Local Flaps in Facial Reconstruction

26  COMPLICATIONS OF LOCAL FLAPS
699
asymmetries. On occasion, preexisting structural abnor­
malities of the nose are corrected during reconstructive
surgery of the nose, when the exposure of the nasal
framework is sufficient to allow alterations that could
provide potential improvement in aesthetic and func­
tional outcomes.
Injury to eyelid structures may lead to devastating
consequences, including lagophthalmos, lacrimal duct
obstruction, visual field obstruction, and vision loss.
Facial surgeons should be familiar with the cross-sectional
areas. The great auricular nerve may be injured during
subcutaneous dissection in the periauricular area. This
nerve is identified and preserved when skin is dissected
away from its attachment to the superior aspect of the
sternocleidomastoid muscle.
Avoidance of injury to the nasal cartilaginous frame­
work is important for nasal symmetry and function to be
maintained. Inadvertent injury to these structures may
lead to obvious nasal deformities, including alar retrac­
tion, nasal valve collapse, saddle nose deformity, and tip
FIGURE 26-2  ■  A, Midface soft tissue and bone defect after resection of skin malignant neoplasm. B, Hematoma developed 1 week
postoperatively, after restarting of anticoagulant medication (warfarin). C, One month after evacuation of hematoma. Lower eyelid
retraction noted. Massage of lower eyelid initiated. D, Postoperative result at 6 months.
A
B
C
D

700
SECTION III  ADJUNCTIVE SURGERY
anatomy of the upper and lower eyelids, especially the
connective tissue support apparatus and the position and
location of the levator muscle. Injury to these structures
is best avoided because treatment is extremely difficult if
scarring has occurred.
Infection
Fortunately, infection during facial surgery is reported to
be as low at 2.8%, perhaps secondary to the rich vascular­
ity of facial tissues.16-20 However, the infection rate associ­
ated with facial flaps is increased in certain circumstances.
Higher infection rates are associated with wounds that
are repaired in a delayed fashion, as is often the case
with facial flaps used to repair wounds created by micro­
graphic surgery.21 Ischemia of flaps is likely to increase
the risk for infection because tissue oxygenation is
extremely important in prevention of wound bacterial
colonization.16,22,23
Wound infection is associated with poor outcomes.
Infection of a cutaneous flap is usually associated with
distortion from inflammatory edema. Release of toxic
substances and free radicals from inflammatory mediators
leads to decreased collagen production and early degra­
dation of suture materials with potential wound dehis­
cence. Necrosis of all or part of the flap may develop,
with the final scar being widened or thickened. Systemic
dissemination of bacteria may occur if wound infections
are not treated promptly.24
Although perioperative antibiotic prophylaxis is con­
troversial in clean wounds, it has been shown to be effec­
tive in decreasing wound infection rates when it is used
for clean-contaminated wounds.16,21,22 Antiseptic solu­
tions for skin preparation, sterile technique, proper
scrubbing, and surgical attire are key elements in helping
FIGURE 26-3  ■  A, B, Infected nasal wound after contouring procedure to correct trap-door deformity of bilobe nasal flap. (Courtesy of
Shan R. Baker, MD.)
A
B
prevent infection. It is also important to avoid crushed,
charred, or excessively thinned tissue. Staphylococcus aureus
is the most common single pathogen causing wound
infections, but streptococci, gram-negative bacteria, and
oral anaerobes may also be isolated from infected
wounds.21 The author uses parenteral antibiotics when
mucosal surfaces are incised, when cartilage grafting is
performed, and during ear reconstruction to help prevent
perichondritis. They are also employed in patients with
underlying medical conditions that may predispose to
infection, such as diabetes and immunosuppression. In
these cases, a preoperative dose of intravenous cephalo­
sporin is administered, followed by 5 days of an oral
cephalosporin. In penicillin-allergic patients, clindamy­
cin is used. In patients with open wounds older than 3
days, a 5-day course of oral cephalosporin is recom­
mended before the surgical repair. This will decrease the
bacterial colonization of the granulation tissue that has
developed in the depths of the wound.
Excessive pain or erythema at the wound site may
herald an infection (Fig. 26-3). These clinical signs
usually appear between the fourth and eighth days after
wound closure. Topical allergies to antibiotic ointments
and creams applied to the wound may be confused with
wound infection. Topical allergic reactions are mani­
fested as erythema, often with vesicle formation and exu­
dates forming on all areas treated with the topical
medication (Fig. 26-4). Treatment consists of discontinu­
ation of the offending agent and cleaning of the wound
with soap and water to remove all residual topical
medication.
If a wound infection does develop, Gram stain and
culture of any drainage from the wound are performed.
The patient is treated with an appropriate broad-spectrum
antibiotic until culture results and sensitivities are

26  COMPLICATIONS OF LOCAL FLAPS
701
Abnormal Scarring
Patients with darker skin and those with a family history
of excessive scarring are prone to the development of
hypertrophic scars and keloids after surgery. Although
numerous treatment modalities have been proposed,
there is no definitive method of managing or preventing
these problems.26 Intralesional triamcinolone acetonide
(10 mg/mL) is often helpful in reducing the volume of
scar tissue within a hypertrophic or keloid scar. If the scar
is responsive to the injections, surgical excision may be
performed after a preoperative injection 1 week before
surgery. Several injections are usually required postop­
eratively every 2 months after excision of the scar for an
indeterminate time interval (Fig. 26-6). Rarely, irradia­
tion is considered for extremely problematic keloids.
Glucocorticoids have a profound anti-inflammatory
effect. The most common form used is triamcinolone
acetonide suspension, which is injected into the depths
of the scar. Injections are used to soften firm scars, to
lower raised keloids, and to prevent their recurrence.
Steroids decrease fibroblast proliferation, reduce blood
vessel formation, and interfere with fibrosis by inhibiting
extracellular matrix protein gene expression. When
steroid injection is used at the time of keloid excision, it
is injected at the wound margins immediately after exci­
sion. Repeated injection is performed at 3- to 6-week
intervals. Multiple injections are usually necessary. Exces­
sive steroid injection of scars may lead to skin atrophy,
hypopigmentation, and telangiectasia (Fig. 26-7).
Scar hyperpigmentation may be seen in patients who
tan easily, particularly if the patient has excessive sun
exposure during the immediate postoperative period.
Hyperpigmentation improves over time and with sun
avoidance. Use of topical hydroquinone gel with or
without the administration of an anti-inflammatory drug
may be helpful in preventing permanent discoloration of
the scar (Fig. 26-8).
Wound Dehiscence
Wound dehiscence may develop secondary to infection,
hematoma, or skin necrosis (Fig. 26-9). In addition,
available. Any wound fluctuance is drained and the wound
irrigated. Significant fluid collections beneath a cutane­
ous flap usually require the placement of a drain or wick
to facilitate further drainage and adherence of the flap to
the underlying wound bed. The presence of excessive
granulation tissue may require débridement to reduce the
bacterial load. Topical antibiotic preparations may also be
employed, and superficial sutures are removed to elimi­
nate foreign bodies in the wound.25 Open wounds are
allowed to heal by secondary intention. The resulting
scar is addressed at a later time once the infection has
been adequately treated and scarring has matured.
Viral and fungal infections of facial wounds are rare
and almost always are associated with skin resurfacing
procedures, such as dermabrasion and laser peels.
Although these infections may occur anywhere on the
face where resurfacing has been performed, they occur
predominantly in the area of the lips when this
facial region is treated (Fig. 26-5). Patients undergoing
dermabrasion or laser treatment to scars of the lip
should receive antiviral therapy before treatment and
postoperatively until the treated area has completely
re-epithelialized.
FIGURE 26-4  ■  Topical allergic reaction to antibiotic ointment
causing erythema and vesicles of skin. (Courtesy of Shan R.
Baker, MD.)
FIGURE 26-5  ■  Herpes simplex infection of perioral area after
dermabrasion. (Courtesy of Shan R. Baker, MD.)

702
SECTION III  ADJUNCTIVE SURGERY
FIGURE 26-6  ■  A-D, Preoperative views and postoperative result 1 year after keloid excisions. Postoperative injection of triamcinolone
acetonide (10 mg/mL) into the surgical site was performed every 2 months. (Courtesy of Shan R. Baker, MD.)
A
B
C
D

26  COMPLICATIONS OF LOCAL FLAPS
703
patient’s medical condition is optimized during the peri­
operative period.
Patients with a history of irradiation have subcutane­
ous scar tissue and decreased vascularity of the skin in the
irradiated area. Cutaneous flaps from adjacent nonirradi­
ated tissue are preferred to flaps harvested in the irradi­
ated area. Nonetheless, even when this recommendation
is followed, revascularization of a flap transferred to an
irradiated recipient site may be compromised, leading to
poor outcome. When an interpolated flap is transferred
to an irradiated area, inset of the flap is best delayed until
revascularization of the flap is certain (usually 6 to 8
weeks). For suitable candidates, consideration is given to
hyperbaric oxygen treatment to optimize tissue oxygen­
ation levels before reconstruction.
Patients are questioned preoperatively concerning
their use of tobacco and alcohol. Heavy alcohol con­
sumption will dilate blood vessels, predisposing to hema­
toma formation. Avoidance of alcohol during the
perioperative period is recommended. Ideally, tobacco
and nicotine products should be avoided, at least 4 to 8
dynamic motion or trauma to wounds may also lead to
wound separation. Typically, wounds have 3% to 5% of
normal skin tensile strength at 2 weeks after surgery,
emphasizing the need for subcutaneous sutures. At 1
month, only 35% of the maximum wound tensile strength
has been gained. However, at this point, the wound is
usually able to withstand the forces of normal physical
activity. During the succeeding months, wound tensile
strength increases to 80% of the strength of normal
tissue. Wound separations in uncomplicated, clean
wounds may be repaired with sutures if this is performed
within 24 hours of wound dehiscence. Wound separa­
tions that have been present for more than 24 hours are
best left to heal by secondary intention, with scar revision
reserved for the future if necessary.24,27
MEDICAL CONDITIONS
Systemic diseases such as diabetes, malnutrition, arterio­
sclerosis, hypertension, and collagen vascular disease can
compromise flap vascularity and lead to necrosis and
impaired wound healing. In addition, diabetics are prone
to infection. In such patients, serum glucose levels are
monitored closely in the perioperative period. Patients
with compromised immune systems and those receiving
immunosuppressive therapy may demonstrate delayed
wound healing, and some may require a “stress dose” of
steroids before surgery. Consulting with the patient’s per­
sonal physician is important to ascertain whether the
FIGURE 26-7  ■  Skin atrophy with telangiectasia after steroid
injection of scar. (Courtesy of Shan R. Baker, MD.)
FIGURE 26-8  ■  A, Cutaneous defect after excision of skin malig­
nant neoplasm. B, Three months after wound closure with
cheek advancement flap. Hyperpigmentation of scar noted.
A
B

704
SECTION III  ADJUNCTIVE SURGERY
weeks before and after surgery. Even smoking cessation
for 2 days before surgery and 7 days after surgery has
been shown to have beneficial effects on flap survival.28
Smokers develop skin necrosis three times more fre­
quently than nonsmokers do, and the extent and depth
of skin slough are more severe.28 Nicotine causes systemic
vasoconstriction through activation of the adrenergic
nervous system, which may lower tissue oxygenation
pressure by more than 50%. This occurs within 10
minutes of smoking a cigarette and lasts approximately
50 minutes. Smoking also produces carbon monoxide,
which has a higher affinity for hemoglobin than oxygen,
thereby producing high levels of carboxyhemoglobin.29-33
This means that less oxygen can be delivered to the
tissues by the vascular system. When possible, consider­
ation is given to delaying surgical procedures until
smoking cessation can be ensured.
SURGICAL TECHNIQUE AND FLAP DESIGN
Ischemia
Appropriate flap design is essential to ensure sufficient
perfusion pressure of the entire flap.34 According to their
vascularity, local and regional flaps may be classified as
random pattern or axial pattern flaps. Flap dissection
should proceed at the appropriate tissue depth to pre­
serve the blood supply to the skin (Fig. 26-10). Random
pattern flaps require an intact subdermal plexus, and dis­
section is performed in the subcutaneous tissue plane.
Too superficial dissection or improper flap design may
lead to compromise of the flap’s vascularity. Random pat­
terned flaps have a critical length beyond which the
FIGURE 26-9  ■  A, Wound dehiscence secondary to local flap necrosis. B, Dehiscence healed by secondary intention. (Courtesy of Shan
R. Baker, MD.)
A
B
perfusion of the distal flap does not occur. Although
increasing the width of a flap’s pedicle potentially increases
the number of vessels contained in the subdermal plexus
of the flap, it does not increase the perfusion pressure to
the distal portion of the flap. Therefore, within certain
limits, widening the pedicle does not increase the survival
of the distal flap. Axial pattern flaps are nourished by a
named artery that is located within the tissues of the flap
and is parallel to the linear axis of the flap.
Design of axial pattern flaps requires a thorough
knowledge of the location and orientation of the arterial
vessels supplying the skin of the donor area to properly
align the flap with the axis of the artery and to avoid
inadvertent injury to the flap’s blood supply. Careful dis­
section is performed around the flap’s pedicle. Increasing
the width of the pedicle of axial flaps does not necessarily
improve perfusion.35,36 In fact, it is more prudent to raise
a thicker flap that contains deeper subcutaneous vessels
than to design the flap with a wider base (Fig. 26-11). An
excessively wide pedicle may also complicate the use of
the donor site for repair of future defects (Fig. 26-12).
Ischemia is defined as vascular perfusion insufficient
to provide the required oxygenation of tissue.25 Cutane­
ous flaps are more vulnerable to tissue ischemia than are
wounds closed primarily, given that the vascularity is iso­
lated to the pedicle of the flap used for repair of the
wound.37 This is especially true in the distal portion of
the flap.38,39 Dissection of flaps causes release of catechol­
amines from severed sympathetic nerves, thromboxane A
from platelet microthrombi, and oxygen free radicals. All
of these substances cause vasoconstriction, which can
enhance tissue ischemia.40,41 The type of flap also is a
factor influencing the degree of tissue ischemia. Trans­
position flaps generate less distal wound tension than

