Pressure Treatment of Auricular Keloids

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active.

I have written of keloid treatment (general, not site specific) previously.  I have always tried to include pressure treatment as part of the plan when treating keloids of the ear lobe.   This pressure treatment came in the form of pressure earrings  -- clip-on, disc-shaped. 

The recent article (full reference below) in the Archives of Facial Plastic Surgery journal introduces a new pressure device which looks like it will work better than what has been available (photo credit) 

and as can be seen in this photo the upper ear can be treated with pressure which has not been possible with the clip earrings. (photo credit)

These devices were custom made which makes them more expensive than off-the-shelve pressure earrings and may make them difficult to get if no one is available in your area to make them.

From the article:

Pressure therapy was popularized in the 1970s after clinicians noticed that pressure stockings used over lower extremity burns caused scars to mature faster with decreased erythema and thickness.  Pressure causes localized hypoxia, resulting in fibroblast degeneration and disintegration owing to decreased intercollagenous cohesion and increased collagenase activity.

Furthermore, pressure has been shown to shorten scar formation time, reorient collagen fibers within the scar to become parallel to skin surface, increase hyaluronic acid levels, and decrease chondroitin sulfate levels, all of which help to flatten the initially elevated scar tissue and reduce recurrence rates.

According to various reviews and guidelines, pressure therapy is a long-standing therapeutic option for keloids, producing thinning and pliability. Although the precise biomolecular mechanism of compression is not understood, success rates of at least a partial reduction of derailed scars, from 60% to 85%, have been reported from a monotherapeutic regimen of pressure therapy. The combination of surgery with postoperative pressure treatment showed good response rates of about 90% to 100%, especially after excision of auricular keloids. ………

Overnight use of the new pressure device seems to be an effective extension of established auricular keloid therapy, with additional potential for prophylaxis of recurrence. Preliminary work was presented and intended to produce a demonstration of an optimized treatment modality. Analysis of this therapeutic regimen based on a larger sample size, and long-term follow-up will be the substance of a future report.

REFERENCE

Auricular Keloids: Combined Therapy With a New Pressure Device; Gregor M. Bran, Jörn Brom, Karl Hörmann, Boris A. Stuck; Arch Facial Plast Surg. 2011;Published online August 15, 2011. doi:10.1001/archfacial.2011.57

Should Langer’s Lines be Used for Incisions?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. 

An old PRS journal article came to my attention recently thanks to a tweet by @prsjournal: “Most Emailed Article Langer's Lines: To Use or Not to Use: Thirty-six differently named guidelines have develope... http://bit.ly/mPR6v1”
[I’m not sure the time frame involved in the “most emailed.” Not sure if it’s for the day, the week, etc.] –
The tweeted article (first full reference below) is a short one and I would recommend it to young plastic surgeons and students.

A state of tension exists naturally in skin. For instance, wounded skin will gape, becoming elliptical instead of round. The first to notice this skin property was Dupuytren. In 1834, he encountered a corpse of a man who had stabbed himself with a round-tipped awl. Dupuytren noticed these stab wounds were elliptical instead of round. Then in 1838, Malgaigne wrote about the direction of these ellipses being different in different areas of the body. These two men did not drive home their point; Karl Langer, however, exhaustively studied the direction of these ellipses by stabbing a round-tipped awl into hundreds of cadavers. …….. but he is best remembered for his lines. ……….

In 1897, Kocher recognized the surgical importance of Langer's tension lines. He advised that surgical incisions follow these lines. However, Langer, an anatomy professor, did not intend for his lines to be used as guides for incisions. Later, Borges pointed out that Langer's lines represent lines of cleavage in cadavers and not lines of relaxed tension……….

Langer's lines are quite different from the relaxed skin tension lines of the face. These lines were described by Borges in 1962,and they are probably the most-accepted guide for incisions of the face………..

Langer's lines are almost perpendicular to Borges's relaxed skin tension lines in the areas of the scalp, forehead, glabella, midcheek, and lateral eye…………….

Cornelius Kraissl maintained that scars were least conspicuous when placed in wrinkle lines. … Kraissl recognized that wrinkles occurred perpendicular to muscle action. From this, he developed a scheme for elective incisions. However, these incisions might not be inconspicuous in patients without wrinkles or with ill-defined wrinkles. Also, wrinkle lines do not always coincide with Borges's relaxed skin tension lines. Hence, Borges's lines are the best guide for elective incisions of the face. …………….

Developed from cadavers with extremities in extension, Langer's lines are longitudinal over joints. Blocker and Hendrix recognized that Langer's longitudinal lines predisposed patients to contractures when they were used over joints. Oriented perpendicular to muscle action, Kraissl's lines have a more transverse orientation than Langer's. Accordingly, Kraissl's transverse lines of the upper extremity do not predispose patients to contracture formation. ……….

Many other factors contribute to the camouflaging of scars, including wrinkle and contour lines. Learn how to assess the direction of least tension on the wound and orient the closure accordingly.

Borges's and Kraissl's lines are better guides for elective incisions in the face and body, respectively, than Langer’s lines. Remember, they are only guidelines. (photo scanned in from 2nd reference article)

REFERENCE

1. Langer's Lines: To Use or Not to Use; Wilhelmi, Bradon J.; Blackwell, Steven J.; Phillips, Linda G.; Plastic & Reconstructive Surgery. 104(1):208-214, July 1999

2. The Selection of Appropriate Lines for Elective Surgical Incisions; Kraissl, Cornelius J; Plastic & Reconstructive Surgery. 8(1):1-28, July 1951.

3. Relaxed Skin Tension Lines (RSTL) versus Other Skin Lines; Borges, Albert F.; Plastic & Reconstructive Surgery. 73(1):144-150, January 1984.

CO2 Laser Use

 Updated 3/2017-- all links removed as many are no longer active and it was easier than checking each one.

