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Oral Maxillofacial Surg Clin N Am 17 (2005) 173 – 189

Secondary Procedures in Maxillofacial Dermatology
James M. Henderson, DDS, MDa,b,c,*, Bruce B. Horswell, DDS, MD, FACSa,b,c,d
Department of Surgery, West Virginia University School of Medicine-Charleston Campus, 3110 MacCorkle Avenue, Charleston, WV 25304, USA b Department of Oral and Maxillofacial Surgery, West Virginia University School of Dentistry, Morgantown, WV 26506, USA c Private Practice, Facial Surgery Center/FACES, 415 Morris Street, Suite 309 Charleston, WV 25302, USA d First Appalachian Craniofacial Deformity Specialists, 830 Pennsylvania Avenue, Suite 302, Charleston, WV 25302, USA
a

The main surgical goal in managing cutaneous carcinomas is eradication of the primary lesion with disease-free margins. Once this goal has been achieved, attention can be turned to reconstruction of the surgical defect with favorable esthetic results. Many of the factors that ultimately lead to an esthetically favorable outcome begin with a critical evaluation of the anatomic subunit involved, primary repair versus secondary repair, choice of flap used for reconstruction, tissue handling, and various host factors (ie, tobacco use, comorbid disease). Some of these factors have been discussed in previous articles and receive only cursory review in this article. This article focuses on secondary procedures used to improve the esthetic outcome of surgical resection. Management of flaps and scars is discussed, including the immediate postoperative period and the late (secondary) period. Various adjunctive measures are discussed, including scar revision, resurfacing procedures, silicone, dressings, and topical agents. Numerous treatments are available for the management of facial scars. Each modality can partially improve the outcome in various ways, and a combination of treatments is often required to achieve optimal results. It is imperative to evaluate patient expectations before excision of facial lesions and

throughout the postoperative period, because patients often have unrealistic expectations about the resolution of their wound and the eventual esthetic outcome. Physicians must emphasize that no therapeutic modality can bring about complete resolution of scarring and that multiple treatments and treatment modalities are often required [1].

Wound healing To fully appreciate the role of secondary procedures in improving the esthetic outcome of surgical resection, one first must have a basic understanding of wound healing. This understanding helps guide the reconstructive surgeon in choosing a mode of therapy best suited to achieve the desired result. Wound healing represents a complex series of events that until recently have been understood poorly. The complex interaction of events in wound healing has been divided into phases, including inflammation, migration, proliferation, and remodeling (contraction). Inflammation begins when a site is injured (surgical incision) and results in a cascade of events that involves vasoconstriction, platelet activation, and eventual clot formation [2 – 9]. Exaggeration of the inflammatory phase increases the concentration of various growth factors, including transforming growth factor beta, platelet-derived growth factor, interleukin-1, and insulin-like growth factor. Neutrophils predominate initially, followed by macrophages several days later. In the migratory phase, angiogenic factors and fibroblasts increase, while excess amounts

* Corresponding author. FACES/Facial Surgery Center, 830 Pennsylvania Avenue, Suite 302, Charleston, WV 25302. E-mail address: james.henderson@camc.org (J.M. Henderson).

1042-3699/05/$ – see front matter D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.coms.2005.02.006