26  COMPLICATIONS OF LOCAL FLAPS
705
FIGURE 26-10  ■  Vascular anatomy of facial skin.
Epidermis
Dermis
Subcutaneous
fat
Fascia
Muscle
Subdermal
plexus
Deep sub-
cutaneous
axial plexus
Musculo-
cutaneous
perforators
rotation or advancement flaps do. This is because the
greatest wound closure tension is at the donor site when
transposition flaps are used, whereas wound tension is
greatest at the distal borders of advancement and rotation
flaps42 (Fig. 26-13). Because rotation and advancement
flaps have innate wound closure tension at the distal
closure site, they likely benefit from multiple, precisely
placed subcutaneous “tacking” sutures to evenly distrib­
ute wound tension along the distal suture line (see
Chapter 6).
With proper technique, cutaneous flap necrosis is
uncommon because most tissue can survive on a fraction
of its average blood flow,37 and eventual neovasculariza­
tion reduces flap dependency on the pedicle’s blood
supply.10,36,42,43 However, reversible ischemia may become
irreversible if improper surgical technique or postopera­
tive wound care causes additional vascular compromise.
Excessive flap thinning, aggressive electrocautery, crush
injury with surgical instruments, and excessive wound
closure tension may worsen flap ischemia44,45 (Fig. 26-14).
Injection of local anesthetic containing vasoconstrictor
agents is used judiciously and avoided in wounds in which
vascular perfusion is a concern.46,47 Infection is treated
expeditiously because edema from inflammation may
decrease tissue perfusion. The effects of excessive wound
closure tension, tight compression dressings, bacterial
contamination, and blood beneath the flap may all cause
irreversible ischemia of the flap.24 When flap ischemia is
evident, local wound factors and factors related to the
patient are assessed and medical conditions are optimized
as discussed previously. In such situations, use of nicotine
by the patient must be avoided.
Ischemia of a skin flap is signaled by color changes of
the flap. Pale flaps and slow capillary refill when the skin
of the flap is compressed are signs of impending ischemia.
A reduced flap temperature below ambience and the
absence of bleeding after pinprick of the flap suggest
arterial insufficiency. Flaps with edema, purple-blue
color, and brisk bleeding of dark blood after pinprick
suggest venous congestion. Flaps may survive arterial
insufficiency for up to 13 hours, but venous congestion
can cause necrosis in as quickly as 3 hours.25 No widely
accepted methods of monitoring flap vascularity have
been established, and most surgeons rely on careful and
frequent examinations of the flap when ischemia is a
concern. Repeated pinpricks of the flap or a trial of
medicinal leeches may be helpful in treating flaps with
venous insufficiency.48,49 Aeromonas infection secondary to
treatment with leeches may occur and should be treated
promptly with appropriate antibiotic coverage.50,51
Arterial insufficiency of a flap may be caused by kinking
of the flap’s pedicle, an excessively tight compression
dressing, or excessive wound closure tension. If these
causative factors are corrected early in the postoperative
period, the ischemia is usually reversible. Correction of
these conditions should improve the vascularity of the

706
SECTION III  ADJUNCTIVE SURGERY
FIGURE 26-11  ■  Widening pedicle of flap does not increase distal flap perfusion, but increasing thickness of flap to include deeper,
larger vessels does.
x
x
2x
Subdermal plexus
Deep subcutaneous
axial plexus
PEDICLE

26  COMPLICATIONS OF LOCAL FLAPS
707
FIGURE 26-12  ■  Patient with history of prior nasal reconstruction
by inappropriately designed paramedian forehead flap. Majority
of flap returned to donor forehead site. Patient referred with
recurrence of malignant disease requiring resection and recon­
struction with second forehead flap. Design of second parame­
dian forehead flap complicated by first flap, which had
excessively wide pedicle and was oriented obliquely toward
contralateral paramedian forehead region.
FIGURE 26-13  ■  Transposition flap is pushed into recipient site (arrow) by closing donor defect. Greatest wound closure tension is at
donor site. Rotation and advancement flaps tend to pull back toward donor site (arrow), and greatest wound closure tension is at
recipient site.
flap. In the case of excessive wound closure tension, the
flap may be returned to its donor site and allowed to
remain in situ for a few days. This has the effect of
delaying the flap, which will cause an enhanced blood
supply to the flap. The flap is then usually transferred
to the recipient site without ischemia.24 There are numer­
ous reported experimental treatments for flap ischemia
with pharmacologic agents, such as vasodilators, sympa­
tholytics, and free radical scavengers; however, there
is no widely accepted agent for treatment of arterial
insufficiency.52-55 Skin blanching may become progres­
sively prolonged with digital compression until capillary
refill cannot be elicited, signaling flap failure.34,55 When
ischemia causes epidermolysis or skin necrosis, the tissue
is allowed to demarcate because the more proximal
portion of the flap is usually viable (Fig. 26-15). Devital­
ized tissue that is easily removed from the wound bed is
débrided. Tissue adherence signifies some underlying
viable tissue and is left as a biologic wound dressing.
Patients are instructed to keep the wound moist with
petroleum or water-based antibiotic ointment, and the
wound is allowed to heal by secondary intention. Fre­
quent follow-up examination is essential for maintaining
appropriate wound care and providing reassurance to the
patient.
Trap-Door Deformity
Trap-door deformity may result from persistent edema
and poor lymphatic drainage of flaps with incisions on
three borders (Fig. 26-16). Flaps with curvilinear borders
are particularly prone to development of trap-door defor­
mity. The scar around the border of the flap contracts
in a concentric fashion. This concentric contraction

708
SECTION III  ADJUNCTIVE SURGERY
FIGURE 26-14  ■  A, Melanoma in situ of cheek marked for excision. Advancement flap designed for reconstruction of face after resec­
tion of melanoma. B, Defect repaired with advancement flap combined with full-thickness skin graft (beneath bolster dressing).
C, Five days after surgery. Excessive wound closure tension has caused limited necrosis of borders of flap. (Courtesy of Shan R.
Baker, MD.)
A
B
C
A
B
C
FIGURE 26-15  ■  A, A 3 × 2.5-cm cutaneous defect of cheek and a 2 × 1-cm defect of lower eyelid. B, C, Defects repaired with rotation
cheek flap and full-thickness skin graft (lower eyelid).

26  COMPLICATIONS OF LOCAL FLAPS
709
D
E
F
G
D-G, Eschar resulting from flap necrosis left in situ. Wound healed beneath eschar by secondary intention.
Patient developed ectropion of lower eyelid that did not require treatment because left eye was artificial. (Courtesy of Shan R. Baker,
MD.)
FIGURE 26-15, cont’d  ■

710
SECTION III  ADJUNCTIVE SURGERY
combines with contraction of the scar sheet beneath the
flap to push the skin upward in a mushroom effect.56-58
Bilobe flaps of the nasal skin are particularly susceptible
to development of trap-door deformity because of the
two circular lobes used for construction of the flap. The
deformity is even more likely to occur when a bilobe flap
is used to repair a nasal cutaneous defect in which the
nasal skin is thick and has sebaceous gland hypertrophy
(Fig. 26-17). Proper flap design and adequate tissue
undermining reduce the incidence of trap-door defor­
mity. Wide skin undermining around the border of the
recipient site of the flap is thought to limit trap-door
deformity. Wide undermining presumably reduces scar
contractile vectors toward the center of the flap by enlarg­
ing the area of the underlying sheet of scar.56,57,59,60 Flaps
that are superiorly based are more prone to development
of trap-door deformity than inferiorly based flaps because
lymphatic channels of the face drain in an inferior
direction.
Trap-door deformity usually improves with time.
Steroid injections into the subcutaneous tissue plane
beneath the flap may be performed with triamcinolone
acetonide (10 mg/mL). If time and steroid injections are
not successful, contouring of the flap with or without scar
revision is necessary. This involves incising the flap along
one of its borders, removing subcutaneous fat and scar
tissue beneath the flap, and redraping the skin. Excess
skin is trimmed as indicated. Z-plasties performed along
the incision are helpful in preventing recurrence of the
trap-door deformity by preventing a concentric scar from
redeveloping.
FIGURE 26-16  ■  Small transposition flap manifesting trap-door
deformity. (Courtesy of Shan R. Baker, MD.)
FIGURE 26-17  ■  A, B, Trap-door deformity and depressed scar of
nose after reconstruction with bilobe nasal flap in patient with
thick nasal skin. (Courtesy of Shan R. Baker, MD.)
A
B

26  COMPLICATIONS OF LOCAL FLAPS
711
Distortion of Facial Features
Scar contracture may lead to poor aesthetic and func­
tional outcomes, especially in regions of the face with
mobile facial structures, such as the eyelids, lips, and nasal
alae. This is especially a problem in the periocular and
oral area, where inadequate lip or eyelid closure leads to
problems with eating, phonation, excessive tearing, and
dry eye symptoms. Excessive wound closure tension may
also lead to flap compromise and distortion of adjacent
facial structures. Cervical facial flaps used to repair cuta­
neous defects near the lower eyelids should be secured to
the periosteum of the maxilla or nasal bones with a
tacking suture to reduce wound closure tension on the
lower eyelid. This in turn reduces the risk for develop­
ment of lower eyelid retraction. A temporary Frost suture
may also be used to limit the downward pull of the flap
on the eyelid skin. In spite of these precautionary mea­
sures, reconstruction of large cutaneous defects adjacent
to the lower eyelid is often associated with lower eyelid
retraction or ectropion. This is especially true in elderly
patients because they have less muscle tone of the orbi­
cularis oculi and less overall connective tissue to support
the eyelid (Fig. 26-20). In the case of nasal reconstruc­
tion, flaps used for repair of the nose are designed
sufficiently large to avoid alar retraction. For defects
adjacent to the alar rim, cartilage grafting is routinely
employed to provide a strut against the contractive forces
of wound healing.
Unsightly Scars
Scars continue to change and to improve during the
remodeling phase of wound healing. This includes col­
lagen remodeling and collagen fiber reorientation for up
to 18 months. This process may be longer in children.
Young patients may have an exaggerated healing reaction
with increased scar erythema and hypertrophy, so scar
revisions in children should be delayed as long as feasible.
Immature scars tend to be erythematous, which will
usually fade over time. The scar’s appearance will also
improve as it matures. There are a number of factors
during wound healing that influence the ultimate appear­
ance of a scar. Wounds subjected to excessive wound
closure tension typically result in scars that are hypopig­
mented and often hypertrophied. Incisions made in thick
skin, especially if there is sebaceous gland hypertrophy,
often heal with depressed or widened scars (Fig. 26-18).
Patients who can bend their thumb back to the volar
surface of their forearm or touch their tongues to their
noses (Gorlin’s sign) are more flexible than the average
person. These individuals possess more elastin within
the dermis and are more likely to spread their scars
(Fig. 26-19).
FIGURE 26-18  ■  Wide depressed scar of cheek after reconstruc­
tion in patient with thick skin and sebaceous gland hyperplasia.
(Courtesy of Shan R. Baker, MD.)
FIGURE 26-19  ■  Unsightly scar after transposition flap in patient
with hyperelastic skin. (Courtesy of Shan R. Baker, MD.)

