CHAPTER
22 Secondary Revision of Soft Tissue Injury
Michael R. Markiewicz
| R. Bryan Bell
OUTLINE
Soft Tissue Wound Healing
Principles of Wound Management
Preoperative Consultation
Scar Analysis
Incision Placement
Facial Aesthetic Units
Scar Type, Pattern, and Color
Scar Location
Sun-Reactive Skin Type Classification
Skin and Aging
Timing of Scar Revision
Surgical Options
General Principles of Linear Scar Revision
Procedures
Complications
Hematoma
Infection
Necrosis
Hyperpigmentation
S
carring is a natural progression of healing following
soft tissue injury.1-3 The primary and immediate sec-
ondary management of head and neck wounds will
inevitably affect the long-term aesthetic and functional
outcomes of the resulting scar. Therefore, meticulous
planning is needed from the initial patient encounter to
ensure successful outcomes in scar healing, maturation,
and revision. This chapter will review the evaluation and
management of various post-traumatic scarring, with an
emphasis on commonly encountered clinical scenarios.
It is meant to provide the reader with a literature-based
rationale for treatment.
SOFT TISSUE WOUND HEALING
A basic understanding of wound healing is needed
because of its relevance to scar formation and subse-
quent effects on revision.3-5 Wound healing is classified
into three main phases (Fig. 22-1). These include the
immediate inflammatory phase (1 to 3 days), which is
characterized by a vascular and inflammatory response
including local vasoconstriction for the first 5 to 10
minutes followed by a local vasodilatory response. The
inflammatory phase takes place the first few days after
injury, during which wound strength relies mainly on the
fibrin clot. The second phase, the proliferation phase (3
to 12 days), begins within 24 hours after injury and is
characterized by the recruitment of blood vessels and
566
Distortion of Mobile Landmarks
Recurrent Scar Widening
Recurrent Scar Contracture
Specific Types of Scars
Depressed Scar
Electric Burns
Eyelid Ectropion
Hypertrophic Scars and Keloids
Resurfacing Procedures
Preoperative Considerations
Patient Preparation
Specific Techniques
General Postoperative Care for All Ablative Techniques
Adjunctive Scar Revision Techniques
Tissue Expansion
Steroids
Filler Materials
Botox
Summery
fibroblasts, resulting in granulation tissue. Epithelializa-
tion may be completed in 24 to 48 hours in primarily
closed wounds or be delayed for as long as 3 to 5 days in
wounds healing by secondary intention The final phase
of wound healing is the maturation phase, during
which the scar gains strength and volume and erythema
decreases. Complete scar maturation and final tensile
strength generally take 12 to 18 months (Fig. 22-2).
In any wound, even one with adequate primary closure,
the gap between wound edges is temporarily repaired in
the form of a clot consisting of platelets engrossed in a
mesh of cross-linked fibrin fibers derived from fibrino-
gen cleaved by thrombin. The platelet clot serves as a
reservoir of cytokines and growth factors that are released
as platelets degranulate. Growth factors and cytokines
recruit inflammatory cells, fibroblasts, and capillary
ingrowth to the wound site, which invade the clot to
form granulation tissue, leading to contraction of
wound margins. A connective tissue scar remains when
wounds are closed by secondary intention—the larger
the wound gap, the wider the connective tissue scar.
Scar consists of a poorly constructed collagen matrix
in dense parallel bundles, which is contrasted to the
efficiently cross-linked meshwork of collagen in the
native dermis. It occurs in three phases—epithelialization
migration, collagenization, and angiogenesis–granulation
tissue formation. Epithelialization occurs by migration of
keratinocytes over the dermis and under the clot (Fig.
 Secondary Revision of Soft Tissue Injury CHAPTER 22 567

Vasoconstriction
Vasodilation Inflammatory phase

Cellular response

Proliferative phase
Reepithelial-
ization
Fibroplasia: collagen synthesis
Wound contraction

Maturation / remodeling phase

Scar: collagen remodeling

Injury 30 minutes 1 day 1 week 2 weeks 3 weeks 6 months 1 year

FIGURE 22-1 Phases of inflammation.

100
Tensile strength*

80

60

40

20

0
1 2 3 4 5 6 7 8 9 10
Time after wounding (weeks)
*Percent of normal unwounded skin

FIGURE 22-2 Maximum scar tensile strength is obtained

approximately 12 to 18 months following injury. (Adapted from A
Goslin JB: Wound healing for the dermatologic surgeon.
J Dermatol Surg Oncol 14:959–972, 1988.)

22-3), which is facilitated by growth factors such as epi-

dermal growth factor (EGF) and transforming growth
factor α (TGF-α).6-8 Once a monolayer of keratinocytes
covers the denuded wound surface, epithelial migration
ceases and a new stratified epidermis with underlying
basal lamina is reestablished from the margins of the
wound inward. All aspects of a skin flap rarely touch
along all the length of the wound; migration is aided by
contraction of the underlying connective tissue. Within
3 to 4 days of injury, dermal fibroblasts around the wound
begin to proliferate and lay down a collagen-rich matrix,
a process modulated by platelet-derived growth factor
(PDGF) and transforming growth factor β (TGF-β).9-12
Finally, angiogenesis of the wound and the incorporation B
of pink, capillary-filled granulation tissue is mediated by FIGURE 22-3 A, A leading front of basal epithelial cells divides and
fibroblast growth factor 2 (FGF2) and vascular endothe- migrates beneath a dried clot. B, Contact inhibition and further
lial growth factor (VEGF) released at the site of the differentiation and epithelial stratification.
wound.13 Connective tissue contraction ultimately closes
embryonic and adult wounds. The major difference
between scar-free healing and scar formation is that a initial thorough removal of foreign bodies, débridement,
scar-free wound site has significantly less inflammation and cleansing of the wound with copious pulsatile irriga-
present.5 tion. Formal scrubbing of the wound may be undertaken
if necessary but should be done sparingly to spare further
PRINCIPLES OF WOUND MANAGEMENT damage to soft tissues. All devitalized soft tissue should
be débrided and excised and sharp healthy wound
General principles of wound management should always margins should be obtained to facilitate closure, with
be followed in the traumatic setting. These include an minimal scarring.14 Devitalized tissue increases the local
568 PART III Management of Head and Neck Injuries
inflammatory response and subsequent scarring. Undi-
luted hydrogen peroxide use in open wounds should be
avoided because it inhibits wound healing and may cause
tissue necrosis. Normal saline with or without bacitracin
is the preferred irrigant for soft tissue trauma. Although
delayed closure may be necessary in some wounds caused
by edema and/or high-velocity injuries such as gunshot
wounds, in wounds with a significant amount of devital-
ized tissue, or because of other, more urgent medical and
surgical interventions that precede the treatment of head
and neck injuries, primary closure should be attempted,
if feasible. In the case of avulsed tissue or the inability to
reapproximate local tissue under minimal tension, local
flaps, regional flaps, or free tissue transfer may be needed
to restore tissues adequately to previous form and func-
tion.15 Wounds should be closed in layers, if possible, to
place minimum tension on the superficial skin closure
and aid in the eversion of skin edges to minimize scar
widening.16 Tension across a wound decreases blood flow,
which leads to necrosis of wound edges and increased
connective tissue growth in the proliferation phase, and
to elongation of scars in the remodeling phase.17,18
Skin flaps should be appropriately undermined so that
wound edges can be everted, which will minimize scar
depression.19
Meticulous attention to detail and gentle tissue han-
dling are important to optimize wound healing and mini-
mize scarring.1 A multivariate analysis has shown that
characteristics associated with suboptimal cosmetic
appearance following laceration and surgical incision
closure are associated tissue trauma, use of electrocau-
tery, incomplete wound edge apposition, and increased
wound width (healing by secondary intention).20 If per-
manent sutures are used for wound closure, they should
be removed in 5 days or less to prevent track marks.
Another option is to use fast, resorbing plain gut suture
(5.0 to 6.0). In a study that compared 5.0 or 6.0 nylon
sutures versus plain gut sutures for skin closure in a
population of pediatric patients who suffered lacera-
tions, no difference in infection or wound dehiscence
was found between the two groups; however, slightly
better cosmesis was found in the plain gut suture group.21
Similar studies,22 including a meta-analysis,23 have con-
firmed these results, demonstrating no difference in
long-term cosmesis, scar hypertrophy, infection rate,
wound dehiscence, and wound erythema or edema
between lacerations closed with nylon versus plain gut
suture. For scalp incision and laceration repair, the use
of staples as an alternative to suturing has been demon-
strated in a randomized control trial to reduce proce-
dure time significantly while not demonstrating any
difference in cosmesis by a blinded physician at 1 week
and 6 to 18 months postrepair.24
Adhesive bandages such as Steri-Strips (3M, Maple-
wood, Minn) should be used to reduce wound tension at
the time of closure and to reduce the need for long-term
suture placement in those wounds under increased
tension. The use of 2-octyl cyanoacrylate–based fast-
acting skin adhesives has been shown to be just as
effective as Steri-Strips in reducing hypertrophic scar for-
mation,25 although other study results have demonstrated
superior cosmesis in wounds dressed with Steri-Strips.26
FIGURE 22-4 The effects of a moist occlusion dressing on
stimulating more rapid epithelialization (left) than under a dried clot
(right). (From Brenner MJ, Perro SA: Recontouring, resurfacing,
and scar revision in skin cancer reconstruction. Facial Plast Surg
Clin N AM 7:469–487, 2009.)
A review comparing the use of tissue adhesives versus
standard wound closure in patients with traumatic lacera-
tions found that pain and procedure time were signifi-
cantly reduced in the tissue adhesive group and wound
dehiscence and erythema were significantly reduced in
the standard wound closure group; however, there was
no difference in final cosmesis or scar appearance
between the two groups.27
Desiccated and crusted wounds heal slower than those
kept moist.28 Epithelial migration follows a path of mois-
ture and humidity, even if this route is longer (Fig. 22-4).
This often requires more energy expenditure by the cell.
In addition, an apoptosis-mediated decrease in granula-
tion tissue has been shown to occur in vitro in flaps that
are covered postoperatively.29 Therefore, occlusive dress-
ings and antibiotic ointment use are recommended so
that epithelial migration proceeds in a direct and effi-
cient manner. The use of occlusive or semiocclusive
dressings has also been advocated as a means of promot-
ing wound healing. Commercially available dressings,
such as Tegaderm (3M), Opsite (Smith & Nephew,
London), or similar polyurethane dressings minimize
the amount of atmospheric oxygen that is absorbed
directly through an open wound30,31 and have been
shown to decrease epithelial closure time by as much as
50%.28,31-33 The moist environment is optimal for epithe-
lial migration, with minimization of connective tissue
formation, therefore expediting healing and reducing
scar formation. These effects, however, have not been
verified in a randomized control trial.34 Antibiotic oint-
ment should be applied to the wound until epithelializa-
tion occurs. Bacteria delay healing by direct cell damage,
prolonging the inflammatory phase of wound healing by
competing for oxygen; therefore, in addition to provid-
ing a moist environment, antibiotic ointment is benefi-
cial for reducing bacterial colonization.35
Wounds should be cleaned daily during the immedi-
ate postoperative period using a mixture of 50%
 Secondary Revision of Soft Tissue Injury CHAPTER 22 569

hydrogen peroxide and 50% water. Sunblock should be
applied to the area of wound closure to reduce irritation
and minimize the inflammatory response. The patient
should be instructed to massage the wound once epithe-
lialization occurs using a simple base cream twice a day,
10 minutes at a time.36,37 The effects of scar massage,
however, have been questioned.38 In addition, silicone
sheets or gels may be used after epithelialization occurs
and may assist in better scar maturation of hypertrophic
and keloid scars.39-44 Although a barrier, silicone sheets
do allow the passage of oxygen. It has been shown in an
animal model that silicone sheets cause hydration of
keratinocytes within the stratum corneum of the epider-
mis, which has a suppressive effect on the metabolism of
underlying fibroblasts and results in decreased capillary
activity, hyperemia, and collagen deposition, and there-
fore decreases dermal thickness and subsequent scar
hypertrophy.45 Oxygen tension, pressure, or silicone
leakage into dermis, however, has not been shown to be
mechanisms for silicone effectiveness.46-49 Furthermore,
silicone sheets have been found to improve pigmenta-
tion, vascularity, and reduce the height of scars after 3
months of postoperative use.50,51 Reduction of pain and
pruritus has also been demonstrated to be a benefit of
silicone sheets, but these benefits are not seen until after
6 months of use.52 In a study that used the Vancouver
Scar Scale to assess the effects of silicone gel, silicone gel
sheets, and allantoin in improving postburn scarring less
than 6 months from injury, the investigators found no
significant difference in the silicone gel and gel sheet
group, but there was a significant difference in improve-
ment when comparing the allantoin groups with the sili-
cone sheet and silicone gels group.53 All three groups
showed a significant improvement 6 months from base-
line. The effects of silicone sheet use have been shown
to last up to 6 months after removal; therefore, their
benefits are maintained once they are discontinued54
Onion extract, another popular topical treatment for
scars, has shown only to improve scar color while not
having an effect on scar height.55
PREOPERATIVE CONSULTATION
Detailed explanation of possible and realistic outcomes
at the initial encounter will help circumvent any unrea-
sonable expectations that the patient might have and
prepare the patient for the reality that further proce-
dures will be needed. Although the surgeon may have a
good idea of which scar revision procedure the patient
will need at the time of initial repair, it may not be until
weeks to months later, after scar maturation occurs, that
the surgeon will be able to formulate a definitive treat-
ment plan. Depressed scars tend to contract initially and
then relax as they mature, whereas hypertrophic scars
and keloids will often grow as the patient ages. On
follow-up examination, the surgeon should note scar
tension and adjacent tissue laxity of the scar while
attempting to predict the outcome of tissue rearrange-
ment. In addition, the patient’s medical history should
be revisited because much may be left out in the emer-
gent setting. Hereditary, vascular, metabolic, and immune
deficiencies may be detrimental to wound healing.
Finally, the patient must be compliant with postoperative
care. This not only includes local care to the wound, but
maintaining proper nutrition, because vitamin and trace
mineral deficiencies such as deficiencies of vitamin A, C,
E, zinc, and iron can be detrimental to wound healing.31,56
SCAR ANALYSIS
The purpose of scar analysis is to use a reliable and valid
measure for quick and efficient scar assessment, which
requires that the surgeon have a firm understanding of
scar terminology (Table 22-1).57 Documentation of a
standardized assessment is necessary for developing a
treatment plan and for serial evaluations. Photographic

TABLE 22-1 Scar Terminology

Scar Classification Features

Mature scar A light-colored, flat scar.
Immature scar A red, sometimes itchy or painful, and slightly elevated scar in the process of remodeling. Many
of these will mature normally over time, become flat, and assume a pigmentation that is similar
to the surrounding skin, although they can be paler or slightly darker.
Linear hypertrophic (e.g., A red, raised, sometimes itchy scar confined to the border of the original surgical incision. This
surgical or traumatic) scar usually occurs within weeks after surgery. These scars may increase in size rapidly for 3-6 mo
and then, after a static phase, begin to regress. They generally mature to have an elevated,
slightly ropelike appearance with increased width, which is variable. The full maturation process
may take up to 2 yr.
Widespread hypertrophic (e.g., A widespread, red, raised, sometimes itchy scar that remains within the borders of the burn
burn) scar injury.
Minor keloid A focally raised itchy scar extending over normal tissue. This may develop up to 1 yr after injury
and does not regress on its own. Simple surgical excision is often followed by recurrence. There
may be a genetic abnormality involved in keloid scarring. Typical sites include earlobes.
Major keloid A large, raised (>0.5 cm) scar, possibly painful or pruritic and extending over normal tissue. This
often results from minor trauma and can continue to spread over years.
Adapted from Mustoe TA, Cooter RD, Gold MH, et al: International clinical recommendations on scar management. Plast Reconstr Surg 110:560–571 ,
2002.
570 PART III Management of Head and Neck Injuries

assessment using standardized lighting, spacing, posi- Vancouver scale, but relies on patient opinion (Table
tioning, camera settings, and background is beneficial 22-3).70 A number of other subjective and objective assess-
for initially assessing and serially tracking the progress of ment tools and devices have been reported in the
the scar maturation.58-65 Imaging software can be used to literature.71-76 Most indices include the clinical assess-
analyze, measure, and follow scars and can aid in surgical ment of vascularization, pigmentation, thickness, surface,
planning by almost performing the surgery before the pliability, size, reflection, distortion, texture, functional
actual procedure.66 Immediate preoperative and postop- deficits, and pain. These characteristics are often a clue
erative photographs should be taken.67 It is useful to to the cause of the scar. For example, postinflammatory
review photographs after the patient has left. It is then hyperpigmentation is often seen in scars associated with
that the surgeon will often notice subtle abnormalities acne, inherited and acquired diseases, temperature
that could affect the management of the scar. Also, pho-
tographs will document changes in following appoint-
ments often overlooked by the patient and surgeon.
Several factors must be considered when developing BOX 22-1 Factors Influencing Selection of Technique in
a treatment plan for scar revision, such as scar width, Scar Revision
length, relationship to relaxed skin tension lines (RSTLs),
neighboring anatomic landmark distortion, tissue loss, Medical comorbidities
scar type, patient age and race, scar location (visible Scar width
versus nonvisible with clothing), skin type (Fitzpatrick), Scar length
Relationship to RSTLs
tissue tension and laxity, and local tissue reservoirs (Box
Distortion of anatomic landmarks
22-1). Figure 22-5 illustrates a basic template for the
Tissue or volume deficit
surgeon to use for scar revision, but this must be tailored Type of scar
to the specific patient and scar. Age of patient
The most widely used scarring index is the Vancouver Race of patient
Scar Scale, which gives the surgeon an objective measure Patient expectations
of burn scars and assists in prognosis and management. Scar location
Although some have described it as a valid research tool Skin type (Fitzpatrick)
with good interrater reliability (Table 22-2),68 others have Local tissue laxity
not.69 Another scale, the patient and observer scar assess- Adjacent tissue reservoir
ment, has an objective component comparable to the

Scar revision algorithm

Scar

Hypertrophic Wide or
Scar maturation
or keloid malpositioned

Excise Moderate width Large width

Large Small

Distorted landmark Serial excision Local flap or graft

Excision Steroid injection No
or interferon Yes
Within RSTL
No
Pressure
or radiation Yes
Reposition scar Scar contracted
or gel sheeting
Yes
> 1 cm No Z-plasty
Depressed Effacement

G-broken line
Slight elevation or W-plasty

Collagen injection
Alloderm Dermabrasion or
Fat/dermis graft Shave excision laser resurfacing