Over the past couple of months there have been a few good commentary articles on the use of CO2 laser us. 

The first one referenced below is a commentary by Dr. Scott J. Trimas on the treatment of facial acne scarring using CO2 laser abrasion.  He references his article from 10 years ago (2nd reference).  Full references are given to both articles below.

Over a 10 year period, Dr. Trimas, did 54 additional patients not included in his first article (the 2nd reference below) using full-face CO2 laser treatment for facial acne scarring. Their ages ranged from 16 to 74 years. Of those patients reviewed, 8 were male and 46 were female. He notes this population was similar to that of the original study. Most patients were followed for up to 2 years.

Dr. Trimas writes “notable improvement can be achieved with the use of the carbon dioxide laser, especially in the areas of the forehead, medial cheeks, and perioral region. Lesser improvement is noted in the areas of the lateral cheeks and temples. Nevertheless, substantial improvement is achieved in all areas.”

He also adds that one of the most substantial changes he has made is the addition of surgical excision of ice-pick scars prior to the laser resurfacing procedure. He performs the excision of the ice-pick scars at least 6 weeks prior to carbon dioxide laser abrasion.

The rationale for this excision technique was that some of the areas of the face did not seem to improve enough with just resurfacing, and I felt that ice-pick scars may have been the contributing factor. In fact, most ice-pick scars that were punch excised were in the lateral cheek regions.

That makes sense to me, as ice-picks scars are often too deep to be adequately treated by resurfacing procedures (laser or chemical peel) alone.

…..

The other recent article (third reference below) covers the use of CO2 laser for more than simply acne scarring.  It was published in the February 2011 issue of the Plastic Surgery Practice.  In the article, Dr. Joseph Niamtu III, discusses his use of the CO2 laser, giving practical tips – both the traditional ablative and the newer fractional lasers.

Take for example his notes on “Postlaser Wound Care—Past and Present”

If there is one drawback in employing traditional CO₂ ablative laser resurfacing, it is the area of postlaser wound care. It adds extra layers of work (and sometimes frustration) for the patient, surgeon, and staff. If the process and experience of postlaser wound care could be ultimately simplified, the promoting of traditional CO₂ treatments would be much easier.

I know several experienced laser surgeons who have abandoned the procedure because of the intensity of the wound care and the hand-holding required to get the patient through it successfully.

Inducing an intentional and controlled second-degree facial burn removes the entire epithelium and part of the dermis. This is obviously a giant insult to the normally intact integument. Patients who undergo fully ablative, high-fluence, high-density, multipass CO₂ laser resurfacing have to understand in the preop period that this treatment will be their hobby for 4 to 6 weeks. I am very blunt with my patients who are considering this type of laser treatment, and I do not sugarcoat the recovery.

Incidentally, for new practitioners, understating a recovery from laser treatment—or any procedure, for that matter—can really come back and bite you in the foot. In an era of new "miracle" treatments and surgeries emerging daily, some surgeons feel compelled to downplay the patient-recovery phase of treatment in hopes of "selling" a procedure. There is no better way to infuriate a patient then to tell them that a 2-week recovery is 1 week, etc. Not only does it upset them, it can cost them in other ways, such as missed work and other scheduled events, and disrupt family life in general.

I tell my patients that they won't like me for a week, that they will need about 2 weeks before they can get back in makeup, and that they will be pink for several more weeks. If I tell them the recovery is 14 days and it takes only 10 days, I am a hero. If I tell the inverse, I am a zero.

Understating a recovery is unethical and promotes negative marketing. I have seen too many instances in which a physician says 1 week for a 2-week recovery, then tries to squirm out of it by blaming the patient for "not healing well."

I really appreciate how he is blunt with his patients regarding the recovery.  Patients need to hear this along with the expected results and risks.

REFERENCES 

1.  Facial Acne Scarring:  Ten Years of Treatment With the Carbon Dioxide Laser (Commentary); Trimas SJ; Arch Facial Plast Surg Jan/Feb 2011 2011;13(1):62-64.

2.  Carbon Dioxide Laser Abrasion: Is It Appropriate for All Regions of the Face?; Trimas SJ, Boudreaux CE, Metz RD;  Arch Facial Plast Surg. 2000;2(2):137–140, pmid:10925440

3.  Confessions of a Master Blaster:  How to use CO2 laster in a cosmetic facial surgery practice; Niamtu III, Joseph; Plastic Surgery Practice, February 2011

New Research in Prevention of Keloid Scars

Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

A keloid scar is the result of an abnormal proliferation of scar tissue that forms at the site of an injury to the skin (eg, on the site of a surgical incision or trauma).  Keloid scars do not regress.  They grow beyond the original margins of the scar which differs from hypertrophic scars which while raised do not grow beyond the boundaries of the original wound.  Hypertrophic scars may reduce over time. 

Keloid scars tend to recur after excision so anything that can help me prevent their formation is welcome.

I stumbled across this press release a few weeks ago.  It explains the findings published in the article (first reference below) published online January 21, 2011in the British Journal of Dermatology which notes a possible molecular target in the prevention of keloid scarring.

Collagen triple helix repeat containing-1 protein (CTHRC1) inhibits the transforming growth factor (TGF)-β1-stimulated collagen production that occurs in keloid scar formation, report researchers.

"Keloids are manifestations of an abnormal process of tissue repair after trauma to the skin. Options for treatment are limited because of lack of understanding of the molecular and cellular mechanisms governing the formation," explain Hongxiang Chen (Huazhong University of Science and Technology, Wuhan, China) and colleagues.

"Increased understanding of the role of TGF-β signaling in keloids makes manipulation of TGF-β an attractive therapeutic strategy," they say.