712
SECTION III  ADJUNCTIVE SURGERY
FIGURE 26-20  ■  A, Squamous cell carcinoma of skin marked for excision. Rotation flap designed for reconstruction after resection.
Horizontal lines mark anticipated standing cutaneous deformity. B, Flap in place after resection of skin cancer. C, Postoperative result
at 2 months. Wound repair has caused ectropion of lower eyelid. (Courtesy of Shan R. Baker, MD.)
A
B
C
FIGURE 26-21  ■  A, Patient with full-thickness alar defect after excision of skin malignant neoplasm. Defect repaired with ipsilateral
septal mucoperichondrial hinge flap, auricular cartilage graft, and paramedian forehead flap. B, Two months after inset of forehead
flap. Alar retraction observed despite cartilage graft used for framework. C, Six months after contouring procedure, release of scar
contracture, and insertion of cartilage graft at alar rim.
A
B
C
Distorted anatomic structures may respond to massage
but may also require surgical revision, sometimes with
cartilaginous grafts for support (Fig. 26-21). Like the
nose, the lip is vulnerable to distortion by scars because
of the mobile nature of the lips and the discrete border­
line between the skin and vermilion. During healing,
vertically oriented scars of the upper lip require only
minimal contraction to cause notching or distortion of
the vermilion-cutaneous border. Such distortion is quite
noticeable to the observer, particularly when the vermil­
ion is well-developed (Fig. 26-22). As with all lip wound
closures, tension should be minimized. Precise alignment
of the opposing edges of the lip wound in the vicinity of
the vermilion-cutaneous borders is extremely important
in repair of lacerations or cutaneous defects of the lip.
Facial Aesthetic Regions and Units
It is important to respect the borders of facial aesthetic
regions and units when designing cutaneous flaps to
avoid unsightly scars. This is particularly true of the alar-
facial sulcus, which is an important boundary between the
aesthetic regions of the nose, cheek, and upper lip. Larger
defects of the ala are best reconstructed with interpolated
cheek flaps that cross over the alar-facial sulcus rather
than with transposition or advancement cheek flaps
because these flaps obliterate this aesthetic boundary line
(Fig. 26-23).
Cutaneous defects that extend from the nose to the
medial cheek or to the upper lip are best repaired with
separate flaps for each aesthetic region. Individual flaps

26  COMPLICATIONS OF LOCAL FLAPS
713
FIGURE 26-22  ■  A, A 1 × 1.5-cm skin defect of upper lip. Primary wound closure planned. Anticipated standing cutaneous deformities
marked with horizontal lines. B, Wound repaired. Deformities excised. C, Postoperative result at 4 months. Notching of vermilion-
cutaneous border noted. (Courtesy of Shan R. Baker, MD.)
A
B
C
FIGURE 26-23  ■  A, Elderly, frail patient with cutaneous defect of ala and caudal nasal sidewall after excision of skin malignant neo­
plasm. Patient desired simple, one-stage reconstruction. Cheek transposition flap performed. B, Postoperative result at 3 months.
Flap has caused obliteration of superior aspect of alar-facial sulcus.
A
B
are designed to repair the nasal component of the defect
and the cheek or lip component of the defect. This
approach positions some of the borders of the flaps in
aesthetic boundary lines that help camouflage scars. More
important, the concave topography of the sulcus separat­
ing the nose from the cheek and the nose from the lip is
not obliterated by advancing or transposing skin from the
cheek to the nose (Fig. 26-24).
The principle of employing separate flaps is equally
important in reconstructing skin defects that cross over
the melolabial crease from the lip to the cheek. When a
cheek advancement flap is used to repair both the lip and
cheek component of the defect, the flap inevitably
obscures the melolabial crease, which is the aesthetic
boundary line between the lip and cheek aesthetic regions
(Fig. 26-25).
Standing cutaneous deformities should be anticipated
during facial reconstructive surgery and removed when
possible along relaxed skin tension lines. Care is taken to
avoid narrowing the pedicle of the flap during the process
of removing the deformity. When this is not possible, it
may be prudent to remove the deformity as a second-
stage procedure, 2 to 3 weeks after the initial transfer of
the flap.
Standing cutaneous deformities result from transfer of
local flaps or from wound closures that result in unequal
wound borders. In the majority of cases, these deformi­
ties may be safely excised at the time of wound repair. It
is a common error to underestimate the size of standing
cutaneous deformities and to excise too little skin. This
is particularly true for wounds repaired on the cheek and
lips (Fig. 26-26). This may in part be related to the

714
SECTION III  ADJUNCTIVE SURGERY
FIGURE 26-24  ■  A, B, Patient with obliteration of alar-facial sulcus
secondary to cheek advancement flap employed to repair alar
defect.
A
B
FIGURE 26-25  ■  A, B, Obliteration of superior aspect of melolabial
crease has occurred from use of cheek advancement flap to
repair upper lip skin defect. (Courtesy of Shan R. Baker, MD.)
A
B
FIGURE 26-26  ■  A, B, A 4 × 4-cm skin defect of lip. Subcutaneous tissue pedicled island advancement flap designed for repair. Shaded
area at commissure represents anticipated standing cutaneous deformity forming from pivotal movement of flap. C, Deformity
excised and flap in place. D, Postoperative result at 4 months. Fullness at oral commissure represents persistent standing cutaneous
deformity (SCD). E, Four months after excision of redundant skin at commissure. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
SCD
E

26  COMPLICATIONS OF LOCAL FLAPS
715
swelling of the soft tissues in the vicinity of the flap donor
site during dissection and transfer of the flap. This swell­
ing may prevent an accurate estimate of the size of the
deformity and thus leads to an error in the amount of
skin excised (Fig. 26-27).
CASE REPORTS
The following case examples are divided into two catego­
ries: wounds repaired with excessive wound closure
tension and wounds repaired with improperly designed
cutaneous flaps. There is some overlap in the two catego­
ries because an improperly designed flap often causes
excessive wound closure tension at the distal border of
the flap.
Excessive Wound Closure Tension
Case 1
A 45-year-old patient developed a melanoma in situ
of the left superior cheek. Margins around the lesion
were ensured by the square technique as discussed in
Chapter 8, Case 3. The area requiring excision measured
4 × 2-cm. A laterally based transposition cheek flap was
designed for reconstruction after excision of the mela­
noma (Fig. 26-28). Figure 26-28B shows the flap sewn
into the recipient site. There is marked pallor indicating
ischemia of the distal portion of the flap due to excessive
wound closure tension. The majority of this apparent
ischemia proved to be reversible and was in part related
to the vasoconstrictive effects of the anesthetic injected
into the area in anticipation of reconstructing the cheek.
FIGURE 26-27  ■  A, B, A 1 × 1-cm skin defect of lip. Transposition note flap (see Chapters 6 and 8) designed for repair. Anticipated
standing cutaneous deformity marked with horizontal lines. C, Flap in place. Deformity excised. D, E, Postoperative result at 10
months. Insufficient excision of standing cutaneous deformity has pushed lateral vermilion downward, causing loss of visible ver­
milion border near commissure. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
E
However, a small area of the distal flap suffered irrevers­
ible ischemia, and this resulted in necrosis of the skin,
causing the eschar shown in Figure 26-28C. The closure
of the flap donor site was also under sufficient wound
closure tension to cause a small area of skin necrosis.
The skin over the malar eminence where the mela­
noma developed is inelastic, and there is no significant
skin laxity because of the strong zygomatic cutaneous
ligaments that firmly attach the overlying skin to the
zygomatic bone. Therefore, minimal secondary tissue
movement to help reduce wound closure tension can be
expected when skin defects in this area of the cheek are
repaired. A transposition flap used to repair a skin defect
of the malar eminence must have the same surface area
as the defect it is designed to repair to minimize wound
closure tension at the recipient site.
Case 2
A 75-year-old patient underwent micrographic surgical
resection of a large recurrent basal cell carcinoma that
demonstrated aggressive growth patterns. The tumor
extended to the periosteum of the zygomatic arch and
required excision of a large portion of the posterior and
superior cheek skin during a few days of surgical excision
(Fig. 26-29). Because the wound had been open for
several days during multiple staged surgical excisions of
the tumor, it was elected to allow the wound to granulate
for 2 weeks before reconstruction. A large inferiorly
based pivotal advancement flap was designed to recruit
skin for construction of the flap from the postauricular
and superior regions of the neck. A small portion of the
donor site wound posterior to the ear was closed with a
full-thickness skin graft. The flap was transposed into the

716
SECTION III  ADJUNCTIVE SURGERY
FIGURE 26-28  ■  A, Melanoma in situ, 4 × 2-cm area marked for excision. Transposition flap marked for repair after resection. B, Mela­
noma excised. Flap in place. Distal flap has pallor, suggesting ischemia. C, Postoperative result at 2 weeks. Small area of necrosis
of distal flap and at donor site wound has occurred. D, Postoperative result at 1 month. (Courtesy of Shan R. Baker, MD.)
A
B
C
D

26  COMPLICATIONS OF LOCAL FLAPS
717
for combining local flaps with skin grafts are discussed in
detail in Chapter 16.
Case 3
A 35-year-old patient presented with a 1 × 1-cm defect
of the skin and vermilion of the upper lip after micro­
graphic excision of a basal cell carcinoma. An A-T repair
of the defect was planned with bilateral unipedicled
advancement flaps (Fig. 26-30). However, at the time of
surgery, it was elected to use a V-Y island advancement
flap based on an orbicularis oris muscle pedicle. This was
an error in judgment because the orbicularis muscle did
recipient site and advanced considerably for the flap to
reach the most superior border of the defect. The extreme
advancement necessary for wound repair resulted in
excessive wound closure tension along the distal suture
line. This in turn resulted in a limited necrosis of the
distal border of the flap. The area of necrosis healed by
secondary intention, and revision surgery was not neces­
sary. The complication of flap necrosis could likely have
been avoided by combining the flap with a full-thickness
skin graft to assist with the wound repair. The graft could
have been used to cover the superior portion of the
defect, thereby reducing the degree of flap advancement
required in this case. The technique of and indications
FIGURE 26-29  ■  A, A 75-year-old man after micrographic excision of extensive basal cell carcinoma. Wound allowed to granulate for
2 weeks. B, C, Pivotal advancement flap designed for repair of defect. D, Postoperative result at 1 month. Necrosis of distal borders
of flap has occurred. E, Necrotic wound allowed to heal by secondary intention. No revision surgery performed. (Courtesy of Shan
R. Baker, MD.)
A
B
C
D
E

718
SECTION III  ADJUNCTIVE SURGERY
reconstruction. This allowed better symmetry of vermil­
ion vertical height in the area of reconstruction. Fortu­
nately, the revision surgery provided the patient with an
acceptable appearance of the lip.
V-Y island advancement flaps are best used in areas of
the face with ample subcutaneous fat that can provide a
pedicle of sufficient mobility to enable the flap to be
advanced into a recipient site without excessive wound
closure tension. For this reason, island advancement flaps
work best for repair of defects of the medial cheek, which
has the greatest amount of subcutaneous fat of the face.
not provide sufficient mobility to the island flap. This in
turn resulted in excessive wound tension on the vermil­
ion. As the wound healed, scar contracture and the exces­
sive wound closure tension led to notching and superior
migration of the vermilion-cutaneous border. Subse­
quent surgery was necessary to rectify the situation. Two
Z-plasties were performed on either side of the inferior
border of the flap to lengthen the scars and to release the
superior pull on the vermilion by the flap (Fig. 26-31).
It was also necessary to resect a small ellipse of
mucosa along the wet line of the lip in the area of the
FIGURE 26-30  ■  A, A 1 × 1-cm skin defect of lip and vermilion. A-T repair planned. B-D, Subcutaneous tissue pedicled island advance­
ment flap used for reconstruction instead of A-T repair.
A
B
C
D

