An Algorithm for Prevention of

Unsightly Facial Scars Considering the

Newest Research Insights : Plastic and
Reconstructive Surgery – Global Open
Current Issue

Previous Article
Next Article

Outline

Takeaways

INTRODUCTION

Patient Assessment

Planning of Incision Location

Kind of Incision

Wound Closure

Postoperative Scar Management

METHODS

DISCUSSION

Patient Assessment

Planning of Incision Location

Kind of Incision

Wound Closure

Postoperative Scar Management

CONCLUSIONS

REFERENCES

Images

Slideshow

Gallery

Export PowerPoint file

Download

PDF

EPUB

Cite
:
 Copy

Export to RIS

Export to EndNote

Share

Email

Facebook

Twitter

LinkedIn

Favorites

Permissions

More

Cite

Permissions

Image Gallery

Reconstructive: Original Article

An Algorithm for Prevention of Unsightly Facial

Scars Considering the Newest Research Insights
Feinendegen, Dominik L. Prof (UA) Dr. med*,†; Grubnik, Alexandra Dr. med‡;
Feinendegen, Sandra Y. MLitt§

Author Information

From the *Institute of Plastic, Reconstructive and Aesthetic Surgery, Zurich-Zollikon,

Switzerland
†Department of Surgery, National Medical University of Odessa, Odessa, Ukraine

‡Millpark Hospital, Benmore, South Africa

§Institute of Ethics, History and Theory of Medicine, LMU Munich, Munich, Germany.

Published online 7 November 2022.

Received for publication April 8, 2022; accepted August 31, 2022.

Disclosure:The authors have no financial interest to declare in relation to the content

of this article.

Dominik L. Feinendegen, Dr. med, Institute of Plastic, Reconstructive and Aesthetic

Surgery, Dufourstrasse 38, CH 8702 Zurich, Switzerland; and Department of Surgery,
:
 National Medical University of Odessa, Valikhovs`kiy ln 2, Odessa 65000, Ukraine, E-
mail: dr.feinendegen@feinendegen.ch

This is an open-access article distributed under the terms of the Creative Commons
Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is
permissible to download and share the work provided it is properly cited. The work cannot
be changed in any way or used commercially without permission from the journal.

Plastic and Reconstructive Surgery - Global Open: November 2022 -

Volume 10 - Issue 11 - p e4635
doi: 10.1097/GOX.0000000000004635
Open
SWITZERLAND

Metrics

Abstract
Background:

Unsightly scars after facial surgery might be a worry for patients and surgeons alike. To
prevent unfavorable scars after facial operations, it is inevitable for the surgeon to adhere
to different principles and to follow an algorithm: patient assessment, incision planning,
surgical technique, suture material, and postoperative scar management. A defined
knowledge about the pathophysiology of wound healing is required. The aim of this report
is to serve as a teaching purpose and to verify the well-known empirical practices in scar
prevention with the corresponding explanatory research. Based on these findings, the
suggestion of an appropriate algorithm for the best scar management will be elaborated.

Methods:

This article elucidates the basics of unsightly scar prevention and the concomitant
scientific proofs in detail by reviewing the literature and newest research published in
PubMed.

Results:

The preoperative, intraoperative, and postoperative guidelines for the achievement of

acceptable facial scars will be distinguished regarding the valid state of knowledge. Special
attention is drawn to the “flat incision technique” as the first surgical step. Based on the
newest research, an algorithm of the important preoperative, intraoperative, and
postoperative features to achieve scar improvement is presented.

Conclusions:
:
 To prevent unsightly facial scars, a well-defined algorithm must be followed. In summary,
three well-established, empirically proven measures are documented now by the
equivalent physiological scientific proof: (1) the flat incision technique, (2) the wound
closure with maximal tension reduction, and (3) the postoperative scar management with
further tension reduction and more moisturizing of the scar.

Takeaways

Question: How can we improve the outcome of facial scars?

Findings: With an extensive literature search, three well-established, empirically proven

measures are documented now by the equivalent physiological scientific proof: (1) the flat
incision technique; (2) The wound closure with maximal tension reduction; and (3) the
postoperative scar management with further tension reduction and more moisturizing of
the scar.

Meaning: The flat incision technique is recommended for all facial incisions. The
importance of wound closure with maximal tension reduction on the wound edges and the
postoperative wound management with the aim of further tension reduction and more
moisturizing of the scar is highlighted.

