Scar Lymphedema: Fact or Fiction?
Anne G. Warren, BA and Sumner A. Slavin, MD
BACKGROUND
Few concepts are as fundamental to plastic surgery as scarring, yet swelling within a scar and
its adjacent tissues is a common observation which is not well understood. The term “trapdoor
deformity” has been used to describe swelling within healed curvilinear lacerations or incisions,
although this effect has also been noted in the presence of linear scars. Mechanical forces (1,
2), scar contracture (3), fibrosis, and lymphatic dysfunction (4-6) have been considered as
possible explanations for these edematous-appearing areas, yet few studies have carefully
evaluated the specific etiology.
PATIENTS AND METHODS
Eleven patients (mean age: 43 years, range: 15 to 70) with localized swelling in conjunction
with linear or curvilinear scars were evaluated. Nine patients presented with facial scars and
two with scars of the chest wall and abdomen. Locations of the facial scars included three on
the chin, four on the cheek, and two on the forehead. 6/11 scars were semicircular and the
rest were linear. Reported onset of swelling was in the range of 9 months to 13 years (mean:
4.5 years) before initial consultation. Patients described either a history of trauma (6 patients)
or prior reconstructive (3 patients), excisional (2 patients) or aesthetic (1 patient) surgical
procedures. Two patients had undergone previous Z-plasty revisions to the limbs of their
curvilinear scars, with one patient additionally receiving collagen injections to the scar.
To better understand the etiology of their scar deformities, all patients underwent lymphatic
imaging of the affected area. Radiocolloid lymphoscintigraphy with Technetium-99m Sb2S3
colloid was performed by single or multiple injection technique into the site of the scar
corresponding to local edema. Images of the lymphatic channels were taken at 10, 40, 90,
and 180 minutes after injection of the tracer. The presence or absence of lymphatic
dysfunction was documented through evaluation of drainage into local and regional lymph
nodes as well as visualization of lymphatic channels bridging the scar.
.
RESULTS
Following injection, rapid egress of radiotracer was visualized along lymphatic pathways with
continuation to locoregional nodes in all patients with “U”-shaped or linear scar configurations.
Of patients with curvilinear scars, five (83.3%) demonstrated no visualization of lymphatic
channels draining or bridging the scar from the area of most significant swelling.
Lymphoscintigrams from two patients who had undergone multiple prior Z-plasty revisions to
the limbs of curvilinear scars revealed no apparent visualization of lymph channels across the
Z-plasty flaps. Patients with swelling adjacent to linear scars demonstrated normal lymphatic
drainage and no pooling of the radiotracer in two cases, while three patients with linear scars
were shown to have no evidence of lymphatic channels draining localized aspects of their
scars and/or myocutaneous flaps.
CONCLUSIONS
Using radionuclide lymphoscintigraphy, scar lymphedema was diagnosed in nine patients with
linear and curvilinear scars by a failure to identify any lymphatic channels in areas of localized
swelling. Patients with curvilinear scars had demonstrable lymphatic pathways posterior to the
scar but no visualization of lymphatic channels across it. These findings suggest that
undrained lymphatic fluid contributes to the pathogenesis of the raised and swollen tissues
seen abutting a “U” shaped scar. Furthermore, as lymphatic pathways are not re-established
across scars, Z-plasty revisions may not succeed in patients with clinical “trap-door” scar
deformities. Determination of scar lymphedema can assist in the selection of proper
management for patients seeking scar revision.
REFERENCES
1. Ju DM. The physical basis of scar contraction. Plast Reconstr Surg. 7: 343, 1951.
2. Ausin A. The “trap-door” scar deformity. Clin Plas Surg. 4: 255, 1977.
3. Hosokawa K, Susuki T, Kikui T, et al. Sheet of scar causes trapdoor deformity: a
hypothesis. Ann Plast Surg. 25: 134, 1990.
4. Van Duyn J. Lymphedema in face scars. South Med J. 62: 1149, 1969.
5. Van Duyn J. First appearance of lymphedema in facial scars. South Med J. 67: 1502,
1974.
6. Kazanjian VH, Converse JM. Early treatment of facial injuries. In: Kazanjian, V. H. and
Converse, J. M., eds. Surgical Treatment of Facial Injuries. Baltimore: Williams & Wilkins Co.,
1974