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the more accelerated and predictable the healing process and the less susceptible a wound is to adverse microbial and local environmental influences. and genetic factors also may be altered during the phases of wound healing. Reducing or controlling smoking (particularly in the perioperative period). Mustoe et al [13] gathered international recommendations on prevention and management of abnormal scarring and provided evidence-based recommendations for treatment. or pigmentary changes. prospective studies and point out therapies based on small-scale reviews or anecdotal reports. and glycosaminoglycans [2 – 9. and existing dermatologic disease [14]. The consensus of this international group of experts emphasizes the primary role of silicone gel sheeting and intralesional corticosteroids in scar management. unless there are adverse functional concerns). improper tissue handling. including infection. epithelial architecture is stable. foreign body. including topical and systemic agents. water. which lead to a compromised esthetic result. poor nutritional status.10]. has more appendages. Various growth. Numerous host factors play a critical role in normal wound healing. Nutrition should be optimized to provide an intact immune system and the building blocks needed for normal healing. the authors attempt to highlight treatments supported by large-scale. with patients and their health in mind. With regard to scar management. Host and local factors Systemic health of the patient who undergoes surgery or dermatologic corrective measures has long been recognized as a key component in achieving a good result. Local host factors also play a key role in normal healing. fibronectin. Ultimately. because many studies are based on dermatologic wound healing in other body regions. prolonged healing by secondary intention.174 henderson & horswell of collagen and extracellular matrix are produced [8. evidence-based trials. oxygenation. and wound vascularity and is believed to be the result of myofibroblasts [8]. Numerous factors can affect the delicate balance of wound healing and lead to scar formation. The proliferative phase is characterized by an increase in collagen production and epithelial cell migration and regeneration. A review of the literature indicates that two or more comorbid systemic diseases significantly affect surgical outcome. however. any disruption of a specific component leads to an imbalance in the process that may lead to excessive wound contracture. few of these modalities have been supported by prospective studies with adequate control groups and long-term follow-up. and wound tension (traction) [11]. systemic toxins. the more one can anticipate problems—and possibly failure—in a compromised patient. and substance abuse [11.14. and may be affected adversely by some scar treatment modalities [1]. coexisting disease. Scar contracture and collagen reorganization are observed in the remodeling (late) phase of wound healing. The phases of wound healing seem to act in concert to various degrees. Vitamins A and C and ferrous iron are needed for normal collagen synthesis. Granulation tissue also becomes evident during this phase. Surgeons should consider options carefully for dermatologic revision or correction. improving nutritional status if malnourishment is suspected. contributing to an imbalance in the process and eventual scar formation. prospective. keloids. hormonal. macrophages. The more involved the planned procedure (ie. This is particularly relevant in oncologic patients who also may have undergone radiation treatment for their disease. immunologic. Throughout the remainder of this article. A wide and deep excision to bone or scar that necessitates local flap advancement in a smoker with poorly controlled diabetes may invite disaster and . and optimizing the general medical condition improve outcomes after surgery for even minor procedures [11]. hematoma. can be used inappropriately and disrupt the normal mechanism of wound healing. tissue hypoxia. numerous techniques and therapies have been advocated in the literature. any of the factors listed previously increase metabolic and cellular activity within the wound leading to an excessive deposition of tissue collagen. Many therapies have been shown to be effective in small-scale studies and anecdotal reports. Any of the agents typically used to improve healing. Care must be exercised when applying information from these studies and extrapolating it to the treatment of facial scars.15]. Collagen cross-linking and alignment characterize the mature wound. which is compounded by increasing age. although it never returns to its preinjured state [11]. The healthier a patient. Patient selection for a particular procedure is paramount (some patients may not be good candidates for revision surgery. hypertrophic scar formation. Facial skin is thinner.12]. deeper and more extensive flaps or grafts). Wound contraction is characterized by a decrease in fibroblasts. and it is based on largescale. Reduced levels of zinc lead to decreased protein production and delayed epithelialization. Numerous studies have shown that scarring is minimized when a patient’s health status has been optimized. As a result. including nutrition.

Even minimal sun exposure within the first 60 days of repair can lead to hyperpigmentation. Regions of the head and neck that have received more than 50 Gy generally have compromised cutaneous characteristics of basilar fibrosis. Many patients who have undergone resection of skin malignancies have had an extensive sun exposure history and may continue to work outdoors or engage in outdoor recreational activities. This situation must be discussed carefully with patients before treatment. and. especially the epidermis. Darkly pigmented individuals (Fitzpatrick IV. These conditions lead to delayed healing and an increased risk of wound complications that may contribute to a poor esthetic outcome [15]. with thick sebaceous skin being more prone to milia formation.or hyperpigmentation. vasularity. Persons with darker skin have a tendency to unpredictable dyschromia caused by melanocytic dysfunction that results in either hypo. Fig. For patients who are otherwise healthy and have received less than 50 Gy.19]. The more extensive the resurfacing procedure. Preoperative adjuncts include resurfacing procedures (eg. successful secondary procedures can be performed in an effort to reduce scarring. chemical. It is important to briefly review several factors involved in the surgical planning and resection of skin lesions and scars that have a profound impact on the eventual esthetic result. particularly vitamins C and E. dermal plexus obliteration. or dermabrasion techniques) that improve skin metabolism. eczema. surface exfoliating adjuncts (eg. A broad-brimmed hat and sunblock should be recommended to every patient to prevent these changes [14]. A patient with active acne lesions in the midst of a wound have worse wound healing and increased scarring (Fig. rosacea. or other inflammatory dermatoses should have secondary revision surgery deferred until the condition Optimizing a patient’s skin condition is paramount for revision surgery success. and collagen or elastin components in the dermis [20]. the longer the healing period until final secondary procedures can be performed. in severe cases. Surgical management The most critical time to prevent scar formation is at the time of injury or surgical resection. atrophy of the subcutaneous and surface epithelium. Preoperative mechanical or chemical resurfacing procedures may need to be planned before more extensive dermatologic surgery to optimize local skin conditions.secondary procedures in maxillofacial dermatology 175 more problems. 1. it is critical to review any history of radiation therapy. V. Active acne is usually treated with a combination of antibiotics. is controlled or in remission [18. Tissue type is also critical. benzoyl peroxide). and some loss of dermal appendages. Skin preparation Dermatologic conditions Inherent ethnic and skin characteristics affect results. retinoic acid derivatives [19]. Judicious use of perioperative steroids and 4% hydroquinone may assist in modulating abnormal melanocytic responses [17]. laser. Some clinicians believe that preoperative administration of multivitamins. orderliness of skin cell maturation. and often less desirable results (Fig. Patients with active acne. Generally. acneiform eruption. Surgical defects located in areas of function may be prone to widened and deformed scars for similar reasons. 1) [16]. one or two weeks before surgery enhances healing and . the skin should be prepared approximately 4 weeks before revision surgery to allow some maturation of the skin layers. In the postablative patient. Not only can continued sun exposure lead to further solar damage to the skin and risk of malignancy but it also can lead to significant pigmentary changes in postsurgical scars [16]. 2). and VI) are prone to prolonged. unpredictable. and prolonged inflammation [16 – 19]. Sun exposure is another host factor that is often overlooked when discussing postoperative secondary procedures and the prevention of scarring. salicylic and azeleic acids. Hyperpigmentation of scars in Fitzpatrick V individual. Scars located over convex surfaces can be difficult to revise because of unfavorable forces and high surface tension.