INTRODUCTION
Regardless of the indication, whether for reconstructive or aesthetic reasons, facial
12
surgery often leaves the patients with unsightly scars. , The prevention of unsightly facial
scars so far has been achieved by the knowledge of empirical data, but with the lack of
physiological scientific proof. The aim of this work is to present the newest physiological
scientific aspects and a complete overview of all features which might influence the final
outcome of the facial scar quality.

According to the basics of a Preferred Reporting Items for Systematic Reviews and Meta-
analysis (PRISMA) analysis‚ all aspects that might influence the final outcome of facial
scars are allegorized and step by step analyzed. These are‚ in detail, patient assessment,
planning of incision location, kind of incision, wound closure, and postoperative scar
management. Every detail is discussed by presenting the relevant literature.

Patient Assessment

First of all, there might be a genetic tendency of the skin to react in form of hypertrophic
34
scarring or even keloid formation after surgery. , For example, Asian or African people
56
are well known to be candidates and risk patients for bad scarring. , Furthermore,
medical conditions such as diabetes mellitus or metabolic diseases, nicotine abuse, and
the need of medications that bear a secondary risk for bad scarring may play an important
4
role in the scar quality. Additionally, patients’ compliance preoperatively and
postoperatively should not be underestimated.
:
 Planning of Incision Location

Before performing a facial surgery, the surgeon must be aware which location would be
7
the best for the placement of the skin incision.

Kind of Incision

Except for existing medical conditions which bear the risk of a diminished
microcirculation, like in smokers or diabetic patients, it is advisable to perform the skin
8
incision in the face with the flat incision technique (FIT). Herein, the scalpel is beveled
against the skin surface in an angle of about 20 degrees (Fig. 1).

Fig. 1.:
The “flat incision” with a 20-degree angle to the skin surface will enhance the
surface of the dermal layers in the wound more than factor 2 compared with
the standard incision (see the red-lined markings). More hair follicles can be
saved in the wound for the later regrowth.

Wound Closure

An anatomical and surgical correct wound closure is essential for the development of an
acceptable scar. Three requirements are inevitably necessary: (1) the closure of the wound
without marked tension on the upper dermal and epidermal layers, (2) the exact adaption
of the wound layers without any steps (Fig. 2), and (3) the use of appropriate suture
material.

Fig. 2.:
Suture technique in wound irregularity. Every irregularity along the epidermal
layers within the final wound closure should be avoided. The needle of the
suture has to grasp the inverted part of the wound edge deeper than the upper
laying part to compensate the irregularity. If ever possible, the sutures should
be placed subcuticular with the knot away from the surface.

Postoperative Scar Management

During the initial wound healing, it is mandatory to prohibit any kind of infection. After
completed wound healing, several procedures are useful as adjuncts: sun protection over 6
months; covering of the scar with a plaster for 3 to 6 weeks or even longer, depending on
7 8 37
the scar location and on the skin type; , , and alternative application of silicone gel or
2 5 9–12 38
sheets as long as the scar needs to fade. , , , Preventively, it might also be useful to
inject local effective corticosteroids in 3-to-4-time intervals of several weeks, especially in
6 12
patients with known risk for hypertrophic scarring or keloids. ,
:
 METHODS
A literature review of PubMed of the most significant risk factors of the relevant scar
pathophysiology and the latest published research-based evidence on existing scar
management options has been performed. Herein, the newest preoperative,
intraoperative, and postoperative guidelines for the achievement of acceptable facial scars
will be emphasized. Only prospective studies with adequate control groups and literature
with evidence-based recommendations have been taken under consideration. We acquired
our algorithm for optimization of facial scars according to the basics of a PRISMA
analysis.

All the aspects that might influence the final outcome of facial scars are allegorized and
step by step analyzed. These are‚ in detail, patient assessment, planning of incision
location, kind of incision, wound closure, and postoperative scar management. Every
detail is discussed by presenting the relevant literature. We found appropriate literature
from the following time intervals: 1972–1977, 2; 1978–1983, 0; 1984–1989, 2; 1990–1995,
4; 1996–2001, 5; 2002–2007, 6; 2008–2013, 10; 2014–2021, 20.

DISCUSSION
All skin damage that involves the dermal layers leads as a natural healing process to the
formation of a scar. Hence, any kind of surgery in the face might bear the risk for the
development of unsightly scars. Figures 3 and 4 present histological specimens of
unsightly scars with inversion of the epidermal and dermal wound layers.