26  COMPLICATIONS OF LOCAL FLAPS
719
Case 4
A 32-year-old patient had micrographic surgery to
remove two basal cell carcinomas involving the lower lip
and chin. The defect of the lip measured 2 × 2-cm
and involved skin and vermilion of the lip. The skin
defect of the chin measured 1 × 1-cm (Fig. 26-32). It was
The skin of the lips is tightly attached to the underlying
muscle, and there is no significant subcutaneous fat on
which to create a pedicle for an island flap. For this reason,
use of V-Y island advancement flaps of the lip should be
confined to the repair of very small defects in the midline
of the lip between the philtral ridges. Island advancement
flaps are discussed in detail in Chapters 6 and 9.
FIGURE 26-31  ■  A, B, Same patient as shown in Figure 26-30, postoperative view at 5 months. Distortion of vermilion-cutaneous
border resulting from excessive wound closure tension. C, Z-plasties at base of flap and elliptical excision of mucosa along wet line
of lip planned to correct lip deformity. D, Revision surgery completed. E, F, One year after revision surgery. (Courtesy of Shan R.
Baker, MD.)
A
B
C
D
E
F
FIGURE 26-32  ■  A, A 2 × 2-cm skin and vermilion defect of lip and a 1 × 1-cm skin defect of chin. B, C, Defects repaired with bilateral
unipedicled advancement flaps. Mucosal advancement flap harvested from inner aspect of lip used to repair vermilion component
of lip defect. D, Excessive wound closure tension caused necrosis of small area of opposing borders of advancement flaps. Area
healed by secondary intention. E, Postoperative result at 5 months. Hypertrophic scar noted in area of necrosis. (Courtesy of Shan
R. Baker, MD.)
A
B
C
D
E

720
SECTION III  ADJUNCTIVE SURGERY
elected to repair both defects simultaneously with bilat­
eral unipedicled advancement flaps. The vermilion com­
ponent of the lip defect was reconstructed with a separate
mucosal advancement flap. The mucosal flap was con­
structed from mucosa on the inner aspect of the lower lip
and was advanced outward to cover the orbicularis muscle
exposed by the vermilion defect. Although the surgical
plan was sound, the skin of the lip is inelastic and without
redundancy. For this reason, cutaneous advancement
flaps of the lips are typically subjected to greater wound
closure tension than cutaneous flaps used to repair
similar-sized defects elsewhere on the face. In this case,
the wound tension from closure of the lip defect resulted
in a small area of skin necrosis. The involved area was
allowed to heal by secondary intention. On healing, some
deformation of the vermilion occurred, but the severity
of the distortion did not require revision surgery.
Improper Flap Design
Case 5
A 47-year-old man developed a melanoma in situ of the
superior medial cheek immediately inferior to the eyelid.
Tumor-free margins around the lesion were ensured by
the square technique. The area requiring resection mea­
sured 2 × 1.75-cm and was rhombus shaped. A superiorly
based Dufourmentel flap was designed for repair of the
wound resulting from resection of the melanoma (Fig.
26-33). The flap healed without causing distortion of the
lower eyelid. However, the flap was harvested in the hair-
bearing region of the cheek and transferred to an area that
was not hair bearing. In fair-skinned men, this does not
cause a very noticeable deformity. The patient in this case
was dark complected and had dense, dark facial hair. This
quality caused a noticeable discrepancy in appearance
between the skin of the flap and the adjacent skin of the
superior cheek. For this complication to be avoided, it may
have been wiser to use a rotation flap to reconstruct the
cheek. The rotation flap could have been designed to
recruit skin for construction of the flap from the non–hair-
bearing skin immediately lateral to the tumor resection.
Case 6
A 67-year-old patient developed a melanoma in situ of the
cheek requiring the square technique to achieve tumor-
free margins around the lesion. The planned resection
measured 3.5 × 2.5-cm and involved excision of the skin
over the malar eminence (Fig. 26-34). A transposition flap
was designed for repair of the defect resulting from resec­
tion of the melanoma. Because the flap was too small to
cover the entire defect, a full-thickness skin graft har­
vested from the standing cutaneous deformity formed by
pivoting the flap was used to cover the superior portion of
the defect. In spite of the use of a skin graft to assist with
wound closure, a portion of the distal flap suffered necro­
sis, although the skin graft survived completely. The area
of necrosis healed by secondary intention, and the result
after wound healing was acceptable but less than ideal.
The error in planning the reconstruction of this
patient was in the design of the transposition flap. The
flap was designed too small to completely cover the defect
left from excision of the melanoma. This led to excessive
wound closure tension and flap necrosis.
Case 7
A 64-year-old patient was treated for melanoma in situ
of the cheek by the square technique to ensure tumor-
free margins around the lesion. The necessary area of
resection measured 3 × 2.5-cm and required excision of
the skin covering the malar eminence. Similar to Case 6,
a transposition flap was selected for repair of the cheek
after tumor excision (Fig. 26-35). The flap was inferiorly
based and was harvested from the melolabial fold. As with
the previous case, the flap proved to be too small to cover
the entire defect resulting from excision of the mela­
noma. Therefore, a full-thickness skin graft was used to
repair a portion of the defect adjacent to the lower eyelid.
The distal portion of the flap suffered necrosis, and unlike
in the previous case, the skin graft did not survive. The
complete loss of the skin graft and the necrosis of the
distal flap resulted in a poor outcome. The patient devel­
oped severe lower eyelid ectropion and hypertrophic
scarring of the cheek.
This case is an example of an error in flap selection
and design. The flap was designed too small to recon­
struct the defect, necessitating the concurrent use of a
skin graft. The flap was based inferiorly, with construc­
tion of the flap from the skin of the superior aspect of
the melolabial fold. There is less skin redundancy in
this area of the cheek compared with the inferior fold
and jowl area. The preferred design for the flap would
have been a superiorly based flap so that skin could
have been recruited from the jowl for construction of
the flap. The lower medial cheek where the jowl forms
with age represents the area of the face with the great­
est skin redundancy and the area where most large
transposition flaps should be harvested in repair of
medial and central cheek defects. Another surgical
approach preferable to this one would have been to use
a rotation flap lateral to the defect. This surgical
approach would have enabled a large flap to be con­
structed, eliminating the need for a skin graft to assist
with the repair of the defect.
Similar to Cases 1 and 6, the patient being discussed
had excision of a sizable area of skin from the malar
eminence. In all three patients, necrosis of the distal
portion of the flap used to repair their wounds developed.
In two cases, necrosis was the direct result of designing
a flap that was too small to cover the defect. In one case,
excessive wound closure tension was the cause of flap
necrosis. As discussed in Case 1, the skin in the vicinity
of the malar eminence is inelastic, and there is minimal
redundancy of skin because of the firm attachment of the
facial skin to the underlying zygomatic bone. For this
reason, there is no significant secondary tissue movement
during repair of defects in this region of the cheek.
Therefore, in planning reconstruction of cutaneous
defects located on the malar eminence or zygomatic areas
of the cheek, it is incumbent on the surgeon to carefully
design local flaps that do not depend on secondary tissue
movement for successful wound repair.

26  COMPLICATIONS OF LOCAL FLAPS
721
FIGURE 26-33  ■  A, Melanoma in situ marked for excision by square technique. B, Dufourmentel flap designed for wound repair after
excision of melanoma. Anticipated standing cutaneous deformity marked with vertical lines. C, Melanoma excised. Flap in place.
D, Postoperative result at 6 months. Hair-bearing flap has caused noticeable discrepancy in appearance between skin of flap and
adjacent non–hair-bearing skin of cheek. (Courtesy of Shan R. Baker, MD.)
A
B
C
D

722
SECTION III  ADJUNCTIVE SURGERY
FIGURE 26-34  ■  A, Melanoma in situ, 3.5 × 2.5-cm area marked for excision. Transposition flap designed for repair. B, Melanoma
excised. Flap transferred. Full-thickness skin graft combined with flap for wound repair. C, Postoperative result at 2 weeks. Skin graft
survived, but portion of flap suffered necrosis. Wound healed by secondary intention. D, Postoperative result at 1 year. No revision
surgery performed. (Courtesy of Shan R. Baker, MD.)
A
B
C
D

26  COMPLICATIONS OF LOCAL FLAPS
723
designed at the base of the flap. On transfer of the flap, it
was not necessary to use the entire length of the planned
incision line. Therefore, the Z-plasty was positioned more
superiorly over the body of the mandible.
Postoperatively, ischemia of the distal flap and subse­
quent full-thickness necrosis of the most distal corner of
the flap developed. The necrosis resulted in scarring,
which in turn led to the development of lower eyelid
ectropion (Fig. 26-37). Because the area of necrosis occu­
pied the lateral aspect of the anterior lamellae of the
Even when a local flap is designed sufficiently large to
cover a defect over the malar eminence, flap necrosis may
occur. This is more likely in smokers and when defects are
large, requiring movement of flap skin for considerable
distance. An example of this is shown in Figure 26-36. An
area of melanoma in situ measuring 6 × 5-cm over the
malar eminence is marked with sutures. After excision of
the melanoma, a large pivotal advancement flap was used
to reconstruct the defect. The flap recruited redundant
skin from the superior cervical area and a Z-plasty was
FIGURE 26-35  ■  A, Melanoma in situ, 3 × 2.5-cm area marked for excision. Transposition flap designed for repair of wound
after resection of melanoma. B, Melanoma excised. Flap in place. Full-thickness skin graft (FTSG) combined with flap for wound
repair. C, D, Skin graft did not survive and distal portion of flap underwent necrosis. This resulted in ectropion of lower eyelid and
hypertrophic scarring. (Courtesy of Shan R. Baker, MD.)
A
B
FTSG
C
D

724
SECTION III  ADJUNCTIVE SURGERY
FIGURE 26-36  ■  A, Melanoma in situ, 6 × 5-cm area marked by sutures for excision. Pivotal advancement flap designed for repair.
B, Melanoma excised and flap transferred to recipient area. Z-plasty positioned over body of mandible because entire length of
planned flap incision was not required. C, D, Postoperative result at 1 week. Flap demonstrates signs of ischemia. E, Postoperative
result at 3 weeks. Full-thickness necrosis of most distal portion of flap observed. (Courtesy of Shan R. Baker, MD.)
A
B
C
D
E
FIGURE 26-37  ■  A, Same patient shown in Figure 26-36. Flap necrosis caused severe ectropion of eyelid. B, Ectropion corrected with
full-thickness skin graft and lateral canthoplasty. (Courtesy of Shan R. Baker, MD.)
A
B

26  COMPLICATIONS OF LOCAL FLAPS
725
24. Salische SJ. Complications of local flaps. In: Baker SR, Swanson
NA, editors. Local flaps in facial reconstruction. New York: Mosby;
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25. Vural E, Key JM. Complications, salvage, and enhancement of local
flaps in facial reconstruction. Otolaryngol Clin North Am
2001;4:739.
26. Niessen FB, Spauwen PHM, Schalkwijk J, et al. On the nature of
hypertrophic scars and keloids: a review. Plast Reconstr Surg
1999;104:1435.
27. Edlich RF, Friedman HI, Haines PC, et al. Biology of wound
repair: its influence on surgical decision. Facial Plast Surg 1984;
1:169.
28. Golminz D, Bennett RG. Cigarette smoking and flap and full thick­
ness graft failure. Arch Dermatol 1991;127:1012.
29. Craig S, Rees TD. The effect of smoking on experimental flaps in
hamsters. Plast Reconstr Surg 1985;75:842.
30. Forrest C, Pang C, Lindsay W. Dose and time effects of nicotine
treatment on the capillary blood flow and viability of random
pattern flaps in the rat. Br J Plast Surg 1987;40:295.
31. Jensen JA, Coodson WH, Hopf HW, et al. Cigarette smoking
decreases tissue oxygen. Arch Surg 1991;126:1131.
32. Nolan J, Jenkins RA, Kurihara K, et al. The acute effects of ciga­
rette exposure on experimental skin flaps. Plast Reconstr Surg
1985;75:544.
33. Kinsella JB, Rassekh CH, Wassmuth ZD, et al. Smoking increases
skin flap complications. Ann Otol Rhinol Laryngol 1999;108:139.
34. Kerrigan CL, Daniel FI. Monitoring acute skin flap failure. Plast
Reconstr Surg 1983;71:519.
35. Milton SH. Pedicled skin flaps: the fallacy of the length:width ratio.
Br J Surg 1970;57:502.
36. Daniel RK, Kerrigan CL. Skin flaps: an anatomical and hemody­
namic approach. Clin Plast Surg 1979;6:181.
37. Myers B. Understanding flap necrosis. Plast Reconstr Surg
1986;78:813.
38. Cutting CB. Critical closing and perfusion pressures in flap sur­
vival. Ann Plast Surg 1982;9:534.
39. Suzuki S, Isshiki N, Ogawa Y, et al. The minimal requirement of
circulation for survival of undelayed flaps in rats. Plast Reconstr
Surg 1986;78:221.
40. Angel MR, Narayanan K, Swartz WM, et al. Deferoxamine
increases skin flap survival: additional evidence of free radical
involvement in ischemic flap surgery. Br J Plast Surg 1986;39:469.
41. Angel MF, Ramasastry SS, Swartz WM, et al. The critical relation­
ship between free radicals and degree of ischemia: evidence for
tissue intolerance of marginal perfusion. Plast Reconstr Surg
1988;81:233.
42. Angel MF, Kaufman T, Swartz WM, et al. Studies of the nature of
flap/bed interactions in rodents: part I. Ann Plast Surg 1986;17:317.
43. Angel MF, Ramasastry SS, Narayanan K, et al. Studies on the
nature of flap/bed interactions in rodents: part II. Ann Plast Surg
1986;17:434.
44. Larrabee WF Jr, Holloway GA Jr, Trachy RE, et al. Skin flap
tension and wound slough: correlation with laser Doppler velocim­
etry. Otolaryngol Head Neck Surg 1982;90:185.
45. Larrabee WF Jr, Holloway GA Jr, Sutton D. Wound tension and
blood flow in skin flap. Ann Otol Rhinol Laryngol 1984;93:112.
46. Pang CY, Neligan PC, Forrest CR, et al. Hemodynamics and
vascular sensitivity to circulating norepinephrine in normal skin
and delayed and acute random skin flaps in the pig. Plast Reconstr
Surg 1986;78:75.
47. Wu G, Calamel PM, Shedd DP. The hazards of injecting local
anesthetic solutions with epinephrine into flaps. Plast Reconstr
Surg 1978;62:396.
48. Dabb RW, Malone JM, Leverett LC. The use of medicinal leeches
in the salvage of flaps with venous congestion. Ann Plast Surg
1992;29:250.
49. Utley DS, Koch RJ, Goode RL. The failing flap in facial plastic
and reconstructive surgery: role of the medicinal leech. Laryngo­
scope 1998;108:1129.
50. Lineaweaver WC, Hill MK, Buncke GM, et al. Aeromonas hydroph­
ila infections following use of medicinal leeches in replantation and
flap surgery. Ann Plast Surg 1992;29:238.
51. Mackay DR, Manders EK, Saggers GC, et al. Aeromonas species
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lower eyelid, the ectropion was severe and required surgi­
cal treatment. Correction of the ectropion was accom­
plished by excision of the scar and reconstruction of the
area with a full-thickness skin graft. A lateral canthoplasty
was also performed (Fig. 26-37).
Although the local flap used in this case was appropri­
ately designed, dissected, and transferred to the recipient
site, partial necrosis of the flap occurred. Even in the
most experienced surgical hands, complications such as
the one described will occasionally occur. Surgeons per­
forming local flap surgery should have experience in
managing complications born from flap surgery. This
experience usually prevents complications from progress­
ing to permanent functional impairment.
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726
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treatment. J Am Acad Dermatol 1986;15:1163.
56. Hosokawa K, Susuki T, Kikui T, et al. Sheet of scar causes
trap-door deformity: a hypothesis. Ann Plast Surg 1990;25:
134.