several factors must be considered before planning reexcision of scar tissue or lesions. scar revision can be done too early [24]. increased scarring [1. Factors such as harassment and social alienation by other children and parental anxieties also may lead to earlier intervention [24].15. hypertrophied scars may be better suited to intralesional excision or resurfacing [24. although this has not been proven [21. has similar color and texture to the surrounding tissues. RSTLs of the facial region with lines of maximal extensibility that run perpendicular. and planning for surgery may take place earlier. deferment for 1 or 2 years may be prudent [27]. For wounds with poor scar orientation or wound alignment.29].176 henderson & horswell need to be revised much sooner than anticipated. improves surgical results. neck. These scars may Fig. is oriented within or along resting skin tension lines (RSTLs). These flaps are discussed later. Wounds in the inflammatory and proliferative phases of healing are more prone to exaggerated and prolonged inflammation and.22]. Children heal quickly but with longer periods of vascularity and more collagen depot. width. Scar location It is important to understand that the goal of scar modification surgery is not to eliminate scars but to hide them and make them as inconspicuous as possible [15. scar modification surgery should be deferred 6 to 12 months. Limberg’s excellent treatise on scar revision is foundational to our understanding and practice in dermatologic surgery [23]. 3.25]. may need earlier intervention. consequently. No amount of time improves a scar or defect that has resulted in tissue mismatch in the vermilion border or eyelid margins or in a disfiguring avulsion defect with foreign body inflammation. and oral cavity. however. Timing It is never too late to perform a scar revision. 2. Scars ideally should lie within the relaxed skin tension lines (Fig. such as the eyelid. He designed many flaps based on mathematical configurations. Scars in regions that restrict function. Active acne and increased inflammation in scars. . and may have a geometric design that is less detectable to the naked eye [12. One also must take into account how the scar appears and may be accentuated during animation. As a general rule. Wide. Adults typically have less wound healing vigor. Planning for scar or defect revision with local flaps should incorporate this objective so that healing proceeds without excessive Fig.25]. and location.24. This is the time when mature collagen makes up most of the wound bed. 3). however. surgery can be considered earlier [26]. Incorporation and deformation of normal surrounding tissue must be minimized as much as possible. The practicality of this concept is limited by scar maturity. Scar revision Several types of excisional designs are available to the surgeon.15.28]. This time period results in some improvement in appearance of the scar and diminution of scar size and bulk. which are useful for reconstructing defects with local tissue. A scar with favorable characteristics is flat (level with surrounding tissue).