FIGURE 22-5 Flow diagram for management of optimal scar revision. (Adapted from Thomas JR. Facial scars. In Thomas JR, Holt GR,
editors: Facial scars: Incision, revision, and camouflage, St. Louis, 1989, CV Mosby.)
 Secondary Revision of Soft Tissue Injury CHAPTER 22 571

extremes, sites of allergic reaction, radiation, and sun

TABLE 22-2 Vancouver Scar Scale exposure.77 Hypopigmentation often has iatrogenic
causes, such as chemical peel, dermabrasion, laser resur-
Scar Characteristic Rating facing or, with burns, trauma and infection.78,79
Vascularity Scar contour exists on a continuum, from the
Normal 0
depressed scar to the hypertrophic scar and keloid.
Hypertrophic scars typically remain confined to the
Pink 1
borders of the inciting injury and usually retain their
Red 2 shape, whereas keloids are defined as scars that extend
Purple 3 beyond the borders of the original wound, do not regress
Pigmentation spontaneously, and tend to recur following excision.80
Normal 0 Keloids present a special problem in treatment (see
Hypopigmentation 1 later). Scar depression often results from excessive
tension across the wound. Scar texture and reflection are
Mixed 2
mainly concerns of aesthetics. Scar contracture may have
Hyperpigmentation 3 functional and aesthetic ramifications in the head and
Pliability neck. Pertinent to the craniomaxillofacial skeleton, scar
Normal 0 tethering to underlying fascia, muscle, or bone may
Supple 1 occur, resulting in aesthetic and functional deficits,
Yielding 2 mainly the failure to animate or move the face and neck.
Firm 3
Painful scars, especially those associated with burns,
can severely debilitate the patient. The patient may
Ropes 4
present with allodynia, hyperesthesia, hypoesthesia, or
Contracture 5 dysesthesia, often caused by tissue adhesion, surround
Height soft tissue damage, underlying skeletal damage, or
Flat 0 neuroma or perineural scar formation. An increase in
<2 mm 1 nociceptive nerve fibers following burn injury is associ-
2-5 mm 2 ated with increased cutaneous innervation and increased
density of certain neuropeptides, and may be responsible
<5 mm 3
for chronic pain in patients with burns.81-83 Excision of

TABLE 22-3 Patient and Observer Scar Assessment Scale

OBSERVER SCAR ASSESSMENT SCALE

Normal Skin 1 2 3 4 5 6 7 8 9 10 Worst Scar Imaginable
Vascularization 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊
Pigmentation 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 Hypo 䊐
Mix 䊐
Hyper 䊐
Thickness 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊
Relief 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊
Pliability 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊

Total score, Observer Scar Scale

PATIENT SCAR ASSESSMENT SCALE
No, no Complaints 1 2 3 4 5 6 7 8 9 10 Yes, Worst Imaginable
Is the scar painful? 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊
Is the scar itching? 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊
No, As Normal Skin 1 2 3 4 5 6 7 8 9 10 Yes, Very Different
Is the color of the scar different? 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊
Is the scar more stiff?
Is the thickness of the scar different? 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊
Is the scar irregular? 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊 䊊

Total score, Patient Scar Scale

Adapted from Draaijers LJ, Tempelman FR, Botman YA, et al: The patient and observer scar assessment scale: A reliable and feasible tool for scar
evaluation. Plast Reconstr Surg 113:1960–1965, 2004.
572 PART III Management of Head and Neck Injuries
this tissue, in addition to reconstruction using local,
regional, or distant flaps, may relieve pain in some
patients. Scars in the midline are less likely to produce
pain, but may cause more scarring because of increased
tension.84
Elevated scars present in different patterns, depend-
ing on the thickness and integrity of the remaining
dermal wound edges. Hypertrophic scars are dome-
shaped and have a thin epidermis, whereas partially avul-
sive or oblique wounds result in contraction at the base
of the wound, creating an elevated and inclined scar. As
the scar matures, wound edges of different dermal thick-
ness and elevation result in elevated scars with gradual
step-offs; misaligned wound edges of the same dermal
thickness produce elevated scars with abrupt step-offs.
Depressed scars may be related to underlying tissue loss
or to increased tension across the wound, resulting in
atrophy of the underlying dermis, which results in a
smooth and shiny scar.
INCISION PLACEMENT
Understanding of the natural lines of tension of the head
and neck is imperative for proper placement of skin inci-
sions and to optimize final scar appearance (Fig. 22-6).
Dupuytren first observed that an oval wound was created
when a round instrument punctured the skin.85 Karl
Langer, an anatomist, further studied this change in
facial skin configuration in cadavers in rigor mortis and
postulated that intrinsic skin tension occurred along pre-
dictable lines of cleavage.86 Later called Langer’s lines,
these lines of tension became the basis for elective facial
FIGURE 22-6 The relaxed skin tension lines of the face. (From
Kaminer M, Arndt K, Dover J, et al: Atlas of cosmetic surgery, ed
2, St. Louis, 2009 Saunders.)
skin incisions for the next century. Langer’s studies were,
however, limited because they were performed in cadav-
ers, showing the effects of rigor mortis. Kraissl et al pre-
ferred lines perpendicular to the action of the underlying
muscle.87-89 Borges has studied this concept in vivo and
distinguished lines that follow furrows when the skin is
relaxed from those that are produced by pinching the
skin, and found that these lines are distinct from wrin-
kles, creases, and Langer’s lines and that the number of
lines and spacing varies among individuals.90,91 Numer-
ous other lines of tension have been described in the past
by Cox, Webster, Stark, and Ogilvie, Kocher, and Kazan-
jian, among others.87,92 These lines of tension would be
called Borges’ lines, or RSTLs. They follow furrows
formed on relaxed skin. It has been demonstrated that
placing incisions in the direction of RSTLs will produce
more aesthetic outcomes with minimal scarring. RSTLs
and wrinkles caused by aging may not be in the same
location. Wrinkles are the change in overlying skin as a
result of muscle pull over time. Conversely, RSTLs of the
face often run perpendicular to the underlying muscle
and, in the neck, they usually run perpendicular to areas
of flexion (i.e., RSTLs run horizontally on the forehead,
perpendicular to the vertical frontalis muscle). Examples
of wrinkles that do not coincide with RSTLs include gla-
bellar lines, crow’s feet, and bunny lines. An exception
to this rule is in the area of the circular orbicularis oculi
underlying the eyelids, where RSTLs run horizontal and
parallel to the muscle because of the rigid scaffold of the
tarsal plate. In older patients, RSTLs often run parallel
with the natural creases and wrinkles of the face. RSTLs
are determined by having the patient go through a series
of facial expressions (e.g., smile, frown, laugh, squint)
and then pinching the skin. The line where the longest
straightest line results is the RSTL.93 RSTLS should be
determined prior to administration of local anesthesia.
The lines of maximum extensibility (LMEs), also
known as antitension lines (ATLs), run perpendicular to
RSTLs. When incisions are placed perpendicular to
RSTLs, an S-shaped scar will develop. Pinching the skin
perpendicular to RSTLs produces humps; incisions par-
allel to this plane should be avoided. When the areas is
too distorted for assessment, the contralateral side may
be used.94 Incisions made parallel to the RSTL will
produce a narrow scar under minimal tension, as opposed
to those placed parallel to the LME or ATL, which will
be under maximum tension and will have a significant
propensity to widen and produce broad unsightly scars.
A major factor in deciding to undertake scar revision is
whether scars are located perpendicular to RSTLs or in
ATLs. Note that the ultimate goal of scar revision is to
orient the scar parallel to RSTLs.
FACIAL AESTHETIC UNITS
In trauma and reconstructive facial surgery, the face can
be divided into facial aesthetic units.95 Gonzales-Ulloa
initially described 14 aesthetic units.96-99 These include
the forehead, right and left cheeks, nose, right and left
upper lids, right and left lower lids, right and left ears,
upper lip, lower lip, mental region, and the neck (Fig.
22-7). These aesthetic units can be further classified into
subunits based on skin thickness, color, elasticity, and
 Secondary Revision of Soft Tissue Injury CHAPTER 22 573

1B 1A 1A
1C 1B 1C
3B 3B
3C 3D 3C 3D
3A 2 3A
4B 2
4A 4B
8 8 4A
5 5
4C 5C 4D 4C 5C
4D 6B 6B
6A 6A
7
7

9 9

A B

2C 5B 5A 5B
2D 2D 5C
FIGURE 22-7 A, Frontal and profile (B) views of the
6B face. C-E, Nasal, lip, and ear units of the face,
2F 2A 2F
6A respectively. 1, Forehead. Subunits—A, central;
2E 2E
2B B, lateral; C, eyebrow. 2, Nasal. Subunits—A, tip;
C
D B, columellar; C, dorsal; D, right and left dorsal
side wall; E, right and left lateral alar base; F, right
and left alar side wall. 3, Periorbital. Subunits—
A, lower eyelid; B, upper eyelid; C, lateral canthal;
8A 8C
8B
D, medial canthal. 4, Cheek units. Subunits—
A, medial; B, zygomatic; C, lateral; D, buccal.
8D
5, Upper lip unit. Subunits—A, philtrum; B, lateral;
C, mucosal. 6, Lower lip. Subunits—A, central;
B, mucosal. 7, Mental. 8, Auricular. Subunits—
8E A, helical; B, antihelical; C, triangular fossa;
E D, conchal; E, lobe. 9, Neck.

underlying structural support. Additional subunits within
each facial unit have been described that delineate
natural break lines that allow the surgeon to conceal a
scar or skin graft placement100 (Fig. 22-7). For example,
the nose can be broken down into the nasal bridge, side-
wall, tip, ala, soft triangle, and columella.101 The upper
lip is divided into the philtrum column, nostril sill, alar
base, and nasolabial crease102 Placement of incisions at
the seams of these units or subunits, or at facial midline
will produce the least perceivable scars.
The division of facial aesthetic units is based on natural
breaks formed by shadows, folds, hair, and on skin thick-
ness, color, and texture. Facial restoration should respect
the boundaries of facial units and subunits. Any restora-
tion that includes two or more units may result in aes-
thetic and functional deficits; superior cosmetic results
are often obtained when treatment is rendered to an
entire aesthetic unit rather than to an isolated scar within
a unit. An example would be when planning for derm-
abrasion as revision treatment to a scar of the nose. In
this case, the entire nasal unit should be treated to mini-
mize the perception of residual scarring and the final
scar will blend better with the adjacent units and not
appear as a stand-alone patch.
When planning excisional scar revision, care should
be taken to limit the revision to within one facial unit.
For example, when revising a scar of the cheek, the
revised procedure should not encroach on the upper lip
or lower eyelid unit. Facial units are important in onco-
logic skin resection and in regard to tissue avulsion in
trauma, when it is important to remove the entire unit
or subunit, even if extension of the incision is necessary.
The subsequent reconstruction, whether it be local or
regional flaps or free tissue transfer, should span the
entire facial unit or subunit. When the avulsed or excised
area of tissue encompasses an entire unit and subunit,
the final outcome blends with surrounding tissues and is
less conspicuous.1,102
SCAR TYPE, PATTERN, AND COLOR
It is important for the surgeon to consider the type and
pattern of scar when considering surgical revision, which
also may give an indication about the type and extent of
injury. For example, flat, linear, or curved scars often
result from low-energy injuries and are more easily
treated than depressed scars and scars resulting from
high-energy avulsive tissue loss. Wide scars caused by
increased wound tension or tissue loss are often flat and
574 PART III Management of Head and Neck Injuries
faded and are difficult to treat because of a texture mis-
match with surrounding tissues. These scars often need
reexcision and closure. Some hypertrophic scars or
keloids may benefit from excision or other nonsurgical
treatment such as intralesional steroid injection, chemo-
therapy, cryotherapy, radiation, laser, or silicone sheet
treatment.80 Atrophic or volume-depleted scars often
result from wounds not closed primarily, in stellate scars,
with inappropriate approximation of wound edges in
primary closure, or in deep abrasions. These scars often
require dermal fillers, including autogenous materials
such as fat transfer103,104 and synthetic fillers.1
Scar camouflage is difficult in widened scars because
of their smooth shiny surface, which reflects light differ-
ently than adjacent tissues. Similarly, scars that cross mul-
tiple facial units and subunits are challenging to treat
because they are usually have varying skin texture, thick-
ness, and histologic makeup. For example, nasal skin is
different than skin of surrounding facial subunits con-
taining a thicker dermis and higher density of sebaceous
glands; therefore, the nearest skin is the best donor for
reconstruction.101
Red scars are often immature and turn whiter than
surrounding tissues once fully matured. Erythematous
scars seen in the early stages of scar maturation are not
good candidates for revision unless the redness is con-
fined to the scar itself. The color of white scars may be
the only concern of the patient; these are often treated
successfully with tattooing, making them appear similar
to surrounding skin.
SCAR LOCATION
The location of the scar should be considered before
developing a treatment plan for scar revision. Facial units
such as the forehead and nose are well supported by the
underlying skeleton and tend to result in better out-
comes than other facial units. Areas with multiple vectors
of muscle pull, such as the medial canthus, lateral cheek,
and submandibular area, often result in suboptimal out-
comes. Scars with similar adjacent local skin color, thick-
ness, and texture that are easy to mobilize and transfer
without distorting the donor site area are likely to have
better outcomes. A discussion of specific local and
regional flaps is beyond the discussion of this chapter.
SUN-REACTIVE SKIN TYPE CLASSIFICATION
Fitzpatrick developed the sun-reactive skin type classifica-
tion to describe the degree of skin reaction after sun
exposure105-107 (Table 22-4). Although developed as a
guide for the treatment of skin rejuvenation procedures,
this classification scheme is useful when choosing the
correct management of the traumatic scar. Patients with
a higher classification will often experience inflamma-
tory changes such as dyspigmentation after soft tissue
injury. Although hyperpigmentation is usually tempo-
rary, hypopigmentation is often the permanent result of
a mature scar. Furthermore, patients with a very fair skin
(Fitzpatrick classification type I or II) will often respond
better to laser resurfacing, whereas patients with very
dark skin (Fitzpatrick type IV or V) may benefit from
more conservative treatment, such as superficial chemi-
cal peels and scar excision.108,109
TABLE 22-4 Fitzpatrick Classification of Sun-Reactive
Skin Type
Skin Type Skin Color Sunburn Tan
I White Always Never
II White Usually With difficulty
III White Mild Average
IV Moderate Rarely Easy
brown
V Dark brown Very rarely Very easily
VI Black Never Always
SKIN AND AGING
A patient’s age will often guide the surgeon to the timing
and type of treatment chosen for scar revision. Older
patients should be evaluated for the risks versus benefit
in any surgical procedure in the context of complex
medical comorbidities. Glogau has developed a classifica-
tion for skin wrinkling related to aging as a guide to
treatment for each skin type (Table 22-5). This should be
taken into consideration before undertaking scar revi-
sion procedures, because skin resurfacing techniques
can be chosen to match the depth of wrinkles and degree
of wrinkling.110
It has been recommended that children have a higher
tendency for scar widening than adults and should
undergo scar revision after puberty because of a pro-
longed and exuberant inflammatory response, increased
skin tension, diminished skin and dermal thickness, and
higher concentration of collagen and elastin,.111 Chil-
dren past the age of puberty are more likely to cooperate
with treatment and postoperative care than their younger
counterparts. Severe psychological or functional impair-
ment secondary to scar formation, however, may warrant
earlier treatment.
TIMING OF SCAR REVISION
Experience has shown that in general, the appearance of
most scars tends to improve spontaneously after a period
of maturation during the first year after injury, after
which time the appearance of the scar stabilizes and
surgical revision may be considered.112,113 However, scars
oriented perpendicular to RSTLs or those associated
with functional impairment may be revised earlier than
1 year on an individualized basis.114,115
Early scar revision may be undertaken as early as 4
weeks when there is severe functional impairment, such
as salivary and lacrimal gland obstruction, lip incompe-
tence, or lagophthalmos with corneal exposure. Early
scar revision may also be advisable in well-localized scars
sustained from low-energy injuries in which adjacent skin
damage is minimal. Although a delay in scar revision of
at least 6 months is generally recommended for most
adult scars, high-energy injuries may continue to remodel
and mature over a longer period of time, and delay for
12 months may be advisable.116
Interventions such as dermabrasion and shave exci-
sion may be performed as soon as 4 weeks from the initial
 Secondary Revision of Soft Tissue Injury CHAPTER 22 575

