Dan Preece
CSPM Class 2009
Fig. 1
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African Americans
Areas of high hair follicle density
Wounds crossing a joint(s).
Wounds on the ears, neck, jaw, presternal
chest, shoulders, and upper back.
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Normal Scar Formation:
Hypertrophic Scar:
Enlarged/elevated scar
within wound margins.
Keloid:
Scar extending beyond
wound margins.
Elevated:
Wound closure under tension
Inadequate apposition of edges
Full-thickness grafts (oversized)
Depressed scar:
Deep shave biopsy
Electrodesiccation/curettage
Deficient wound eversion
Prior hematoma or infection
Widened scars:
Wound closed under tension
Long linear scar:
Laceration, Poor preoperative planning
Contracted/webbed:
Traverse concavities
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Correct incision placement goals:
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Avoid neurovascular structures
Avoid areas of shoe pressure or WB pressure
Follow RSTL’s
Achieve adequate exposure to the surgical target.
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Borges and Alexander (8) described lines similar to those
described by Cox, but termed the former set of lines RSTLs.
RSTLs are formed by the dynamic action of muscles creating
tension and laxity across the skin surface.
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To find the RSTLs, one simply relaxes the skin
in an area by passive manipulation at a joint or
by muscle movement.
In areas where motion is minimal, the RSTLs
may be found by using the pinch test (7)
Incisions perpendicular to RSTLs will tend to gap.
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Curvilinear incisions over joints.
Contracting scar force will not be
perpendicular to axis of joint.
Avoid skiving incision edges.
Leads to devascularization.
Long single passes with knife instead of multiple short passes.
If WB surface is unavoidable, non-WB post-op period can help
reduce scar formation.
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Use a skin marker. "Measure twice, cut once“.
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Use “cross hatches”, avoids creating redundant skin. (7)
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“Reapproximate not strangulate" the wound
edges.
Tight sutures can create areas of localized
ischemia. Suture deep tissues or undermine
skin edges to help with reapproximation.
Choose suture material carefully. Use nonabsorbable monofilament to avoid suture
reactivity and harboring of bacteria.
Consider fibrin glues (has been shown to have the
same strength at 2 weeks post op as suture).
Currently available therapies
Proposed Mechanism of Action
Corticosteroids (injection)
Inhibition of inflammatory mediators.
Inhibition of fibroblast proliferation.
Inhibition of collagen synthesis.
Enhanced collagen degradation.
Inhibition of TGF-1 and TGF
5-Fluorouracil
Inhibition of fibroblast proliferation
Inhibition of TGF-1–induced collagen synthesis
Bleomycin (injection)
Inhibition of collagen synthesis
Inhibition of lysyl-oxidase or TGF (2)
CurrentlyAvailable Therapies
Proposed Mechanism of Action
Laser therapy
Selective photothermolysis of scar vascular supply,
inhibition of TGF-, fibroblast proliferation, and
collagen type III deposition.
Silicone gel sheeting
Hydration, inhibition of collagen deposition
down-regulation of TGF
Pressure therapy
Reduced oxygen tension ¡ inhibition of fibroblast
proliferation and collagen synthesis, and increase in
collagen lysis.
Radiation
Inhibition of fibroblast proliferation and
neovascular bud formation
Cryotherapy
Decreases collagen synthesis, mechanical scar tissue
destruction, scar neovascularization. (2)
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Surgical Treatment Strategies:
Excision with linear closure
 Excision with split- or full-thickness skin grafting
 Z-plasty or W-plasty
 If all other options fail, excision followed by flap coverage,
possibly incorporating balloon skin expansion.
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Surgical excision as a sole treatment of
keloids/hypertrophic scars has a very high
recurrence rate, between 45 and 100 percent. (1)
Excision followed by radiation therapy has a 16
to 27 percent recurrence rate. (9) The radiation
treatment is carried out in 200-rad increments
daily for 5 days and is ideally begun on the day
of surgery.
(Above) A 35-year-old African American man with a history of a large
recurrent irregular keloid. Had previously undergone two surgical excisions
followed by corticosteroid injections with recurrence of the keloid.
(Below) Appearance 9 months after treatment with surgical resection and
immediate postoperative radiation treatment.
Tissue expansion:
Allows revision of large
scars in a rapid, twostage fashion.
1.The expander is placed in
the subcutaneous space
and sequentially filled
with saline.
2. The expanded skin is
used to replace the
excised scar.
The skin may be reexpanded as necessary.
(10)
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Studies of fetal wound healing suggest that a high
level of inflammation may promote scar
formation rather than enhancing wound
healing. (6)
Up-regulation of TGF-1 and TGF-2 can lead to
excessive scarring as demonstrated in numerous
animal models. Techniques for neutralizing
these substances are being investigated. (4)
There are several ongoing Phase II clinical trials
evaluating Juvista, human recombinant TGF-3
that helps to decrease collagen synthesis(5)
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Topical application of a selective COX-2
inhibitor immediately after wounding
resulted in a statistically significant
reduction in local neutrophils, prostaglandin
E2 levels, TGF-1, collagen deposition, and
scar formation in a mouse study. (3)
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1. Berman, B., and Bieley, H. C. Adjunct therapies to surgical management of keloids. Dermatol. Surg. 22: 126, 1996.
2. Richard G. Reish, M.D. Elof Eriksson, M.D., Ph.D.Scars: A Review of Emerging and Currently Available Therapies. Plast.
Reconstr. Surg. 122: 1068, 2008.)
3. Wilgus, T. A., Vodovotz, Y., Vittadini, E., Clubbs, E. A., and Oberyszyn, T. M. Reduction of scar formation in full-thickness
wounds with topical celecoxib treatment. Wound Repair Regen. 11: 25, 2003.
4. Wang, X., Smith, P., Pu, L. L., Kim, Y. J., Ko, F., and Robson, M. C. Exogenous transforming growth factor beta 2
modulates collagen I and collagen III synthesis in proliferative scar xenografts in nude rats. J. Surg. Res. 87: 194, 1999.
5. Lin, R. Y., Sullivan, K. M., Argenta, P. A., Meuli, M., Lorenz, H. P., and Adzick, N. S. Exogenous transforming growth
factor-beta amplifies its own expression and induces scar formation in a model of human fetal skin repair. Ann. Surg. 222:
146, 1995.
6. Mast, B. A., Diegelmann, R. F., Krummel, T. M., and Cohen, I. K. Scarless wound healing in the mammalian fetus. Surg.
Gynecol. Obstet. 174: 441, 1992.
7. Storm T, Lee M. Plastic and Reconstructive Surgery. McGlamry’s Textbook of Foot and Ankle Surgery. 2001. Ch 44, pg
1487-1583.
8. Borges AF, Alexander JE. Relaxed skin tension lines, Z-plasties on scars, and fusiform excision of lesions. Br J Plan Surg
1962;15: 242-254.
9. Ragoowansi, R., Cornes, P. G., Moss, A. L., and Glees, J. P. Treatment of keloids by surgical excision and immediate
postoperative single-fraction radiotherapy. Plast. Reconstr. Surg. 111: 1853, 2003.
10. Coughlin, Man, Saltzman. Surgery of the Foot and Ankle. Ch 34, pg 1903-05.
Figures:
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1. Reish, RG and Eriksson E. Scars: a review of emerging and currently available therapies. Plast Reconstr Surg. 2008
Oct;122(4):1068-78.