Surgery for scar revision and reduction: from primary closure to flap surgery

Abstract

Scars are the final result of the four processes that constitute cutaneous wound healing, namely, coagulation, inflammation, proliferation, and remodeling. Permanent scars are produced if the wounds reach the reticular dermis. The nature of these scars depends on the four wound healing processes. If the remodeling process is excessive, collagen degradation exceeds collagen synthesis and atrophic scars are produced. If the inflammation phase is prolonged and/or more potent for some reason, inflammatory/pathological scars such as keloids or hypertrophic scars can arise. If these pathological scars are located on joints or mobile regions, scar contractures can develop. When used with the appropriate timing and when selected on the basis of individual factors, surgical techniques can improve mature scars. This review paper focuses on the surgical techniques that are used to improve mature scars, burn scars, and scar contractures. Those methods include z-plasties, w-plasties, split-thickness skin grafting, full-thickness skin grafting, local flaps (including the square flap method and the propeller flap), and expanded flaps, distant flaps, regional flaps, and free flaps.

Keywords: Expander; Hypertrophic scar; Keloid; Local flap; Perforator flap; Scar; Scar contracture; Surgery; W-plasty; Z-plasty.

Fig. 1

Reconstruction of scar contractures by using multiple z-plasties. a Preoperative view. b Design of the z-plasties. c Immediate postoperative view. d Eighteen months after surgery. A major benefit of z-plasties is that segmented scars mature faster than long linear scars

Fig. 2

Resection and w-plasty of a scar between the lower lip and the jaw. a Preoperative view. b Design of the w-plasty. c Intraoperative view. d Immediate postoperative view. e Twelve months after the operation. The indication for w-plasty is a scar on the flat surfaces of the face such as the cheek and the area between the lower lip and the jaw

Fig. 3

Full-thickness skin graft for hypertrophic scars on the hand. a Preoperative view. b Eighteen months after the operation. Full-thickness skin grafts should be the first choice for secondary scar reconstruction. (The figure is reproduced with permission from the article [7] (Copyright 2010 by Wolters Kluwer Health))

Fig. 4

Thin split-thickness skin graft for self-harm scars on the forearm. a The scar area. b After the thin skin graft was harvested. c The harvested thin skin. d Immediate postoperative view. e Twelve months after the operation. A thin split-skin graft (8/1000 in.) was taken from the affected area, after which the wide dermal scars were excised and the graft was closed by placing the graft back onto the harvest site

Fig. 5

The square flap method for elbow joint contracture. a Design of the square flap method. b Intraoperative view. c Immediate postoperative view. d Eighteen months after the operation. The square flap method involves one square flap and two triangular flaps. The extensibility of these flaps is much higher than that of the triangular z-plasty flaps

Fig. 6

The propeller flap method for upper lip scar contracture. a Design of the propeller flap approach. b Immediate postoperative view. c Thirty-six months after the operation. In this case, a nasolabial flap was harvested to serve as the tunneled propeller flap

Fig. 7

The expander flap method for forearm scars. a Design of the first operation, where an expander was implanted. b View during the first operation. c View immediately before the second operation. d Eighteen months after the second operation. Healthy skin was expanded for 3 months after the first operation. In the second operation, the entire scar area was excised and closed primarily with z-plasties.

Fig. 8

Reconstruction of multiple finger joint contractures with distant flaps. a Preoperative view. b View after releasing the contractures. c Design of the abdominal distant flaps. d Immediately after the operation. e, f Thirty-six months after the operation. Multiple finger joint contractures were reconstructed by using abdominal distant flaps. The flaps were transplanted and cut 3 weeks after the operation in this case

Fig. 9

Internal mammary artery supercharged-transposition flap for anterior neck scar contractures. a Design of the flap. b Intraoperative view. c Perforators were attached to the flap. d View 1 week after surgery. e Eighteen months after the operation. A transposition flap bearing the internal mammary artery perforator was harvested from the anterior chest wall to repair the neck wounds that were left after removing the scar. At the same time, the tracheal fistula was covered by the flap. The esthetic and functional results were acceptable. (The figure is reproduced with permission from the article [19] published by Wolters Kluwer Health (Copyright 2018 by Rei Ogawa et al.)) In case of PRS-GO article, copyright is kept by authors

Fig. 10

Reconstruction of chin scars by using a free scapular flap. a Preoperative view. b Design of the free scapular flap. c Thirty-six months after the operation. Free flaps remain a good choice for replacing large or specialized defects because they have good functional or esthetic results and minimal donor-site morbidity