Fig. 3.:
Representative histology of an unsightly surgical scar with severe epidermal
inversion and wide dermal scarring.

Fig. 4.:
Histology specimens of a 54-year-old female patient 6 months after facelift
using a vertical incision (A) and FIT (B). Notice the epidermal inversion and
wide dermal scarring within the vertical skin incision (A) compared with the
FIT (B) with no epidermal inversion, showing a reduced scar zone, less
inflammatory reaction, less macrophages, less foreign body reaction, and more
hair follicles.

The risk for the development of unpleasant scars depends on multiple patient- and
surgeon-related circumstances.

Patient Assessment

The patient-related factors depend on individual genetics and medical and behavioral
patterns alike. Bearing these factors in mind, several pre-emptive procedures are available
:
 9–12
to prevent bad scarring. Pre-existing and innate conditions with medical risk factors
such as first-grade diabetes mellitus, nicotine abuse, or dependence on medication which
may lead to insufficient or prolonged wound healing can be improved preoperatively.

Furthermore, patient compliance preoperatively and postoperatively should not be

13
underestimated. For example, if a patient is asking for an aesthetic surgical intervention
but seems to be without compliance and lacks the understanding of the proposed
procedure or has self-destructive psychological problems, there might be some likelihood
that the preoperative and postoperative required behavior pattern will not be followed. It
might be worthwhile to include more intensive explanations and preoperative education
14
of the patient.

Planning of Incision Location

The next step in scar prevention adheres to the ideal planning of the skin incision on the
7–
face. If ever possible, the incision should be placed along the Langer’s skin tension lines.
9
If there is the choice, it is furthermore desirable to place the incision in between two
16–18
aesthetic units, along or into the hairline, which makes the final scar even more
inconspicuous.

Kind of Incision

The kind of incision angle also can make a big step forward to finally achieve an
17
inconspicuous scar. In 1997, Camirand et al presented a technique where the scalpel was
beveled with a 45-degree angle to the skin surface into the hairline border when
performing facelifts. Herewith, hair follicles could be saved for the later regrowth through
the final scar, making it less visible. In 2012 and 2016, the FIT was introduced for the
8 18
direct brow lift and for the correction of different brow deformities. , By beveling the
skin incision 20 degrees to the underlying surface, the dermal layers in the wound edges
were doubled in diameter compared with the conventional vertical skin incision in a 90-
degree angle. This led to a marked improvement of the scar quality. Incisions that have
been placed along the hairlines led to less visible scars because of the excellent regrowth of
hair follicles through the final scar. Compared with an incision angle of 45 degrees, an
incision angle of 20 degrees saves even more hair follicles for the later regrowth, which
makes the final scar even more inconspicuous (Fig. 1). Another advantage of flattening the
incision angle to 20 degrees is that the distance for the regrowing hair to reach the skin
surface is strongly reduced, which provides a denser regrowth of hairs. Assuming that a
patient bears no risk for vascular compromise, the thinning of the dermal wound layers
does not lead to a higher risk of skin necrosis because of the dense intradermal and
19–22
subdermal vascular plexus along the facial skin.

With a histomorphcological study, the hypothesis of scar improvement by strongly

23
increasing the dermal layers could be confirmed (Fig. 4). If one considers the physiology
of the wound healing and the role of the dermal layers within it, one recognizes the big
:
 advantage for wound healing by increasing the dermal wound layers. The three-
dimensional structure of the dermis acts as a template for regulation of the properties of
24
reparative cells. The dermal layers are of particular importance in the wound healing
25–28
process, primarily the fibroblasts and the extracellular matrix. The degree of any
dermal injury defines the natural process of wound healing. The hypothesis is that with
increasing the dermal wound layers about factor 2, the wound could heal faster and help
the healing tissue in early resistance to tension. Tension reduction along the wound edges
is mandatory for a good scar quality (see below).

Figure 5 presents the big difference of scar quality in the temporal region of a patient after
facelift where one side was incised with the FIT and the other with the standard vertical
incision.

Fig. 5.:
Photography of a scar at the left temporal region of a 71-year-old female
patient 7 months after a facelift where a vertical incision technique has been
used (A) and at the right temporal region with magnified view where the FIT
has been used (B). Notice the marked scar improvement with the FIT.