TABLE 22-5 Glogau Classification of Photoaging

Group Classification Typical Age (yr) Description Skin Characteristics

I Mild 28-35 No wrinkles Early photoaging, mild pigmentary changes no keratosis, minimal
wrinkles, minimal or no makeup
II Moderate 35-50 Wrinkles in motion Early to moderate photoaging, early senile lentigines visible, keratoses
palpable but not visible, parallel smile lines beginning to appear, usually
wears some foundation
III Advanced 50-60 Wrinkles at rest Advanced photoaging, obvious dyschromia, telangiectasia visible
keratosis, wrinkles even when not moving, always wears heavy
foundation
IV Severe ≥60 Only wrinkles Severe photoaging, yellow-gray color of skin, prior skin malignancies,
wrinkled throughout, no normal skin patient age, cannot wear
makeup—“cakes and cracks”

or regional flaps, or free tissue transfer may be indicated

BOX 22-2 Steps in Scar Revision
1. Shave excision (for elevated scars)
• Serial scar excision
2. Tissue rearrangement
• W-plasty
• Z-plasty
• Geometric broken line closure
3. Surface retreatment
• Dermabrasion/microdermabrasion
• Chemical peels
• Laser (CO2,2, erbium : YAG, 585-nm flashlamp-pumped
PDL)
wound repair, based on the high level of fibroblastic
activity during this period. Because dermabrasion itself
causes erythema, early intervention may overlap with ery-
thema from initial repair, leading to less total time of
erythema for the patient. For hypertrophic scars and
keloids, steroid injections may be considered as early as
3 weeks and may be given at the time of scar revision.
Cigarette smoking, isotretinoin, and vitamin E use are
injurious to wounds and scar revision should be delayed
until they have been discontinued.117
SURGICAL OPTIONS
Scar revision can be broken down into three different
treatment modalities—scar excision, tissue rearrange-
ment, and surface treatment (Box 22-2). The selection
of treatment should be based on the individual scar and
on the needs and expectations of the patient. For
example, conservative treatment may be warranted for a
demanding patient with unrealistic expectations. Narrow
scars parallel to RSTLs may have distracting features such
as surface discoloration and texture irregularities. These
scars will often benefit from surface treatments. Longer
scars, which vary more than 35 degree from neighboring
RSTLs and have a local tissue reservoir, may be improved
with tissue rearrangement such as W-plasty or geometric
broken line excision and closure (GBLC). Z-plasty, local
if neighboring tissue reservoirs are deficient or if ana-
tomic structures and landmarks would be distorted by
closure.
GENERAL PRINCIPLES OF LINEAR SCAR REVISION
The first step in any scar revision procedure is to examine
skin thickness, elasticity, texture, hair growth, and RSTLs.
A fine-tipped marking pen should be used to plan the
incision, which should be measured and remeasured as
many times as necessary before the skin is incised. Care
should be taken to avoid excess tension or forceps com-
pression at wound edges because this might cause tissue
slough because of compromised blood flow to flap
margins and distort adjacent landmarks, ultimately
causing hypertrophic or widened scars.
Most facial incisions may be made with a no. 15 or no.
11 blade on a no. 9 knife handle. The no. 11 blade is the
most useful for straight cuts; these should be made per-
pendicular to the skin in a sawing-type motion, with the
tip of the blade used to make initial incision. The handle
of the blade is then brought down toward the skin so that
the belly of the blade cuts the middle part of the incision.
Finally, the blade handle is brought up again so that the
tip finishes the incision. This technique ensures that skin
and subcutaneous layers are incised evenly throughout
the entire incision. If incising a scar, the blade should be
beveled outward (Fig. 22-8A). This aids in creating a
plane for undermining skin, allowing eversion of the
wound edges and minimizing scar depression. The skin
at the ends and sides of the incision should then be
undermined with a no. 15 blade or curved scissors at least
2 cm in the subdermal plane to avoid motor nerves of
the face (see Fig. 22-8B). Undermining the scalp will not
aid in closure because of the tensile strength of the galea
aponeurosis. Galeotomies, however, may assist with mobi-
lization and eversion of scalp tissue.
Primary closure should be achieved, whenever possi-
ble. Healing by secondary intention may be advisable in
some cases, however, such as the lateral canthi of the
eyes, where skin is thin and well-contoured and is subject
to constant motion because of lid closure. To avoid
bunching (dog ear) at wound edges, the principle of
halving should be used, whereby the first suture is placed
576 PART III Management of Head and Neck Injuries
Beveled
Vertical
Beveling outward from lesion when creating skin incision
A
Undermining skin with skin
hook and no. 15 blade
Undermining skin with forceps
and scissors
B
FIGURE 22-8 A, Beveling the blade outward when excising a scar.
B, Undermining skin should be done with a skin hook and no. 15
blade or forceps and scissors.
at the center of the incision and the next two are placed
at the center of the remaining halves (Fig. 22-9A). Con-
tinuing this down the length of the skin margins will
close the wound with equal tension and eversion through-
out. When incisions are not of equal length and shape,
the principle of equalizing edges should be used (see Fig.
22-9B). In this technique, a Burow’s triangle is removed
from the longer skin flap and closed primarily to make
the two primary skin flaps equal in length.
Meticulous attention to proper suturing technique is
important for successful outcomes. A simple stitch pro-
vides minimal wound eversion and scant relief of wound
tension, and should be avoided in the face. Alternatively,
a mattress suturing technique is best for ensuring a
tension-free wound closure, with eversion of the skin
edges. The suture needle should be angled outward from
the skin edge and the knot tied as far as possible from
the wound (Fig. 22-10A). The vertical mattress suture is
performed by placing the innermost suture first while
holding up the wound edge, causing eversion of the skin
flap. The wide suture should be thrown next. There are
two types of vertical mattress sutures, the Donati and
Allgower types (see Fig. 22-10B). Bolsters of silicone
Principles of halving
1 2
3 4
A
Equalizing length of edges with a Burow’s triangle
1 2
3 4
B
FIGURE 22-9 A, The principle of halving is used to avoid a
standing cone deformity at the end of the incision. B, When an
incision is not of equal skin flap proportion at both ends, a triangle
is removed from the longer skin flap and closed primarily, making
skin flaps of equal size.
tubing or swabs may be placed under the knots of the
vertical mattress to minimize tension (see Fig. 22-10C).
A simple interrupted (see Fig. 22-10D) or, preferably, a
Gilles half- buried corner stitch should be used (see Fig.
22-10E) for tacking wound corners, The Gilles half-
buried stich is performed by placing a subcutaneous
suture in the corner flap, finishing transcutaneously in
the opposing skin edge. The most useful stitch for reliev-
ing skin tension and everting wound edges, however, is
the running buried subcuticular stich. However, care
must be taken to avoid tension and skin edge vascular
compromise ( see Fig. 22-10F). It should be noted that a
running subcuticular suture does not relieve tension
from wound edges like a simple subcuticular stich. Pref-
erably, a monofilament absorbable suture on a small half-
curved reverse cutting needle should be used. The stich
should be placed while everting the skin edge with a skin
hook at the middle finger of the surgeon and reaching
the suture back under the dermis 2 to 3 mm from the
wound edge. The knot should be buried. The skin should
then be closed with fast-absorbing gut or monofilament
to align the depth of the two skin flaps. Skin staples
provide wound eversion, are positioned above the level
of the skin when placed, and are useful for scalp and
neck defect closure (see Fig. 22-10G).
 Secondary Revision of Soft Tissue Injury CHAPTER 22 577

Vertical mattress suture Vertical mattress suture

(Donati type) (Allgöwer type)

B C

Corner stitch Corner stitch Subcuticular

D E F

Staple

G
FIGURE 22-10 A, For simple sutures, the needle should be inserted at an outward angle from the incision, with the knot tied as far away
from the incision as possible. B, To create more eversion of skin edges in a vertical mattress suture, a bolster may be placed between
the knot and the skin (C). D, To create maximum skin eversion, the Gilles half-buried stich is recommended. E, However, a simple
interrupted corner stich may be used for a triangular skin flap. F, A subcuticular stich is useful for creating skin eversion. G, Staples
provide good wound eversion for scalp and neck closure.

3 : 1 to limit dog ears (Fig. 22-11). It may be straight or

PROCEDURES
Scar Excision
The fusiform, or elliptical, incision is the most common
incision used in the head and neck. It should be placed
within the RSTL, with a length-to-width ratio of 2.5 : 1 to
crescent-shaped, but should always follow a long axis
parallel to RSTLs and be limited to scars shorter than
2 cm.115,118,119 The only exception to this is the lower
eyelid, where a crescent-shaped incision may leave an
unsightly scar. It should be used for short anti-RSTL
578 PART III Management of Head and Neck Injuries

FIGURE 22-12 A, The skin edges at the end of the fusiform

incision should be no more than 30 degrees apart. B, If a larger
FIGURE 22-11 Fusiform, or elliptical, excisions are useful for small
angle is used, the risk of a standing cone deformity is more likely.
scars that lie parallel to RSTLs.
(From Robinson J, Hanke CW, Siegel D, et al: Surgery of the skin,
ed 2, Philadelphia, 2010, Mosby.)

scars, achieving a more favorable reorientation of the

lesion, or for short but widened or depressed scars. Inter-
nal angles of the planned excision may not exceed 30
degrees (Fig. 22-12).
An abundance of subcutaneous tissue in present in
areas such as the ear and nose because of loose cartilage,
which leads to loss of surface definition and results in
unpredictable wound healing. In these areas, the surgeon
may choose to debulk, inject steroids, or use local skin
flaps to obtain an optimal result as an alternative to stan-
dard incisions. Furthermore, the standard elliptical exci-
sion may lead to bunching or a standing cone deformity
at the end of a wound, which results from rotation of skin
around a pivot point. These can be predicted and pre-
vented by the excision of excess tissue parallel to RSTLs FIGURE 22-13 An M-plasty may be used to decrease the length of
(Burow’s triangle) that allows the cone to lie flat (see Fig. the incision needed, but requires additional incisions. (From
22-9B). If a shorter incision is needed, an M-plasty can Kaminer M, Arndt K, Dover J, et al: Atlas of cosmetic surgery, ed
be created at the end of the incision to decrease the 2, St. Louis, 2009 Saunders.)
volume of healthy tissue removal, with the additional
incisions functioning as Burow’s triangles (Fig. 22-13).
The limbs of an M-plasty should be less than 30 degrees creep, which involves elongation of the skin from con-
to avoid cone deformities; closure is performed using a stant tension over time.120 This is distinguished from bio-
V-Y maneuver. This shortens the scar length along its logic creep, which involves the generation of skin from
central axis and should be used when a longer fusiform constant tension over time and only occurs with tissue
excision would encroach along a landmark, such as the expansion techniques.121
lateral cantus or the vermillion. The compromise is that Initially described by Morestin,122 the technique of
an M-plasty requires additional incisions. serial excision is especially useful for larger scars closed
primarily with a skin graft, as well as burn injuries, and
Serial Excision uses the skin’s ability to stretch and accommodate. Serial
Serial excision is a technique that can be used when a excisions can be used to move scars to or away from a
scar is too large to allow closure of the surrounding skin more or less conspicuous facial unit or area, such as junc-
in one stage. Serial excision allows for the recruitment tions of facial units, hair lines, or RSTLs. Its goal is to
of adjacent skin through a process called mechanical recruit adjacent normal tissue to cover a defect in stages.
 Secondary Revision of Soft Tissue Injury CHAPTER 22 579

Skin
tension
lines
a
b
a'
Scar
b'
Outline of
W-Plasty

FIGURE 22-14 A W-plasty may be used for scars with a long axis more than 35 degrees from the RSTLs.

Serial excision should only be used on scars without
any suspicion of malignancy and should be performed
as early as possible, because scar elasticity decreases with
time. All incisions should be kept within the previous scar
and wounds should be undermined and closed under
minimal tension.
The initial excision removes an ellipse from within the
body of the scar, or from along one of its edges. Wound
margins are undermined and a portion of the scar is
excised after advancement and the wound is closed.123
The skin of the wound is allowed to stretch for 8 to 12
weeks and then the procedure is repeated. For the last
excision, the remaining scar is excised and native skin
margins are approximated in a straight line, W-plasty, or
broken line closure. One drawback of this technique is
that it may lead to wide and atrophied scars caused by
the tension across the wound.124 A variety of other serial
excision techniques have been described in the litera-
ture.120,125-127 One technique divides the initial scar into
four segments along RSTLs; two of the opposing seg-
ments are excised. The remaining flaps are advanced in
a sigmoid-shaped ellipse and the remaining incision is
closed in a Z pattern. This is repeated as needed and a
fusiform excision is used to for final closure.
W-Plasty
Borges initially proposed the running W-plasty, so-named
for it resemblance to the letter W128,129 (Figs. 22-14 and
22-15). The benefit of this technique is that it will break
up a long scar into smaller ones that are more aligned
parallel to RSTLs, thus improving its overall appearance.
This technique is indicated for long scars with a long axis
more than 35 degrees from the RSTL; it is particularly
useful to camouflage vertical linear scars of the forehead
and temples, linear horizontal scars of the chin and
cheeks, and scars located along a wrinkle. W-plasty is
optimal around nonanimated facial units such as the
forehead (Fig. 22-16), but is contraindicated for scars
with a long axis less than 30 degrees from the RSTL, and
should be avoided around the eyelids, nose, vermillion,
and neck (Fig. 22-17).130 Furthermore, the use of W-plasty
is not recommended in the presence of excess tissue
tension or distorted landmarks, and in scars involving
two different skin types, such the cheek and lower eyelid.
Advantages of the W-plasty technique include reduced
tension and simple design and execution, and it can be
used for nonlinear scars. Unlike a Z-plasty, it does not
lengthen a scar. For long linear scars, a GBLC is prefer-
able to the W-plasty, because the repeating W pattern is
readily noticeable by the eye.
Technique. Standard marking for a W-plasty is shown
in Figure 22-18. The patient’s skin should be thoroughly
cleaned and degreased with alcohol or acetone to remove
surface oils and should be allowed to dry completely
before marking the skin to prevent smearing of the ink.
Then, 1-cm segments are marked perpendicular to the
580 PART III Management of Head and Neck Injuries

A B

C D
FIGURE 22-15 Reconstruction of post-traumatic scalp avulsion with secondary cicatricial alopecia, brow asymmetry, and hairline
deformity. Patient was managed with tissue expansion, W-plasty excision, local rotation-advancement flaps, and brow lift. A, Preoperative
appearance. B, Tissue expander in place. C, Outline of W-plasty. D, Postoperative appearance 1 year following surgery.

A B
FIGURE 22-16 Depressed post-traumatic forehead scar in 27-year-old woman treated with W-plasty excision. A, Preoperative
appearance. B, 1 year postoperatively.
 Secondary Revision of Soft Tissue Injury CHAPTER 22 581

long axis of the scar and the limbs are drawn using these
marks and the RSTLs as a guide. The ideal length of
W-plasty limbs should be approximately 5 to 8 mm. If the
limbs are smaller than this, they become more noticeable
and the goal of camouflaging is lost. Limbs longer than
7 mm become aesthetically unsightly. After prepping and
draping the area, and atraumatically injecting local anes-
W
thetic, a no. 11 blade is used to excise the limbs. The
limbs are incised in a punch manner, directing the tip of
the blade toward the scar to help prevent undesired
Z Z damage to healthy tissue. No part of the pattern should
Z Z cross the scar. A running set of triangles, alternating with
their base toward and away from the scar, should be
drawn out. The angle between limbs should be between
W W 50 and 60 degrees and oriented as closely as possible to
Z Z
the RSTLs. Wider angles will not appreciate the elasticity
throughout the excision seen with more acute angles.
Z
Narrower angles compromise blood supply to the tip of
the triangle. To avoid a repeating pattern, the surgeon
W should slightly vary each triangle. Each proposed limb
incision should be marked as close to the scar as possible
to minimize tissue loss. Triangles along the scar should
have their points facing the midbase of the triangles on
the other side. It is easiest to begin marking each incision
centrally on one side of the scar and then its counterpart
on the other side of the scar in sequence. Unlike doing
all of one side and then the other, this maintains wound
tension and allows more efficient excision. This should
FIGURE 22-17 W-plasty (W) should be used around nonanimated continue toward the end of the incision, finishing with a
facial areas, whereas Z-plasty (Z) is more appropriate around small right triangle with its base perpendicular to the
mobile facial landmarks. long axis at the end of the scar. Incision design in this
manner will create a 30-degree closing angle of the
wound and help minimize a standing cone deformity.
Hemostasis should be obtained before closure. In
longer wounds, it may be useful to place several tempo-
W-plasty rary skin sutures to align flap edges before placing dermal
sutures. Often, a fusiform incision may be needed at the
end of a W-plasty to reorient any anti-RSTL lines that
have formed during closure or to excise any standing
cone deformity.131 It is essential to evert wound edges at
the dermal layer with interrupted absorbable sutures
placed at the midpoint of the tips of each point of the
triangles (Fig. 22-19). Alternatively, running subcuticular
monofilament absorbable sutures may be used. Skin may
be closed with running absorbable or nonabsorbable
sutures, with careful attention to evert wound edges.
Postoperative wound care (see earlier) should be used.
To prevent scar widening, Steri-Strips may be placed
across the wound for 4 to 6 weeks after surgery because
wound tensile strength progressively increases during
this period. Dermabrasion or laser resurfacing may
usually be performed 6 to 8 weeks after the W-plasty
surgery to blend the scar with adjacent tissues.132
Z-Plasty
There is debate in the literature about who reported the
Relaxed skin tension lines first Z-plasty. Many credit Denonvilliers with describing
A B the first Z-plasty in 1854 for a case of lower eyelid ectro-
pion in a patient following a shrapnel injury.133 Others
FIGURE 22-18 A, Markings for W-plasty should be in 1-cm argue that the first true Z-plasty was reported by Berger
segments drawn perpendicular to the long axis of the scar, with in 1904.134 The goal of Z-plasty is to take a scar perpen-
limbs drawn parallel to RSTLs (B). dicular to RSTLs and align the axis of the central
582 PART III Management of Head and Neck Injuries
Scar tissue
A tip increases as the angle decreases. Therefore, the angle
B however, can vary between 30 and 90 degrees. Generally,
C a no. 11 blade should be used in a punchlike fashion to
D using horizontal mattress, or running locked absorbable
FIGURE 22-19 A, The scar is excised and undermined down to
the level of the subcutaneous layer (B). C, D, The dermis is
approximated, with eversion of its edges.
diagonal limb parallel to RSTLs (Fig. 22-20). Then, using
triangular flaps, a contracted or webbed scar can be
lengthened, a depressed scar may be leveled, or a long
scar may be divided into multiple shorter segments. Its
use is optimal around the mobile parts of the head and
neck, such as the eye,135 ear,136 lip,137,138 nose,139 and intra-
oral mucosa scars caused by trauma and tissue loss (Fig.
22-21; see Fig. 22-17).
Unlike the actual letter Z, which has a diagonal longer
than the other shorter limbs, the traditional Z-plasty has
three limbs of equal length, with the central diagonal
representing the original scar to be revised.140 It is ideal
for revision of the scar that runs parallel to ATL (see Fig.
22-20B and C). Its primary purposes are simply to rotate
the long axis of the scar to a favorable position within
the RSTL, lengthen a contracted scar, and align mis-
aligned scars around important facial landmarks. The
peripheral limbs are parallel and the angles of diver-
gence from the diagonal should be equal and lie as close
to RSTLs as possible. The peripheral limbs should be of
equal length and at an angle of 60 degrees from the
central limb (Fig. 22-22).141 This angle will give the best
balance for optimizing flap rotation and lengthening
and for tension-free closure while limiting flap tip necro-
sis and the possibility of a standing cone deformity at
final closure. The smaller the angle between the central
and peripheral limbs, the less chance that the resultant
scar will lengthen and a smaller amount of rotation will
be achieved. Also, the chance of necrosis of the skin flap
should never be less than 30 degrees. With a larger angle,
more flap rotation and longer resulting scar length is
achieved; however, with larger angles, more tension is
placed on the wound at closure and may cause a standing
cone deformity. Angles that exceed 70 degree are more
likely to result in a standing cone deformity. Increase in
scar length is usually less than predicted. This angle,
30-degree Z-plasty achieves a 25% increase in length of
the axis to the central limb, a 45-degree Z-plasty achieves
a 50% increase, and a 60-degree Z-plasty achieves a 75%
increase (Fig. 22-23).
Technique. Z-plasties should be planned and marked
ahead of surgery, if possible, using a set of Castroviejo
calipers.142 If the central diagonal scar is wide, it should
be preserved and transposed rather than excised to
prevent recurrent scar widening. Similar to the W-plasty,
create skin flaps, moving from side to side and undermin-
ing each flap, as described earlier. Like other techniques,
eversion of wound edges and management of the stand-
ing goal deformity will optimize wound esthetics. Closure
should be started with tension-free placement of inter-
rupted, subcuticular, dermal absorbable monofilament
sutures, with eversion of the dermis. Skin is then closed
gut, or nonabsorbable monofilament sutures. Like previ-
ous techniques, wound edges should be held with skin
hooks with only minimal tension, not forceps. Hemosta-
sis must be achieved before closure and appropriate post-
operative care should be used (see earlier).143
Many variations of the traditional Z-plasty have been
described. Standard Z-plasty is often referred to as the
stereometric Z-plasty because it will often alter tissue
depths, producing elevations and depressions. Roggen-
dorf144 has described a planimetric Z-plasty that produces
scar lengthening without the surface irregularities accom-
panying the traditional Z-plasty.145 The planimetric
Z-plasty include 75-degree transposition angles, a central
limb half the length of the lateral limbs, and a geometric
pattern area of excision to eliminate excess scar tissue.
Using this technique, the peripheral arms are longer
than the central limb, which is compensated for with two
excisions on either end of those arms. making the angles
more obtuse than with a standard Z-plasty (Fig. 22-24).
The technique can be adapted to local skin conditions,
deepithelialized excess skin can be buried to provide
underlying wound support, and scar line can be varied
more easily, as needed, than with a traditional Z-plasty,
giving the surgeon more variety.
A multiple Z-plasty is a useful scar revision for the
trapdoor or gouge defect, curved depressed scars, when
there is inadequate tissue for a large Z-plasty or when the
arms of a single Z-plasty would encroach on another
 Secondary Revision of Soft Tissue Injury CHAPTER 22 583

Relaxed X
skin Y
tension
lines

Scar
X
Y

A B

X
Y

C
FIGURE 22-20 A, A Z-plasty is designed so that the central limb (the scar) of the Z-plasty (B) is reoriented to a plane parallel with
RSTLs (C).