CTHRC1 is expressed in the adventitia and neointima on arterial injury. Chen and team assessed regulation of the CTHRC1 gene, its interaction with TGF-β1, and its possible role in keloid scar formation in fibroblast cells from keloid tissue and normal skin.

TGF-β1 and CTHRC1 were localized to the dermis in both normal and keloid skin fibroblasts. Expression of both factors were increased in keloid compared with normal skin and CTHRC1 appeared to increase in a TGF-β1 concentration-dependent manner.

When keloid fibroblasts were treated with TGF-β1 (10 ng/ml), cell proliferation increased dramatically, specifically, collagen type I synthesis was preferentially stimulated.

However, when recombinant CTHRC1 was added to the TGF-β1-treated keloid cells, the proliferation effect was reversed and excess collagen synthesis was inhibited.

Notably, treatment with recombinant CTHRC1 appeared to have no adverse effects on cell viability.

"Our data indicated that TGF-β1 was overexpressed in keloid fibroblasts and recombinant CTHRC1 could reverse TGF-β1-induced collagen type I expression at least in part by decreasing collagen synthesis," conclude the authors.

"As a potent negative regulator of collagen matrix deposition, CTHRC1 may have therapeutic value in antifibrotic treatment strategies," they suggest.

It would be nice if someday this research lead to a “prevention” therapy.


Related posts:
Scars and Their Therapy – an Article Review  (January 21, 2009)
Fluorouracil Treatment of Problematic Scars – an Article Review  (April 1, 2009)
Scar Scales and Measuring Devices  (September 8, 2010)
 

REFERENCES

1.  Collagen triple helix repeat containing 1 inhibits TGF-β1-induced collagen type I expression in keloid; J. Li, J. Cao, M. Li, Y. Yu, Y. Yang, X. Xiao, Z. Wu, L. Wang, Y. Tu, H. Chen; British Journal of Dermatology, January 2011, DOI: 10.1111/j.1365-2133.2011.10215.x

2.  Treatment of a Postburn Keloid Scar with Topical Captopril: Report of the First Case; Ardekani, Gholamreza Safaee; Aghaie, Shahin; Nemati, Mohammad Hassan; Handjani, Farhad; Kasraee, Behrooz; Plastic & Reconstructive Surgery. 123(3):112e-113e, March 2009; doi: 10.1097/PRS.0b013e31819a34db

3.  Correction: Treatment of a Postburn Keloid Scar with Topical Captopril: Report of the First Case; Plastic & Reconstructive Surgery. 123(6):1898, June 2009; doi: 10.1097/PRS.0b013e3181abc4b4

4.  Keloid and Hypertrophic Scar; eMedicine article, May 2010; Brian Berman, MD, PhD, Whitney Valins, Sadegh Amini, MD, Martha H Viera, MD

5.  Wound Healing, Keloids; eMedicine article, June 26, 2009; R Edward Newsome, MD, Ravi Tandon, MD, Robert P Bolling, MD, MPH, Alun R Wang, MD, PhD, David A Jansen, MD

The Scar Project

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

We all know October is breast cancer awareness month.  The pink ribbon is how many think of breast cancer, but as this tweet reminds us all breast cancer is much more serious.

RT @laikas: RT @gfry "Breast cancer is not a pink ribbon" Exhibition has its own site: http://www.thescarproject.org/home.html Impressive!

I had not known of The Scar Project (photo create) prior to reading that tweet on Monday, but I have seen and created many of the scars.  The physical breast cancer scars come from biopsies, lumpectomies, mastectomies, and even the reconstruction.

The Scar Project, photographer David Jay, and all the women who participated are to be commended. 

The SCAR Project is a series of large-scale portraits of young breast cancer survivors shot by fashion photographer David Jay. Primarily an awareness raising campaign, The SCAR Project puts a raw, unflinching face on early onset breast cancer while paying tribute to the courage and spirit of so many brave young women.

Dedicated to the more than 10,000 women under the age of 40 who will be diagnosed this year alone The SCAR Project is an exercise in awareness, hope, reflection and healing. The mission is three-fold: Raise public consciousness of early-onset breast cancer, raise funds for breast cancer research/outreach programs and help young survivors see their scars, faces, figures and experiences through a new, honest and ultimately empowering lens.

The SCAR Project subjects range from ages 18 to 35 and represent the often overlooked group of young women living with breast cancer. (Breast cancer is the leading cause of cancer deaths in young women ages 15-40). They journey from across America and the world to be photographed for The SCAR Project. Nearly 100 so far. The youngest 18.

There was an exhibition of the project in New York this past weekend.   Even though, the exhibition is over, there is a book for sale of The Scar Project. 

Scar Scales and Measuring Devices

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

In clinical practice, scars are most often evaluated simply by the patient and surgeon’s subjective assessments of color (redness, traumatic tattooing, faded since last assessment, etc) and physical qualities (adherent, depressed, flat, raised, texture, etc).   The patient may comment that the scar is painful or itchy. 

Some objective measurements such as length and width can easily be made and compared over time.  Thickness is a bit trickier to easily measure without specialized tools.

I recently stumbled over a review article of the scales and measuring devices used for scar assessment on Medscape (full reference below).  Most, I admit, I have never seen or used as I am not an academic plastic surgeon.  The article is a nice review.  While it may help me better understand research articles I read, I doubt it will change how I assess scars in my practice.

Scar-measuring devices used for objectively measuring certain scar traits:

Pliability

• Pneumatonometer uses pressure to objectively measure skin pliability. It is composed of a sensor, a membrane, and an air-flow system that measures the amount of pressure needed to lock the system.  Most commonly used to measure intra-ocular pressure.
• Cutometer is a noninvasive suction device that has been applied to the objective and quantitative measurement of skin elasticity.  It measures the viscoelasticity of the skin by analyzing its vertical deformation in response to negative pressure.   (photo credit)

Firmness

• Durometer measures tissue firmness by applying a vertically directed indentation load on the scar.   It was originally described for use in scleroderma.