Wound Closure

To additionally reduce tension along the wound edges during closure, it is helpful to
meticulously dissect the wound edges above the fascial layers in kind of flaps along several
centimeters. By tentatively pulling these flaps together, the surgeon can estimate whether
the final wound closure is feasible without remarkable tension. By dissecting these flaps
away from the wound edges, a further stabilization can be achieved due to the consecutive
scarring between the dissected layers, either subcutaneous or subdermal, therefore
reducing the long-term tension along the wound edges even more.

Recent studies revealed that mechanical forces, which lead to tension along the wound
edges and the ensuing cellular mechanotransduction, may also influence the degree of
scar formation, scar contracture, and the formation/progression of keloids and
4
hypertrophic scars.

It was estimated that the mechanical force is a key regulator of hypertrophic scar
29
formation. Jiahao et al found a novel mechanically activated cation, the Piezo1 channel.
This is reportedly capable of regulating force-mediated cellular biological behaviors.
Piezo1 was found to be overexpressed in myofibroblasts of human and rat hypertrophic
scar tissues. In vitro, cyclic mechanical stretch increased Piezo1 expression and Piezo1-
mediated calcium influx in human dermal fibroblasts. In addition, Piezo1 activity
promoted human dermal fibroblast proliferation, motility, and differentiation in response
to cyclic mechanical stretch. More importantly, intradermal injection of GsMT × 4, a
Piezo1-blocking peptide, protected rats from stretch-induced hypertrophic scar formation.
Together, Piezo1 was shown to participate in hypertrophic scar formation and might be a
novel target for the development of promising therapies for hypertrophic scar formation.
:
 In this consensus, the importance of a tension-reduced wound closure cannot be
4 7 29–34
overestimated. , ,

A meticulous adaption of the wound edges is also very important for the achievement of a
33 35
pleasant scar. Every irregularity along the epidermal layers should be avoided. , Quite
often, the surgeon has to place the sutures during wound closure at different heights in the
wound edges to compensate irregularities (Fig. 2). If ever possible, the sutures should be
placed subcutaneous and or intracutaneous with the knot away from the surface.
Lacerations of the outer skin should be avoided because they may lead to the formation of
an everlasting visible penetration channel. But in case of very thin skin, for example, along
the lips or in elderly patients and if there is not much tension involved, the sutures can be
placed transcutaneous and stitch removal performed after some days. As a rule, it counts
that the longer cutaneous stitches are left in place the higher the risk of lasting visible
penetration channels.

The right choice of the appropriate suture material is mandatory. Eligible suture materials
are smooth (monofil) or have a swirl surface (polyfil), are available in different calibers,
and are nonresorbable or have different resorption times. This can range from some days
to several weeks. Which kind of suture material should be used is dependent on the kind
of tissue that has to be closed and the amount of tension that has to be compensated.

Sutures are placed either as single knots or in a running line. Generally, single knots are
used into the deep dermal and subcutaneous layers (“subcuticular”) to reduce the tension
along the wound edges and running epidermal sutures to achieve the exact final adaption
30
of the wound edges.

In younger patients who have not yet undergone dermal atrophy and in tension exposed
wound closure, it is always advisable to use subcuticular resorbable single-knot sutures
like Biosyn (synthetic polyester composed of glycolide, dioxanone, and trimethylene
carbonate) (Covidien, Medtronic, Minneapolis, Minn.) with a tensile strength of 21 days,
as the first step to compensate mechanical forces during collagen synthesis. Alternatively,
Monocryl (poliglecaprone), (Ethicon, Johnson&Johnson, New Brunswick, N.J.) could be
used, but it has less grip, and therefore, the stability of the knot is less than with Biosyn
(personal experience).

In every part of thin skin like the eyelids or lips, we recommend using either very thin (5-
0, 6-0, or even 7-0) nonabsorbable Prolene TM (Polypropylene) (Ethicon,
Johnson&Johnson, New Brunswick, N.J.) or Surgipro TM (Polypropylene and
Polyethylene) (Covidien, Medtronic, Minneapolis, Minn.) intracutaneous or
transcutaneous. For the closure of mucous membranes, we prefer either thin (5-0, 6-0, or
even 7-0) Vicryl rapid TM (90% Glycolide and 10% L-lactide) (Ethicon,
Johnson&Johnson, New Brunswick, N.J.) with 5 days 50% tensile strength or Catgut
(from the serosal layer of selected bovines) (Frank Healthcare Co., China, also available in
the US).