FIGURE 22-21 Hypertrophic scar with lower

lip retraction. A Z-plasty is used to excise
and reorient the scar to elevate the
lower lip and improve lip competence.
A, Preoperative appearance. B, 8 weeks
A B
postoperative appearance.
584 PART III Management of Head and Neck Injuries

FIGURE 22-22 A, Peripheral arms designed at an angle of 60 degrees from the central limb will give the best balance for optimizing flap
rotation and lengthening (B) and tension-free closure while limiting flap tip necrosis and the possibility of a standing cone deformity at
final closure (C). (From Robinson J: Surgery of the skin, St. Louis, 2006, Mosby)

25% Scar
30°
increase

E (excision
area)
50%
45°
increase
75° 75°

E (excision
75% area)
60°
increase

FIGURE 22-23 In general, as the angle between the peripheral and

central limb increases, so does the length of the resulting scar.
facial subunit (Figs. 22-25 and 22-26). This technique has
less tension on closure and less surface depression, eleva-
tion, and lateral distortion. It may provide even more
scar lengthening and camouflage than the traditional
Z-plasty because of the smaller peripheral limbs used.
The surface depression, elevation, and lateral distortion
seen with a large, single-unit Z-plasty are lessened when
multiple units are used. Multiple small Z-plasty units
may achieve additional scar lengthening and result in
improved scar camouflage as compared with a single
Z-plasty. A drawback of multiple Z-plasties is the creation
FIGURE 22-24 Planimetric Z-plasty. This includes 75-degree
transposition angles, a central limb half the length of the lateral
limbs, and a geometric pattern area of excision to eliminate
excess scar tissue.
of more scars. This may be avoided by using serial
Z-plasties for oblique scars of equal dimensions. Serial
Z-plasties can be arranged in continuity or can also be
interrupted. These are particularly useful in situations in
which there is not enough surrounding tissue for trans-
position if one large Z-plasty were to be designed.143,146
For final closure, an elliptical or fusiform excision may
be preferred to a Z-plasty if the original scar is close to
 Secondary Revision of Soft Tissue Injury CHAPTER 22 585

Existing scar a
perpendicular
to RSTLs a
b
b

c c

d d
Relaxed skin
tension lines A e
e
A
c
c b
d
b
d
e
f
b d
c
a
a
a e e
B
B
FIGURE 22-27 Various combinations of Z-plasties and fusiform
Alternate limbs of excisions may be used, depending on the relationship of the
Z-plasty oriented defect to the orientation of the RSTLs. A, Two fusiform excisions
along RSTLs
and three Z-plasties are used for defects perpendicular to RSTLs.
de
f B, One fusiform excision and four Z-plasties are used for defects
bc
a parallel to RSTLs.

being parallel to an RSTL; this technique that will avoid

C triangular flaps with very acute angles and probable skin
FIGURE 22-25 A, B, Multiple Z-plasties may be designed with the
peripheral limbs at acute angles to the central limb, reorienting
multiple segments of the central limb to RSTLs of the face (C).
(From Arndt K: Procedures in cosmetic dermatology series: Scar
revision, Philadelphia, 2006, WB Saunders.)
FIGURE 22-26 Final closure of multiple Z-plasties will reorient the
divided central limb to the RSTLs. (From Canale ST, Beaty JH,
editors: Campbell’s operative orthopaedics, ed 11, Philadelphia,
2008, Mosby.)
necrosis. Borges has described a combination Z-plasty
and fusiform excision for U-shaped or semicircular trap-
door deformities.94 Segments of the scar parallel to
RSTLs will benefit from fusiform excisions, whereas seg-
ments oblique or perpendicular to RSTLs benefit from
Z-plasty. An example of this technique would include two
fusiform excisions and three Z-plasties for defects per-
pendicular to RSTLs (Fig. 22-27A), or one fusiform exci-
sion and four Z-plasties for defects parallel to RSTLs (see
Fig. 22-27B).
A variation of this technique has been described in
which the distortion of small angled flaps is overcome by
converting a two-flap Z-plasty to a four-flap Z-plasty.147 It
is especially useful in the webbed and functionally con-
tracted neck. This technique involves marking a 120-
degree angle Z-plasty and dividing each flap into two
flaps, creating four equal 60-degree triangle flaps. This
then allows for maximum lengthening of the scar without
sacrificing ease of closure (Fig. 22-28). Before dividing a
two-flap Z-plasty, the surgeon must make sure that the
initial flaps are of large enough angles. Dividing flaps of
questionable size may compromise blood supply and can
result in necrosis to the flap tip. In general, 60 degrees
should be the smallest angle used.
To gain maximum length of the final scar, another set
of modifications has been described. This includes a
90-degree four-flap Z-plasty, lengthening the scar by up
to 111%, and a 120-degree four-flap Z-plasty, lengthening
the scar by 164%.148 Alternatively, a 90-degree six-flap
Z-plasty achieves 180% of flap lengthening (Fig. 22-29).
The surgeon should begin with a simple 90-degree
Z-plasty. If excess tension is encountered on transposi-
tion, converting to a four-flap Z-plasty is advisable. The
six-flap Z-plasty may be considered when more length is
desired and performed after a four-flap Z-plasty is marked
and incised, or even after a 90-degree Z-plasty is designed,
regardless of tension encountered.
586 PART III Management of Head and Neck Injuries

b’
b’
d d
a
c’ c’
b a
d’
d’
c
b
a’ c
a’

A B

b’
b b b’
c’ c’
c d c
d’ d’

a
a
a’ a’

C D

FIGURE 22-28 Two 120-degree angle Z-plasties are divided into two flaps, creating four equal 60-degree triangle flaps, which maximizes
the lengthening of the scar without sacrificing ease of closure.

5 3

5 5
1 3
2 4
4

3 1 1
4 2
6 6

6 2

FIGURE 22-29 The peripheral arms of the six-flap Z-plasty may be up to 90 degrees from the central limb and may achieve up to 180%
of scar lengthening.

A B
FIGURE 22-31 The GBLC technique is used for scars parallel to ATLs. The random pattern renders the scar less conspicuous. (From
Arndt K: Procedures in cosmetic dermatology series: Scar revision, Philadelphia, 2006, WB Saunders.)
As an alternative to standard two-dimensional
Z-plasties, a three-dimensional technique may be used.
These types of Z-plasties are especially useful in the
webbed neck (Fig. 22-30).149 They can turn a cleft into a
peak or depress hypertrophic tissue by incorporating
tissue wedges into the transposed flaps. Several three-
dimensional Z-plasties have been described, including a
five-flap technique-s such as Converse’s double-opposing
Z-plasty, Numanoglu’s paired five-flap Z-plasty, or Mus-
tarde’s jumping man flap. Building on these flaps is a
modification by Hirschowitz that combines a five-flap
Z-plasty with a V-Y advancement.150-152
Secondary Revision of Soft Tissue Injury CHAPTER 22 587
FIGURE 22-30 Vertical scar band of the
neck following neck dissection and
pectoralis major muscle flap reconstruction
treated with Z-plasty to lengthen tissue and
improve mobility. A, Preoperative
appearance. B, Postoperative appearance.
Geometric Broken Line Closure
The regular repeating pattern of the W-plasty can detract
from its value in scar camouflage, especially in longer
scars. Initially described by Webster, the GBLC is similar
to a W-plasty but relies on creating a combination of
various geometric shapes (e.g., crescents, squares, trian-
gles, rectangles, trapezoids) along a scar, with corre-
sponding shapes on the opposite side to allow for precise
closure, orienting most of the scar more parallel with
RSTLs (Fig. 22-31).153,154 In general, W-plasty and GBLC
techniques are identical, with similar indications and
contraindications. The resulting pattern from GBLC is
588 PART III Management of Head and Neck Injuries
less predictable to the observer and thus is less noticeable
than that of a W-plasty. In general, rectangles and squares
produce superior results when kept small and as parallel
to RSTLs as possible. Crescent shapes may result in small
trapdoor defects and should be used minimally in the
incision design. Each shaped segment should be between
5 to 7 mm in length. Smaller segments will resemble a
straight line, whereas larger ones will result in a more
unsightly scar.
There are several drawbacks to the GBLC technique.
As compared with the W-plasty, it is conceptually more
difficult to design, is significantly more time-consuming,
and it lacks usefulness for curved scars. In addition, by
nature of the design, some segments of the resulting scar
will be at 90 degree to the RSTLs. Some investigators
have questioned whether the outcome from GLBC is
actually more aesthetically pleasing than from W-plasty.155
Like the W-plasty, this technique should not be used for
scars less than 30 degrees to RSTLs; these scars are better
treated with a simple fusiform excision.
Technique. Preparation for GBLC is the same as for
previously described techniques; incision design is the
same as for a W-plasty, except geometric shapes instead
of running W are marked out. A random pattern of geo-
metric shapes, with most being rectangles and squares,
are marked on one side of the incision and then the
other to allow the original side to key into the opposing
side on closure. The shapes should not exceed 7 mm in
length in the case of rectangles, triangles, or squares or
diameter in the case of crescents or circles. The design
is finalized by placement of a right triangle at each end
of the scar to produce a 30-degree closing angle of the
wound, minimizing a standing cone deformity. Wounds
should be closed with technique identical to that de-
scribed for a W-plasty. Wound care after surgery and
planned dermabrasion are the same as for a W-plasty.
Similar to patients undergoing W-plasty, patients under-
going GBLC should be warned that they will experience
moderate to severe erythema for several months before
the scar will turn pale. Dermabrasion should be planned
as early as 6 weeks postoperatively, just after the prolifera-
tive phase of wound healing and just before scar contrac-
ture begins.115,117,119
COMPLICATIONS
Scar revision requires meticulous planning, precision,
patient cooperation, and surgical skill. Even when all
these factors are present, errors may occur; therefore, it
is imperative that the surgeon optimize the patient’s
chance for success. Diagnostic, planning, and execution
errors can result in catastrophic results following scar
revision. The most common complications include
hematoma, infection, necrosis, hyperpigmentation, dis-
tortion of facial landmarks and their function, and recur-
rent scar widening or contracture. Because of not only
the functional and aesthetic results, but also the psycho-
logical repercussions of these adverse outcomes, the
surgeon is encouraged to try to prevent any unforeseen
complications from occurring. Inevitably, it is not the
complication, but its management that will predict the
final outcome.
HEMATOMA
The prevention of hematoma begins with the initial
preoperative visit, obtaining a comprehensive medical
history, history of medication, vital signs, social history,
psychological status, and normal activity schedule.156
Patients on medications affecting the coagulation cascade
or platelet function, such as acetylsalicylic acid or warfa-
rin (Coumadin), are at high risk for hematoma forma-
tion within the first 14 days after surgery.157,158 Patients
with cardiovascular comorbidities may forget that they
are taking these medications. A thorough history of
bruising and bleeding should be obtained.159 Other risk
factors for hematoma include excessive alcohol intake
and poorly controlled hypertension. These factors
should be identified and the risks and benefits of surgery
discussed with patient. Intraoperative factors associated
with hematoma formation include hemodynamic
instability and poor wound hemostasis. Postoperative
factors associated with hematoma formation include
increased postoperative activity, nausea, and vomiting
and retching.
Prior to wound closure, the wound bed and skin flaps
should be examined for any bleeding and meticulous
hemostasis should be obtained using local techniques,
such as ligation of vessels and electrocautery. Surgical
clip placement should be avoided in the face because of
the risk of their expulsion. All dead space should be
eliminated by compressive closure of all wound layers.
Drains should be used whenever dead space is suspected.
Finally, pressure dressings should be used to minimize
dead space formation edema from fluid accumulation.
Small hematomas may be treated with needle aspira-
tion,156 whereas large hematoma should undergo formal
wound exploration and all sources of bleeding should be
identified and stopped. Failure to treat hematomas in
promptly may result in infection, skin flap necrosis, and
increased scarring.
INFECTION
Like hematoma, prevention is the best form of treatment
for infection. A thorough medical history that includes
questions about immunologic disease and immunosup-
pressive medications should be performed in the preop-
erative period. Infection following scar revision is rare
and follows the rate seen with other cosmetic head and
neck procedures.160,161 Redundant tissue, electrocautery
char, and excess suture may act as a foreign body and
become a nidus for infection in patients.162 When sterility
is compromised, such as in procedures in which the oral
mucosa is breached, lip and ear procedures, skin flaps
on the nose, skin grafts, patients with extensive inflam-
matory skin disease, or a surgical site infection is present,
administration of antibiotics should be considered.163,164
Hematoma and seroma are also risk factors for infection,
so dead space should be eliminated using the techniques
described earlier. The type of prep used for surgery has
been questioned with conflicting opinions about the
superiority of chlorhexidine- based preps165 versus
povidone-iodine.166 Swenson and Sawyer have concluded
that the use of alcohol is key for preventing surgical site
infections, regardless of the product used.167