are at high risk for widened scar formation [24.31]. Dosage (mg) 20 40 80 Adapted from Chowdri NA. Mattoo MM. Keloids and hypertrophic scars: results with intra-operative and serial postoperative corticosteroid injection therapy. Preoperative triamcinolone injection two or three times before planned excision helps prepare Fig. Tissue loss connotes increased skin tension during primary and secondary closure.secondary procedures in maxillofacial dermatology 177 tension [28]. Triamcinolone injection of keloid before revision surgery. particularly over convex surfaces [30]. Typically. Scar morphology Scars that are raised and high profile are more difficult to camouflage than depressed scars hidden in RSTLs or under anatomic borders (eg.31]. and use of adjunctive preoperative agents is important before revision surgery (Table 1) [29]. with the expectation that some amount of keloid scarring will recur. which can be achieved through Z-plasties of varying lengths. Some surgeons culture the tissue to confirm reduced bacterial load (<105 organisms/ gram of tissue) before repair [11]. keloids) Patients with a history of keloid formation should be approached with caution. Aust N Z J Surg 1999. 4.15. 7). Generally. Table 1 Dosage of Kenalog (triamcinalone acetonide) for adults and children Adults Lesion size (cm2) 1–2 2–6 6 – 10 >10 Children Age (y) 1–2 3–5 6 – 10 Dosage (mg) 20 – 40 40 – 80 80 – 100 100 – 120 Simple excision Fusiform and Z-plasty techniques Unsightly scars can be re-excised with a fusiform or geometric design (Fig. Normal skin texture is not obtained with re-epithelialization. and the resultant dermis is characteristically thin and atrophic [24].29]. accurate wound alignment. 4). evacuation of blood from the wound. and careful suture placement reduce inflammation and subsequent scarring [8. honest discussion with patients before surgery is mandatory. Fig. 6).9. the ala or lower lip) [30. A frank. Wound healing history (hypertrophic scars. and angles. such as skin preparation. . resurfacing. and postoperative modalities. Nature of injury or procedure Areas of tissue loss. Scars that cross RSTLs typically widen and become hypertrophic.69:656. 5 (an algorithm for dermatologic secondary procedures) represents a decision-making tree on which the surgeon can add or modify adjunctive treatments.24. such as those seen after Mohs’ surgery or excision of facial skin lesions. Darzi MA. Time usually does not improve a keloid. the less the gain in length of repair and reorientation of the scar [31. fusiform excision is performed for smaller scars or lesions that lie parallel to the RSTLs. Meticulous handling of the tissues. number. which places the repair in a favorable and esthetic position after healing (Fig. a keloid for more ordered and controlled healing (Fig. and patients must be informed of possible protracted treatment. Scars that run across RSTLs need some reorientation. More staged revision is required for the former type of scar. Selection of excisional and reconstructive techniques follows a simple to more complex design algorithm.32]. Earlier reorientation of the scar or placement of a free graft (not as ideal as local tissue) to avoid tension may be indicated. the more acute the angle of the limb. Avulsive wounds and heavily contaminated wounds require judicious management to preserve viability and reduce bacterial load to prepare the bed for reconstruction.

Scar modification: techniques for revision and camouflage. Atlas Oral Maxillofac Surg Clin North Am 1998. 5. (From Horswell BB.) . Algorithm for decision making in dermatologic revision surgery.6:55 – 72.178 henderson & horswell Fig. with permission.

or forehead can be improved through incorporating multiple segmental Z-plasties or a ‘‘W-plasty’’ configuration (Fig. 8 illustrates a Z-plasty design for a scar band in the cheek that runs perpendicular to the RSTLs. nasal tip. (Image n Bill Winn. with permission. Multiple Z-plasties also may be constructed to lengthen scar and decrease tension across the revised tissue plane [28. (A ) Fusiform. round. 7. undermining of the triangle bases must be performed to effect ease in transposition. Diagram of closed scar excisions of Fig. 6. 9) [32. or squared ends to help break up the scar profile. yet judicious. (D ) Z-plasty.secondary procedures in maxillofacial dermatology 179 Fig. upper jaw line. which results in a softer. 6. It correctly reorients the incision and limbs in the direction of the RSTL and allows the retracted lip and cheek to displace inferiorly. For U-shaped scars on a convex surface. Because of a broader tip. Often. Vigorous. The S-plasty is indicated in higher profile or convex surfaces. the tips become edematous and may heal with some element of hypertrophy. Diagram of various facial scar excisions. there is less distal ischemia and necrosis than in Z-plasty [33]. (Image n Bill Winn. (E ) Elliptical and Z-plasty combined. Stippled areas of (E ) and (F ) represent simultaneous dermabrasion. (F ) geometric design.33].34].32. the inner arch of W-plasties Fig.) areas.) . with permission. (B ) H-flap. less obvious linear arrangement. Geometric designs A long linear scar over the cheek. A variant of Z-plasty is an S-plasty design. The tips can be designed with pointed. and chin Fig. (C ) W-plasty. which can be dermabraded for a final smooth appearance after initial healing. This design favorably realigns the scar that runs across RSTLs into one that is more parallel or more easily hidden. as in over-the-cheek.

9. Larger local flaps may need to be designed that can move tissue from the Fig. (A ) Preoperative. 8. 10) [35]. Flaps After excision of scar or a lesion. should have less length and angle (approximately 45°) than the outer W-plasties (approximately 60°).180 henderson & horswell Fig. Release of retracted lip and cheek with Z-plasty technique. so that the advanced tissue runs radially in direction with and easily incorporate into the outer arc of tissue (Fig. the defect may be too large for simple closure. X indicates subcutaneous scar band. . (A ) Preoperative. (B ) Intraoperative Z-plasty incision. (B ) Postoperative. (C ) Postoperative closure of Z-plasty with inferior rotation of lip. W-plasty revision of cheek and lip scar followed by postoperative dermabrasion.