727
C H A P T E R 2 7 
SCAR REVISION AND LOCAL
FLAP REFINEMENT
Deirdre S. Leake  •  Shan R. Baker
INTRODUCTION
A scar, as defined in Webster’s dictionary, is a “mark left
after injured tissue has healed.” Any full-thickness injury
of the skin, planned or unplanned, will leave a scar. It is
the body’s way of repairing itself. Although scars are vital
in the reparative process, they can be aesthetically and
functionally disruptive. Scars can interfere with normal
motion and be disfiguring, decreasing the quality of life.
Each person deals with a scar differently, depending on
the inciting event that caused the scar. In some countries,
very deforming scars can be a sign of nobility or bravery.
However, to another individual, the same scar can be
emotionally devastating. If the scar was caused by an
altercation or disease process, it is a reminder of the
vulnerability and fragility of the body.
SCAR REVISION
Wound Healing and Contributing Factors
Factors that influence scar formation and appearance
after wound healing depend on the initial injury, location
of the wound, and local cellular and humoral responses.1-3
Wound healing is a natural phenomenon that progresses
through many states before complete healing. The stages
of wound healing include initial coagulation, inflamma­
tory phase with re-epithelialization, fibroblastic phase,
and maturation phase with the deposition of collagen and
glycoproteins.2 The process of healing is complete after
approximately 1 year, at which time the scar will reach
80% of the original tissue tensile strength.4 Wound
healing is discussed in detail in Chapter 4.
Unsightly scars may develop for a number of reasons.
Inappropriate placement of incisions or poorly designed
local flaps may contribute to a less than desirable result.
Other factors include the location and size of the wound.
Certain surgical techniques used for repair of wounds
may adversely affect scar formation. These include failure
to properly approximate and evert wound edges, failure
to perform sufficient undermining of tissue, failure to
close the deep layers of a wound, and removal of cutane­
ous sutures in an untimely manner. One of the most
important factors influencing scar formation is the degree
of wound closure tension. Whenever possible, wounds
should be repaired with the least degree of tension. Inci­
sions adjacent to mobile structures are more likely to
result in an apparent scar. For example, scars of the lip
and of the skin overlying the body of the mandible are
more likely to widen or to become hypertrophied because
of the frequent motion of the skin in these areas. Incisions
and lacerations of thick skin are more likely to produce
noticeable scars than are incisions and lacerations of thin
skin. On the face, thicker skin is located on the chin,
caudal nose, and forehead. Thus, incisions in these areas
are more likely to develop hypertrophic raised scars that
can widen and have prolonged erythema compared with
other regions of the face.
The circumstance of wounding is a factor in scar for­
mation. Planned surgical wounds heal better than con­
taminated wounds.5 Skin wounds from traumatic injuries
or disease usually heal with more scarring. In traumatic
and surgically created wounds, greater tissue loss is asso­
ciated with greater scarring. When lacerations or skin
avulsions are ragged but parallel to relaxed skin tension
lines (RSTLs), the irregular borders can be excised and
the wound closed in a straight line. However, if the
wound is perpendicular to RSTLs, it may be prudent to
close the wound while preserving the ragged border to
help create an irregular scar.6 Thermal injuries and
wounds containing foreign material are likely to heal with
hypertrophy.3
Patient factors are important in predicting the outcome
of healing wounds. Individuals with hyperelastic joints
have more elastin in the dermis of the skin and are likely
to form widened scars even when wound closure tension
is minimal or absent. Other factors include race, skin
type, age, and general health of the patient. Scars in fair-
skinned patients tend to remain pink for an extended
interval. Darker skinned individuals (Fitzpatrick types III
to VI) often form hyperpigmented scars and are more
likely to form keloid scars. Children and younger adults
are more likely to heal with thick, firm scars than older
patients are. For this reason, improving scars in children
is particularly challenging, and it is often prudent to post­
pone scar revisions until after puberty.
Optimizing a patient’s nutrition and immune system
is beneficial to wound healing. Collagen synthesis
requires vitamins A and C and iron. Epithelialization
requires zinc. Certain chronic diseases affect wound
healing. Patients requiring insulin for diabetes, steroids

728
SECTION III  ADJUNCTIVE SURGERY
for collagen vascular disease, or antimetabolites for
cancer have an increased risk of poor wound healing and
wound infection.7 Individuals with atrophic dermatitis or
psoriasis tend to have staphylococcal colonization of their
skin and as a consequence have a higher risk of postopera­
tive wound infections. Wounds created in areas previ­
ously treated with 50 Gy or greater of irradiation are
more likely to heal slowly or not at all. This is due to
irradiation-induced changes of the skin that include
fibrosis and obliteration of the subdermal vasculature,
atrophy of the skin and subcutaneous fat, and loss of
cutaneous appendages.7 Nicotine can increase the risk of
skin necrosis after wounding. This is due to the effects
of nicotine on the vasculature of the skin, which include
endothelial thickening and damage to small vessels. It
is also related to the vasoconstrictive properties of
nicotine.
Ideal Scar
A scar cannot be removed or eliminated, but in certain
instances it may be improved. One of the goals of plastic
surgery is to create scars only when necessary. Ideally,
scars should be imperceptible and not impair function,
especially around the mouth, eyes, and nose. Scars should
lie in aesthetic borders or in RSTLs, where wound
closure can be performed with the least amount of wound
closure tension. The ideal scar should be flat and level
with surrounding skin without depressions, bulges, or
step-offs that create shadows in certain lighting. Scars
should be narrow and should not cause distortion of
adjacent tissue. Ideal scars should display the same color
and texture as surrounding skin. Scars should be parallel
to RSTLs or lie in a natural skin crease.
To achieve an ideal scar when performing flap surgery,
the surgeon must have a thorough understanding of skin
anatomy and physiology, perform careful analysis of the
defect, be knowledgeable concerning alternative recon­
struction methods, employ skillful and meticulous soft
tissue handling techniques, and understand the patient’s
expectations. The surgeon must also be aware of the
limitations of each surgical procedure. When alternatives
are available, the surgeon should avoid creating long,
straight, unbroken incisions that tend to make scars more
visible.8,9
The patient should be informed at the time of scar
revision that more than one procedure may be required,
with appropriate intervals between each stage. A common
question of patients is, How much can my scars be
improved? Always err on the conservative side when
responding to this question and never promise complete
improvement. Scars cannot be eliminated, and in reality
the surgeon is exchanging one scar for another. If the scar
is similar in color to surrounding tissues, narrow, flat, and
well positioned in RSTLs or aesthetic boundaries or in
the midline, it would be imprudent to recommend scar
revision.
Timing of Scar Revision
Traditional teaching dictates that scar revisions should
not be performed until 6 to 12 months after the initial
surgery or wounding. This is to allow scar maturation.
Wounds have only 20% of their final strength by the
third week of wound healing.10 Scars continue to change
and to improve during the remodeling phase of wound
healing. This includes collagen remodeling and collagen
fiber reorientation for up to 18 months. This process can
be longer in children. Young patients may have an exag­
gerated healing reaction with increased scar erythema
and hypertrophy, so scar revisions in children should be
delayed as long as feasible (Fig. 27-1). Immature scars
tend to be erythematous, which will usually fade over
time (Fig. 27-2). The scar’s appearance will also improve
as it matures. However, early scar revision may be neces­
sary if scars are grossly deforming, such as those that are
perpendicular to RSTLs, cross or deform facial aesthetic
regions or units, or have traumatically implanted foreign
material. In such circumstances, it is recommended to
delay scar revision for only 2 or 3 months after wounding
to allow the deposition of dermal scar, which can serve
as a wound base. Dermabrasion of scars may be per­
formed 6 to 9 weeks after initial wounding. The first 2
months of wound healing manifest a high fibroblast activ­
ity and collagen remodeling; therefore, dermabrasion is
more effective at this time.11,12
PATIENT ASSESSMENT
An understanding of the mechanical properties of facial
skin and the principles of facial aesthetic regions and
units is necessary to perform skillful scar revision surgery.
Skin anatomy is discussed in depth in Chapter 1. Facial
aesthetic regions and units are described in Chapter 6. A
history of how the patient has healed from previous inju­
ries is important. Patients who can bend their thumb back
to the volar surface of their forearm (Fig. 27-3) or touch
their tongues to their noses (Gorlin’s sign) are more flex­
ible than the average person. These individuals possess
more elastin within their dermis and are more likely to
spread their scars.
Scars should be classified according to etiology (acne,
varicella, disease process, trauma, tattoos, surgical) and
type (keloid or hypertrophic, depressed, widened, ele­
vated). The nature of scars should be described as to size,
shape, contour, structural distortion, and color. Scars may
often be improved if they are widened, are perpendicular
to RSTLs, or interrupt an aesthetic boundary of the face.
Webbed, depressed, atrophic, hypertrophic, and keloid
scars can usually be improved with revision surgery. Scars
that display trap-door deformity and that do not improve
with time or with subcutaneous injections of triamcino­
lone should be considered for revision surgery. Scars
adjacent to but not lying in a favorable site may be relo­
cated to a preferable location. Long unbroken lines not
within RSTLs can frequently be improved with scar revi­
sion. Scars causing distortion of facial features or impair­
ing the function of structures should be revised.
Patients should discontinue the use of tobacco prod­
ucts, nonsteroidal medications, and vitamin E before scar
revision. Scar revision should not be performed in an area
of active infection. Active acne should be controlled with
antibiotics, topical retinoic acid, and keratolytics.7 If the

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
729
FIGURE 27-1  ■  Multiple facial scars in a 13-year-old patient after an automobile accident. A-D, A few weeks after the accident and 3
years later. Scars matured and erythema regressed. Scars were treated with single intrascar injection of triamcinolone in select
areas and silicone sheeting over all scars at bedtime for 1 year.
A
B
C
D

730
SECTION III  ADJUNCTIVE SURGERY
FIGURE 27-2  ■  A, Scar from laceration. B, Three years later. Scar was not treated. Scar matured and is only slightly visible in spite
of not being parallel to RSTLs.
A
B
FIGURE 27-3  ■  A, Patients who can bend thumb back to volar surface of forearm possess more than average elastin in dermis.
B, Same patient showing facial scars from varicella. Increased elastin in skin causes scars of all types to spread as they mature.
A
B