NECROSIS
Fortunately, gross necrosis of skin following scar revision
procedures is rare. Minor necrosis of skin flaps edges is
not uncommon. This can be avoided using the tech-
niques described earlier. It results from skin flaps with
vascular compromise, including poorly designed skin
flaps such as small skin flaps or flaps designed without
consideration for an adequate blood supply, skin flaps
without a broad enough base, excessive suturing of skin
flaps, and placing too much tension on a wound at final
closure.168 In addition, complications such as hematoma
formation from inadequate hemostasis or inadequate
drain place and infection can also initiate skin flap necro-
sis.169,170 Inadequate wound undermining and closure at
the dermal level will help decrease wound dehiscence
and necrosis. Medical problems such as Raynaud’s disease
may contribute to wound-healing difficulties and skin
necrosis.171 In a landmark study by Saran et al, it was
concluded that a single cigarette reduces mean blood
flow velocity to the fingers by 42%.172 Smokers have a
higher incidence of skin flap necrosis,173-178 which has
been demonstrated to be caused by the effects of nico-
tine, a vasoconstrictor, on local capillary blood flow.179
Local exposure to noradrenaline does not seem to affect
the incidence of skin flap necrosis.180 In the trauma
patient, previous embolization of major vessels caused by
uncontrollable bleeding may compromise skin flaps in
scar revision.181
Topical agents such as nifedipine, trolamine, and salic-
ylate have been found to help salvage failing necrotic
skin flaps. However, the efficacy of these agents needs to
be explored further.182 Other agents have been described
for skin flap salvage.183 Leech therapy has been shown to
be beneficial in the treatment of skin necrosis secondary
to venous congestion,184-193 but its use is also associated
with complications such as Aeromonas spp. infections and
anemia that might require a blood transfusion.194 The
surgical treatment of gross skin necrosis involves débride-
ment of all compromised tissue, allowing the remaining
wound to heal by secondary intention. To minimize con-
tracture, earlier skin graft placement, a local or regional
flap, or even free tissue transfer may be performed to
limit long-term aesthetic and functional impairment.
HYPERPIGMENTATION
Sun exposure is the most common cause of hyperpig-
mentation following scar revision. Hyperpigmentation
caused by sun exposure is readily preventable; all patients
should be educated to wear sunblock and protective
clothing for the first 8 weeks following surgery. First- line
treatment for hyperpigmentation includes the tyrosinase
inhibitor 4% hydroquinone, twice daily.195 Hydroqui-
none acts by blocking tyrosinase from developing melanin
precursors for the production of new melanin. Essen-
tially, it blocks new pigment formation as the new epider-
mis heals following a procedure. Secondary topical
treatments include topical retinoids such as tretinoin,
adapalene, tazarotene, mequinol, azelaic acid, kojic
acid, and arbutin.195 Over-the-counter remedies such
as soy, licorice extracts, niacinamide, N-acetylglucosamine,
and green tea have been shown to be beneficial in
Secondary Revision of Soft Tissue Injury CHAPTER 22 589
the treatment of hyperpigmentation.196,197 Ablative non-
surgical treatments include chemical peels such as
glycolic acid, salicylic acid, trichloroacetic acid, and Jess-
ner’s solution; laser therapy such as blue light pho-
todynamic therapy, fractional photothermolysis, and
neodymium-doped (Nd):YAG (yttrium- aluminum-
garnet) laser have also been shown to be effective in
treating hyperpigmentation.
DISTORTION OF MOBILE LANDMARKS
Trauma to mobile landmarks such as the lips, eyelids, or
nose is not uncommon; scar revision is often difficult
because of the constant muscle pull, tension, and motion
present. Unless there is a preexisting vertical asymmetry,
revision in a vertical vector should be avoided. Treatment
must be tailored to the patient. In general, W-plasty
should be avoided. Z-plasty is the preferred treatment
around the eyelids, nose, vermilion, and neck because of
excess tissue tension in these areas.135,137-139
RECURRENT SCAR WIDENING
Scar widening will often take place within several months
after injury and may occur in a scar that appears to be
healing without difficulty.198 It occurs when opposing
forces such as muscle pull, elastic forces of skin, and
external pressure are applied to newly formed collagen
before it reaches final maturity. It may take several
months before completion of collagen maturation.199
Demographic factors associated with scar widening
include increased age and race. Location of the scar and
amount of volume loss have severe implications on
scar widening. For example, scars around facial land-
marks in constant motion or those under constant
tension because of loss of local tissues are at risk for scar
widening. Patients should be screened for heritable
collagen diseases such as Ehlers-Danlos syndrome, osteo-
genesis imperfect, cutis laxa, Marfan’s syndrome, homo-
cystinuria, Menkes syndrome, focal dermal hypoplasia,
tuberous sclerosis, familial cutaneous collagenoma, and
epidermolysis bullosa, because these will contribute to
postoperative scar widening. When it occurs, the cause
of scar widening must be determined to manage the
deformity correctly.200
Although there are many therapies available for hyper-
trophic scarring,201-203 there are no time- proven interven-
tions available to correct scar widening. Wide and
hypertrophic scars resulting from straight linear incisions
are difficult to treat surgically. The most common cause
of scar widening is from excess skin tension caused by
tissue volume loss. These defects are best treated with
tissue transfer in the form of local, regional, or free tissue
flaps, because excision and manipulation techniques
such as fusiform scar excision, Z-plasty, or W-plasty often
result in recurrent scar widening and increased scar
length. In an attempt to provide support to skin edges in
the widened scar, Millard has advocated leaving a base of
scar tissue and suturing wound edges to the base to
diminish opposing skin flap forces on each other.204 In
this technique, the area of scar is deepithelialized and
then incised on one side down to subcutaneous tissue
(Fig. 22-32A). Using a curved scissors, the healthy wound
edge away from scar is undermined to at least double the
590 PART III Management of Head and Neck Injuries
A B
FIGURE 22-32 A, The epithelium of the scar is excised, leaving an exposed dermal sheet. B, A vertical incision is made through one edge
of the dermal sheet, undermining that skin edge slightly more than the width of the scar. C, The dermal scar sheet is now undermined
for a greater distance in the opposite direction (see broken line in cross-sectional view). D, An incision on the bias (diagonal) is made at
the opposite edge and carried partially through the dermis to provide an edge equal to the opposite side.
width of the scar (see Fig. 22-32B). The dermal scar sheet
is then undermined in the opposite direction (see Fig.
22-32C). An incision at a diagonal is made at the opposite
skin edge and carried partially through dermis to provide
an edge equal to the opposite side (see Fig. 22-32D). The
dermal scar sheet is then advanced and sutured subcuta-
neously, taking tension off the new surface closure that
is now sutured in a staggered location away from the
deep closure. In the case of a depressed scar, the scarred
dermal sheet may be advanced to fill the defect. Wilson
has shown good success with this technique in a series of
patients undergoing revision surgery for widened scars.199
RECURRENT SCAR CONTRACTURE
Scar contracture of the head and neck is an especially
difficult problem because of the aesthetic changes and
functional disability that it may cause in the patient.
These types of scars are especially common in post-
traumatic and burn patients. Scar release incisions should
be placed in facial unit or subunit borders to aid in the
aesthetic placement of skin grafts. Scar release may be
performed by fusiform excision, Z-plasty, W-plasty, or
straight line incision.
Smaller areas of contracted scar may be treated by the
Y-V skin flap, avoiding the need for grafting.205-213 A single
or running Y-V flap will result in scar lengthening without
flap transposition. The stem of the Y must be placed
perpendicular to RSTLs. The scar release occurs at the
stem of the Y and skin is then advanced, creating a
V-shaped defect. The triangular flap of healthy skin is
advanced to fill the defects (Fig. 22-33). Alternatively, a
V-Y release may be performed, in which a V is incised and
the tissue inside the V is advanced and used to bulk up
an area and lengthen the long axis of the scar (Fig.
22-34).214-216 Other simple local skin flaps may be used,
C D
including a single advancement, bilateral advancement,
and rotational, sliding, bilobed, and rhomboid flaps.217
Scar release will often result in tissue loss and may
cause tethering of skin to deep tissues, such as bone or
muscle, severely limiting function. These scars are often
caused by trauma, burns, or infection and will ultimately
need tissue transfer in the form of a graft or flap. Small
areas of scar contracture may be released with minimally
invasive procedures such as subcision (subcutaneous
incisionless surgery) and subsequent injection with
autogenous or nonautogenous fillers. Scar subcision is
used to treat contracted, atrophic, or depressed scars or
deep wrinkles.218-221 It should be attempted before using
any filler material. It is most commonly done with a
needle that acts as a scalpel and releases fibrotic strands
within a scar, elevating the surface of the scar. Briefly, the
needle is introduced at an angle into the skin and then
manipulated back and forth in a lateral motion to break
any fibrous bands. The placement of the needle should
be meticulously planned in an orientation parallel to the
underside of the dermis, because the sharp cutting edge
is a threat to deeper vital head and neck structures. Care
must be taken by the surgeon not to rotate the needle,
so that its triangular tip stays horizontal to the skin
surface. This procedure should be avoided in the preau-
ricular, temporal, and mandibular areas to avoid injuries
to the facial nerve and major vessels. Some standard
principles include the following: individual scars should
be treated using separate, multiple puncture sites and,
when multiple scars are treated, the most dependent one
should be treated first. This procedure may be repeated
multiple times, with 3 weeks between sessions, and the
procedure should be ideally performed before a weekend
or holiday for working patients.222 Following subcision,
there is an organization of blood in the induced dermal
 Secondary Revision of Soft Tissue Injury CHAPTER 22 591

Running plasty
Single flap Y-V plasty Double arrows represent length gained

FIGURE 22-33 The V-Y flap can be used in single (A)

A or multiple (B) units.

A B C
FIGURE 22-34 A, A scar is lengthened by making a V-shaped incision in the area of contraction. B, The flap is then advanced in the
direction of the arrow. C, The final closure resembles the letter Y.

pocket, followed by connective tissue formation and
collagenization. Patients should be counseled about tem-
porary hematoma formation and bluish discoloration
that will occur. This procedure has the advantage that
it can be done in the outpatient setting under local
anesthesia.
SPECIFIC TYPES OF SCARS
DEPRESSED SCAR
Scar depression usually occurs secondary to loss or
atrophy of subcutaneous or dermal layers, and therefore
is not amenable to traditional surgical techniques (see
earlier). Management of the depressed scar involves
restoring bulk to the subcutaneous and dermal soft tissue
structures. Dermal restoration may be achieved by col-
lagen injection, including bovine (Zyderm, Zyplast,
Inamed, Santa Barbara, Calif) and autologous dermal
collagen (Autologen, Collagenesis Corporation, Bever-
ley, Mass) or, less commonly, by steroid injection.223 Sub-
cutaneous restoration of facial contour defect may be
done with autologous fat transplantation,103,104,224-226
although some have reported conflicting long-term
results using these techniques.227 Other options for soft
tissue augmentation include autogenous dermal fat
grafts and acellular dermal grafts (AlloDerm, LifeCell,
Branchburg, NJ). These materials may result in a
longer lasting improvement of depressed facial scars but
they are implantable rather than injectable and may be
592 PART III Management of Head and Neck Injuries
Extended C-shaped incision and release for medial eyelid ectropion
A B
FIGURE 22-35 A, Extended C-shaped incision and release for medial eyelid ectropion (B).
technically more difficult to use.228 The use of these mate-
rials will be discussed later in the chapter. Previously
described minimally invasive techniques, such as subci-
sion, are also useful for the management of depressed
scars.218
ELECTRIC BURNS
The treatment of electrical burns is challenging because
the resulting scar often spreads from the skin at the point
of contact to the periphery and generally has an indis-
tinct end point of collateral damage.229 In the head and
neck region, these scars often occur when a child sucks
on the female end or junction of an extension cord, or
when a child chews on the end of a poorly insulated wire.
Generated by a temperature of up to 2500 to 3000° C
(≈4500° to 5400° F), electrical burns initially appear as a
grayish-white coagulated lesion with an erythematous
rim. After 2 to 4 weeks, an eschar will slough off, leaving
an ulcerated area. This area will slowly be replaced by
fibrous connective tissue and undergo maturation. In
addition to unsightly scarring, fibrosis and scar contrac-
ture may occur with head and neck burns, which can be
debilitating to the patient by causing trismus, dysphagia,
dysarthria, or changes in facial expression.
Early splint therapy is important to relieve and prevent
microstomia for patients with perioral burns. Patients will
often need multiple débridements of scar tissue.230-236
The initial surgical goal is to line up the vermilion. Then,
if possible, fusiform scar excision or Z-plasty may be per-
formed. Z-plasties may be used extraorally and intraorally
to relive contracture and lengthen scars. Dermabrasion
of skin may follow to relieve any skin surface
irregularities.
EYELID ECTROPION
There are several types of eyelid ectropion, including
congenital, senile, neurogenic, and cicatricial.237-239 Cica-
tricial ectropion results from scarring of the anterior
lamella, which consists of the skin of the eyelid and orbi-
cularis muscle. It usually occurs as a result of facial trauma
and may be associated with orbital fractures, facial burns,
or chronic dermatitis, or as an iatrogenic result of exces-
sive skin excision during cosmetic blepharoplasty. It may
involve the upper or lower eye lids, or both. It may be
medial or lateral and may shorten the eyelid vertically or
horizontally, or both. In general, the goal of ectropion
repair is to restore the original size and position of dis-
torted tissues and to replace lost tissue with similar
tissue.240 Anterior lamellar reconstruction is best achieved
using full-thickness skin grafts or local skin flaps.
Extrinsic medial ectropion may be caused by scarring
of the nasal dorsum, resulting in anterior and medial pull
of the medial canthus. The result is epicanthal folding,
exposure of the cornea, and epiphora. Scar release in
this area involves a C-shaped excision of scar tissue from
the upper and lower eyelids and lateral nose (Fig. 22-35).
The resulting defect is then grafted with a full- thickness
skin graft. Skin over the nose adjacent to the release inci-
sion should be undermined to allow maximal release; the
periosteum overlying the frontal process of the maxilla
is excised to allow for graft adherence to bone. The use
of a full-thickness skin graft is preferred here to minimize
contracture. In addition, medial canthopexy may be per-
formed, if needed.241
As with other mobile facial landmarks, the Z-plasty is
optimal for treating scarring around the eye and should
be considered for the treatment of lateral ectropion (Fig.
22-36). The advantage of the Z-plasty is that it transposes
retracted lower eyelid tissue superiorly and posteriorly,
resulting in better adaptation of the lid margin to the
globe (Fig. 22-37).133,242
Intrinsic contracture of either eyelid and associated
vertical shortening may be approached with a supracili-
ary or subciliary incision.243 The incision should extend
just short of the lateral and medial canthi. Skin flaps are
raised and the upper or lower eyelid is approximated.

The skin flap is then undermined and the underlying
stable pretarsal orbicularis oculi is used as a graft bed. A
full-thickness skin graft is applied in the area of tissue
loss. The advantage of this technique is that the tarsus
acts as a splint, limiting contraction of the graft, and the
FIGURE 22-36 Z-plasty for lateral lower eyelid ectropion,
transposing the retracted lower eyelid tissue superiorly and
posteriorly, and acquiring better adaptation of the lid margin to
the globe.
A B
FIGURE 22-37 Post-traumatic cicatricial ectropion, managed with scar excision and primary skin grafting with Z-plasty and lateral
canthopexy. A, Initial post-traumatic appearance, age 8 years. B, Preoperative appearance, age 13 years. C, 1 year postsurgery, age 14
years.
Secondary Revision of Soft Tissue Injury CHAPTER 22 593
position of the lid crease may be limited by the position
of the incision. The eyelids may be separated immedi-
ately or in a delayed fashion. If indicated, a C-shaped
release of skin can be combined with the approach.241
Unlike upper eye lid ectropion, which usually is caused
by scarring in the forehead and temples and is generally
repaired with scar release and grafting, lower eye lid
ectropion repair is more complex. Restoration of its
underlying tissues is crucial to prevent recurrence. The
lower eyelid has almost no excess tissue, so only a small
degree of scarring may cause retraction of the lower
eyelid.244 A number of techniques have been described
to correct lower eyelid ectropion. Management should be
tailored to the specific injury (Fig. 22-38). One approach
involves subperiosteal release of all extrinsic and intrinsic
components, with mobilization of the lower eyelid and
grafting as necessary. A subciliary incision with a lateral
canthotomy is performed, occasionally combined with a
transoral vestibular approach, which facilitates subperi-
osteal dissection from the zygomatic arch to the pyriform
rim, down to the alveolus. After release of the lower
eyelid, a middle lamellar graft harvested from the hard
palate or conchal bowel is secured superficially and infe-
riorly to the tarsal plate, if necessary. The orbicularis oris
is then dissected, redraped over the lower eyelid, and
sutured to the lateral orbital rim and lateral nasal wall.
Medial and lateral canthopexy is completed, and a skin
graft is placed.245,246 If skin is missing, a variety of local
skin flaps may be used in lieu of skin grafts .242,247,248 In
addition, autologous or allogenic dermis–only grafts may
be used for the correction of lower lid retraction in which
a spacer is needed but stiffness is not a concern. These
grafts are associated with low donor site morbidity, but
may undergo more contracture than split-thickness skin
grafts. The drawback of acellular allogenic dermis grafts
is that they are associated with significantly more
C
594 PART III Management of Head and Neck Injuries
FIGURE 22-38 Lower eyelid ectropion and
retraction following repair of comminuted
orbital fracture and associated periorbital
lacerations. Ectropion repair consisted of
transconjunctival cantholysis and
orbitotomy, removal of previously placed
hardware, subperiosteal midface lift, and
lateral canthopexy. A, Preoperative
A B
appearance; B, 6 months postoperatively.
contracture than full-thickness skin grafts and are show
significant degration by 4 months postoperatively.249,250
For conjunctival reconstruction, the use of amniotic
membrane transplantation has been described, with
some success.251,252 The advantages of these grafts over
oral mucosa grafts include less donor site morbidity and
the structural arrangement of collagen and lamina is
similar to that of the conjunctiva, providing an excellent
scaffold for proliferating conjunctival cells.
HYPERTROPHIC SCARS AND KELOIDS
Keloids are defined as scars that extend beyond the edges
of the original wound or incision, invading surrounding
normal tissue,253,254 and affect an estimated 1.5% to 4.5%
of the population.255 Hypertrophic scars, on the other
hand, are elevated scars that remain within the original
tissue injury site.256,257 Both hypertrophic scars and keloids
result from alterations in normal cutaneous wound
healing that include the proliferation of the dermal
tissue and excess deposition of fibroblast-derived extra-
cellular matrix (ECM).258-260 In normal wounds, there is
a decrease in cellularity mediated by apoptosis during
the transition from granulation to scar tissue. In hyper-
trophic scars, however, granulation tissue does not regress
and alpha smooth muscle actin-expressing myofibro-
blasts produce excess ECM, resulting in a red, raised
rigid scar.261,262 These scars may develop only weeks after
injury. Dark-skinned individuals are at increased risk for
keloid formation, with the earlobe and cheek being the
areas usually affected.263 Keloids may be symptomatic and
cause pain, but hypertrophic scars may be painless and
fade over time.
Surgical excision of keloids is characterized by recur-
rence and is generally avoided in the absence of pain or
dysfunction.80 If excision is performed, care should be
taken so that the tissue is handled in an atraumatic
manner, using skin hooks to minimize trauma to skin
flaps, and results in a layered, tension-free closure.
Radiation therapy with or without surgical excision
has been advocated for the treatment of keloids. One
reported protocol has called for keloids of the earlobe
to receive 10 Gy in two fractions over 2 days, and other
sites of the head and neck to receive 15 Gy in three
fractions over 3 days. Surgical excision is performed and
adjuvant radiation therapy is initiated on postoperative
day 1 or 2. The reported recurrence rate with this proto-
col was 14% at 18 months of follow-up. A side effect of
this procedure is hyperpigmentation of the irradiated
area. To prevent this complication, investigators have
recommended that steroid ointments be applied to the
surgical site, reducing the radiation dose, or increasing
the time between radiation sessions.264 Malignant trans-
formation is rare but has been reported.
The use of lasers has been advocated for the treatment
of keloids and hypertrophic scars. Although the argon,
CO2,265,266 and Nd : YAG lasers267,268 have been found to be
of little benefit, the flashlamp-pumped pulsed dye laser
(PDL) has shown good results, with significant improve-
ments in contour, texture, color, pliability, and pain relief
and minimal side effects.57,269-271 Early PDL treatment may
fundamentally change the physiology of wound healing
by reducing scare microcirculation and preventing excess
scar formation.272,273
Intralesional corticosteroid injection is a common
treatment modality for keloids and hypertrophic scars.274
It has been shown to reduce scar volume significantly and
increase scar pliability and height while reducing symp-
toms such as pruritus and pain in the patient with
keloids.57,275 It works by three primary mechanisms: (1) by
suppressing inflammation by inhibiting leukocyte and
monocyte migration and phagocytosis; (2) by causing
vasoconstriction, therefore reducing the delivery of
oxygen and nutrients to the wound bed; and (3) by exhib-
iting an antibiotic effect on keratinocytes and fibroblasts,
slowing reepithelialization and new collagen forma-
tion.276 Insoluble triamcinolone acetonide (10 to 40 mg/