37]. Surgeons should remember that greatest tension is at the leading edge of the flap. These flaps have various geometric designs. 11) [37]. Rotation flaps may be used to reconstruct large defects or lesions. 11. of which one is more ideal for tissue transfer and final limb orientation (Fig. where the incision limbs can align with anatomic margins or RSTLs. care should be taken to avoid overexpansion and tissue transfer. expander instrumenta- Fig. 12). brows. the less tissue distortion and vascular compromise will occur [38]. and allows tissue to rotate easily as the flap extends from lax tissue (perpendicular to the RSTLs). Temporary distortion of cosmetic units may occur. The less the lobed flap must rotate (less arc of rotation). secure. Final closure should provide a limb that aligns with the RSTLs. Four possible rhomboid flaps for a nasal lesion. Semi-rigid (reinforced) expander bases can be used in areas of underlying soft tissue (eg. Tissue expansion At times. one (X ) of which is ideal because of final position of the incisional limbs and direction of tissue transfer. neck) to ensure overlying skin expansion without deeper structure distortion. (A ) W-plasty excision (white lines indicate radial advancement of arc). large avulsion or resection defects may require reconstruction through tissue recruitment via expansion. surrounding region into the defect. dehiscence. cheeks. Flaps based on the infratrochlear (glabellar). and superior labial (nasolabial) vascular branches are useful for reconstructing nasal region defects (Fig. Larger cheek or lower eyelid defects can be closed with a random-pattern cheek flap that is rotated anteriorly (Fig. most notably the rhomboid flap. Lobed flaps are useful for smaller defects or lesions in the nasal region. (B ) Closure of W-plasty excision. and lips [40]. U-shaped W-plasty excision of scar. 14) [39]. Flaps also can be raised on a vascular pedicle (axial-pattern) and rotated to a defect. permanent subcuticular sutures may be helpful in this area [38]. which may have several lobed components. Every defect has four possible rhomboid flaps. it should be close enough to afford local tissue matching and ease of transfer. Rhomboid flaps are the workhorse facial flaps for reconstructing defects not amenable to local closure [36. The area to be reconstructed must be mature. and some cheek and neck defects (Fig. . 10. A variation of rhomboid flaps is the lobed flap. This technique is particularly useful for scalp. They are particularly useful over the cheek and in nasal sidewalls. The tissue reservoir to be expanded also should be uninvolved and distant enough to allow generous expansion without defect distortion. which move the ears. however. Tissue expansion requires good knowledge of tissue mechanics.secondary procedures in maxillofacial dermatology 181 Fig. supratrochlear (forehead). 13). with no recent incisions. forehead. or inflammation.

Experience is the key to success. Recent evidence from the literature suggests that hydration is the most important external factor responsible for optimal wound healing and an esthetically pleasing scar [7. and perforated plastic films [14. Scab formation should be prevented.41].27]. tion. allow rapid epithelialization. and blood products that retard healing through inhibition of epithelial migration. fibrosis. Appropriate dressings include polyurethane films. and skill with placement. whereas multidirectional tension or intermittent tension leads to hypertrophic scarring [12. Excess tension along a single axis may result in a widened or stretched scar. (C ) Postoperative view. Antibiotic ointments may serve as effective topical dressings during the exudative postoperative period. and development of resistant organisms are all concerns associated with prolonged antibiotic ointment use.12. By 3 weeks. which can lead to exaggerated scarring.42]. Wound support with microporous tape is also critical in the immediate postsurgical phase.11. however. Immediate postoperative wound management The incidence of hypertrophic scarring after surgery is approximately 40% to 70%. Occlusive dressings prevent scab formation. however. fibrin. With open wounds. The rate is considerably higher in burn injuries [9]. cleaning the wound daily to remove the film and reapplying the ointment are imperative.182 henderson & horswell Fig. which produce a better cosmetic result [11].34. wounds have attained only 20% of their final strength. an occlusive dressing is recommended in the immediate postoperative phase. Scabs consist of necrotic cells. allergy. (B ) Clinical photo of advanced cheek flap.41]. Interventions too early in the healing process can weaken the closure and lead to an unaesthetic scar [12. . Advancement cheek flap (rotational) into infraorbital defect. Topical antibiotics are usually not necessary beyond day 5 for closed facial wounds. Scar support. Neomycin is particularly prone to cause skin sensitivity. 12. The vector of tension is also important. hydrogels. is critical during this period to prevent increased tension across the scar. and infection. and reduce wound pain. Dermatitis. (A ) Diagram of cheek advancement flap to repair infraorbital defect. Ointments with multiple antibiotics are available to broaden the spectrum of coverage [14].