If wound closure can be accomplished without tension, we just use a running suture with
Prolene or Surgipro 6-0, either intracutaneous or transcutaneous.
:
 Postoperative Scar Management

The postoperative handling of the fresh scar has gained great importance, due to the
knowledge of scar pathology.

Most reports about postoperative facial scar management used empirical data. Valuable
7
reports with statistical analysis and using control groups were by Atkinson et al, Maher et
10 37 38 39
al, Rosengren et al, Bianchi et al, and De Giorgi. Three principles for the
postoperative wound management are fundamental. The first is the prevention of wound
infection. This situation inevitably would bear the risk to interrupt the physiology of
normal wound healing with an increased risk for bad scarring. To prevent infection, daily
cleaning of the fresh scar is needed, either in the form of simple washing with water and
soap or in risk patients with some kind of disinfectant, at least until the first wound
healing has been completed. We prefer to use octenisept solution (ingredients: 100 g
solution contains 0.1 g octenidindihydrochlorid and 2.0 g phenoxyethanol) (Schülke &
Mayr AG, Zurich, Switzerland, also available in the US). It is useful for both skin and
47
mucous membrane disinfection and is well tolerated. It has a rapid effect and a broad
antiseptic spectrum, for MRSA, chlamydia trachomatis, pseudomonas aeruginosa,
neisseria gonorrhoeae, gardnerella vaginalis, candida albicans, and trichomonas.

Furthermore, we recommend the following procedure for every patient during the first 2–
3 days: local application of terracortril ointment (Intrapharm Laboratories Limited,
United Kingdom, also available in the US) with the initial dressing for a maximal 2–3
days. Based on liquid paraffin, each gram of terracortril ointment contains 30-mg
oxytetracycline as oxytetracycline hydrochloride and 10-mg hydrocortisone. It helps the
initial wound healing against early bacterial contamination. Particularly, it is efficient
43 45
against Staphylococcus aureus, the main causative organism for skin infections. , It
44
also reduces swelling and serves moisture with the liquid paraffin.

The second principle is based on the necessity for immobilization of the fresh scar as
much as possible and parallel, providing the wound surface with moisture for better scar
6 7 9–13 29 36–40 7 37
hydration. , , , , Aktinson et al and Rosengren et al examined the benefit of
using paper taping and found significant reductions in scar volume and scar width.
38 39
Bianchi et al and De Giorgi et al examined the effect of silicone gel and revealed
significant improvements of the scar quality in color, stiffness, irregularities, pliability,
10
and pigmentation.

To point out again, these methods make sense as long as collagen maturation is
completed, which means about 6 weeks. If, after this time, the scars present themselves
still discolored, it is advisable to continue this treatment until the scar has faded. Two
regimens have gained broad acceptance: the use of plaster tapering and silicon gel or
5–7 9–13 37–39
silicon plates. , , The advantage of plastering is that it is simultaneously a kind of
immobilization and a moisturizing effect. If plastering is impossible, just moisturizing
11
with fatty ointment is useful.
:
 For the plastering, we recommend 3M Micropore tan surgical tape 0.5-inch wide (3M
GmbH, Germany, also available in the US). It is a sufficiently sticky plaster.

About 1 week after wound closure and removal of cutaneous stitches, we ask the patient to
start with plastering of the fresh scar for 6 weeks, or alternatively, if a plaster cannot be
tolerated, with silicone gel. The plaster stays in place as long as it remains stable on the
surface of the scar, normally for a week. After showering or getting into contact with
water, it should be dried with a hair dryer. Before the exchange of the plaster, the patient
should use Bepanthen ointment (dexapanthenol) (Bayer, Switzerland) during the night
until the next morning and then apply the plaster again. Dexapanthenol used once weekly
helps to enhance the skin barrier, prevents skin irritation, and stimulates skin
46
regeneration.

