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Surgical scar revision is typically performed to blend, recontour, and/or reposition the scar. Appropriate tools, including the best-adapted suture and surgical instruments, should be available. Specific strategies may include dermabrasion, scar repositioning, single or multiple Z-plasty, W-plasty, fusiform or serial excision, and geometric broken line closure. Postoperative care is meticulous, with any bleeding and infection addressed promptly, and significant contour abnormalities corrected as soon as possible.
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HISTORY OF SCAR REVISION
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The origin of the word “scar” can be traced back to the Greek word “eskhara,” first used in English in the late fourteenth century. Surgical techniques commonly employed today to address unsightly scars were introduced in the medical literature in the early nineteenth century. In a review of the history of Z-plasty, Borges and Gibson1 credit William Horner with the first published description of Z-plasty in 1837, when he utilized this technique to correct a lower eyelid deformed by burn and subsequent contracture formation.2 Another early pioneer of Z-plasty was Charles Pierre Denonvilliers, who published several papers on its use, the first in 1854, when he utilized it in a patient in whom a large facial scar resulted in both ectropion and ipsilateral oral commissure distortion.3 Subsequently, Borges introduced the W-plasty for scar irregularization in 1959,4 and Webster described geometric broken line closure in 1977 as a potentially superior alternative for the same purpose.5
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INDICATIONS AND PATIENT SELECTION
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While it is often possible to camouflage or cover an unsightly scar on the trunk or extremities, scars on the face or neck are generally quite visible and may be extremely bothersome to patients. The presence of a facial scar often has a significant impact on a patient’s psychological and social well-being. As physicians, we have the ability to effect a substantial positive change for patients with facial scars, but careful patient selection and surgical planning are imperative.
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At the time of injury, the treating physician needs to promptly manage the wound but should take care to do so in a manner that optimizes the opportunity for future scar revision if necessary. Ensuring conservative debridement of only clearly devitalized tissue and avoidance of excision of any normal tissue are both important aspects of setting the patient up for success in future revision efforts. Some mild contour irregularities may ultimately help camouflage the scar. Use of sterile technique is imperative, and wound irrigation has been shown to decrease bacterial counts. Any foreign body material present should be meticulously removed prior to closure of the wound. In some cases, using optimal techniques at the time of injury may obviate the need for revision procedures in the future. After thorough cleaning, wound edges should be undermined and then closed in multiple layers to avoid excessive tension on the epidermis, which carries an increased risk of widened or hypertrophic scar. Following initial repair, ...