secondary procedures in maxillofacial dermatology 183 Fig. heat. and increased scarring [11]. (B ) After expansion of tissue fields lateral to defect. bone. At least 2 weeks should be allowed for healing after Fig. breakdown. (A ) Large scar and forehead defect. mucosa) postradiation defect of the nasal-canthal region. Note: care must be taken not to encroach on the brow region or overexpand the scar defect. 13. Tissue expanders for scar excision and scalp reconstruction. . 14. full-thickness (skin. particularly during early wound healing. and other irritants should be care- ful to protect surgical sites or defer surgery until such time that initial healing can be guaranteed. smoke. Forehead and nasolabial flaps for reconstruction of a large. (B ) The nasolabial flap is de-epithelialized and advanced superiorly to line nasal cavity and the forehead flap is turned down over it (top right ). (C ) Final result 6 months after division of forehead flap. infection. It is well known that potentially harmful biofilms colonize chronically exposed or challenged skin and render the revised wound more susceptible to inflammation. Patients whose employment or hobbies include exposure to potential biohazards. dust. (A ) Full-thickness defect of nasal-canthal area with forehead (F ) and nasolabial (N ) flaps outlined for incision. It is important to remove or reduce excessive wetting and drying and protect the skin in extreme climatic conditions. The skin is exquisitely sensitive to adverse environmental influences.

hydroquinone (4% – 8%). Antiviral agents should be administered preoperatively and during the process of re-epithelialization (7 – 10 days). laser therapy) Dermabrasion may play a role in the management of postablative scarring and treatment of certain benign lesions. lentigines. however. One should defer greater depth peels until the skin has matured. Keloids. Several modalities are available to for surgeons to use in conjunction with. V. and improvement with surgery. The most common complication of dermabrasion is pigmentary alteration [16]. Typical treatment regimens involve fluences of 6. These flares are treated the same as any other acne flare and usually do not lead to new acne scars. epidermal nevi. Postinflammatory hyperpigmentation is the most common pigmentary alteration encountered after dermabrasion. Potential complications of dermabrasion include milia formation. and sun avoidance [17. and molluscum. Prolonged adjunctive therapy for keloid scar revision includes periodic steroid injections—if not performed preoperatively— and pressure therapy up to 1 year after revision.20]. and pruritis [10. and VI skin [41]. Patients with breakthrough viral infections or a predisposition to herpetic outbreaks should be treated with a zoster dose of antiviral medication. and up to 6 weeks should be allowed after advanced procedures that involve regional flaps. have a familial tendency. including actinic and seborrheic keratoses. Clinical characteristics of hypertrophic scars include confinement to original wound. After initial healing (2 – 3 weeks). Preoperative management may include staged skin preparation with glycolic acid peels or microdermabrasion. acne flares. angiofibromas. height. but one must be careful not to overinflame the skin just before surgery. with treatments repeated at 6. trichoepitheliomas.5 to 7. Late postoperative wound management The choice of treatment modality for the management of existing scars depends on a careful evaluation of scar characteristics.43]. It is important to assess how patients have healed previously and whether they have a propensity toward hypertrophic scar production or the development of keloids. the revised scar and surrounding tissues can be re-treated with peels or microdermabrasion to enhance epithelial leveling. and contact dermatitis. except in patients with a history of rosacea or impetigo.34. pigmentary changes. changes begin 3 to 4 weeks after surgery and can be reversed with topical steroids. viral and bacterial infections. Distinguishing between hypertrophic scars and keloid formation is critical in planning intervention and choosing an appropriate therapeutic modality. Late or persistent erythema heralds the onset of scar formation and must be aggressively diagnosed and managed.41].42]. milia.to 8-week intervals until the desired result is achieved or no further improvement is noted. In a retrospective review by . scar revision procedures and are discussed in the following section. and VI. or tissue expansion in susceptible patients whose activities or work may compromise healing. syringomas. have an onset of months to years after injury. secondary intention healing can equal or surpass surgical reconstruction. One area that shows promise for using laser resurfacing immediately after Mohs’ surgery is the nose. The flashlamp-pumped pulse-dye laser was developed as a means to obliterate underlying vasculature believed to play a role in blood-borne tissue factors and growth factors that stimulate fibroblast activity [41. Acne flares are temporary and may persist for 6 to 12 weeks. but intralesional steroids are used once any papular quality or induration develops [43]. Resurfacing (dermabrasion. 15) [43]. grafts. a surgeon can expect less surface irritation. Scars treated with the pulse-dye laser have shown a decrease in erythema and improved scar texture. or after. onset within 3 months of injury. Permanent hypopigmentation can occur in 10% to 20% of patients and is more common in persons with Fitzpatrick skin types IV. cysts. and healing properties of patients. For surgical defects of concave nasal surfaces. spontaneous regression. The effects are not as effective in patients with Fitzpatrick types IV. By relying on subcutaneous sutures and little surface sutures for tissue support and approximation. persist over time. however. Typically. Prophylactic antibiotics are not typically warranted. but one must ensure that no excessive inflammation or dehiscence is present.5 J/cm2 using a spot size of 5 mm. and may worsen with surgery [8. age of the scar. Dermabrasion can be performed safely with simultaneous scar revision procedures (Fig. V. Most viral infections can be prevented with proper prophylaxis. Glycolic acid peels are a predictable way to prepare skin for revision procedures.42].184 henderson & horswell simple or local skin flap surgery. Laser resurfacing of new surgical scars 6 to 8 weeks postoperatively produces results similar to those achieved with dermabrasion [1. extend beyond the original wound margins. The predictability of secondary intention healing of defects on convex nasal surfaces is not reliable. Topical steroids may be useful during the initial phase.

