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Scar formation is vital to the wound healing process. As surgeons, we spend much of our day creating wounds in the skin, and as a result, scarring is an inherent reality of surgical practice. Many patients may present with reconstructive challenges, resulting in scars that are cosmetically or functionally unsatisfactory to the patient, physician, or both. As such, a comprehensive understanding of scar revision and the various modalities by which scars may be managed is essential. While a plethora of techniques are available to improve both functional and cosmetic outcomes, this chapter focuses specifically on “cold steel” surgical scar revision techniques. With proper preoperative analysis of the scar and surrounding tissue, as well as skilled execution of an appropriately planned surgical revision, optimal results may be consistently attained.


Proper planning and attention to detail during the initial reconstruction may obviate the need for scar revision in many cases. This goal is attained by adhering to basic principles of surgical reconstruction, specifically avoiding unnecessary trauma to the surrounding tissues, successfully accessing available tissue reservoirs, careful planning of reconstruction to camouflage incision lines along junctions of cosmetic subunits and within relaxed skin tension lines (RSTL), and flawless suturing technique with meticulous reapproximation, eversion, and avoidance of epidermal strangulation. When successful, reconstructive surgeons may achieve their goal of creating a scar that is nearly imperceptible. This scar is level with and similar in texture and color to the surrounding skin, is under minimal tension, follows underlying structural contours, aligns with RSTL or the junctions of cosmetic subunits, and is not straight, but favorably broken up to scatter reflected light. These features minimize any negative functional or aesthetic impact of the scar.


As wound repair and new collagen formation proceed, the aforementioned criteria may be compromised, and result in an unsatisfactory scar. There are four main ways in which this may occur, conveniently dividing scars into the following etiologic categories: (1) traumatic; (2) poor design; (3) poor healing; and (4) disease-related.1 Table 21-1 summarizes scar characteristics, possible etiologies, and recommended approaches to revision.

TABLE 21-1Scar Abnormalities and Surgical Treatment Approaches1,5

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