mL) is the most common steroid used in scar treatment.268
The use of a topical and/or local anesthetic is recom-
mended prior to injection. The steroid is ideally injected
into the superior dermal layer, the papillary dermis, which
is where steroids promote collagenase activity. Injections
may be repeated twice monthly and may be combined
with surgical excision. Following surgical excision and
primary closure, steroid may be injected into the wound
and its edges.277 Side effects include short-term hypopig-
mentation and injection pain.57,278 Long-term side effects
include skin and subcutaneous fat atrophy, telangiecta-
sias, scar widening, and rebound effects.279 Topical ste-
roids have not been shown to be effective for the treatment
of hypertrophic scars or keloids.280,281
Silicone gel has shown some success in the treatment
of hypertrophic scars and keloids. First used in the
1960s,282 and rediscovered in the 1980s253,283-285 for the
management of burn scars, silicone materials, including
creams, gel sheets, Silastic sheets, and garments, have
become popular for the prevention and treatment of hyper-
trophic scarring and burns. Their use has been shown to
reduce scar height and hardness, and increase scar pli-
ability; they may be used for several years after injury.47,49,286-
288
The usefulness of silicone sheeting may be greatest in
children because it is noninvasive and painless. Better
effects have been shown with early treatment and their
use should be started 2 weeks after wound healing. Treat-
ment usually lasts 6 to 12 months; patients are advised to
wear the silicone material for the entire day and only
remove it for cleaning. Each sheet lasts 2 to 3 weeks and
the adherent types seem to work better than others.279
A review and meta-analysis has assessed the effects of
silicone sheeting in preventing and treating hypertro-
phic scars and keloids following surgery, using the pooled
results of randomized controlled trials (RCTs).289 The
investigators found that silicone sheeting reduces the
incidence of keloid and scar formation by approximately
55% in patients prone to scarring following surgery when
compared with no treatment, and that silicone sheeting
produces a significant reduction in scar thickness while
significantly improving scar color. However, it was noted
that most of the RCTs studied were of poor quality and
possibly biased. Although most research has focused on
the efficacy of gel sheets, semiliquid gels have also been
evaluated. Their advantage is that they are composed
of a clear material that adapts to the underlying skin,
producing a more inconspicuous appearance than the
sheets.253 Silicone gel may be used for 12 to 24 hours,
washed off, and reapplied.290 Because silicone sheets have
a water vaporization rate lower than that of skin, water
accumulation may cause skin maceration.291 Other com-
plications include pruritus, skin breakdown, skin rash, a
foul smell from the gel pad, and poor durability of the
sheet.282,292
Other nonsurgical options for keloids and hypertro-
phic scars include dermatography,268,274 intradermal epi-
catechin gallate injections,293 the ThermaCool TC system,
which uses radiofrequency waves (Thermage, Hayward,
Calif),294 adhesive tape support, subdermal injection of
interferon-α2b (IFN-α2b),295,296 verapamil,296,297 hyal-
uronic acid,298-300 5-fluorouracil,301,302 collagenase,303 bleo-
mycin,304 madecassol and alpha Centella cream,305
Secondary Revision of Soft Tissue Injury CHAPTER 22 595
imiquimod, tacrolimus, onion, adhesive tape support,
vitamin E, and massage.256,264,269 Pressure garments have
been popular in the past, but studies have shown these
treatments to be minimally effective.306 Furthermore,
their use is associated with problems such as nonadher-
ence, patient discomfort, eczema, rashes, pruritus, and
ulceration from excessive pressure and friction.307
Massage of the scar has also been advocated as a
method of minimizing scar prominence. Keloids and
hypertrophic scars contain a considerable amount of
ground substance, which is composed of glycoproteins
and glycosaminoglycans. This ground substance is fluid
and can be displaced by pressure; therefore, massage of
these scars can reduce swelling from a reduction in ground
substance. The reported benefits of massage include
increased scar pliability and decreased scar banding308;
however, there is little evidence to support these find-
ings.309 Scar massage appears to have little to no effect on
the vascularity, pliability, and height of the hypertrophic
scar but it has been shown to reduce pain and itching.310,311
Emerging nonsurgical therapies are being developed
that exploit an association of TGF-β with hypertrophic
scar formation57,312,313 in an effort to alter the scar forma-
tion cascade. Cryotherapy with liquid nitrogen causes
ischemic necrosis and has shown to improve or com-
pletely regress keloids in significantly 51% to 74% of
patients after two or more sessions.274,314-316 To avoid
potential drawbacks of classic cryotherapy, such as skin
atrophy, pain, and hyperpigmentation, intralesional
needle therapy has been developed and shown to be
effective in the alleviation of symptoms.
Shave excision has been shown to be an effective treat-
ment for keloids317,318 and may be considered in elevated
scars.319 The purpose of shave excision is to flatten the
scar so that it is level with surrounding tissues, making it
less noticeable. It may be performed with a scalpel or a
razor blade (Fig. 22-39). The wound is allowed to heal by
secondary intention. It can be combined with dermabra-
sion or laser resurfacing. It has been found to be an
exceptionally effective treatment when combined with
5% imiquimod cream for keloids of the ear. Following
shave excision, patients are treated with imiquimod 5%
cream nightly for 2 weeks and then three times weekly
under occlusion for 1 month. Shave excision is associated
with complications such as a high rate of recurrence, scar
depression, and hyperpigmentation.320 Mustoe et al have
provided an algorithm for the management of various
types of hypertrophic scars57 (Fig. 22-40).
Despite much interest and a century of work on the
problem of keloids and hypertrophic scarring, results of
treatment remain generally unsatisfying. A meta-analysis
by Leventhal et al has concluded that all currently avail-
able treatments for keloids and hypertrophic scars dem-
onstrate only minimal improvement when compared
with no treatment.80 In addition, they found no differ-
ence in scar improvement among any of the treatment
modalities assessed.
RESURFACING PROCEDURES
Facial skin resurfacing is performed to treat scarring
above the skin level, scars with an irregular surface area,
596 PART III Management of Head and Neck Injuries

Syringe

A B
No. 15 blade scalpel
Forceps

E
FIGURE 22-39 A, An elevated scar should be anesthetized with local anesthesia at the periphery of the lesion and, using a scalpel or
razor blade (C) and forceps (D), the lesions is excised (E). (From Nouri K, Leal-Khouri S: Techniques in dermatologic surgery, St. Louis,
2003, Mosby,)

acne scars, and scars resulting from abrasions and tattoos
caused by debris remaining in tissues following primary
repair. However, they may also be used to blend depressed
scars with surrounding normal tissue by reducing the
height of adjacent normal tissue. Skin resurfacing proce-
dures treat lesions no deeper than the boundary of the
epidermis and dermis and aim to produce a smoother
scar that blends in with surrounding tissues.
The concept of facial skin resurfacing was used by the
ancient Egyptians as a procedure whereby they used
lactic and alpha-hydroxy acids to produce from sour
milk, which was applied to the skin as a way to restore its
youthful appearance321; the same concept was used later
in the French revolution, when aged wine was used for
the same purpose.322 The most significant innovation in
the modern era of facial resurfacing was developed by
Max Jessner, who reported the application of a
combination of 14% salicylic acid, 14% lactic acid, and
14% resorcinol in an alcohol solution, known today as
Jessner’s solution.321
In general, for larger treatment areas, the entire facial
subunit, unit, or face should be treated to blend final
color and texture. These procedures are best performed
early in the healing process, from 6 to 9 weeks after tissue
injury, because during this time there is a high degree of
intrinsic fibroblastic activity. When treating nonfacial
skin, the surgeon should always be cautious and conser-
vative with all ablative techniques because the lack of
pilosebaceous units outside the face and upper neck
reduce the regenerative capabilities of skin throughout
other areas of the body. There are a variety of resurfacing
procedures currently in use (see Box 22-2), generally
classified according to the depth of tissue affected—
superficial, medium, or deep. Superficial resurfacing
 Secondary Revision of Soft Tissue Injury CHAPTER 22 597

Scar

Classification

Immature Linear hyper-

Major high Widespread burn
hypertrophic trophic (surgical/ Minor keloid
risk keloid hypertrophic
(red, slightly traumatic) scar (red/raised)
(dark/raised) scar (red/raised)
raised) (red/raised, itchy)

Apply prevention Silicone gel sheeting (2 months)

algorithm. Progress
to treatment as a
hypertrophic scar
Initial Steroid injections 2.5 - 20 mg/mL (face)
if erythema
management 20-40 mg/mL (body). Repeat monthly.
continues for more
than 1 month

Localized pressure therapy if possible Speciality

(duration 3-12 months) burns unit

Pressure Pressure
Specific wavelength laser therapy
therapy garments and/or
silicone gel
sheeting
Secondary Surgery with adjunctive silicone gel (duration 6-12
management sheeting (two months) months)

Department specializing in scar therapy

Combination / Monotherapy
Primarily: steroids, silicones, pressure therapy, surgery/grafting
Occasionally: cryotherapy, radiotherapy, laser, other therapies

FIGURE 22-40 Algorithm for the treatment of scars. (Adapted from Mustoe TA, Cooter RD, Gold MH, et al: International clinical
recommendations on scar management. Plast Reconstr Surg 110:560–571, 2002.)

affects the papillary dermis, medium-depth resurfacing
affects the upper reticular dermis, and deep tissue resur-
facing affects the midreticular dermis.
PREOPERATIVE CONSIDERATIONS
The patient’s Fitzpatrick skin type and response to sun
exposure should be considered prior to facial
resurfacing.105-107,276,323 Hypo- and hyperpigmentation
changes are rarely associated with skin types I and II;
therefore, all types of facial resurfacing procedures are
considered safe in these patients. However, patients with
type I or II skin are usually best treated with lasers. Some
type III or IV patents may benefit from a medium-depth
chemical peel. Before treating types IV to VI patients, the
selected procedure should be performed as a test spot at
the hairline to assess pigment changes prior to a defini-
tive procedure.324 The data regarding the appropriate
treatment for type V or VI patients is conflicting because
they are always at risk for hyperpigmentation and/or
hypopigmentation regardless of the procedure. An
erbium (Er):YAG laser may be better suited for types V
and VI skin types because it is associated with less thermal
damage.325 The degree of photoaging should be consid-
ered. The Glogau classification (see earlier, Table 22-5)
provides a measure of photoaging that occurs as a result
of exposure to ultraviolet light (UV) radiation, specifi-
cally UVB (290 to 320 nm) and UVA (320 to 400 nm),
with wavelengths that penetrate the dermis and cause
photodamage.110,326 Resorption of elastin and collagen
leads to a prominent epidermis that rests on a thin
damaged epidermis, resulting in wrinkle formation.
A complete medical history should be obtained and a
physical examination performed on any patient consid-
ered for facial resurfacing. Patients with medical comor-
bidities, such as systemic lupus erythematosus, active
herpetic infections, Ehlers-Danlos syndrome, sclero-
derma, vitiligo, discoid lupus, and ectodermal dysplasia,
are at an increased risk of scarring following facial
598 PART III Management of Head and Neck Injuries
resurfacing.325 Patients with lupus in particular are at
increased risk for developing Koebner reactions follow-
ing a resurfacing procedure.327,328 Immunocompromised
patients such as those with human immunodeficiency
virus (HIV) infection or those undergoing chemother-
apy are at increased risk for developing postoperative
infections.329 Patients who have received chemotherapy
or radiation to skin in the past should not have surgery
until 6 months after therapy to ensure that dermal col-
lagen remodeling is complete. In addition, patients with
previous radiation therapy may have chronic dermatitis,
which decreases the body’s ability to heal.330 Previous
areas of radiation should be examined for intact hair
growth. The presence of hair usually correlates with
enough pilosebaceous glands for adequate healing after
medium or deep chemical peels.
A complete medication history is also crucial to deter-
mine in the patient undergoing resurfacing. Women
taking birth control pills or supplemental hormones are
at increased risk for hyperpigmentation. Patients with a
history of isotretinoin are at increased risk for postpro-
cedure scarring following ablative procedures because
the drug is thought to shut down the pilosebaceous unit
(sebostatic), which is necessary for reepithelialization,
and may contribute to delayed wound healing. It is also
thought to cause loss of collagenase function, which will
cause increased fibrosis and scarring.331 If patients taking
isotretinoin complain of dry skin or anhidrosis, treat-
ment should be avoided for at least 6 months to 2
years.325,332-335 The use of vitamin E should be noted and
its use should be discontinued prior to resurfacing. Medi-
cations that affect the coagulation cascade such as aspirin
or warfarin should also be discontinued if not otherwise
medically contraindicated.
Patients undergoing perioral resurfacing treatment or
those with a history of herpes infection should receive
antiviral chemoprophylaxis. This is especially important
in trauma patients because they are at an increased
stress level and increased risk for viral activation. Patients
undergoing CO2 laser resurfacing are at increased risk
for herpes infection. Patients may be prescribed valacy-
clovir, 500 mg twice daily, acyclovir, 400 mg three times
daily, or famciclovir, 250 mg twice daily.336 Prophylaxis
should be initiated at least 24 hours before the proce-
dure and continued for 2 weeks, or until reepithelializa-
tion is complete. Because the virus only creates lesions
in the epidermis in the early stages of wound healing,
herpetic lesions will manifest as superficial erosive
ulcers.337-339 It is best to avoid ablative procedures during
the summer because there is an increased risk of postin-
flammatory hyperpigmentation caused by UV damage.340
PATIENT PREPARATION
Topical tretinoin has been shown to be efficacious in
the treatment of photodamaged skin by increasing type
I collagen formation and inhibiting collagenase,341-346
and it potentiates the effects of superficial chemical
peels and hydroquinone in melasma treatment.347 Pre-
treatment with topical tretinoin in the form of 0.1%
tretinoin cream for 2 weeks prior to 35% trichloroacetic
acid (TCA) peels has been shown to enhance the
healing time as well.348 Patients with Fitzpatrick type
III or IV skin may also be pretreated with a modified
Kligman formula (0.1% tretinoin, 4% hydroquinone,
and 0.1% triamcinolone) twice daily for 6 weeks in an
effort to minimize the risk of pigment change.349,350 This
regimen is usually resumed in 2 to 3 weeks postopera-
tively. If the formula is too irritating, kojic acid can be
substituted for hydroquinone.332,333
The patient should be advised to wear comfortable
clothing on the day of the procedure. The patient should
remove all makeup and then wash the face and neck with
an antibacterial soap such as chlorhexidine gluconate
(Hibiclens). Preoperative photographs should be taken.
If lasers are being used, the appropriate eyewear should
be applied. For chemical peels, moist gauze should be
applied to both eyes and the skin should be scrubbed
with acetone or other cleanser for 2 to 3 minutes to
remove the stratum corneum and allow deep penetra-
tion. Petrolatum or other ointment is then applied with
a cotton-tipped applicator to the deep grooves or rhyt-
ides (wrinkles) of the face to prevent chemical buildup
in these areas. A fan blowing on the patient will decrease
patient discomfort throughout this process.
SPECIFIC TECHNIQUES
Chemical Peels
Of all resurfacing procedures, chemical peels may offer
the least benefit for post-traumatic scarring. Because of
the irregularities of the scar, it is hard to control the
depth of penetration using chemical peels. This tech-
nique, however, may be a useful adjunct for blending the
margins of a scar previously treated by surgical revision,
dermabrasion, or laser therapy.
Chemical peeling is the application of a chemical
exfoliant to the epidermis and dermis for removal of
superficial lesions. Its goal is to improve the texture of
skin and remove irregularities. New epidermal growth is
stimulated by removal of the stratum corneum with more
superficial chemical peels. Medium chemical peels stim-
ulate an inflammatory response, leading to new collagen
formation in the deep reticular dermis; deep chemical
peels stimulate ground substance formation.351 Fitzpat-
rick skin types I and II patients have little risk for dyspig-
mentation, whereas type III or VI skin has an increased
risk for hyper- or hypopigmentation following a chemical
peel.352,353 Pigment changes are usually not of concern
for superficial chemical peels, but have a higher inci-
dence in medium and deep chemical peels. Specific
areas at risk include the lips and eyelids. Patients with
extensive photodamage may require stronger chemical
peels with greater frequency.
After skin preparation, the chemical to be used is
applied with one or two cotton-tipped applicators, gauze,
large swabs, or a fan-shaped sable hair brush in a rapid
and uniform manner for approximately 1 minute. It can
be done superior to inferior, or medial to lateral, and
should be applied to the following facial units—the man-
dible, chin, temples, upper lip, cheeks, glabella, nose,
and forehead—taking care to feather the chemical into
the hair and jawline. Increasing pressure and number of
applications increase the depth of penetration. Frosting
of the skin often occurs and is an indication of the

