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To treat functionally restrictive and disfiguring scars after burns and trauma, it is important to master specific procedural techniques. How to use these methods in combination to address a particular scar can be challenging. A review of common scenarios can help clarify how the therapeutic armamentarium can be deployed to alleviate the problems of individual patients.


In wound repair biology, there are 3 general, overlapping stages that occur from the initial insult to formation of a stable, mature scar: inflammation (from 0 to 48 hours), proliferation (day 2 to 10), and remodeling (week 2 to over a year; see Chap. 2). Despite the potentially undesirable aesthetic outcome, scar formation is the healthy end result of wound repair. Aberrant healing precipitates problem wounds, resulting in delayed wound healing (e.g., diabetic ulcer) or excessive healing (e.g., hypertrophic or keloid scar formation).1,2

Scars arising subsequent to trauma and burns represent an immense challenge clinically, each with a unique problem and solution. This in turn necessitates the treating clinician to be adaptable and possess considerable knowledge over a myriad of treatment strategies. At the foundation of optimal scarring is optimal wound healing. Wound healing may take one of many diverse avenues, with the target goal of reaching a stable repair with minimal scarring. The cornerstone for efficacious wound healing is meticulous surgical technique, which entails the principles of sterilization, debridement of nonviable tissue, close apposition of well-vascularized tissue (primary, graft, etc.), minimizing tension, and scrupulous wound care.

The following cases demonstrate these foundational principles, as they illustrate the dynamic clinical course of treatment for 4 different injuries:

  • Case 1 – Pediatric laceration from a dog

  • Case 2 – Large, recalcitrant keloid

  • Case 3 – Marjolin ulcer

  • Case 4 – Pediatric burn


A 3-year-old girl presented to the emergency room after sustaining a deep laceration spanning the entirety of her right cheek from her family’s pit bull terrier (Fig. 16-1). The injury was most concerning for the possibility of damage to the branches of her facial nerve. After irrigation, the surgeon first explored the facial nerve branches at the site of trauma and confidently determined that they were deep to the plane of injury and nerve repair was not indicated. Thereafter, the edges of the wound were debrided sharply and brought together for primary closure using a 6-0 fast-absorbing suture plane to preclude removal at 4 to 5 days (Fig. 16-2).

Figure 16-01

Initial presentation of dog bite in a 3-year-old girl.

Figure 16-02

Immediately postoperative: wound approximation using fast-absorbing suture plane.

Five days postoperation, the patient returned ...

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