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
731
patient has been taking isotretinoin (Accutane) within 18
months, dermabrasion or laser resurfacing should be
postponed. Isotretinoin reduces the cellular activity of
cutaneous adnexal appendages that is necessary for
re-epithelialization of superficial surface wounds. Before
dermabrasion or laser resurfacing, the skin may be con­
ditioned by treatment with a tretinoin. Tretinoin has
been shown to inhibit dermal collagenase, preventing
breakdown of collagen. Patients should be instructed to
avoid excessive sunlight exposure to a scar before and for
3 months after revision surgery.
TECHNIQUES
Selection of the most appropriate surgical technique for
scar revision depends on the condition and location of
the scar. Treatment options may include elliptical exci­
sion of the scar, irregularization, epithelial abrasion, and
filler implantation. The simplest method is often the pre­
ferred, and more than one procedure may be required.
Scar Excision
Excisional techniques are designed to reduce wound
closure tension, to change the shape of a scar, to correct
uneven tissue apposition, or to fill in contour depressions.
The most common excisional technique is the elliptical
excision, which is used for scars that are elevated or
depressed in relationship to the level of the adjacent skin.
Elliptical excision is also useful for treatment of malaligned
or wide scars and those that can be repositioned into an
aesthetic boundary. Elliptical excision is often reserved
for scars that are parallel to RSTLs or in favorable areas
of the face and less than 2 cm in length. Elliptical excision
is particularly useful for individual ice pick acne or pox
scars or short, straight, wide, depressed, or raised scars.
Fusiform incisions are made parallel to RSTLs or in
aesthetic boundaries. The ellipse is designed with angles
of 30° or less at each end to prevent skin redundancy. To
shorten the elliptical excision, an M-plasty may be per­
formed. Excisions that are longer than 1 cm may be
designed sinusoidally and parallel to contour lines or
RSTLs. Compared with a standard elliptical excision, a
lazy S–shaped excision may close easier and avoid bunch­
ing at the ends of the wound with less midpoint wound
closure tension.13 The length-to-width ratio of elliptical
excisions should be 3 : 1 to allow wound closure without
standing cutaneous deformities. If standing cutaneous
deformities form, they can often be corrected by sewing
out the extra length. When the two borders of an incision
are unequal in length, a standing cutaneous deformity
may occur along the border of the wound with the longest
length. An equalizing Burow triangle can be excised to
shorten the long border. This consists of making an inci­
sion perpendicular to the long side of the wound and
removing a triangle of skin. In performing an elliptically
shaped scar excision, it is helpful to leave the deeper
dermal scar in situ to augment the depth of the wound.
Most scars are excised just outside of the scar margins;
however, keloids and hypertrophic scars heal with less
hypertrophy if they are excised slightly inside the margin
of the scar.14,15
Scar excisions in the form of skin punch excisions to
treat ice pick–type acne scars may be beneficial. The
depressed scar is punched out with a skin punch and
discarded. The edges of the wound are approximated
with eversion. This works well if the adjacent skin is
normal. Punch grafts from the postauricular skin can be
placed into the hole created by excised ice pick scars.
Punch excisions and grafts are usually followed by derm­
abrasion within 6 weeks to achieve optimal results.16
Punch incision can also be performed and the scar plug
elevated and sutured to the adjacent skin.
Partial or multiple serial excisions of scars may be used
when the elasticity of the scar and surrounding tissue
prohibits one-stage excision. Stress-relaxation causes
tissue to stretch over time, which facilitates re-excision
of scars.17 Serial excision is a particularly useful technique
for removal of skin grafts or pigmented lesions (Fig.
27-4). It may also be an effective method for excision of
broad scars and burn scars or where severe disfigurement
would occur if the area were excised in one stage. Tissue
expansion can accomplish the same goal as serial exci­
sions of scars but in two or more stages. Tissue expansion
uses the advantage of the stress-strain curve beyond the
elastic limit of skin.18 Adjacent tissue usually provides the
best skin color and textural match for repair of wounds.
Thus, tissue expansion or serial excision provides a
method of transferring like tissue into an area deficient
of skin where a single surgical stage does not provide a
means to accomplish this.18
FIGURE 27-4  ■  A, Full-thickness skin graft of left side of forehead. B, One year after serial excision of graft.
A
B

732
SECTION III  ADJUNCTIVE SURGERY
Scar Irregularization
Scar irregularization may improve the appearance of
scars that are long (>2 cm), straight, predictable, and fol­
lowed easily by an observer’s eye. The eye can be tricked
by creating irregular scars that reflect less light and
shadow compared with straight regular scars, making a
scar less visible. Irregularization is also useful to change
scars that cross adjacent aesthetic units, distort facial fea­
tures, or are webbed.
Z-Plasty
Z-plasty is a form of scar irregularization. It can be used
to interrupt scar linearity, to elongate contracted scars, to
efface webs or clefts, and to change the orientation of
scars so that the majority of the length of a scar is aligned
with RSTLs.9,17 Z-plasty can also be used to correct dis­
torted anatomic facial landmarks caused by scars (Figs.
27-5 and 27-6). An example of this is use of a Z-plasty to
lengthen a scar causing lower eyelid retraction.21 Z-plasty
can realign a scar that crosses the alar-facial sulcus or
melolabial crease. Z-plasty is an effective method of
reducing trap-door deformity.
In designing a Z-plasty, all limbs and angles of each
triangular flap are equal to each other. The angles of the
tip of the flaps may vary from 30° to 60°. The degree of
release of contracted scars by Z-plasty is related to the
Proper tissue handling is important for successful scar
excision techniques. Undermining in the subcutaneous
tissue plane at least 1 cm beyond the borders of the scar
excision is necessary to reduce wound closure tension.17
Dermal approximation is recommended to reduce tension
and to eliminate dead space. Accurate alignment of
muscles is necessary for proper restoration of function.
Absorbable sutures are used for dermal apposition with
attention toward precise eversion of wound edges to
prevent discrepancies in the level of the epidermis. Ever­
sion of the skin edges of a wound can be accomplished
with deep subcutaneous sutures, epidermal vertical mat­
tress sutures, or simple cutaneous sutures placed perpen­
dicular to the skin surface. Unequal depths of the bites
of the dermis on either side of the wound may be neces­
sary to create a level everted wound edge. There is much
controversy concerning the preferred method and mate­
rials used for closure of wounds. Issues include the use of
absorbable or nonabsorbable cutaneous sutures and
whether to repair a skin incision with simple running or
mattress sutures. Karounis et al19 and Singer et al20 studied
the issue of absorbable versus nonabsorbable cutaneous
sutures and found that the repair of traumatic lacerations
in children with absorbable sutures appeared to be as
acceptable as that with nonabsorbable sutures. The long-
term aesthetic results were deemed to be similar.19,20 An
in-depth discussion of wound closure techniques is pre­
sented in Chapter 4.
FIGURE 27-5  ■  A, Hypertrophic scars of cheek and upper and lower lips after a dog bite. B, Improvement of scars after staged Z-plasty
procedures (three stages) and dermabrasion.
A
B
FIGURE 27-6  ■  A, Scarring of upper lip with distortion of vermilion border. B, After multiple Z-plasties and two dermabrasions of
scars.
A
B

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
733
inferior advancement of the island flap to create the
resemblance of a Cupid’s bow (Fig. 27-8). This is an
effective method of restoring this important landmark of
the upper lip. Another example of this technique is dis­
cussed in Chapter 9.
Figure 22-9 shows distortion of the vermilion border
of the upper lip after reconstruction of a 2 × 2-cm skin
defect with a rotation lip flap. The distortion resulted
from contraction of the vertical scar along the length of
the medial border of the flap. In addition to causing
distortion of the vermilion border, the scar was exces­
sively wide and exhibited a slight depressed contour. To
correct the vermilion deformity and to improve the
contour of the scar, a Z-plasty was performed. This was
successful in restoring a natural border to the vermilion
and in correcting the depressed scar.
Notching of the nostril margin can result from lacera­
tions of the nostril or after reconstruction of the alar or
nasal facet with a local cutaneous flap or skin graft. If the
size and angulation of the triangular flaps of the Z-plasty.
Flaps of 60°, 45°, and 30° will have the effect of releasing
a contracted scar by approximately 75%, 50%, and 25%
and changing the orientation of the scar 90°, 60°, and 45°,
respectively.2 The final position of the new central limb
of the Z can be predicted by envisioning an imaginary line
that connects the two free ends of the original Z.
Z-plasty is a powerful and effective method of correct­
ing distortion of the vermilion or realigning irregularities
of the vermilion. Figure 27-7 shows distortion of the
vermilion after an A-T wound closure of a 1.5-cm skin
and vermilion defect of the upper lip. The deformity was
first corrected by employing a double Z-plasty to lower
the level of the vermilion border in the midline (Fig.
27-7E). A second surgical stage was performed to recon­
struct a Cupid’s bow. This was accomplished by using a
V-Y island advancement flap based on a subdermal orbi­
cularis muscle pedicle. A small ellipse of vermilion was
excised to create a midline tissue void that allowed
FIGURE 27-7  ■  A, A 1.5 × 1.5-cm defect of skin and vermilion repaired with A-T wound closure (see Chapter 9). B, Scar contraction
caused distortion of vermilion. C, D, Double Z-plasty used to correct distortion. E, Postoperative result at 3 months.
A
B
C
D
E
FIGURE 27-8  ■  A, Same patient shown in Figure 27-7. V-Y island advancement flap based on orbicularis oris muscle pedicle designed
to restore Cupid’s bow. Flap advanced inferiorly after resection of small ellipse of vermilion. B, Flap in place. C, Postoperative result
at 1.5 years. Resemblance of Cupid’s bow restored to vermilion border.
A
B
C

734
SECTION III  ADJUNCTIVE SURGERY
FIGURE 27-9  ■  A, A 2 × 2-cm skin defect of upper lip. Rotation flap designed for repair. Anticipated standing cutaneous deformity
(horizontal lines) marked for excision. Z-plasty marked at pivotal point of flap. B, Flap in place. C, Healing of flap resulted in distor­
tion of vermilion border. D, E, Z-plasty performed to correct distorted vermilion border. F, Six months after Z-plasty.
A
B
C
D
E
F
notching is not severe, it can frequently be corrected with
Z-plasty (Fig. 27-10). The linear axis of the notch is
incorporated into the central limb of the Z-plasty. Trian­
gular flaps with angles of 45° to 60° are marked on either
end of the central limb to complete the Z-plasty design.
Transposing the flaps releases the contracture of the scar
causing the notching. On occasion, insertion of a small
cartilage graft beneath the flaps of the Z-plasty may be
beneficial in reinforcing the scar lengthening achieved
with the Z-plasty.
A common use of Z-plasty is for release of scar con­
tractures. Scar contractures can result from any cutane­
ous surgery. Severe contractures may occur in scars
resulting from burns or deep skin injury from the use of
laser or chemical peels. Z-plasty is frequently employed
in the treatment of burn scars of the neck to release con­
tractures that impair movement of the head and neck.
Frequently, multiple Z-plasties are required (Fig. 27-11).
Chapter 14 is devoted solely to the subject of Z-plasty.
W-Plasty
Like Z-plasty, W-plasty is another method of converting
a scar with a regular configuration into one with an irreg­
ular pattern. A W-plasty consists of uniform interposed
triangular advancement flaps (Fig. 27-12).17,22 It creates
a recurring irregularly patterned scar that is less likely
to be noticed by an observer’s eye. W-plasty creates a
scar that avoids sharp demarcation between scar and adja­
cent skin by interdigitating small triangles of normal

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
735
FIGURE 27-10  ■  A, A 1.5 × 1.5-cm skin and soft tissue defect of ala. B, Four months after reconstruction. Ala repaired with auricular
cartilage graft for structural support and interpolated melolabial flap for external cover (see Chapter 18). Notching of nostril margin
has occurred. C, D, Z-plasty performed to correct deformity. E, Four months after Z-plasty.
A
B
E
C
D

736
SECTION III  ADJUNCTIVE SURGERY
FIGURE 27-11  ■  A, Burn scar contractures of neck. Multiple Z-plasties marked for correction of contractures. B, Contractures released.
C, Z-plasties completed.
A
B
C
FIGURE 27-12  ■  A, Scar perpendicular to RSTLs. B, W-plasty performed by designing repeating triangular flaps roughly parallel to
RSTLs on either side of scar. Scar excised and flaps interdigitated. C, Wound closure with interrupted buried dermal sutures and
running locked 6-0 rapidly absorbing gut suture.
A
B
C