For all patients who do not tolerate any kind of plaster but with a known risk for bad
scarring, the application of silicon gel or silicon plates is useful to achieve more
moisturizing of the scar by the occlusion effect.
12
Mustoe et al examined the advantage of this modality and explained that due to the
occlusion of the scar, the consecutive hydration of the stratum corneum leads to cytokine-
mediated signaling of keratinocytes to dermal fibroblasts, which finally reduces scarring.
40
Furthermore, Zhong et al proved that reduced hydration increased the expression of
S100 protein family members, S100A8/S100A9, in stratified keratinocyte culture and
human ex vivo skin culture. S100A8/A9 has been found to be highly expressed in the
epidermis of human hypertrophic scar and keloid tissues. Diminished hydration led to the
activation of fibroblasts in the keratinocyte-fibroblast coculture. In contrast, knockdown
of S100A8 or S100A9 by ribonucleic acid (RNA) interference in keratinocytes failed to
activate fibroblasts. Interestingly, application of pharmacological blockers of S100A8/A9
receptors, toll-like receptor 4, and receptor for advanced glycation end products inhibited
fibroblast activation induced by recombinant S100A8/A9 proteins. It could be further
shown that local delivery of S100A8 protein resulted in considerably more hypertrophic
scarring in the in vivo rabbit ear scar model.

The third principle of postoperative scar management is sun protection for at least 6
36 41 42
months, either by continuously covering with clothes or applying a sun blocker. , ,

Furthermore, early postoperative compression therapy with special garments and

intralesional corticosteroid injections has been proven to be very effective in risk
2 5 36
patients. , ,

CONCLUSIONS
To prevent unsightly facial scars after aesthetic or reconstructive surgery, an algorithm
based on important perioperative scientific evidence-based guidelines must be followed.
This includes patient preparation, choosing of the best incision location, the right incision
technique, the best wound closure with appropriate suture technique and material, and
finally, the adequate postoperative wound and scar management.
:
 With our systematic literature search, we present current scientific proofs of three well-
established empirical measures. These are (1) the FIT, (2) the importance of maximal
tension reduction along the dermal layers during wound closure as well as
postoperatively, and (3) the importance of maximal hydration of the scar by covering it
with plaster or any kind of silicone.

REFERENCES
1. Kim YS, Na YC, Park JH. Hair transplantation in patients with hair loss or scar
deformity in the side hairline after midfacelifting surgery. Arch Plast Surg. 2019;46:147–
151.

Cited Here |
Google Scholar

2. Wang J, Wu J, Xu M, et al. A comprehensive reconstruction strategy for moderate to

severe faciocervical scar contractures. Lasers Med Sci. 2021;36:1275–1282.

Cited Here |
Google Scholar

3. Thomas DW, Hopkinson I, Harding KG, et al. The pathogenesis of hypertrophic/keloid

scarring. Int J Oral Maxillofac Surg. 1994;23:232–236.

Cited Here |
PubMed | CrossRef |
Google Scholar

4. Tsai CH, Ogawa R. Keloid research: current status and future directions. Scars Burn
Heal. 2019;5:2059513119868659.

Cited Here |
Google Scholar

5. Kim S, Choi TH, Liu W, et al. Update on scar management: guidelines for treating Asian
patients. Plast Reconstr Surg. 2013;132:1580–1589.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

6. Ogawa R. The most current algorithms for the treatment and prevention of
hypertrophic scars and keloids. Plast Reconstr Surg. 2010;125:557–568.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

7. Atkinson JM, et al. A randomized, controlled trial to determine the efficacy of paper
:
 tape in preventing hypertrophic scar formation in surgical incisions that traverse Langer’s
skin tension lines. Plast Reconstr Surg. 2005;116:1648–1656.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

8. Feinendegen DL, Constantinescu MA, Knutti DA, et al. Brow reduction, reshaping and
suspension by a 20-degree beveled brow incision technique. J Craniomaxillofac Surg.
2016;44:958–963.

Cited Here |
PubMed | CrossRef |
Google Scholar

9. Monstrey S, Middelkoop E, Vranckx JJ, et al. Updated scar management practical

guidelines: non-invasive and invasive measures. J Plast Reconstr Aesthet Surg.
2014;67:1017–1025.

Cited Here |
PubMed | CrossRef |
Google Scholar

10. Maher SF, et al. Linear scar reduction using silicone gel sheets in individuals with
normal healing. J Wound Care. 2012;21:602–609.

Cited Here |
PubMed | CrossRef |
Google Scholar

11. Meaume S, Le Pillouer-Prost A, Richert B, et al. Management of scars: updated

practical guidelines and use of silicones. Eur J Dermatol. 2014;24:435–443.

