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Practical.plastic.surgery

Practical.plastic.surgery

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03/31/2014

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Zol B. Kryger

Scar Definitions

An immature scar is red, slightly elevated and may be pruritic or tender. With
time, it will usually become mature.
A mature scar is flat and usually slightly paler, but occasionally darker than the

surrounding skin.

A linear hypertrophic scar is red, raised and confined to the original borders of
the incision. It usually occurs weeks after surgery and can continue to increase in
size over the next few months. It will often become less raised with time.
A widespread hypertrophic scar, such as a burn scar, is red, raised and confined
to the original borders of injury.
Minor keloids are raised and usually pruritic. They extend beyond the borders
of original injury, over the normal skin. They can develop up to a year post injury.
They do not regress spontaneously, and if excised, usually return.
Major keloids are over 5 mm in diameter. They can be painful, and often will
continue to spread over years. Keloids have a familial predilection. They are much
more common in blacks and Asians than in whites.

Pathogenesis

Hypertrophic scarring and keloid formation are the result of excess collagen ac-
cumulation in a healing wound. The collagen is largely Type III, the form found in
normal immature scars. Causes include excessive skin tension, wound infection,
delayed healing, abnormal fibroblast metabolism, and an array of hereditary abnor-
malities. The importance of excess tension cannot be overemphasized. Hypertrophic
scars tend to form in areas of high tension, such as the anterior chest and upper
back. All measures for reducing tension on a healing scar should be employed.
The molecular mechanisms for pathological scarring are under intense investiga-
tion. Many studies have shown that levels of various cytokines are elevated in hyper-
trophic scars and keloids. For example, the transforming growth factor-beta (TGF-β)
superfamily has been implicated in hypertrophic scarring. Other cytokines, such as
tumor necrosis factor and interleukin-1, show decreased levels in keloids. Research
is ongoing, and several active clinical trials are evaluating agents that inhibit or in-
crease key mediators in the process of excessive scarring.

Surgical Excision

Surgery alone is not recommended for keloids due to the very high rate of recur-
rence (50-100%). It should be combined with additional treatment modalities such
as steroid injection or silicone sheeting. For hypertrophic scars, excision alone may
be indicated if it is felt that the abnormal scarring was due to excessive tension or

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wound complications (e.g., infection or delayed healing). In such cases, excision
should be accompanied by a measure to decrease tension. Splinting of the incision is
most effectively accomplished by intradermal sutures left in place for 6 weeks to 6
months, depending on the degree of tension. Z-plasties and other techniques of
reorienting the direction of tension can be used as well.

Silicone Gel Sheeting

This modality has become standard of care for the treatment of hypertrophic
scars. It should be used as a first-line agent for linear hypertrophic scars. Numerous
randomized, double-blind studies have shown that it is efficacious for treating hy-
pertrophic scars and small keloids. The benefits of silicone sheeting have not been
demonstrated with other types of semi- or total occlusive dressings. Since this treat-
ment is painless, it is an excellent option for children or adults unwilling to tolerate
more painful options. For prophylaxis in those at risk for hypertrophic scarring,
treatment should begin a few days postoperatively. Silicone sheeting should be worn
a minimum of 12 hours a day, and preferably the entire day. It should be continued
for several weeks postoperatively.

Corticosteroid Injections

Years of clinical experience and many randomized, prospective trials have shown
that triamcinolone injected into the scar is efficacious at decreasing scarring. Re-
sponse rates range from 50-100%, with a recurrence rate of 10-50%. It should be
the first-line therapy for keloids and second-line for hypertrophic scars. In combina-
tion with other therapies such as surgery and cryotherapy, corticosteroid injections
can be even more effective. Side effects are common and include skin atrophy,
telengiectasias and pigment changes. The exact mechanism by which steroids di-
minish scarring is still largely unknown. What has been shown is that topical ste-
roids are not effective in reducing scarring.

Pressure Therapy

Compression is the first-line treatment for post-burn, widespread hypertrophic
scars. In order to be effective, pressure must be maintained between 24-30 mm Hg
for at least 6 months duration. The longer the treatment, the more efficacious pres-
sure therapy has been shown to be.