hyperpigmented scars. a low concentration is used (Kenalog. granulomas. Many of these agents are vitamin based or contain herbal extracts. Topical agents Many topical agents are available for use in the management of scars. (C ) Postoperative view at 6 months. inhibition of collagen and extracellular matrix protein synthesis. After scar maturation and in persons with a predisposition to excessive scarring. he begins with a dose of 3 mg/mL and increases this to 10 mg/mL. For the treatment of facial lesions.41].15. Grossman [1] recommends starting with lower concentrations and slowly increasing the dose over several sessions. higher concentrations are used (Kenalog.9. For early preexcisional treatment and early postsurgical treatment. Ammirati et al [44]. and development of telangiectasias [1. decreased cytokine production. 40 mg/mL). (A ) Preoperative view of multiple uneven. (B ) Clinical photo of planned areas for excision and dermabrasion. Simultaneous scar revision and dermabrasion. Complications of steroid administration include skin atrophy. decreased fibroblast proliferation. Mechanisms of action include reduced angiogenesis.9. pigmentary changes. To reduce the risk of these complications.41]. Steroids can be used at various times during therapy.secondary procedures in maxillofacial dermatology 185 Fig.10. and disruption of fibrosis [1. 74 patients underwent immediate postoperative laser resurfacing of convex nasal surfaces after Mohs’ surgery using a scanned carbon dioxide or long-pulsed Er:YAG laser. 15. All of the patients in their series were satisfied with the result. Treatment is usually administered with multiple injections given 4 to 6 weeks apart (Table 1) [1.41. 10– 20 mg/mL). Topical .42]. and an independent panel of nine physicians who reviewed postoperative photographs of 30 patients in the series deemed the results acceptable or excellent. Medications Steroids Steroid preparations commonly used in the management of hypertrophic scars and keloids include triamcinolone acetonide (Kenalog) and triamcinolone diacetate (Aristocort).

Topical vitamin E also has been observed to have mild deleterious effects on the esthetic outcome of some wounds if administered too early in the healing process by reducing tensile strength of the wound [12. infection.45].17. which results in decreased capillary hyperemia. which is incorporated into DNA and inhibits DNA synthesis. Contraindications to the use of 5-fluorouracil include existing bone marrow depression.42]. The mechanism of action seems to be related to reduction of oxygen radicals. Other agents Calcium channel blockers may play a role in the management of existing hypertrophic scars by inducing collagenase production. cellular membranes. 16. Cells that synthesize increased amounts of DNA. with frequent injections to maximize scar tissue resolution.22]. are targeted.186 henderson & horswell vitamin E has been advocated by medical professionals and lay people alike for the treatment of scars.46].12. thereafter they should be continued on a weaning basis over the next 3 months until maturation is complete. Topical use of vitamin E later in the wound healing process (4 – 6 weeks) may contribute to a flatter scar but also may result in a stretched and weakened scar [12]. Alternatively. Some authors recommend combining 5-fluorouracil with triamcinalone. and K also have been used in the perioperative management of dermatologic wounds [21. collagen deposition. Despite having widespread anecdotal support. Hydration has been shown to inhibit the production of collagen and glycosaminoglycans by fibroblasts [41]. Silicone gel sheets to reduce keloid tendencies in scars. proteins. and lactation [1. and lipids [41. their use is not supported Fig. a double-blind study by Bauman and Spencer [45] using topical vitamin E showed no improvement in the cosmetic appearance of surgical scars [45]. 4% to 5% verapamil in a cream base can be applied topically. Their antioxidant properties are believed to soften and flatten scars. and hypertrophic scar formation [1. Bleomycin is available in 15-U vials. One advantage of the use of antimitotic agents is that steroid atrophy can be avoided [1]. Use should begin when the incision has epithelialized fully. Silicone gel sheets should be worn 12 to 24 hours per day for at least a month. 1 mg/mL. such as fibroblasts.41]. Antimetabolites Another scar treatment that shows promise is intralesional injection of bleomycin and 5-fluorouracil [41]. Wound healing amid actinic conditions has been shown to be improved with limited use of 5-fluorouracil and glycolic acid peels in the perioperative period. 16) [13]. Topical administration of vitamin E has shown mixed results in the literature [12.9. Systemic use of vitamin A has shown a modest improvement in the appearance of some hypertrophic scars and keloids [41]. which leads to decreased proliferation. Systemic use of vitamin E seems to slow early wound healing by downregulating the inflammatory response and may lead to decreased tensile strength. . and prevent capillary leakage. Silicone gels have been shown to be effective in reducing scar size and erythema through steady-state oxygen and hydration maintenance. Silicone ointments may be useful. C. which leads to scar tissue degradation. controlled trials and a meta study of 27 trials have demonstrated that silicone gel sheeting is a safe and effective therapeutic technique in the prevention and management of hypertrophic scars and keloids (Fig.45]. particularly in the head and neck region. A single application in the first few days after wound closure seems to be effective. 5-fluorouracil is converted into its active substrate. however. and 5-fluorouracil is available in 50-mg/mL vials. pregnancy. Silicone gel seems to function like the stratum corneum by reducing water loss and restoring homeostasis to the scar. Topical vitamins A. decrease pruritus. which alter collagen and glycosaminoglycan production and decrease healing by damaging DNA. Silicone gel sheeting Numerous randomized. Verapamil or other calcium channel blockers can be injected into the lesions in a manner similar to that for corticosteroids. 22. This application often can be alternated with steroid injections to achieve a reasonable response [9].