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
737
alignment of the epithelial surface is critical. The wound
is reinforced with paper tape for 1 week. The greatest
disadvantage of W-plasty is that it creates a scar that is
predictably irregular, so when a long scar is revised, it
may result in a new scar that is still readily detected by
an observer. Thus, for very long scars (more than 4 cm),
a geometric broken-line closure is recommended.
Geometric Broken Line
The greatest disadvantage of W-plasty scar revision is
that the procedure creates a predictably irregular scar.
Thus, long W-plasties may cause a scar to be more
detectable than if a geometric broken-line scar revision
is performed. A geometric broken-line scar revision con­
sists of a series of random, irregular geometric shapes
incised along one border of the scar with the mirror
image of this pattern incised on the opposite border (Fig.
27-15). The randomness of the design causes the scar to
be more difficult for the observer’s eye to follow, thus
having the effect of scar camouflage. The geometric
broken line is most useful for treatment of scars that are
long and linear and cross RSTLs (Fig. 27-16). Similar to
W-plasty, each geometrically shaped component of a
geometric broken-line scar revision should measure 3 to
7 mm in length.22 Much of the scar created by the geo­
metric broken-line technique will not parallel RSTLs.
Rectangle-shaped components should be interspersed
with other angular shapes to prevent circular scar con­
traction. To reduce trap-door deformity, the use of curved
components should be limited (Fig. 27-17). Similar to
W-plasty, the superficial portion of the scar is excised,
leaving the deep dermal and subdermal scar in situ. The
surrounding borders of the excised scar are widely under­
mined, and the geometrically shaped skin edges of the
wound are carefully opposed so that the corresponding
unscarred skin, which has the effect of camouflaging the
scar. W-plasty may also be helpful in aligning scars to
more nearly approximate the direction of RSTLs of the
face.23 It is indicated for scars of the forehead, eyebrow,
temple, nose, cheek, and chin that are oriented 35° or
more from RSTLs (Fig. 27-13).24 W-plasty is frequently
effective in improving the appearance of scars over a
convex facial contour. Examples are scars located along
the mandibular border, the anterior surface of the ear,
and the central forehead.7,17,22
In performing a W-plasty, the scar should be outlined
and RSTLs should be marked where they cross the scar.
The orientation of the triangular flaps of the W-plasty is
parallel to the RSTLs or slanted in the direction of the
RSTLs.17 A series of Ws are drawn so that the apices of
the triangles are 5 to 7 mm peripheral to the scar (Fig.
27-14); 3 mm or less tends to be too small to irregularize
the scar sufficiently to prevent it from appearing as a
straight line, and limbs of more than 7 mm are suffi­
ciently long that the limbs of the flaps create a scar that
is individually visible. A mirror image of the first side is
drawn on the opposite side of a scar so that the tips of
the triangular flaps will interdigitate when the skin is
advanced perpendicular to the direction of the scar.
Angles of the W-plasty should be designed to be at least
60° to allow adequate tissue interposition, optimal vascu­
larity with minimal tip of flap edema, and interposition
of tissue that will resist scar contracture.3,7 A M-plasty can
be used at the end of the scar to prevent extension of the
incision. Incisions should be made with a No. 11 scalpel
blade. Mature subdermal scar tissue is left in situ to help
resist contracture and depression of the scar during
healing. Wide undermining of the borders of the inci­
sions is performed. The wound is approximated in layers.
The cutaneous suture may be a running locking or inter­
rupted suture of nylon or 6-0 fast absorbing gut. Exact
A
W-plasty
B
C
FIGURE 27-13  ■  A, W-plasty designed to revise cheek scar. B, C, Scar excised and W-plasty completed.
Continued

738
SECTION III  ADJUNCTIVE SURGERY
D
E
F
G
D-G, Preoperative and 2-month postoperative views.
FIGURE 27-13, cont’d  ■

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
739
FIGURE 27-14  ■  A, Unsightly scar from rotation flap. Superior portion of scar is perpendicular to RSTLs. B, Superior portion of flap
contoured concomitant with W-plasty scar revision. Persistent standing cutaneous deformity excised inferiorly. C, D, Scar excised
and W-plasty completed. E, Postoperative result at 1 year.
A
W-plasty
Elliptical excision
Contour
B
C
D
E

740
SECTION III  ADJUNCTIVE SURGERY
FIGURE 27-15  ■  Geometric broken-line scar revision. A, Random geometric figures designed on either side of scar. B, Scar excised,
leaving mirror-image wound edges. C, Wound edges advanced and approximated with running locking 6-0 rapidly absorbing gut
suture.
A
B
C
FIGURE 27-16  ■  A, Wide unsightly scar not parallel to RSTLs. B, Geometric scar revision designed. Geometric shapes mirror each
other on either side of scar. C, Note how wound spreads when contracted scar is excised. D, Wound approximated. E, Postoperative
result at 4 months immediately before dermabrasion. F, Postoperative result at 10 months.
A
B
C
D
E
F

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
741
site. Thus, the flap is allowed to move into the recipient
site in a nearly tension-free fashion. The secondary
triangle-shaped donor defect is then repaired with wound
closure tension by advancing the two borders of the
remaining wound toward each other. In so doing, the
wound closure suture line assumes a Y configuration,
with the common limb of the Y representing the suture
line resulting from closure of the secondary defect. The
flap is optimally designed so that the common limb of the
Y falls in the boundary of neighboring aesthetic regions
or within a natural crease, fold, or wrinkle.
V-Y advancement is useful in situations in which a
structure or region requires lengthening or release from
a contracted state. The technique is particularly effective
in lengthening the columella during the repair of cleft lip
nasal deformities in which a portion or all of the colu­
mella is underdeveloped. A V-shaped advancement flap
is elevated, recruiting skin from the midportion of the lip
between the philtral ridges. The length of the columella
is augmented by advancement of the flap upward into the
base of the columella. The secondary donor defect is
approximated by advancement of the remaining lip skin
together in the midline. V-Y advancement is helpful in
releasing contracted scars that are distorting adjacent
structures, such as the eyelid or vermilion.25 An example
is the correction of a contracted scar causing elevation of
the vermilion border. The segment of distorted vermilion
is incorporated into the V-shaped flap and the flap is
advanced toward the lip to restore the natural topography
of the vermilion-cutaneous junction. The skin of the
borders of the secondary defect is then advanced toward
each other and sutured. This suture line becomes the
vertical component of the Y configuration. The V-Y
island advancement flap is also useful in restoring Cupid’s
bow after repair of midline upper lip defects in which
geometric shapes fit precisely together. A two-layered
wound closure is always performed.
Wound Care
Proper wound care after scar irregularization is impor­
tant. Re-epithelialization of the wound begins 2 days after
injury.6 The wound is cleaned with water or hydrogen
peroxide twice daily, and antibiotic ointment is applied for
48 hours. The wound is kept moist with occlusive oint­
ment until the sutures are removed. The ointment helps
prevent debris and exudates from accumulating between
wound edges, which can separate and cause widening of
the wound edges. Cutaneous sutures are removed in 5
days to prevent epithelial tracking and to avoid punctate
scars. After the removal of sutures, Steri-Strips are applied
along the scar. Epithelial abrasion of the scar is usually
performed 6 to 8 weeks after scar irregularization. Protec­
tion from sunlight is recommended to decrease postin­
flammatory hyperpigmentation.
V-Y and Y-V Advancement Flaps
V-Y and Y-V advancement flaps are a method of transfer­
ring additional tissue toward an area of tissue deficiency.
This is similar to Z-plasty in its effect of elongating an
area of scar contracture, except the additional skin sup­
plied to the area of contracture is advanced rather than
transposed into the affected area. Whenever possible,
incisions are placed in natural skin creases. V-Y advance­
ment flaps are helpful for correcting webbed scars near
the eye, mouth, or nose. The V-Y advancement flap is
unique in that the V-shaped flap is not stretched or pulled
toward the recipient site but rather achieves its advance­
ment by recoil or by being pushed toward the recipient
FIGURE 27-17  ■  A, Wide unsightly scar not parallel to RSTLs. B, Geometric scar revision designed so each geometric shape is 3 to
7 mm and angular, not curvilinear. C, Scar excised. D, Wound approximated. E, Postoperative result at 1 year. Scar dermabraded
2 months after revision.
A
B
C
D
E

742
SECTION III  ADJUNCTIVE SURGERY
The Y-V advancement flap has a similar principle to
the V-Y flap except that the V-shaped flap is stretched or
pulled toward a linear incision made at the apex of the
triangle-shaped flap. The borders of this incision are
allowed to spread apart, creating a tissue void. The flap
is advanced into the void and sutured in place. The
wound closure suture line assumes a V configuration.
The maximal wound closure tension is at the apex of the
flap. The Y-V advancement flap has fewer applications
than the V-Y flap but may be used on some occasions to
Cupid’s bow has been destroyed (Fig. 27-18; see also Fig.
27-7). This is accomplished by a midline upper lip island
flap based on its subdermal orbicularis muscle pedicle. A
small ellipse of vermilion is excised to create a tissue void
in the area of the missing Cupid’s bow. This excision
should be slightly larger than ideal to correct for scar
contraction. The island flap is then advanced into the
defect created by the vermilion excision. As with all V-Y
island advancement flaps, the donor defect is closed by
advancing adjacent skin.
FIGURE 27-18  ■  A, A 2.5 × 1.5-cm skin defect of filtrum and vermilion. B, C, Defect converted to full thickness and closed primarily.
D, Postoperative result at 1 year. Note absence of Cupid’s bow. E-H, Construction of Cupid’s bow with V-Y island advancement flap.
I, Six months after construction of Cupid’s bow. Scar dermabraded 2 months after revision surgery.
A
B
C
D
E
Island flap
Vermilion excised here
F
G
H
I

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
743
After scar irregularization, dermabrasion is recom­
mended 6 weeks later to optimize scar camouflage and to
smooth and blend wound edges with surrounding skin.
Spot dermabrasion of traumatic scars is usually beneficial
and can be performed 1 to 3 months after injury. This
time frame is when collagen is undergoing active remod­
eling. Katz27 found that scars improved most when derm­
abraded 8 weeks after their development, and Yarborough
showed that immature scars respond better after resur­
facing than mature scars do.28,29
The entire scar and adjacent skin are dermabraded to
allow uniform texture and color. The depth of the derm­
abrasion at the periphery should be feathered to facilitate
a smooth transition. If a skin graft is dermabraded, the
depth of abrasion is limited over the graft because of lack
of dermal appendages unless the graft was full thickness
and harvested from the face. Dermabrasion is performed
with an electric-powered rotary wheel at 10,000 to
15,000 rpm. Diamond fraises are available in different
coarseness and shapes. Abrasion is carried to the level of
the upper to mid reticular dermis along the borders of
the scar and to the papillary (punctuate bleeding) dermis
elsewhere. The endpoint can be determined on the basis
of pinpoint bleeding, which indicates the invasion of the
capillary plexus of the dermal papillae.30 The skin can be
painted with gentian violet to provide a helpful guide to
the depth of dermabrasion and to act as an antiseptic.
Dermabrasion should progress until all the violet is
removed, indicating that the epidermis has been com­
pletely removed. When dermabrasion is performed near
mobile structures, the direction of rotation of the fraise
should be oriented toward the structure to avoid tearing
of tissue at the margin of the structure.
Dermabrasion wounds are covered with an occlusive
dressing. The area should be cleaned with water and
acetic acid (25% concentration) to soften any crusts. A
petroleum ointment or hydrocolloid dressing is used
relocate a distorted facial structure in a more natural
position. An example would be in correcting the position
of an oral commissure that has been displaced medially
by the scar. The commissure is incorporated into the
triangular flap, and a horizontal incision is made lateral
to the commissure. The flap consisting of the commis­
sure is then advanced laterally into the tissue void created
by the horizontal incision, restoring a more natural posi­
tion to the commissure.
Dermabrasion
Dermabrasion can improve scar color and texture, which
may help camouflage the scar. Dermabrasion causes a
superficial injury to the papillary dermis that heals by
re-epithelialization from adnexal structures in the reticu­
lar dermis. This healing process results in a smoother
surface. This phenomenon occurs because of the deposi­
tion of new collagen within the dermis of the treated area.
Superficial collagen bundles develop a more organized
appearance and display an increased density, bundle size,
and unidirectional orientation after dermabrasion.26
Dermabrasion can improve surface irregularities and pig­
mentary discrepancies between flaps or grafts and adja­
cent skin (Figs. 27-19 and 27-20). It may be useful in
improving step-off deformities of scar margins and the
skin color and texture match of a flap with the adjacent
facial skin. In this regard, dermabrasion is particularly
helpful when a cheek flap has been used to reconstruct a
defect of the upper or lower lip in older patients who have
perioral rhytids. In such circumstances, the cheek flap
will not display similar vertically oriented rhytids. This
can result in a marked discrepancy in skin texture between
flap and native lip skin (Fig. 27-21). Dermabrasion of the
native lip skin will reduce the presence of the rhytids and
provide an improved skin color and texture match with
the flap skin.
FIGURE 27-19  ■  A, Hyperpigmentation of full-thickness skin graft. B, Immediately after dermabrasion of skin graft to improve color
match with adjacent cheek skin. C, Seven months after dermabrasion. Color match has improved.
A
B
C