Steri-Strips®

Adhesive microporous paper tape applied to fresh incisions for several weeks
postoperatively is moderately useful in preventing hypertrophic scaring. The mecha-
nism is not entirely clear. It is likely a combination of occlusion and splinting of the
incision.

Radiation Therapy

Radiotherapy should be reserved for adults with keloids resistant to other treat-
ment modalities. Monotherapy is controversial, and most authors recommend us-
ing it following surgical excision. Response rates range from 10-90% for radiotherapy
alone, and in combination with surgery it is more likely to be effective. Recurrence
is very common, ranging from 50-100%.

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Hypertrophic Scars and Keloids

Cryotherapy

This modality has shown benefit in acne-induced scarring. It should not be used
for large scars. Side effects are common and include hypo- or hyperpigmentation,
skin atrophy and pain.

Laser Treatment

Various lasers have been used in an attempt to treat hypertrophic scars and keloids,
and the results have been largely disappointing. The flashlamp-pumped pulsed-dye
laser appears promising, but more studies are needed. In combination with other
modalities, such as corticosteroid injection, it has been shown to be effective. Its
primary role is in reducing scar erythema and flattening mildly atrophic and hyper-
trophic scars. At this point, it is largely an emerging technology.

Other Emerging Therapies

A number of chemotherapeutic agents have demonstrated efficacy in treating
hypertrophic scarring and keloids. These include intralesional injections of inter-
feron, 5-fluorouracil, and bleomycin, as well as topical administration with retinoic
acid. Other emerging novel treatments focus on interfering with collagen synthesis
and the cytokines involved in scarring, such as inhibitors of TGF-β.

Summary

Hypertrophic scars and keloids can be a formidable problem. Many approaches
have been tried, but the recurrence rate is high for most treatments, especially for
keloids. Surgical excision should be followed by an additional preventative measure,
such as silicone gel sheeting. Ongoing research is attempting to pinpoint the mecha-
nisms for these pathologic processes in hopes of uncovering more effective therapies.

Pearls and Pitfalls

The recommended treatment modality for the various types of pathologic scars
is summarized in Table 22.1.

Table 22.1.Recommended treatment modality for various types
of pathologic scars

Type of Scar

Recommended Management

Prophylaxis

Avoidance of infection and delayed healing; Steri-strips® for
occlusion; silicone sheeting

Immature

Follow closely and treat as a linear scar if it progresses;

hypertrophic scarpulsed-dye laser for redness
Linear

Silicone gel sheeting; pressure garments and intralesional
hypertrophic scarcorticosteroid if it fails. Surgical excision with silicone
sheeting if 1 year of conservative management fails

Widespread

Pressure garments and silicone gel sheeting; massage
hypertrophic scarand/or physical therapy can help
Minor keloids

Silicone sheeting combined with intralesional corticosteroids;
add surgical excision if these fail (use epidermis as a STSG);
add postoperative radiotherapy only for refractory cases

Major keloids

No consensus on treatment; radiation therapy or other
emerging modalities (e.g., 5-fluorouracil) should be attempted

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Practical Plastic Surgery

Suggested Reading

1.Chang P, Laubenthal KN, Lewis IInd RW et al. Prospective, randomized study of the
efficacy of pressure garment therapy in patients with burns. J Burn Care Rehabil 1995;
16:473.

2.Gold MH. A controlled clinical trial of topical silicone gel sheeting in the treatment of
hypertrophic scars and keloids. J Am Acad Dermatol 1994; 30:506.
3.Mustoe TA, Cooter RD, Gold MH et al. International clinical recommendations on
scar management. Plast Reconstr Surg 2002; 110:560.
4.Poston J. The use of silicone gel sheeting in the management of hypertrophic and
keloid scars. J Wound Care 2000; 9:10.
5.Rockwell WB, Cohen IK, Ehrlich HP. Keloids and hypertrophic scars: A comprehen-
sive review. Plast Reconstr Surg 1989; 84:827.
6.Tang YW. Intra- and postoperative steroid injections for keloids and hypertrophic scars.
Br J Plast Surg 1992; 45:371

Chapter 23

Practical Plastic Surgery, edited by Zol B. Kryger and Mark Sisco. ©2007 Landes Bioscience.

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