camouflage therapy may represent a viable option for improved cosmesis. with various studies showing degradation after 6 to 9 months. Sites for fat harvest include the abdomen.41. The amount of fat needed for transplantation is approximately 3 cm3/cm of scar length [49]. Fig. pressure of 24 to 30 mm Hg must be maintained for several hours per day over a period of 6 to 12 months [10. Alloderm can be used to elevate depressed scars and prevent recurrence of the contracted scar tissue bands. In general.13. Water-based cosmetics can be applied as soon as sutures are removed (5 – 7 days) or after re-epithelialization is complete (10 – 14 days) [15. When used. such as HIV. The lower layer of fat is used for transplantation. The beneficial effects of compression seem to be related to local tissue hypoxia. Allogeneic collagen is derived from donated human skin from donors who have been screened carefully for infectious diseases.10. Other adverse reactions to bovine collagen injection include bruising. providing a psychological lift to a patient. decreased edema.13. In addition to being used in an injectable form.50]. and buttocks.secondary procedures in maxillofacial dermatology 187 by controlled trials. decreased protein deposition. Pressure therapy Pressure therapy is often used as first-line therapy in the management and prevention of scarring and has been used since the 1970s. Three percent to 3. Delicate tissue handling is paramount to successful transfer of viable cells.14]. Several forms are available. Longevity of 6 months to years has been documented when cells are atraumatically harvested and placed [41]. The major drawback to using bovine collagen injections is allergy. Fascia similarly can be used to plump and fill depressed scars (Fig.5% of the population have a localized hypersensitivity reaction. and syphilis [41]. hepatitis B. low-pressure harvesting and injecting devices should be used to maintain cell integrity. and bacterial superinfection [1. Fat is collected and centrifuged at 3000 rpm for 5 minutes. The first material to become available for injection was bovine collagen. Cannulas 4 to 5 mm in diameter are used to transplant the autologous fat. Autologous fat and fascia also have been advocated for soft-tissue augmentation.41. After the scar is excised. Allogeneic collagen has intact collagen fibers. Camouflage also can be used as an interim measure to allow scars to mature or local/systemic factors to improve before definitive secondary procedures [50]. reduced scar blood flow. The endpoint of injection is when the depressed scar is obliterated and approximately 20% to 30% overcorrection is achieved. Fascia is easily harvested from the temporalis or fascia lata of the thigh and has no immune rejection phenomena. and a reduction in the population of mast cells. herpes reactivation. Collagen should not be injected into patients with a history of autoimmune diseases or patients with hypersensitivity to lidocaine [1]. Large-bore. silicone gels are typically applied two times per day after the removal of sutures [1. Subdermal placement of temporalis fascia to ‘‘plump’’ depressed scar at the commissure and cheek. Another form of camouflage therapy is placement of color by micropigmentation or cosmetic tattooing. These techniques are more successful in scars that are distensible and not excessively bound down [41]. which may affect fibroblast growth [10.12. The pigment . which give it greater longevity. 17). hepatitis C. Camouflage therapy can conceal postoperative bruising and erythema and can normalize the skin’s appearance. Camouflage therapy For patients who have local or systemic factors that contraindicate secondary procedures or for patients who do not wish to undergo any surgical revisions. Alloderm is cut to the shape of the defect and the wound edges are approximated and closed over the defect [48]. 17.42].47].42]. White scars can be improved by placing skin-colored pigment into the mature scar tissue. thighs. Soft-tissue augmentation Various materials can be used to augment atrophic and depressed scars.

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