744
SECTION III  ADJUNCTIVE SURGERY
FIGURE 27-20  ■  A, A 4 × 2.5-cm skin and vermilion defect of upper lip. B, Defect covered with full-thickness skin graft. C, Postopera­
tive result at 7 months. Graft has poor color and texture match with native lip skin. Vermilion absent in area of graft. D, E, Vermilion
created with bipedicled mucosal advancement flap. Skin graft dermabraded. F, Five months after mucosal advancement flap and
dermabrasion of graft.
A
B
C
D
E
F

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
745
B
C
A
FIGURE 27-21  ■  A, Lentigo maligna of upper lip marked for excision with vertical lines. Inferiorly based melolabial transposition flap
designed to reconstruct lip after resection of melanoma. B, Tumor excised and flap transposed. C, Six months after reconstruction.
Flap displays trap-door deformity and marked discrepancy between skin texture of flap and native lip skin.
Continued
after each cleaning for 5 to 7 days. Scabbing and crusting
increase the risk of scarring.31 Occlusion enhances
epithelialization, reduces discomfort, prevents infection,
and minimizes eschar formation. This allows the wound
to heal faster with a decreased risk of scarring. Re-
epithelialization of the wound occurs within 7 to 10 days.
Postoperative erythema lasting up to 3 months can be
normal. During this interval, sunscreen protection must
be used at all times to avoid hyperpigmentation.
Many physicians begin topical retinoic acid and 4%
hydroquinone 1 month before dermabrasion or laser resur­
facing to enhance re-epithelialization and to decrease
hyperpigmentation. Topical tretinoin may increase the
rate of re-epithelialization by stimulating epithelial
migration. Patients undergoing dermabrasion of scars of
the lip receive antiviral therapy before and after surgery.
Laser Resurfacing
Similar to dermabrasion, smoothing of scars can be
accomplished by laser resurfacing. A laser is a beam of
photons with a wavelength dependent on the base sub­
stance used to create the laser. The three most important
lasers used for scar revision are carbon dioxide (CO2)
lasers, yttrium-aluminum-garnet (YAG) lasers, and pulsed
dye lasers. The CO2 and erbium:YAG lasers ablate super­
ficial tissues by vaporization of water in skin cells.30
Pulsed dye lasers are frequently used to treat hyperemic
and hypertrophic scars.32 Pulsed lasers allow the energy
of the laser beam to be delivered in a narrow pulse during
a short time. The short time of delivery of the energy to
the skin limits the conduction of heat to adjacent tissues,
which in turn limits damage to adjacent tissues.33-35 The
short pulse or continuous wave CO2 laser with a flash-
scanning attachment can be safely used for scar resurfac­
ing 4 to 8 weeks after wound repair. A precise depth of
injury can be achieved with laser resurfacing. For optimal
results, a greater depth of laser ablation is desirable along
the borders of scars and a more superficial level in the
depths of scars. In general, elevated scars improve more
with laser resurfacing than depressed scars do. Cotton
et al36 demonstrated new collagen formation in the dermis

746
SECTION III  ADJUNCTIVE SURGERY
Z-plasties
Contouring
D
Mucosal advancement
Dermabrasion
E
F
D, Lip marked for dermabrasion (DB), two Z-plasties, mucosal advancement flap, and flap contouring (com­
missure). E, Revision surgery completed. F, Seven months later. Note improved skin texture match between flap and lip.
FIGURE 27-21, cont’d  ■
after laser treatment, along with elastic fiber alteration in
the papillary dermis.
Which is better for scar resurfacing, dermabrader or
laser? Dermabrasion is more dependent on the skill and
experience of the surgeon but requires less expensive
equipment. There is the theoretical risk of aerosolization
of skin cells and blood from dermabrasion. Lasers
have selective photothermolysis that can ablate water-
containing tissues, providing surgeons greater control of
the depth of injury.37 The thermal damage by lasers is
thought to increase collagen remodeling but causes pro­
longed postoperative erythema. Nehal et al38 compared
halves of scars treated to the level of the superficial reticu­
lar dermis by dermabrasion or CO2 laser. Observer analy­
sis and optical profilometry suggested improvement with
both modalities without a statistically significant differ­
ence when the two modalities were compared. Both
dermabrasion and laser resurfacing have their place in
scar revision. Small areas are best treated with dermabra­
sion because of convenience and cost.
The pulsed erbium:YAG laser (2936 nm) has also been
used for resurfacing of scars. It can improve atrophic and
depressed facial scars, such as those resulting from acne
and chickenpox.39 The laser is used in shorter pulses and
ablates more superficially than the CO2 laser and is
absorbed 12 to18 times more efficiently by water.40 It
produces less tissue destruction for each application com­
pared with the CO2 laser. There is minimal adjacent
thermal injury because of the laser’s unique absorption
characteristics in water, and thus there is a low risk of
permanent melanocytic injury.41,42 The laser does not
coagulate small vessels, so hemostasis may be a problem,
and there is limited collagen contraction, which leads to
less impressive clinical results.37 Some machines combine
erbium:YAG and CO2 lasers so that they can be used in
tandem, providing both ablative and coagulative proper­
ties. This combination provides greater contraction of
collagen and improved hemostasis.43,44
Scars may heal with hyperpigmentation and fine tel­
angiectasias. Hyperpigmentation and redness may fade
up to 2 years after wounding. Because of persistent angio­
genic stimuli or delayed capillary regression, some scars
remain erythematous.45 The 585-nm flashlamp-pumped
pulsed dye laser has been helpful in improving color,
texture, and pliability of certain scars.42,46 The laser beam
is absorbed by hemoglobin and penetrates the epidermis
without destruction.30 The laser is most effective for ery­
thematous and hypertrophic scars. It is not as useful in
darker-skinned patients because of the competitive
absorption of laser energy by melanin and hemoglobin.
The mechanism of action is selective photothermolysis
of small cutaneous vessels, resulting in the reduction of
redness of the scar.47 This laser has also been shown to
improve the appearance and to reduce pruritus of
keloids.45,48,49 Treatments can be repeated at 6- to 8-week
intervals. Alster48 demonstrated a 57% to 83% reduction

27  SCAR REVISION AND LOCAL FLAP REFINEMENT
747
in pigmentation, vascularity, pruritus, and bulk of keloid
scars treated with the 585-nm pulsed dye laser. Alster
treated half of the scars with CO2 and pulsed dye lasers
and the other half with CO2 laser alone. The scars treated
with both lasers showed significant improvement in clini­
cal appearance and erythema compared with the single
modality–treated portion of the scars.46
New collagen deposition in the skin has been demon­
strated histologically with nonablative lasers, such as the
1320-nm neodymium:YAG (Nd:YAG) laser,50 intense
pulsed light source,51,52 484-nm pulsed dye laser,53 and
1540-nm erbium : glass laser.54 Nonablative lasers do not
cause any detectable injury to the surface of the skin. The
1320-nm Nd:YAG and 1450-nm diode lasers create
selective thermal injury in the dermis without damage to
the epidermis. The laser energy generated by these
devices penetrates to the papillary and midreticular
dermis and is absorbed by water.55 They have been shown
to improve acne scarring by enhancing dermal collagen
remodeling.31 Their use requires multiple treatments
before improvement can be visualized.55 Tanzi and
Alster56 performed a comparison of the 1450-nm diode
laser and 1320-nm Nd:YAG laser in the treatment of
atrophic facial scars and found the 1450-nm diode laser
to be superior even though both showed an increase in
dermal collagen. Maximum results are seen 6 months
after a series of treatments are performed, and only
improvement in the scar’s surface texture can be expected.
The postoperative complications of laser resurfacing
include pigmentary changes, scarring, acne, milia, ery­
thema, and herpetic breakouts.30 The most common
complication is the development of hyperpigmentation,
particularly in patients with darker skin. Hyperpigmenta­
tion improves over time and with the use of topical
hydroquinone. Sun exposure will exacerbate hyperpig­
mentation, so use of sunscreens is imperative. Hypopig­
mentation of the skin is commonly observed with deeper
levels of laser resurfacing and occurs in 20% of patients
treated with the CO2 laser.43 Ablative lasers tend to cause
prolonged erythema, which is often treated with hydro­
cortisone. Milia may develop approximately a month
after laser resurfacing. Herpes simplex can be reactivated
in the area treated by laser resurfacing, thus the need to
treat all patients prophylactically with an antiviral medi­
cation. Delayed healing may be observed in patients with
autoimmune disorders, diabetes, or steroid dependency.
Patients with collagen vascular diseases have an increased
risk of scarring and persistent erythema. The skin cover­
ing the mandibular ramus, zygomatic arch, malar emi­
nence, upper lip, chin, neck, and bone prominence of the
forehead is at greater risk of scarring from laser resurfac­
ing.30 Irradiation reduces the number of pilosebaceous
units and causes endarteritis obliterans that reduces
re-epithelialization, placing the patient at increased risk
for scarring from laser resurfacing.
ACNE SCAR
Acne scarring can be a psychologically devastating
problem for certain patients. It is imperative to impress
on patients that such scarring can only be improved, not
eliminated. Acne scarring results from acne vulgaris
and cystic acne. Inciting factors include overgrowth of
Propionibacterium acnes, overproduction of sebum, hyper­
keratinization of follicular epithelium, and hormonal
changes.55 The infectious nature of acne vulgaris causes
dermal inflammation, which leads to destruction of col­
lagen, dermal atrophy, and fibrosis, resulting in depressed
or contracted scars.57 Atrophic scars result from collagen
destruction in the dermis, which results in thinning of
the dermis and is often associated with loss of subcutane­
ous fat.37 Atrophic scars appear concave, have thin skin
covering them, and cast shadows in certain lighting.
Ice pick scars are another form of acne scarring. Many
reports of treatment of ice pick acne scars have shown
improvement with punch grafting followed by dermabra­
sion 6 to 8 weeks later. Ice pick scars can be initially
excised with a skin punch and closed with 6-0 absorbable
suture to convert a deep circular scar to a superficial
circular scar that can then be more effectively derm­
abraded. Orentreich has advocated performing multiple
stabs with a hypodermic needle tangentially beneath ice
pick scars to release fibrous adhesions followed by resur­
facing.58 When ice pick scars are too numerous to be
excised individually and are confined to a limited area on
the face, the scars may be excised as a group. This is
accomplished by performing an elliptical excision of the
scars parallel to RSTLs (Fig. 27-22). Nonablative lasers
leave the epidermis intact and have been used to treat
acne scars. The method of action includes thermal injury
to the dermal collagen, which releases inflammatory
mediators that activate fibroblasts, which in turn stimu­
lates collagen remodeling.59
KELOID AND HYPERTROPHIC SCAR
Scars are a natural part of healing, but when the matura­
tion phase of wound healing does not subside within 9 to
12 months of wounding, the scar is considered exuber­
ant.32 Keloid and hypertrophic scars arise from exuberant
scars that are usually firm, raised, and erythematous,
causing symptomatic complaints of pruritus and dyses­
thesias.32 The etiology of keloid and hypertrophic scar­
ring is unknown but is believed to stem from excessive
collagen synthesis and decreased collagen degradation in
the process of wound healing.60,61 Excessive collagen pro­
duction by fibroblasts may be related to high levels of
cytokines.62 Keloids resemble hypertrophic scars but
grow beyond the wound margin. They exhibit a pro­
longed proliferative phase resulting in the appearance of
thick hyalinized collagen bundles.44 The appearance and
thickness of hypertrophic scars typically improve during
the course of a few years. This is not true of keloid scars.63
No single method is ideal for treatment of hypertro­
phic and keloid scars. The recurrence of the condition
after excision can range from 45% to 100%.64 Most of
the time, excision is preceded by serial intrascar injections
of triamcinolone acetonide in an attempt to reduce the
risk of recurrence.13 The appearance of hypertrophic and
keloid scars can be improved with laser resurfacing as
well as with intrascar injections of triamcinolone aceton­
ide. Nonablative lasers have also been shown to improve