Color

Tools developed to objectively measure scar color use spectrophotometric color analysis to calculate erythema and melanin index.  These devices include:

• Chromameter (Minolta, Tokyo, Japan)
• DermaSpectrometer (cyberDERM, Inc, Media, PA, USA)
• Mexameter (Courage-Khazaka, Cologne, Germany)
• Tristimulus colorimeter

Thickness

• Ultrasound scanners, such as the tissue ultrasound palpation system (TUPS) --   “TUPS was found to demonstrate a moderate correlation in terms of reliability.  TUPS does have drawbacks, however, in that it requires technical training and experience in image interpretation and is relatively expensive compared to other modalities.”

Three-dimensional Topography

Three-dimensional systems may be attractive for their ability to capture scar surface characteristics with high definition and reproducibility, but their expense makes them more applicable to research than in my office.

• 3-dimensional optical profiling system (Primos imaging) made by GFMesstechnik (Germany)

Scar scales are subjective measurements used to quantify scar appearance.   The article mentions 5 scar scales that are currently used and were originally designed to assess subjective parameters in an objective way.  All of these scar scales are observer-dependent.  Scales are best used to determine change within an individual rather than between individuals.

• The Vancouver Scar Scale (VSS) --  first described by Sullivan in 1990.  It assesses 4 variables: vascularity, height/thickness, pliability, and pigmentation. Patient perception of his or her respective scars is not factored in to the overall score.
• Manchester Scar Scale (MSS)  -- proposed in 1998. It assesses and rates 7 scar parameters: scar color (perfect, slight, obvious, or gross mismatch to surrounding skin), skin texture (matte or shiny), relationship to surrounding skin (range from flush to keloid), texture (range normal to hard), margins (distinct or indistinct), size (<1 cm, 1–5 cm, >5 cm), and single or multiple.  
• Patient and Observer Scar Assessment Scale (POSAS) -- includes subjective symptoms of pain and pruritus and expands on the objective data captured in the VSS.   It consists of 2 numerical numeric scales: The Patient Scar Assessment Scale and the Observer Scar Assessment Scale. It assesses vascularity, pigmentation, thickness, relief, pliability, and surface area, and it incorporates patient assessments of pain, itching, color, stiffness, thickness, and relief. The POSAS is the only scale that considers subjective symptoms of pain and pruritus, but like other scales it also lacks functional measurements as to whether the pain or pruritus interferes with quality of life.
• Visual Analog Scale (VAS) -- is a photograph-based scale derived from evaluating standardized digital photographs in 4 dimensions (pigmentation, vascularity, acceptability, and observer comfort) plus contour. It sums the individual scores to get a single overall score ranging from "excellent" to "poor." It has demonstrated high observer reliability and internal consistency when compared to expert panel evaluation, but it has shown only moderate reliability when used among lay panels.
• Stony Brook Scar Evaluation Scale (SBSES)  --  was proposed in 2007.  It is a 6-item ordinal wound evaluation scale developed to measure short-term cosmetic outcome of wounds 5 to 10 days after injury up to the time of suture removal. It incorporates assessments of individual attributes with a binary response (1 or 0) for each, as well as overall appearance, to yield a score ranging from 0 (worst) to 5 (best).  It was designed to measure short-term rather than long-term wound outcomes. 

REFERENCE

A Review of Scar Scales and Scar Measuring Devices; Regina Fearmonti, MD; Jennifer Bond, PhD; Detlev Erdmann, MD, PhD; Howard Levinson, MD; Posted: 08/24/2010; ePlasty. 2010;10:e43 © 2010 Open Science Company

The Vancouver Scar Scale: An Administrative Tool and Its Interrater Reliability;  Baryza MJ, Baryza GA.; J Burn Care Rehabil 1995; 16:535-538.

A new quantitative scale for clinical scar assessment;  Beausang E, Floyd H, Dunn KW, Orton CI, Ferguson MW.;  Plast Reconstr Surg, 1998; 102: 1954-61

The Patient and Observer Scar Assessment Scale: a reliable and feasible tool for scar evaluation; Draaijers LJ, Tempelman FR, Botman YA, et al.;  Plast Reconstr Surg. 2004;113:1960–65.

Visual Analogue Scale scoring and ranking: a suitable and sensitive method for assessing scar quality?; Duncan JAL, Bond JS, Mason T, et al.;   PRS. 2006;118(4):909–18.

Development and validation of a novel scar evaluation scale.;  Singer AJ, Arora B, Dagum A, et al.;  Plast Reconstr Surg. 2007;120(7):1892–7

Topical Silicone Gel for Burn Scars

Updated 3/2017-- all links (except to my own posts) removed as many are no longer active and it was easier than checking each one.

I have read the studies the promote the use of silicone sheets for scar treatment.  I know the claims Mederma and other silicone gel scar treatments make.  What do I tell my patients? 

“It doesn’t matter what you use.  It matters that you use it.  Mederma is non-scented and less greasy than Vit E or cocoa butter.  If that will entice you into doing your dailyscar massage, then use it.”

For most scars, I will stand by the above.  Burn scar are characterized by an increasing occurrence of redness, thickness, stiffness, pain, and itching, and a disturbance in pigmentation and surface roughness.   So when I saw there was a new study looking at the use of silicone gel in the treatment of burn scars, I read it (full reference below).

Burn scars are often treated with intralesional corticosteroid injections, occlusive dressings, custom-made pressure garments, and silicone sheets. 

The silicone sheets, introduced in the early 1980s, have been shown to helpful in improving scar appearance.  The drawbacks of their use include compliance issues on scars in visible areas, difficulty of use for scars on or adjacent to joints, and hygienic issues of prolonged use.  The sheets can trap moisture creating skin irritation or rashes.

