars is best with adjunct therapy or lasers. Scars less than six weeks should receive adjunct treatment such as intralesional injections.

Mature scars can receive surgical treatment. The technique used is determined by the scar. Depressed scars respond best to fillers, especially autologous fat injections. Scars with minimal tissue loss can have treatment with elliptical excisions, z-plasty, and w-plasty. The option for scars with significant tissue loss is with skin grafting and flaps or serial excision using the techniques mentioned above.

Enhancing Healthcare Team Outcomes

All healthcare workers must be aware of the wound healing process. The complexity leads to multiple opportunities for chaos. Increased tension, ischemia, infection, poor nutrition, and tobacco use are among the factors that can lead to a suboptimal scar. Any injury to the reticular dermis can result in a scar. This is why the optimal approach to scar revision is with an interprofessional team, that includes physicians, surgeons, specialists, specialty-trained nurses, and when necessary, pharmacists, all collaborating as an interprofessional team to drive patient outcomes successfully. [Level V]

The nurse needs to be well aware of the procedure and complications and assist the surgeon during the scar revision procedure. Prior to the procedure, the nurse should assist with the preoperative preparation of the patient and making sure that the patient has stopped smoking for at least 30 days before the procedure. If there is any concern, then the nurse should report back to the surgeon. Often the nurse will need to monitor the vital signs of the patient preoperatively and during the procedure and should alert the surgeon if there are any changes in the vital signs. Post-operatively, the nurse must monitor for signs of bleeding or infection. Again, quickly informing the surgeon if there is a concern. If the patient is placed on prophylactic antibiotics, the pharmacist should make sure that the patient is not taking any medications that would interact and confirm the patient has no allergic reaction potential to the prescribed antibiotics and again reporting back to the clinician, if there is a concern. The best outcomes will be achieved if an interprofessional approach is employed throughout the performance of scar revision procedures. [Level V]

Nursing, Allied Health, and Interprofessional Team Interventions

• Alert the clinician if there any signs of infection or allergic reaction.
• Alert the clinician if there any signs of complications such as bleeding.

Nursing, Allied Health, and Interprofessional Team Monitoring

• Vital signs
• Signs and/or symptoms of wound infection
• Signs of bleeding