Cited Here |
PubMed | CrossRef |
Google Scholar

12. Mustoe TA, Cooter RD, Gold MH, et al.; International Advisory Panel on Scar
Management. International clinical recommendations on scar management. Plast
Reconstr Surg. 2002;110:560–571.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

13. Del Toro D, Dedhia R, Tollefson TT. Advances in scar management: prevention and
management of hypertrophic scars and keloids. Curr Opin Otolaryngol Head Neck Surg.
2016;24:322–329.
:
 Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

14. Johnson J, Greenspan B, Gorga D, et al. Compliance with pressure garment use in

burn rehabilitation. J Burn Care Rehabil. 1994;15:180–188.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

15. Snowden C, Lynch E, Avery L, et al. Preoperative behavioural intervention to reduce

drinking before elective orthopaedic surgery: the PRE-OP BIRDS feasibility RCT. Health
Technol Assess. 2020;24:1–176.

Google Scholar

16. Robinson JK. Segmental reconstruction of the face. Dermatol Surg. 2004;30:67–74.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

17. Camirand A, Doucet J. A comparison between parallel hairline incisions and

perpendicular incisions when performing a face lift. Plast Reconstr Surg. 1997;99:10–15.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

18. Feinendegen DL. The direct brow-lift using the flat incision technique. Aesthetic Plast
Surg. 2012;36:468–471.

Cited Here |
PubMed | CrossRef |
Google Scholar

19. Tinhofer IE, Zaussinger M, Geyer SH, et al. The dermal arteries in the cutaneous
angiosome of the descending genicular artery. J Anat. 2018;232:979–986.

Cited Here |
Google Scholar

20. Herbert DC, Harrison RG. Nasolabial subcutaneous pedicle flaps. Br J Plast Surg.
1975;28:85–89.

Cited Here |
PubMed | CrossRef |
Google Scholar
:
 21. Cormack GC, Lamberty BGH. The Arterial Anatomy of Skin Flaps. Churchill
Livingstone; 1986.

Cited Here

22. Feinendegen DL, Langer M, Gault D. A combined V-Y advancement-turnover flap for

simultaneous perialar and alar reconstruction. Br J Plast Surg. 2000;53:248–250.

Cited Here |
PubMed | CrossRef |
Google Scholar

23. Feinendegen DL, Waldkircher NJ, Bannwart F, et al. Outcome of beveled versus

vertical incisiontechnique after reconstructive or aesthetic facial surgery. Plast Reconstr
Surg Glob Open. 2019;7:e2286.

Cited Here |
Google Scholar

24. Lu SL, Qin C, Liu YK, et al. [Study on the mechanism of scar formation: epidermis
template defect theory]. Zhonghua Shao Shang Za Zhi. 2007;23:6–12.

Cited Here |
PubMed |
Google Scholar

25. Lindblad WJ. Perspective article: collagen expression by novel cell populations in the
dermal wound environment. Wound Repair Regen. 1998;6:186–193.

Cited Here |
PubMed | CrossRef |
Google Scholar

26. Lamme EN, Van Leeuwen RT, Brandsma K, et al. Higher numbers of autologous
fibroblasts in an artificial dermal substitute improve tissue regeneration and modulate
scar tissue formation. J Pathol. 2000;190:595–603.

Cited Here |
PubMed | CrossRef |
Google Scholar

27. Han SK, Yoon TH, Kim JB, et al. Dermis graft for wound coverage. Plast Reconstr
Surg. 2007;120:166–172.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

28. Nolte SV, Xu W, Rennekampff H-O, et al. Diversity of fibroblasts: a review on

implications for skin tissue engineering. Cells Tissues Org. 2008;187:165–176.
:
 Cited Here |
Google Scholar

29. Jiahao H, et al. Mechanical stretch promotes hypertrophic scar formation through

mechanically activated cation channel Piezo1. Cell Death Dis. 2021;12:226.

Cited Here |
Google Scholar

30. Elliot D, Mahaffey PJ. The stretched scar: the benefit of prolonged dermal support. Br
J Plast Surg. 1989;42:74–78.

Cited Here |
PubMed | CrossRef |
Google Scholar

31. Forrest CR, Phillips JH, Bell TA, et al. The biomechanical effects of deep tissue support
as related to brow and facelift procedures. Plast Reconstr Surg. 1991;88:427–432.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

32. Mommaerts MY, Abeloos JS, De Clercq CA, et al. Brow and forehead lift with cranial
suspension. Technical note. J Craniomaxillofac Surg. 1994;22:33–36.