The article looks at a topical silicone gel named Dermatix (Meda Pharma, Amstelveen, The Netherlands).  It can be applied easily and dries to form a thin, flexible coating that does not restrict movement.  Unlike the silicone sheets, cosmetics can be applied over the silicone layer to camouflage the scar.

Martijn van der Wal, M.D., VU University Medical Center, Netherlands, and colleagues conducted a randomized, double-blinded, within-subject comparative, placebo-controlled trial to investigate the effectiveness of topical silicone gel in the treatment of scars resulting from a burn injury.

Forty-six scars on 23 patients were included in the study and followed for 1 year.  The mean age of the scars at inclusion was 4 months.   The patients were given two blinded and coded products to be applied two times per day on the two included scars with instructions to not interchange the therapies between the two scars.   One tube held a placebo cream and the other tube held Dermatix (kindly provided by Meda Pharma BV).  Effectiveness on scar quality was evaluated at 1, 3, 6, and 12 months using the Patient and Observer Scar Assessment Scale and the DermaSpectrometer.

Over all visits, the benefit on surface roughness was statistically significant (p = 0.012).   The surface of the topical silicone gel–treated scars showed significantly less roughness (p = 0.014) at 3 months after start of the treatment, and the topical silicone gel–treated scars were significantly less itchy (p = 0.018 and p = 0.013, respectively) at 3 and 6 months.

On average, observers rated scars treated with topical silicone gel slightly better than scars treated with the placebo cream, but repeated measures analysis did not show a significant treatment effect (p = 0.154). The patients rated the scars treated with topical silicone gel and the placebo cream almost equally.

So while topical silicone gel may improve the surface roughness of burn scars and aid in decreasing the itching, it is no better in improving the  overall appearance of the scar than the placebo.  To me this implies or suggests that the simple act of scar massage regardless of the cream/gel used may be the most important in aiding the appearance of the scar.

REFERENCES
Topical Silicone Gel versus Placebo in Promoting the Maturation of Burn Scars: A Randomized Controlled Trial; van der Wal, Martijn B. A.; van Zuijlen, Paul P.; van de Ven, Peter; Middelkoop, Esther; Plastic & Reconstructive Surgery. 126(2):524-531, August 2010; doi: 10.1097/PRS.0b013e3181e09559

Preference for Scar Location

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active.

There is a nice main article along with a discussion article in the August issue of the Journal of Plastic and Reconstructive Surgery which focuses on the preference of the scar location from the woman’s (patient’s) standpoint when the latissimus dorsi muscle flap is used in breast reconstruction.

There is always a “robbing Peter to pay Paul” when donor tissue is used in any reconstruction. Some times there is not a choice in how the donor scar will be oriented, but when there is the patient should be involved in the choice.

The surgeon needs to explain the factors which make one scar choice his/her preference. Factors such as the patient’s age, body mass index, other scars, and amount of tissue needed will all factor into the surgeon’s choice.

The patient’s preference is most likely to be made on how they view their body and on the types of clothing they like to wear (or envision wearing). Will the scar be hidden or visible with the clothing choices?

The article surveyed 250 women between the ages of 20 and 80 years, including 50 women with a history of breast cancer. The participation rate was 96% for a total sample size of 240 subjects.

The women were grouped into the following age categories: 20 to 29 years (n = 46); 30 to 39 years ( n = 32); 40 to 49 years (n = 44); 50 to 59 years (n = 70); and 60 to 79 years (n = 48).

The survey for the article study was done used photographs of a patient's back showing the variations of the latissimus dorsi donor-site locations. I scanned this photo from the first reference article.

As with the above, this one was scanned from the first reference article.

The results of the survey found:

The majority of women (66%) noted that the location of the latissimus dorsi flap donor site was important.

The lower transverse scar was the preferred scar location in 54% of the women surveyed. The second most preferred site was the middle transverse scar location.

The ability to conceal the scar in a low-back top or swimwear was noted to be important by 32%. A chance to improve the body’s contour was noted to be important by 30%.

Women younger than 50 years of age were concerned primarily with concealing the scar with clothing options, whereas women older than 50 years were concerned with both clothing options and contour of the back.

The independent factors of age, body mass index, ethnicity, body image, and clothing options were not found to show any significant correlation with scar location.

Maurice Y. Nahabedian, M.D. notes in his discussion of the article:

Personal experience with the latissimus dorsi musculocutaneous flap resonates with the conclusions of this study. The middle and lower transverse incisions have been preferred because they are better concealed. Women are able to wear certain clothing items and not reveal the location of the scar. There is usually less distortion of the posterior thorax and a better quality scar when compared with oblique or vertical incisions. …….

A final thought on this article is in reference to the evolution of breast reconstruction. ……. The posterior thorax is an equally important though less frequent donor site than the anterior abdomen. However, donor-site issues such as strength, scar, contour, and seroma need to be optimized to improve outcomes and increase patient satisfaction. This study has addressed scar and contour issues related to the latissimus dorsi flap, provided data to support the conclusions, and provided a mechanism to improve outcomes.

REFERENCES

Breast Reconstruction with the Latissimus Dorsi Flap: Women's Preference for Scar Location; Bailey, S; Saint-Cyr, M; Zhang, K; Mojallal, A; Wong, C; Ouyang, Da; Maia, M; Zhang, S; Rohrich, R J.; Plastic & Reconstr Surgery. 126(2):358-365, August 2010, doi: 10.1097/PRS.0b013e3181de1b41

Discussion: Breast Reconstruction with the Latissimus Dorsi Flap: Women's Preference for Scar Location; Nahabedian, Maurice Y; Plastic & Reconstructive Surgery. 126(2):366, August 2010; doi: 10.1097/PRS.0b013e3181de1963

Her Scar’s Story

“Can you remove this scar?”

“No, only change it.” She looks deflated. I ask “What happened?”

“My ex-husband stabbed me,” she quietly says.

“I’m sorry. I can’t remove the scar or it’s history. We’ll give it a new story.”

“How?’’

“A new scar. Let it’s story begin there.”

She smiles.

Neoumbilicoplasty

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

The umbilicus is perhaps the only scar that all of us want.  The umbilicus forms after birth as a result of the placental cord being transected as the infant is “detached” from his/her mother.  As the stump of the cord necroses, the scab falls away as the base heals leaving a scar:  the umbilicus.

The umbilicus has been described as a depressed scar surrounded by a natural skin fold that measures 1.5 to 2 cm in diameter and lies anatomically within the midline at the level of superior iliac crest.

Neoumbilicoplasty in simple terms is the creation or reconstruction of a new umbilicus to replace the missing or deformed umbilicus. 

Craig et al. reported on the ideal female umbilicus, but it should always be remembered  “the ideal umbilicus should be regarded as one that is satisfying to the patient.” 

The most aesthetically pleasing umbilicus is small in size, T or vertical in shape, and possesses a superior hood or shelf.

Those characteristics found to be unappealing include a large overall umbilical size, a horizontal or distorted shape, and the presence of umbilical protrusion.

In reconstructing the umbilicus, plastic surgeons should strive to attain these attractive characteristics and incorporate a modest size, with a superior shelf or hood and a T or vertical shape.

Reconstruction of a new umbilicus is indicated in congenital conditions associated with umbilical agenesis, loss of umbilicus due to omphalocele or gastroschisis repair, umbilical loss due to inflammatory destruction, excision of skin cancer involving the umbilical stump, and in surgical procedures for wide ventral herniorrhaphy.

In my humble opinion, the site of the new umbilicus should correspond to where “nature” would have placed it.  If there is any of the old umbilicus present, this can be used as an indication of where the new umbilicus should be placed.  If not, then  Dr. Susam Park, et al has this suggestion:

Based on our study, it is usually 3 cm above the level of the anterior superior iliac spine in a baby and 6 cm above in an adult, although differences in height and weight may affect these measurements.

Or as  Dr. Suhas Abhyankar, et al put it:

1. The distance between the xyph0sternum and umbilicus-distance between the umbilicus and the pubic symphysis ratio is approximately 1.6:1.

2. Also, the distance between the umbilicus and the anterior superior iliac spine-distance between the right and left anterior superior iliac spines ratio is 0.6:1.  This implies that when each of the anterior superior iliac spines is taken as a center, and arcs are drawn with a radius 0.6 times that of the inter-anterior superior iliac spine distance, the point of intersection of these arcs is the location of the umbilicus, taking into consideration the above ratio (1.6:1).

Surgery varies depending on whether a completely new umbilicus is being created or simply an “outie” being turned into an “innie” or maintaining the umbilicus with other surgery (ie abdominoplasty).

 
  
REFERENCES
*****After noticing the first referenced article below on MDLinx, I did a search of articles in the Journal of Plastic and Reconstructive Surgery first using “neoumbilicoplasty” and then “umbilical reconstruction.”  The second gave me a great list of articles (only a few listed below).

Neoumbilicoplasty is a Useful Adjuvant Procedure in Abdominoplasty; Can J Plast Surg 2009; 17 (4): e20-e23; AA Al-shahan

In Search of the Ideal Female Umbilicus; Plast Reconstr Surg 105: 389, 2000; Craig, S. B., Faller, M. S., and Puckett, C. L.

New Technique for Scarless Umbilical Reinsertion in Abdominoplasty Procedures; Plast Reconstr Surg 102(5):1720-1723, 1998; Schoeller, Thomas M.D.; Wechselberger, Gottfried M.D.; Otto, Angela M.D.; Rainer, Christian M.D.; Schwabegger, Anton M.D.; Lille, Sean M.D.; Ninkovic, Milomir M.D.

A Simplified Technique for Umbilical Reconstruction; Plast Reconstr Surg 114(2):619-621, 2004; Korachi, Ali; Oudit, Deemesh; Ellabban, Mohammed

Umbilical Reconstruction after Repair of Omphalocele and Gastroschisis; Plast Reconstr Surg  104(1):204-207, 1999; Park, Susam; Hata, Yuiro; Ito, Osamu; Tokioka, Kazuyuki; Kagawa, Koji

Simplified Technique for Creating a Youthful Umbilicus in Abdominoplasty; Plast Reconstr Surg 109: 2136, 2002; Lee, M. J., and Mustoe, T. A.

Anatomical Localization of the Umbilicus: An Indian Study; Plast Reconstr Surg 117(4):1153-1157, 2006; Abhyankar, Suhas V.; Rajguru, Anirudha G.; Patil, Prajakta A.

Placement of the Umbilicus in an Abdominoplasty;  Plast. Reconstr. Surg. 61: 291, 1978; Dubou, R., and Ousterhout, D.

Umbilical Reconstruction in Abdominoplasty; Melvin A. Shiffman;  International Journal of Cosmetic Surgery and Aesthetic Dermatology. September 2000, 2(3): 171-176. doi:10.1089/153082000750062830

Should Excised Mastectomy Scars Be Routinely Sent for Analysis?

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Surgeons are commonly faced with the question of whether or not a surgical specimen should be submitted for histologic analysis. Routine histologic examination of clinically unsuspected mastectomy scars that are excised during secondary corrective surgery is considered good practice, but in this era of cost containment in medicine should it be done? 

Locoregional recurrence of breast cancer following mastectomy occurs mainly in the first 3 to 5 years at an incidence rate of  3 to 7%.    That risk after breast-conserving therapy is 1.5 to 2 % per year, stabilizing around 10 to 20 % at 10 to 15 years. 

The first reference article below involved a retrospective review of 433 patients with a history of breast cancer whose mastectomy or breast-conserving surgery scars (455 scars, 22 pts had bilateral surgery) were excised and sent for histopathologic examination.   This included all their patients who had delayed breast reconstruction between January of 2000 and December of 2006 at the three National Health Service plastic and reconstructive surgery units in the West Midlands, United Kingdom.   Four (o.9% of 455) of the mastectomy scars (only three patients as one had bilateral scar recurrence) were positive for carcinoma recurrence.    None of the patients had any preoperative clinical suspicion of recurrent disease.  Their patients mean interval from primary breast surgery to reconstruction was 46.8 months (range, 2 months to 32 years).

This studies authors concluded:

In keeping with cancer surgery principles and with the potential for improved patient outcome, we recommend routine histologic examination of mastectomy scars at the time of delayed breast reconstruction.

The second reference article had a similar number of patients (424) treated by plastic surgeons of The Netherlands Cancer Institute from January of 1994 through May of 2004.   They sent 728 scars for routine histologic examination, 503 (70 percent) of which were excised within the first 3 postmastectomy years.  None of the patients had any preoperative clinical suspicion of recurrent disease.  Several patients (210 of 424) had multiple scars excised.  No evidence of metastatic or de novo tumor was found in any of the 728 scars, but residual glandular tissue was found in 11 scars. 

This studies authors concluded:

Because we found no evidence of tumor in any of the 728 scars we, more convincingly, support and extend their conclusion that routine submission of clinically unsuspected scars excised at the time of breast reconstruction or scar correction after prophylactic or curative breast surgery did not benefit our patients.

Which is the correct answer?  I honestly don’t know.  For now, I’ll continue to routinely send any postmastectomy scars.

REFERENCES

Mastectomy Scars following Breast Reconstruction: Should Routine Histologic Analysis Be Performed?; Plast Reconstr Surg. 123(4):1141-1147, April 2009; Warner, Robert M.; Wallace, David L.; Ferran, Nicholas A.; Erel, Ertan; Park, Alan J.; Prinsloo, Daniel J.; Waters, Ruth

Routine histologic examination of 728 mastectomy scars: Did it benefit our patients?;  Plast Reconstr Surg. 2006;118:1288-1292; Woerdeman LA, Kortmann JB, Hage JJ.
Locoregionally recurrent breast cancer: Incidence, risk factors and survival;  Cancer Treat Rev. 2001;27:67-82; Clemons M, Danson S, Hamilton T, Goss P.

Scar-free surgery?

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

H/T to MedGadget for bring this research to my attention.  Wow!  I know it is not ready for primetime, but still – wow!  Currently, this isn’t the case (no scar-free tummy tucks or facelifts), but the possibility may exist in the future.

Michael Berger over at Nanowerk profiles the work of Japanese scientists who created adhesive ultrathin "nanosheets" which are able to bind tissue together.  Their goal was to create a material that can help avoid suturing or stapling of fragile tissue during surgery.   (photo credit)

Shinji Takeoka tells Nanowerk. "We found that our ultra-thin PLLA nanosheet has an excellent sealing efficacy for gastric incision as a novel wound dressing that does not require adhesive agents. Furthermore, the sealing operation repaired the incision completely without scars and tissue adhesion. This approach would constitute an ideal candidate for an alternative to conventional suture/ligation procedures, from the perspective not only of a minimally invasive surgical technique but also reduction of operation times."

Takeoka and colleagues have published their findings in a recent paper in Advanced Materials ("Free-Standing Biodegradable Poly(lactic acid) Nanosheet for Sealing Operations in Surgery").

Torn Earlobe Repair

 Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

Early in my blog life, I did an article on torn earlobe repair.  As I mentioned then, I had not figured out how to put sketches in my posts.  Over the past two years, I have learned how to add them, so am redoing the post with sketches.  I hope they help.

Torn earlobes is a complication of pierced earlobes.  Some preventive tips include:

• Not wearing heavy ear rings.
• Being careful when putting on or removing clothing so as not to "catch" the earring.
• Being careful around babies/toddlers who want to play with shiny/dangling objects can help prevent the lobe from being torn.
• Use the "earlobe support" which is a stick-on disc that help support the earlobe when heavy earrings are worn.

 Once the stretching occurs or the tear is completed, then the only way to fix it is to repair it. For me, this is an office procedure done using a simple local block.  I mix 0.5% Xylocaine with Epi and 0.25% Marcaine without Epi. 

There are variations on "how" this is done, but they all require excising (freshing) the edges so they can be sewn back together. The variations are mainly in how the excision is structured–straight, z-plastied, or L-shaped. 

I do not think the straight excision is the best way to do the repair. If the scar "shortens" at all (as straight scars are prone to do), then the lobe is "gathered" up and ends up "W" shaped at the bottom. Another reason is that unless you (the patient) are very good at repositioning the new hole to the side (either) of the scar (which is weaker by at least 20% of the surrounding skin), the tear is very likely to re-occur as the earrings pull-through the scar over time.

The Z-plasy or L-shaped scar avoid the "W" by changing the scar into a non-straight scar. Which one is best will depend on the tear and shape of the earlobe being repaired. Also, it may depend on whether there is an intention to re-pierce the earlobe. Not all do. Another alternative to pierced ears is magnetic Earrings.

Most insurances will not cover this procedure as they consider it cosmetic in nature.

A really good article with nice, clear instructions on the Z-plasty technique is:
REPAIR OF THE SPLIT EARLOBE USING A HALF Z-PLASTY; Journal of Plastic & Reconstructive Surgery, Vol 101(3):855,856, March 1998; Gajiwala, Kalpesh M.S., M.Ch.
Dr. Michael Bermant, MD ‘s website has some very nice photos of before and after repair.


Related posts
Mending a Hole (June 26, 2007)

Fluorouracil Treatment of Problematic Scars – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I’d like to review this Plastic & Reconstructive Surgery article on using fluorouracil for the treatment of keloids. The full reference (first article listed) is given below. First, a little background on keloids and hypertrophic scars.

Keloids and hypertrophic scars are challenging to treat. Both are benign growths of dense fibrous tissue that develop due to an abnormal healing response to a injury to the skin. A keloid by definition extends beyond the original borders of the wound or inflammatory response. A hypertrophic scar remains within the original boundary. Both are frequently symptomatic. Patients often report tenderness or pruritis.

There are many proposed mechanisms for abnormal scar formation. These include altered growth factor regulation, abnormal collagen turnover, familial genetic predisposition, and immune dysfunction. Although progress has been made in understanding scar pathophysiology, the exact pathogenesis is still unknown.

The response to any accepted scar treatment runs the gamut from minimal to complete. The most commonly used treatment modalities include intralesional steroid injection, surgical excision, cryotherapy, laser therapy, radiation therapy and the application of silicon gel sheets.

Most evidence for these modalities is based on smaller studies that employed little or no placebo control nor blinding of participants or researchers. As the authors of the first article (the one to be reviewed) point out:

Beyond the litany of treatment options, another obstacle in the scar literature is a lack of uniformity in reporting clinical results. This makes extrapolating from or comparing studies difficult. Many authors quantify treatment outcome using a visual appearance rating scale. Other outcome measurement options include symptom relief and direct scar size measurement. Qualitative descriptive scales are available for scars but are far from being widely accepted

And as the authors of the Medscape article point out:

A recent meta-analysis of 39 studies, representing 27 different treatments, reported a 70 percent chance of clinical improvement with any type of treatment.^[34]Therefore, it is possible that current treatments may not have any significant effect on clinical improvement. Based on emerging information on keloid pathophysiology, there is a need for further studies in order to develop better therapies for pathologic scarring.

Now for the article review. The authors stated that after noticing anecdotal reports suggesting low-dose intralesional fluorouracil could be used for treating undesirable scars, they decided to do a prospective case series. As noted above, we need prospective, well designed studies to truly define the best treatment of these scars.

Their method included both keloid and hypertrophic scar patients. Note the small number of patients in the study:

Keloid patients underwent excision followed by a series of treatments with intralesional 5-fluorouracil into the healing scar to prevent recurrence (n = 32).

The hypertrophic scar patients were treated with the same series of injections without scar excision to both control symptoms and improve scar appearance (n = 21).

The primary outcome measures were scar volume and a symptom questionnaire.

Patients were followed for 1 year after completing the injection treatments.

Only patients who had failed corticosteroid therapy were entered in the study. Some had failed other conventional treatments for abnormal scars (ie excision, radiation therapy, topical silicone, and/or pressure therapy). They did not include a control group because “we felt it was unethical to offer patients who had previous failed corticosteroid treatments the potential of the same treatment that did not help them the first time.” I’m not sure I agree with them as the control patients could have received “delayed” treatment in the interest of a better scientific study.

Treatment

Keloid Group (Group 1) patients had their scars excised and primary repair of the defects. Each patient received a total of 10 treatments at least a month apart. If any reaction or infection was identified, no treatment was performed at that visit. The patients returned weekly until the adverse reaction resolved at which time the injections were resumed.

Hypertrophic Scar Group (Group 2) patients did not require excision of the scar. Therefore injection treatment was started after the baseline documentation was obtained.

Baseline documentation included completion of a symptom questionnaire and vinyl polysiloxane molds. Symptom assessment and polyvinyl molds were repeated at the completion of the injection protocol (11 months after the baseline scar documentation) and again at the 1-year posttreatment follow-up

Because of the off-label use of 5-fluorouracil for the treatment of scars, time was spent explaining the indications, techniques, alternatives, benefits, and risks of the therapy. This was reinforced to the patients at each of the 10 injections in the treatment series.
Each treatment involved intralesional injection of 50 mg of 5-fluorouracil (50 mg/ml; American Pharmaceutical Partners, Inc., Schaumburg, Ill.) and 10 mg of lidocaine 1% (Hospira Worldwide, Schaumburg, Ill.).
For most of the scars, the medication was distributed evenly throughout the scar or the healing incision for the keloid group.
For large hypertrophic scars, the medication was injected into the most symptomatic part of the scar at that particular visit.
Treatments were continued until the maximum dose of 500 mg (10 injections) was reached.

Results
Their definition of recurrence was any visible evidence of scar growth. “It did not mean the scar returned to preexcision size or that the patient was dissatisfied with the result.”
In the keloid group, there were no recurrences during the course of the treatment, but there were six (6 / 32) at 1 year follow-up. This represents a success rate of greater than 80% at one year. The literature reports a success rate of 75 – 95 % for radiation combined with excision.
Of the hypertrophic scar patients, 86 percent had symptom improvement which was maintained for 1 year after treatment. More than one-third had complete resolution of the symptoms. Median scar volume reduction was 40 percent in this group.
I find this article interesting, but am not ready to begin using 5-fluorouracil prior to the tradition treatment courses. As the authors point out,

One weakness of the study is the length of follow-up. Although most studies do not report results longer than 1 year after treatment, it is clear that keloid recurrence can occur years later.

REFERENCE

Fluorouracil Treatment of Problematic Scars; Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 139-1485; Haurani, Mounir J. M.D.; Foreman, Kenneth M.D.; Yang, James J. Ph.D.; Siddiqui, Aamir M.D. (need subscription for access online)

Keloids: Pathophysiology and Management; Medscape Online Article, Posted 08/23/2007; David T. Robles MD PhD; Erin Moore; Michelle Draznin MD; Daniel Berg MD