evenness of the peel. Duration of chemical contact is
determined by the condition being treated, patient toler-
ance, desired depth, and/or predetermined end point.
Skin pretreated with tretinoin will frost faster, whereas
photodamaged and highly sebaceous skin frost slower.
Types of Chemical Peels. Chemical peeling agents can
be categorized based on their depth of penetration. They
are classified as superficial, medium, or deep.
Superficial Chemical Peels. Superficial chemical peels
work by exfoliating down to the level of the stratum
corneum (Table 22-6). They are of little use in the post-
traumatic setting and usually need to be applied more
than once for desired effects. Alpha-hydroxy acids (AHAs;
e.g., glycolic [2-hydroxyethanoic] acid and lactic
[2-hydroxypropanoic] acid) are naturally occurring com-
pounds that cause epidermolysis with discohesion of the
keratinocytes of the stratum corneum; they are commonly
used for superficial chemical peels.354-356 Strength and
depth are dependent on the amount of buffering or neu-
tralization of AHA. Therefore, a solution of 30% glycolic
acid in a buffered solution may be equivalent to 15% gly-
colic acid in a more acidic pH preparation. Immediate
neutralization of AHA should take place after frosting,
followed by a water rinse. This may be repeated weekly or
monthly until desired results are obtained. Typical AHA
regimens include applying glycolic acid at a concentra-
tion of 30% to 50% for 1 to 2 minutes. For a deeper super-
ficial peel, glycolic acid at a concentration of 50% to 70%
is applied for a duration of 2 to 20 minutes may be used.
TCA is a useful treatment for superficial problems
such as melasma, superficial acne scarring, actinic kera-
tosis, rhytides, and postinflammatory hyperpigmentation
associated with trauma.357-361 It works by causing coagula-
tion necrosis of epidermal and dermal proteins. Depth
of penetration varies with concentration. The desired
concentration is obtained by mixing TCA crystals with
100 mL of distilled water. For example, 15 g of TCA crys-
tals mixed with 10 mL of distilled water makes A 15%
TCA solution. The solution may be stored in a dark glass
bottle for up to 6 months. After standard application,
neutralization with a cool water mist should take place
after a frost appears. Reapplication may take place, with
35 minutes between coats. For a very superficial peel,
TCA at a concentration of 10% applied for 1 to 2 minutes
may be used. For a deeper superficial peel, TCA at a
concentration of 10% to 30% for 1 to 2 minutes may be
used. Concentrations may be increased by 5% with each
application and may be used weekly to monthly for
desired effect.
Jessner’s solution, which is also known as the Combes
formula consists of 14 g resorcinol, 14 g lactic acid, and
TABLE 22-6 Agents Used for Superficial Chemical Peels
Agent Concentration Mechanism of Action
TCA 10%-30% Protein precipitation
Jessner’s solution Standard formula Keratolysis
Glycolic acid 30%-70% Epidermolysis
Salicylic acid 5%-15% Keratolysis
Secondary Revision of Soft Tissue Injury CHAPTER 22 599
14 g salicylic acid in 95% ethanol to make a total of
100 mL.321,362,363 It is useful for the treatment of dyspig-
mentations of the head and neck. In the immediate 2 to
3 days after application, pigmented tissue may appear
hyperpigmented, with peeling and flaking up to 7 days
after treatment. After standard application, Jessner’s
solution is neutralized by its chemical reaction with epi-
dermal proteins. Superficial chemical peels can be per-
formed with one to ten coats of Jessner’s solution, applied
as three coats per session in 5- to 15-minute intervals.
Other superficial chemical peels include beta-hydroxy
acid, salicylic acid (o-hydroxybenzoic acid), and resor-
cinol (m-dihydroxybenzene); however, their use in post-
traumatic scarring is limited.
Medium Chemical Peels. Medium-depth chemical
peeling agents penetrate and destroy the epidermis, pap-
illary dermis and, in some cases, the reticular dermis.
Medium-depth peeling agents are most useful for treat-
ing fine rhytides, hyperpigmentation, actinic keratosis,
dyschromias, Fitzpatrick type 2 photoaging, acne scars,
and depressed scars. Medium peels are optimal for
blending photoaged skin after deep chemical peels and
laser resurfacing. Unlike superficial chemical peels, only
one treatment session is often necessary. Recovery time
is usually 7 to 10 days. In addition to the agents described
earlier, pyruvic acid, an alpha-keto acid that converts to
lactic acid, is useful for medium-depth chemical peels.364
It works by epidermal lysis and penetrates the dermis in
1 to 2 minutes. Water may add comfort but does not
neutralize the pyruvic acid. Edema and erythema will be
present following its application, with crusting that will
last approximately 10 days. TCA at a concentration of
50% is associated with complications such as scarring.
Therefore, combinations of agents are commonly used
for medium chemical peels, such as the following: 70%
glycolic acid for 3 to 30 minutes, followed by 35% TCA365;
Jessner’s solution followed by 35% TCA366,367; solid CO2
followed by 35% to 50% TCA or pyruvic acid363; and
Jessner’s solution and glycolic acid (Box 22-3).368 Medium-
depth chemical peels may be combined with CO2 laser
therapy, which reduces healing time and minimizes resid-
ual scarring.369 Within approximately 3 months after a
medium-depth chemical peel, thick bands of elastic
fibers are evident in the mid to upper dermis.370 In addi-
tion, there is an increase in glycosaminoglycans and
ground substance in the dermal matrix, which hydrates
and thickens the matrix-inhibiting wrinkling. Dermal
BOX 22-3 Agents Used for Medium Chemical Peels
Combination of Either:
• 35% TCA and Jessner’s solution
• 35% TCA and solid CO2
• 35% TCA and 70% glycolic acid
89% phenol*
TCA, 50% concentration†
*Mainly used for deep chemical peels.
†
Rarely used because of scarring.
600 PART III Management of Head and Neck Injuries
collagen is not finished reorganizing for 60 to 90 days;
therefore, repeat medium-depth chemical peels should
not be done for at least 3 months after the initial session.
Deep Chemical Peels. Deep peeling agents cause
destruction of epidermis, papillary dermis, and extend
into the reticular dermis. The primary agents used in
deep peels are TCA at a concentration higher than 50%
and phenol (carbolic acid). The latter agent penetrates
to the midreticular dermis. Baker et al have used a com-
bination of 3 mL of 88% phenol, 2 mL of water, 8 drops
of hexachlorophene (Septisol) liquid soap, and 3 drops
of croton oil for deep chemical peels.371,372 Histologically,
phenol-treated skin shows a thicker, more organized
connective tissue in the dermis, and a finer network of
elastic fibers than normal skin, which contributes to less
wrinkles.373-375 Phenol is cardiotoxic, hepatotoxic, and
nephrotoxic and is contraindicated in patients with
cardiac arrhythmias.376 Preoperative electrocardiogra-
phy, complete blood count, and electrolyte panel should
be performed before planning a phenol peel.
To reduce toxicity, perioperative IV fluids are admin-
istered to the patient undergoing a phenol peel. The
phenol is applied until a frost appears. Each facial unit
should be treated 10 to 15 minutes apart, for a total treat-
ment time of 1 hour. Immediately following the pro-
cedure, a dusky erythema will develop over the initial
12 hours, with an accentuation of pigmented lesions
and exudative crusting forms. This crusting should be
débrided with soaks, compresses, or occlusive salves. The
goal is to remove the crust and prevent it from hardening
to form a scab. Reepithelialization after a phenol chemi-
cal peel begins after 3 days and continues until 14 days
postoperative. Erythema may be present for 2 to 4
months. Neoangiogenesis and new collagen formation
may take place for up to 4 months during the final stages
of fibroplasia. Patients should wait at least 1 year before
undergoing another session. Common risks of the pro-
cedure include scarring, and hypopigmentation.
Postoperative Care. Following epithelialization, patients
should use a moisturizer twice daily to prevent scarring.
Patients should be advised not to rupture any blisters or
pick any crusts. For major crusting, topical bacitracin or
bacitracin–polymyxin B (Polysporin) should be applied
twice daily. Aspirin and nonsteroidal anti-inflammatory
drugs (NSAIDs) should be avoided for up to 1 week after
surgery. Erythema may last up to 4 weeks. For patients
with significant edema, 2.5% cortisone cream may assist
with recovery. Tretinoin should be resumed 1 week after
a chemical peel. Sun block that prevents exposure to
UVB and UVA should be used to prevent pigmentation
abnormalities and further photoaging for at least the first
month following a chemical peel. After 1 month, the
daily use of a sunblock, SPF 15 to 30, is recommended.
Complications. Complications following chemical peel
usually stem from injury to the epidermis and dermis.
Hyperpigmentation may last several weeks, but treatment
with tretinoin may reduce the duration. Patients with
Fitzpatrick type IV or V skin and those exposed to sun
are at increased risk for hyperpigmentation. They are
best treated with hydroquinone, which is especially useful
in the treatment of dyschromias in Fitzpatrick types III
and IV patients.
Infection, which may be bacterial, viral, or fungal, may
result in prolonged formation of granulation tissue.
Symptoms of a postpeeling infection include fever, pain,
and discharge. Infections may lead to significant scarring
and, when suspected, the skin should be cultured and
treated without delay. Milia, or small inclusion cysts, may
occur during healing and are best treated with extraction
using a no. 11 blade. Preoperative and postoperative
tretinoin has been shown to reduce the incidence of
milia formation.346
Dermabrasion and Microdermabrasion
Dermabrasion and microdermabrasion work by mechani-
cally removing the epidermis along with the papillary or
upper reticular layer of the dermis and are considered as
medium to deep resurfacing procedures.377,378 They may
be used as soon as 6 weeks following injury, with almost
complete disappearance of some scars treated at this time,
and have similar outcomes to the use of lasers for the
treatment of perioral rhytides but are associated with less
postoperative crusting and more rapid reepithelialization
of the skin.379,380 They work by increasing the density of
types I and III collagen and TGF-β in the papillary dermis
and reorienting collagen to a more parallel plane to the
axis of the epidermis, which arises from the deeper, less
photodamaged cells.381-384 In addition, upregulation of
tenascin expression throughout the papillary dermis and
an increase in a6b4 integrin subunits of keratinocytes of
the stratum spinosum are seen on histologic examina-
tion.385 They have been shown to be equally or more effec-
tive than 5-fluorouracil (5-FU) in the treatment of actinic
keratosis and other premalignant lesions.346,386
Indications for dermabrasion related to trauma
include the treatment of post-traumatic keloids, and
hypertrophic or depressed scars378 Dermabrasion is con-
traindicated in patients with a history of abnormal wound
healing, hypertrophic scarring, recent isotretinoin treat-
ment, deep thermal injury, active herpes simplex or
human papilloma virus infection, and congenital ecto-
dermal defects.387 As with chemical peels, because of
sebaceous gland atrophy, patients with a history of
isotretinoin use may be at increased risk for scarring.331,388
However, there have been reports of patients undergoing
dermabrasion following isotretinoin use without any
adverse effects,345,389 and laboratory studies have failed to
show any side effects of isotretinoin with regard to col-
lagen synthesis or fibroblast activity of the skin. Patients
should be informed about the risks and benefits of derm-
abrasion therapy and combination with other scar revi-
sion techniques should be considered.390
The technique of mechanical dermabrasion includes
using a diamond fraise or wire brush burr, moved in a
direction perpendicular to the rotating burr with a
courser grit penetrating deeper than finer grit. It can be
performed using local anesthesia, nerve blocks, and/or
cryogenic freezing. Freezing the skin to −40° C (−40° F)
in 25 seconds produces a firm, anesthetized, bloodless
surface, without distorting skin contours. The disadvan-
tages of freezing, however, is that it is technique-sensitive,
with thermal injury resulting from temperatures lower
than 30° C inducing a frostbite type wound, leading to
hypopigmentation. If too much pressure is placed on the

skin with the operating handpiece sloughing of the skin
may ensue. As an alternative to freezing, local anesthesia
tumescence may be used as an aid to increase skin turgor
and rigidity to abrade.391 For larger areas, to reduce the
risk of lidocaine toxicity, lidocaine diluted in saline, epi-
nephrine, and bicarbonate may be used in a larger
volume. For depressed scars, it may be helpful to paint
the area with 1% gentian violet so that dermabrasion can
be carried to the greatest depth of the scar. Gentian violet
combined with daily petrolatum dressings is also useful
after dermabrasion for tattoo removal, causing the
pigment to leach out of the wound. This creates an
inflammatory response–stimulated phagocytosis of the
remaining pigment.
The treatment should be planned in the order of
cosmetic units performed, moving from unit to unit with
taut skin tension placed on the skin by the assistant, and
using a 4 × 4 gauze soaked in 2% lidocaine with 1 : 000,000
epinephrine, with mild pressure on treated sites for
hemostasis. The surgeon may begin centrally beside the
nose, working outward and moving from just below
the jawline up to the infraorbital area and posterior to
the preauricular area. Unabraded skin such as the eye-
brows and first few centimeters of hair may be treated
with 35% TCA for an even blending of the dermabrasion.
The end point for dermabrasion is the development of
uniform pinpoint bleeding, which will emanate from the
papillary dermis. However, some may use the superficial
reticular dermis as an end point because dermabrasion
at this level is less likely to produce superficial scarring.
This level is apparent by the transition between the
appearance of white parallel bands and the protrusion
of short white fibers.392 At this level, a yellowish appear-
ance resulting from the sebaceous glands at the border
between the reticular and papillary dermis may be
present.337 This endpoint may be used for more signifi-
cant scars, however carries the risk of further scarring.
Postoperative Care. Following hemostasis, a topical
antibiotic, followed by a nonadherent dressing, absor-
bent gauze layer, and more rigid stabilizing layer outside
should be applied. Patients should keep the head ele-
vated; ice packs are recommended. Patients with a history
of herpes simplex infection should begin prophylaxis 24
hours preoperatively and continue for 5 days postopera-
tively. Patients should be advised to soak their face twice
daily and not pick at any crusts. Epithelialization follow-
ing dermabrasion takes approximately 7 days. Following
healing after dermabrasion, the area may be blended
with surrounding tissues using superficial dermabrasion
or a chemical peel. As with chemical peels, the applica-
tion of 0.5% tretinoin for several weeks before and after
dermabrasion has been shown to accelerate wound
healing in the postoperative period.346 In addition, the
use of occlusive dressings in dermabraded wounds has
been shown to increase healing time by up to 40% and
may have a positive effect on collagen synthesis when
compared with wounds left open to air.393 Pain is also
reduced with the use of occlusive dressings.394 In patients
with a history of dyschromia, topical hydroquinone and
tretinoin may be started, with 1% hydrocortisone being
added for patients with persistent hyperpigmentation.
The skin appears normal skin in approximately 1 month.
Secondary Revision of Soft Tissue Injury CHAPTER 22 601
Complications. Postoperative edema will usually resolve
in 4 to 6 weeks. Complications following dermabrasion
include milia, rebound oil production, and acne forma-
tion, but these are usually transient. Infection, hyperpig-
mentation, persistent erythema, and scarring are also
unforeseen potential risks of dermabrasion. Scarring
may be operator- or patient-dependent. Histologic changes
following dermabrasion are similar to that of a deep
chemical peel or CO2 laser treatment.395,396 Clinically,
lasers penetrate the same depth as a phenol deep chemi-
cal peel and dermabrasion.397 However, when compared
with chemical peels one study has found that derm-
abraded skin may be less stiff at 6-month follow-up.398 In
addition, patients undergoing dermabrasion may heal
significantly faster, with less erythema, than when treated
with CO2 laser.
Microdermabrasion. Microdermabrasion involves the
frictional resurfacing of the epidermis and dermis by
circulating a stream of aluminum oxide crystals that are
pulled and blown across the skin. Other types of granules
may be used, but aluminum oxide is the most common.
This is useful for post-traumatic scars; patients may see
beneficial results in as little as four treatments.399 Skin
biopsies taken in patients who have undergone multiple
aluminum oxide microdermabrasion demonstrate a
thicker epidermis and dermis, more hyalinization of the
papillary dermis, and more newly deposited collagen and
elastic fibers when compared with controls.381,382
Clinically, patients show improvement in dyschromias,
actinic changes, and fine rhytides when compared with
controls.
Before the procedure, the skin should be cleansed in
a similar manner as for chemical peeling. No anesthesia
is required. Each facial unit should be treated one at a
time. Patients may cleanse the skin and resume wearing
makeup and normal activities immediately after the
procedure. As with dermabrasion, the skin should be sta-
bilized with firm pressure. A potential concern of micro-
dermabrasion is a resulting granulomatous response from
deep dermal penetration of the aluminum oxide crystals;
however, this reaction has not been seen in the clinical
setting.399
Lasers
Light amplification by stimulated emission of radiation
(LASER) works by emitting electromagnetic radiation in
the form of a stream of photons that travels at the speed
of light. Lasers used clinically emit radiation in a fixed
spectrum of wavelengths (Table 22-7). Materials used
include dye, crystal, gas, or other media. They require an
energy source in the form of radiation, electric current,
or flashlamp, which emits the electrons at an excited,
higher energy level. After returning to their steady state
orbits, electrons release quantums of energy in the form
of photons traveling at a certain wavelength; this stimu-
lates other electrons to release photons that travel along
an optical axis, reflecting back and forth, and causing a
cascading effect of energy and photon release. The result-
ing light is amplified and a laser beam is produced.
Lasers allow the surgeon to select a wavelength for a
particular targeted tissue, or chromophore. The two
most commonly used lasers in facial resurfacing are the
602 PART III Management of Head and Neck Injuries

areas can tolerate deeper resurfacing, whereas other

TABLE 22-7 Lasers and Their Clinical Applications areas such as the jawline and other sharp demarcations
should undergo one pass or lighter resurfacing.
Laser Wavelength (nm) Indications CO2 lasers were the first lasers available for skin reju-
CO2 10,600 Resurfacing, atrophic venation, first being reported by Patel in 1964.402 This
scars type of laser is most useful for the correction of severe
Er : YAG 2,940 Resurfacing, atrophic photodamaged skin, sebaceous hyperplasia, fine or mod-
scars erate rhytides, and dyschromias. The mechanism of
action is by causing thermal injury and subsequent vapor-
Long pulsed ruby 694 Hair removal
ization of the dermis and epidermis, thereby leading to
Long pulsed 755 Hair removal collagen coagulation and shrinking. New collagen pro-
alexandrite
duction continues for up to 2 to 3 months postopera-
Long pulsed diode 800 Hair removal tively. The continuous pulse CO2 laser works at a
Long pulsed 1064 Hair removal wavelength of 10,600 nm, vaporizing approximately 50
Nd : YAG μm of tissue.323,403,404 However, it can also can result in up
Q-s Nd : YAG 1064 Pigmented skin, to 100 μm of thermal injury, which causes erythema,
lesion, or tattoo pigment changes, and scarring. The superpulsed CO2
Q-s ruby 694 Pigmented skin, laser use higher peak powers and shorter pulse duration
lesion, or tattoo to minimize collateral thermal injury while maximizing
Q-s alexandrite 755 Pigmented skin, tissue ablation. The ultrapulse CO2 laser, reported by
lesion, or tattoo Fitzpatrick in 1993, has an even shorter pulse duration
Pulsed dye 510 Pigmented skin, (1000 microseconds) than the superpulsed CO2 laser,
lesion, or tattoo leaving behind as little as 50 μm of adjacent thermal
Q-s Nd : YAG 532 Pigmented skin,
damage. Reepithelialization following CO2 laser resurfac-
(frequency- doubled) lesion, or tattoo ing takes place in approximately 7 to 14 days. Erythema,
KTP which is typical after CO2 laser treatment, tends to fade
over 1 to 6 months.338
Argon-pumped 577, 585 Vascular lesions
tunable dye
The Er : YAG has a wavelength of approximately
2940 nm and has a higher affinity for water than CO2
Flashlamp-pumped 585 Vascular lesions,
lasers, so most of its energy is focused on water vaporiza-
dye hypertrophic scars
tion, minimizing thermal damage and tissue debris.338 It
Pulsed Nd : YAG 532 Vascular lesions produces a more superficial ablation with less postopera-
(frequency-doubled) tive erythema and a shorter recovery phase than other
KTP lasers. It is useful for treating moderate to severe rhyti-
dosis associated, with moderate to severe photodamage,
and has been shown to stimulate collagen formation.404
It has an ablation depth of 10 to 40 μm and leaves a zone
of thermal spread less than 50 μm, which is less than that
CO2 and Er : YAG lasers, which are absorbed by water. of the CO2 laser. This leaves most patients with superior
Water constitutes 90% of the epidermis, so CO2 and cosmetic results with fewer side effects, such as scarring
Er : YAG are optimal for skin resurfacing procedures. and erythema. Complete reepithelialization takes place
Unfortunately, although the targeted chromophore may in 4 to 10 days; postoperative erythema usually resolves
absorb a particular wavelength, so may adjacent chromo- in 4 weeks. The use of the Er : YAG laser is most beneficial
phores. All laser energy is converted to heat in a process for Fitzpatrick types IV to VI skin and may be used as an
called photothermolysis, causing damage to adjacent adjunct in vaporizing the area of thermal necrosis follow-
tissue by heat dissipation, or thermal bleed. Type 1 col- ing ultrapulse CO2 resurfacing, resulting in faster healing
lagen denatures at 70° C (158° F); therefore, the underly- and less erythema in these areas.405 The CO2 and Er : YAG
ing dermis is susceptible to collateral thermal damage, lasers have also been combined, optimizing the advan-
which may lead to scarring. tages of both lasers.406-408 These include the precision and
Histologically, skin treated with lasers looks similar to low thermal ablation of the Er : YAG laser and deep abla-
skin treated with phenol. It demonstrates a zone of tissue tion of the CO2 laser.
vaporization and ablation of the epithelium, with an adja- The 585-nm flashlamp-pumped PDL is indicated for
cent area of a collateral basophilic zone of thermal hypertrophic scarring and keloids. It is especially useful
necrosis of the dermis. An initial pass of the laser will be in post-traumatic injuries, resulting in less recurrent scar
absorbed by the water in the epidermis but because of formation while significantly improving scar contour,
the low water content of the collagen of the dermis and height, pruritus, texture, color, and pliability.57,267,269-273,409
subsequent less absorption, more heat is produced, In addition, PDL reduces scar microcirculation, subse-
causing thermal injury with each successive pass.400,401 quently preventing excess scar formation. Its mechanism
Following laser resurfacing, regeneration of epithelium of action is by acting on hemoglobin-containing struc-
and elastic fiber in the papillary dermis occurs and gly- tures, rather than directly ablating scar tissue.
coprotein tenascin is expressed as new collagen. Facial Lasers should be used in accordance with the safety
units such as the cheeks, chin, forehead, and perioral standards of the American National Standards Institute

(ANSI).410 These include the use of protective eyewear
for the patient, surgeon, and staff, nonflammable drapes,
smoke evacuator, and laser masks. It is safe to use an
aqueous-based solution for skin preparation; alcohol-
based preparations should be avoided. Laser resurfacing
may be performed using general, regional, local, or
topical anesthesia, or sedation. Preoperatively, pretreat-
ment with hydroquinone, tretinoin, or glycolic acid has
been shown to reduce postradiation side effects, such as
hyperpigmentation.411 It is important to know the end
points with laser resurfacing. For CO2 laser resurfacing,
a pink color may be seen once the papillary dermis is
entered. The use of saline gauze to remove vaporized
skin between passes is helpful for visualizing the full
depth of treatment. Because of the hourglass shape of
the pilosebaceous gland, pores increase in diameter as
the level of ablation deepens. Variations in the thickness
of skin among individuals and the facial subunit of each
individual require the surgeon to pay attention con-
stantly to the laser settings with each pass and movement
to a different subunit.
Postoperative Care. Immediately following laser resur-
facing, cool gauze soaked with topical lidocaine should
be applied. In the postoperative period, a semiocclusive
dressing should be used for 3 days and has been shown
to reduce pain and decrease the duration of reepitheli-
alization to as little as 5 days.412-416 Antiviral prophylaxis
should be continued for 7 to 10 days and any preopera-
tive antibiotics, if used, may be discontinued. Antifungal
prophylaxis with fluconazole has not been used routinely
for ablative procedures; however, some believe that it
should be recommended to patients with a history of
oral, vaginal, or nail candidiasis. After reepithelialization
is complete, sun should be avoided for 2 to 3 months. In
patients with severe postoperative edema, corticosteroids
have shown to be of benefit and skin moisturizers should
be used after reepithelialization.
Complications. Excess passes of the laser will lead to an
unintended depth of tissue penetration, which leads to
significant scarring; this typically occurs in the area of
excessive thermal injury or infection. Areas that remain
persistently red for longer than 3 weeks should raise
concern for infection.417 These areas usually appear
dusky red or red-purple, rather than the bright red ini-
tially seen following resurfacing. For progressive scar-
ring, 585-nm flashlamp-pumped PDL therapy can be
performed every 4 weeks.418
A variety of laser systems use a computerized scanner
generator, allowing large surface areas to be scanned in
a systematic manner and minimizing overuse of the laser
in one area.419 It is not uncommon to see a 2- to 6-week
period of hyperpigmentation following laser resurfacing,
especially in Fitzpatrick skin types IV to VI. Topical ste-
roids used two or three times daily, tretinoin, or hydro-
quinone may be beneficial for treating pigmented skin.
Hypopigmentation that results after laser resurfacing is
often unpredictable and permanent. As depth of injury
increases, more melanocytes in hair-bearing areas are
destroyed.417 This occurs in 10 % to 30% of patients and
is usually difficult to treat.420
Other side effects include acneiform eruption, herpes
simplex outbreak, bacterial infection, yeast infection,
Secondary Revision of Soft Tissue Injury CHAPTER 22 603
prolonged erythema beyond 1 month, and contact
dermatitis.421-423 Infections should be suspected when
there is increased pruritus, burning, or pain in the first
3 postoperative days.338,418 Gram staining, Tzanck smear,
or immunofluorescence and potassium hydroxide exam-
ination should be done by direct smear of the areas in
question, when indicated. Any occlusive dressing should
be removed and empirical antibiotic treatment begun,
including gram-negative coverage and antiviral, and anti-
fungal therapy; this should not be delayed because of the
significant long-term effects of infection. Prolonged ery-
thema with skin thickening should be treated with intra-
lesional injections with triamcinolone, 5-fluorouracil,276
or a combination of both. Dermabrasion and CO2 laser
resurfacing should not be used in the lower two thirds
of the face because this area contains fewer adnexal
structures and has a higher chance of scarring. Extreme
caution should be used when considering resurfacing
around the upper neck and jawline.
GENERAL POSTOPERATIVE CARE FOR ALL
ABLATIVE TECHNIQUES
Postoperative care for specific procedures is discussed
earlier in this chapter. In general, occlusive dressings are
recommended for almost all wounds. As noted, reepithe-
lialization is enhanced in a moist environment.5 Wounds
with excess crusting and scarring heal more slowly than
wound meticulously kept clean because epithelium
travels along the most hydrated route28 (Fig. 22-40).
Granulation tissue formation is also hastened in a moist
environment.29 Therefore, occlusive dressings and anti-
biotic ointment use are recommended so that epithelial
migration proceeds in directly and efficiently. Antibiotic
ointment should be applied following surgical scar revi-
sion procedures,34 reducing pain, infection, and scar-
ring.424,425 Antibiotic ointment, however, may be associated
with a higher incidence of contact dermatitis. A cold
compress on postoperative day 1 may be used. Once
initial healing is complete, patients should be instructed
to use a soapless cleanser to wash the face for the next 2
months. Patients may resume wearing makeup once
reepithelialization has occurred. Sunblock (SPF > 30) is
recommended for at least 1 year and encouraged indefi-
nitely following resurfacing to minimize the risk of
hyperpigmentation and skin cancer. Hydroquinone is a
useful adjunct to prevent and/or treat hyperpigmenta-
tion. This can usually be started as soon as 2 to 3 weeks
postresurfacing.
ADJUNCTIVE SCAR REVISION PROCEDURES
TISSUE EXPANSION
Tissue expansion is indicated for scars that cannot be
revised by immediate local or regional flap techniques
without causing significant donor site morbidity and is
especially useful for post-traumatic avulsive defects sus-
taining significant tissue loss. It is most often used for the
scalp and forehead because of the inelasticity of tissue in
these areas. In general, the goal of tissue expansion is to
604 PART III Management of Head and Neck Injuries
increase the size of normal tissue enough to cover a local
scarred defect.
Unlike serial scar excision, which relies on mechanical
creep and tissue elongation, tissue expansion works by
biologic creep and tissue generation. It was popularized
by Radovan for mastectomy reconstruction.426 Expansion
of the skin results in the creation of a new epidermal
layer, with thinning of the dermis and subcutaneous
tissues. Hair follicle morphology will remain the same,
which is a critical advantage of scalp expansion.427 Alter-
natives to tissue expansion include full- and partial-
thickness skin grafting, serial scar excision, and the use
of local regional and distal flaps; however, tissue expan-
sion can be used alone or in combination with these
techniques. Tissue expansion has the benefits of main-
taining identical color, texture, thickness, and hair-
bearing aspect of skin, and improves the vascularization
of the native tissue bed. This proliferation of blood
vessels increases the survivability of flaps raised in
expanded tissue by 117% over flaps raised in nonex-
panded tissue.428 Disadvantages of tissue expansion
include the need for multiple operations, longer dura-
tion of treatment, making the patient live longer with the
deformity, and loss of skin elasticity, along with implant
capsule formation. Also, wounds treated by tissue expan-
sion may experience delayed contracture of expanded
tissue; this may be associated with sensation changes of
the overlying skin.429-433
Tissue expanders should not be placed in areas of scar,
atrophied skin, or irradiated skin because of the increased
risk of skin breakdown and necrosis in these areas.434
Complications include wound dehiscence, port failure,
implant exposure, seroma formation, implant rupture,
and infection.429,431 These might be avoided by using mul-
tiple drains, avoiding custom implant use because they
tend to deflate, and using more than one expander if
space allows. In addition, expanded skin of the neck
should not be advanced past the mandibular border. This
could lead to scar widening, lower eyelid ectropion, or
lip ectropion. Skin expanded in the neck and cheek
region should not cross multiple facial units because dif-
ferences in skin characteristics may result in unsightly
outcomes and be associated with more complications.
Normal unexpanded cheek tissue is ultimately the best
donor for scar revision of the cheek and skin overlying
the mandibular body and inferior border. Inferior
advancement of expanded cheek skin is associated with
a much lower risk of ectropion than superior advance-
ment than tissue of the upper facial third. Advancement
or rotational flaps used in the neck should be performed
with the neck in extension because this decreases skin
tension.
Ideally, if tissue expansion is needed, it is combined
with other revision techniques, such as free tissue trans-
fer,435 skin resurfacing,436 serial scar excision,437 Z-plasty,438
and W-plasty.439 Variations include endoscopic tissue
expander placement, which allows for placement of
expanders away from the site of interest, using small inci-
sions to reduce the risk of wound dehiscence.440
Technique. There are a variety of customized and stan-
dardized implants of various sizes and shapes that can be
used in the head and neck region. However, a detailed
discussion of tissue expander placement is beyond the
scope of this chapter.
In general, incisions should be made in normal healthy
skin, just adjacent to the scarred area and preferably
radial to the implant to minimize wound dehiscence.
Passive placement of the implant into the cavity is essen-
tial. It should be placed within the subcutaneous plane,
in the subgaleal plane in the scalp and just above the
platysma in the neck. Only normal tissue should be
expanded and the scar should remain the same size, with
the ultimate goal of scar excision. In general, inflation
of the implant begins 1 to 2 weeks after placement and
increased in size at 1- to 2-week intervals. Expansion
should not take place in the presence of excess pain or
blanching on follow-up.429 When more rapid expansion
sequences are used, it is advisable to use local pulse
oximetry to monitor for tissue hypoxia.433 As a general
rule, tissue should be expanded at least 2.5 to 3 times the
desired size to allow for recoil and tension-free final
closure after scar excision.441,442 Although lower in elastic-
ity than neighboring skin, expanded skin may be rotated,
transposed, or advanced. It is not recommended to
excise the capsule that develops during expansion
because of its rich vascularity. It may, however, be scored,
advance, and rotated. The patient should be informed
that expanded skin will usually soften and skin character-
istics such as color and texture will improve usually 3
months after final expansion.443
STEROIDS
Intralesional steroid injections are useful for the treat-
ment of keloids and hypertrophic scars (see earlier).276
They are also useful in reducing scar volume and height,
pruritus, edema, and erythema and increasing scar pli-
ability,57,274,275 and are a useful adjunct to surgical scar
revision. They may be started as soon as 2 weeks postop-
eratively.277 The most commonly used agent is insoluble
triamcinolone acetonide (10 to 40 mg/mL).268 There are
few short-term side effects; long-term side effects include
tissue atrophy leading to skin thinning and widen-
ing.57,278,279 Injections may be repeated every 3 to 4 weeks
until the desired effect is achieved, but the dosage must
be adjusted if side effects develop.444
FILLER MATERIALS
Filler materials are used to replace tissues below the epi-
dermis, such as dermal collagen or subcutaneous tissue.445-
447
They are used to treat a variety of defects, most notably
the depressed scar. Xenograft fillers such as injectable
bovine collagen (Zyderm, Zyplast), which is derived from
cowhide and is the purified suspension of bovine dermal
collagen, may be used. The antigenic potential of the
material is reduced by 95% to 98% in a series of purifica-
tion steps.448 When these materials are used, , the double
skin test may be performed 4 weeks apart to test patient
sensitivity. This is done by injecting 0.1 mL of the mate-
rial in the volar forearm; if erythema or induration devel-
ops, the material should not be used. The skin test is
positive in approximately 3% of patients.449 Zyplast is col-
lagen cross-linked with glutaraldehyde which is longer
lasting and less reactive than Zyderm, which is placed
within the dermis.444 Long-term complications of bovine

dermal fillers include local skin necrosis, granulomatous
reactions,446,450,451 and abscess formation.452-454 Other
popular nonhuman filler materials include gelatin matrix
implants455 and hyaluronic acid fillers, such as hylan B456-
458
and Restylane (Medicis Aesthetics, Scottsdale,
Ariz).459-461
Allograft fillers include AlloDerm and/or Cymetra
(LifeCell). AlloDerm is available as sheets and Cymetra
as the injectable form. For post-traumatic lip scarring
secondary to deficient tissue volume, AlloDerm may be
used by creating a submucosal tunnel along the antero-
inferior aspect of the lip, pulling the appropriate-sized
piece of AlloDerm through. AlloDerm may also be
injected in areas of minor defects. Although silicone is
no longer approved for use in the face, other allogenic
fillers that may be used include homologous injectable
collagen.462 However, more studies are needed to evalu-
ate the usefulness of this material.
First described for ophthalmologic procedures,463
autologous dermal grafts are useful after subcision and
undermining of scars for preventing reattachment of the
anchoring fibrous bands from the overlying skin. Dermal
grafts should be used 2 to 6 weeks after subcision.464
Optimal donor sites include the postauricular dermal
tissue because of its inconspicuous nature. Side effects
include hematoma formation, infection, edema, pain,
and graft migration. Grafts will mature to final size in 1
to 6 months.465 Other but less used autologous fillers
include cultured human fibroblasts466-469 and autologous
injectable collagen470-472; however, few clinical studies
have been carried out on the use of these materials.
Autografts such as autologous fat graft or injection
may be used for severely depressed scars. These are espe-
cially useful for post-traumatic defects and scarring.
However, their effects are unpredictable and patients
may experience a 45% weight loss within 1 year.473 Fat
grafts harvested surgically maintain volume better than
those suctioned474,475 and, because of expected absorp-
tion, overcorrection of defects by 30% to 50% is recom-
mended.476,477 Microlipoinjection is performed by first
using a tumescent local anesthesia technique and then
harvesting with a blunt-tipped microcannula or syringe.
After serosanguineous material is separated, the fat is
then washed with sterile saline. After injection, the fat is
massaged to a smooth fill. This technique is useful for
the treatment of defects around glabellar furrows, lips,
melolabial and nasolabial folds, hemifacial atrophy, or
post-traumatic head and neck scarring. As a method to
restore natural skin layers, subcutaneous fat may be used
to restore lost subcutaneous tissue and dermal fillers may
be used to restore the deficient dermis. The epidermis
may then be restored as described earlier. Lipocytic
dermal augmentation is a modification of fat injection;
the remaining intracellular fibrous setae following adipo-
cyte rupture and triglyceride removal is used as collagen
filler.478,479 This seems to be beneficial for atrophy around
the mouth and subcutaneous scars. The process involves
freezing harvested fat in liquid nitrogen and then rapid
thawing in warm water. The supernate is then centri-
fuged to remove the remaining triglycerides. This mate-
rial has been shown to be equal to Zyplast in
longevity for the treatment of atrophic skin and, like
Secondary Revision of Soft Tissue Injury CHAPTER 22 605
microlipoinjection, overcorrection should be done
because of expected absorption.480
Other permanent materials such as expanded polytet-
rafluorethylene (e-PTFE; Gore-Tex, WL Gore, Flagstaff,
Ariz),481-483 may be used as permanent fillers in facial
augmentation and are extremely useful in the lips
because they will not resorb, like other implants.484
However, these materials are associated with side effects
such as extrusion into surrounding tissue layers, espe-
cially in the upper lip because of complex motions, with
the resulting implant creating a capsule of fibrosis around
it.485 Other synthetic permanent materials used as fillers
in the head and neck region include liquid silicone,486
polymethylmethacrylate (PMMA),487 and a biphasic
polymer (Bioplastique).488 Although silicone has shown
to be inert, PMMA and Bioplastique have been associated
with side effects such as granuloma formation.489-491
BOTOX
Botulinum toxin is used for simple facial wrinkles, bleph-
arospasm, and post-traumatic muscle contraction. It
weakens or paralyzes muscle by binding to presynaptic
cholinergic terminals and blocking the release of acetyl-
choline at the neuromuscular junction.492 It comes in two
different preparations, onabotulinumtoxinA (BTX-A)
and rimabotulinumtoxin B (BTX-B). BTX-B is useful for
the treatment of cervical dystonias493,494 and facial
spasm.495,496. BTX-A injections are useful for a variety of
procedures, including the treatment of wrinkles,497 mas-
ticator muscle hypertrophy,498 temporomandibular disor-
ders,499 salivary secretion disorders,500 facial nerve palsy,501
and post-traumatic scars secondary to significant muscle
contraction.502,503
Botulism toxin is useful in combination with resurfac-
ing procedures and dermal fillers. The resulting decrease
in muscle pull allows for new collagen formation in areas
of treatment. In addition, BTX-A injection lengthens the
duration of effect of injectable dermal fillers. Its effects
are noticeable 2 to 3 days after injection, with maximal
weakness occurring 1 to 2 weeks after injection. Although
BTX-A permanently impairs neuromuscular junctions,
repair of muscle, axonal sprouting, and production of
new neuromuscular junctions limit its effects to 3 to 6
months. It is available in a vial form and must be recon-
stituted with sterile, nonpreserved saline prior to IM
injection. Each vial contains 100 units of Clostridium
botulinum toxin type A, 0.5 mg of human albumin, and
0.9 mg of sodium chloride. The 100 units of Botox
(Allergan Irvine, Calif) are significantly below the
median lethal dose (LD50) in an average 70-kg (150-lb)
human.
Complications of Botox injection are usually revers-
ible. These include ptosis after glabellar injection; as a
result of migration of the toxin through the orbital
septum, affecting the levator muscle,504 eyebrow drop-
ping following forehead injection may occur. Other com-
plications include bruising, asymmetry, dysphagia, neck
weakness, perioral droop, and diplopia from lateral
rectus involvement. Permanent side effects include globe
perforation, lagophthalmos, and keratosis. Treatment of
lid ptosis includes eye drops consisting of 0.5% apracloni-
dine (Iopidine) to stimulate Müller’s muscle.505
606 PART III Management of Head and Neck Injuries
SUMMARY
Treatment of the trauma patient begins at the initial
encounter and often continues for the life of the patient.
Limitation in function and associated cosmetic deformi-
ties may leave the patient with significant debilitation.
Skill, knowledge and, most importantly, dedication on
behalf of the surgeon and patient are necessary to achieve
the most optimal outcome.
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