Cited Here |
PubMed | CrossRef |
Google Scholar

33. Buchanan PJ, Kung TA, Cederna PS. Evidence-based medicine: wound closure. Plast
Reconstr Surg. 2016;138(3 suppl):257S–270S.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

34. Knize DM. Anatomic concepts for brow lift procedures. Plast Reconstr Surg.
2009;124:2118–2126.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

35. Janis JE, Harrison B. Wound healing: part I. Basic science. Plast Reconstr Surg.
2016;138(3 suppl):9S–17S.

Cited Here |
View Full Text | PubMed | CrossRef |
:
 Google Scholar

36. Vincent AG, Kadakia S, Barker J, et al. Management of facial scars. Facial Plast Surg.
2019;35:666–671.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

37. Rosengren H, Askew DA, Heal C, et al. Does taping torso scars following dermatologic
surgery improve scar appearance? Dermatol Pract Concept. 2013;3:75–83.

Cited Here |
PubMed |
Google Scholar

38. Bianchi FA, Roccia F, Fiorini P, et al. Use of patient and observer scar assessment
scale for evaluation of facial scars treated with self-drying silicone gel. J Craniofac Surg.
2010;21:719–723.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

39. de Giorgi V, Sestini S, Mannone F, et al. The use of silicone gel in the treatment of
fresh surgical scars: a randomized study. Clin Exp Dermatol. 2009;34:688–693.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

40. Zhong A, Xu W, Zhao J, et al. S100A8 and S100A9 are induced by decreased hydration
in the epidermis and promote fibroblast activation and fibrosis in the dermis. Am J
Pathol. 2016;186:109–122.

Cited Here |
PubMed | CrossRef |
Google Scholar

41. Veldhuizen IJ, et al. Sun protection behavior following skin cancer resection and
reconstruction. J Cancer Educ. 2021.

Cited Here |
Google Scholar

42. Wanitphakdeedecha R, Phuardchantuk R, Manuskiatti W. The use of sunscreen

starting on the first day after ablative fractional skin resurfacing. J Eur Acad Dermatol
Venereol. 2014;28:1522–1528.

Cited Here |
:
 View Full Text | PubMed | CrossRef |
Google Scholar

43. Becker RE, Bubeck Wardenburg J. Staphylococcus aureus and the skin: a longstanding
and complex interaction. Skinmed. 2015;13:111–120.

Cited Here |
Google Scholar

44. Schimpf A. [Clinical experiences with terracortril ointment and cream]. Fortschr Med.
1977;95:382–384.

Cited Here |
Google Scholar

45. Salmanov AG, Shkorbotun VO, Shkorbotun YV. Antimicrobial resistance of

staphylococcus aureus causing of surgical site infections in ear, nose and throat surgery.
Wiad Lek. 2019;72:154–158.

Cited Here |
Google Scholar

46. Proksch E, de Bony R, Trapp S, et al. Topical use of dexpanthenol: a 70th anniversary

article. J Dermatolog Treat. 2017;28:766–773.

Cited Here |
PubMed | CrossRef |
Google Scholar

47. Matiasek J, Kienzl P, Otti GR, et al. Aseptic surgical preparation for upper eyelid
blepharoplasty via full-face octenidine antiseptic without antibiotic medication shows
effective prophylaxis against post-surgical wound infection. Int Wound J. 2018;15:84–89.

Cited Here |
View Full Text | PubMed | CrossRef |
Google Scholar

View full references list

Copyright © 2022 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of
The American Society of Plastic Surgeons.
View full article text

Back to Top
:
 Never Miss an Issue

Get new journal Tables of Contents sent right to your email inbox Type your email

Get New Issue Alerts

Browse Journal Content

Most Popular
For Authors
About the Journal
Past Issues
Current Issue
Register on the website
Get eTOC Alerts

For Journal Authors

Submit an article
How to publish with us

Customer Service

Browse the help center

Help
Contact us at:
EMAIL:
customerservice@lww.com
TEL: (USA):
TEL: (Int’l):
800-638-3030 (within USA)
301-223-2300 (international)


:
 

Privacy Policy (Updated June 1, 2020)

Legal Disclaimer
Terms of Use
Open Access Policy
Feedback
RSS Feeds
LWW Journals

Copyright © 2022
The American Society of Plastic Surgeons Wolters Kluwer Health, Inc. All rights
reserved.

This website uses cookies. By continuing to use this website you are giving consent to
cookies being used. For information on cookies and how you can disable them visit our
Privacy and Cookie Policy.

Got it, thanks!

: