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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 25.108  Total digital amputation. (A) A painful ischemic fifth toe.
(B) Final appearance after racquet-type amputation with excision of the
fifth metatarsal head.
A
B
A
B
Figure 25.109  Total digital amputation. (A) A simple dorsal-plantar toe
amputation is planned. (B) Immediate appearance after amputation.
(C) Final appearance at 2 months postoperative. Note the tendency for
toes to drift toward each other.
C
Total digital amputation
A total digital amputation takes place at the metatarsophalangeal joint,
again with the incision being either dorsal-plantar (more common for
all digital amputations but preferred for the middle three toes),
medial-lateral (less common but may be done on the first and fifth
toes), or racquet-type-style (useful when metatarsal procedures are
needed). With total amputation, the digit is excised at the metatar­
sophalangeal joint. The deep tissues and joint capsule may be closed
separately for a more secure closure as well as to prevent a deep space
void. The wound for total amputation of a digital is also closed with a
well-planned incisional plantar flap technique (Figs 25.108–25.112).
CONCLUSION
From the foregoing information it is apparent that there are numerous
disorders and potential problems that may affect the toes. The best
management of these common disorders requires a good under­
standing of the digital anatomy, function, biomechanics and causes
of these conditions. The surgical management is held in reserve for
the most intractable, symptomatic, or complex deformities. Most of
the conditions discussed will have consistently satisfactory results,
both functionally and cosmetically, with appropriate planning,
detailed attention to surgical techniques, and good postoperative
management.

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| 25 |
Figure 25.110  Total amputation with racquet-type procedure. (A) Fifth toe osteomyelitis with IPK sub-fifth metatarsal head. (B) X-ray showing
destructive changes of osteomyelitis. (C) Racquet-type incision planned to create a lateral flap and gain exposure to metatarsal. (D) Total amputation of
fifth digit and metatarsal head resection. (E) Appearance of flap at 2 months postoperative.
A
B
C
D
E
A
B
Figure 25.111  Total hallux amputation. (A) Ischemia of hallux. (B) Vascular changes apparent in hallux.

354
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
(C) Immediate amputation with dorsal-plantar incision. (D) Appearance at 1 month postoperative.
C
D
A
B
C
D
E
F
Figure 25.111, Continued 
Figure 25.112  Total hallux amputation. (A) Post-debridement of infected ulcer with phalanx osteomyelitis. (B) Plantar appearance of involved
hallux and intractable plantar keratosis sub-first metatarsal. (C) Amputated hallux. (D) Creation of medial skin flap and exposure of metatarsal head.
(E) Crescentic cut of first metatarsal to remove head. (F) First metatarsal head.

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355
| 25 |
(G) Hemostasis and closure of deep layer of tissue. (H) Immediate closure of medial skin flap. (I) Final appearance at 6
weeks postoperative.
G
H
I
Figure 25.112, Continued 
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| 26 |
CHAPTER CONTENTS
General considerations
357
History and physical examination
357
Diagnosis options
357
Treatment options
358
Bursa
359
Epidermal inclusion cyst
359
Fibromas
362
Ganglion cyst
364
Lipoma
370
Pigmented villonodular synovitis
374
General postoperative considerations
378
Conclusion
380
GENERAL CONSIDERATIONS
Soft tissue masses are relatively common on the foot and ankle and
create a diagnostic dilemma, as well as a therapeutic challenge. It
appears to be very easy to just ‘guess’ at the diagnosis, based upon the
general appearance of the mass. It is also common for some doctors
to take a ‘wait-and-see’ attitude about many non-painful soft tissue
masses.
The common benign soft tissue masses presented in this chapter
must be differentiated from similar appearing, but rare malignant
lesions. Deciding which entities are benign and which are malignant
may be extremely challenging. Benign lesions are usually slow growing
and expansile, pushing aside the supporting stroma. The tissues typi­
cally consist of well-differentiated cells with a high degree of structural
differentiation.
Proper diagnosis and treatment of benign soft tissue masses begins
with a level of suspicion by the clinician and their basic knowledge
of the clinical presentations of these conditions. Small masses and
cysts may simply be excised, allowing full material collection for his­
topathological identification, as well as resolution of the condition.
Larger masses may require incisional biopsy to examine the tissue
properly, but in most cases, a well-planned excision is warranted.
Improperly performed excisional procedures can result in difficulty
with further surgery in cases of confirmed malignancy.
Because benign and malignant soft tissue masses may resemble
each other in terms of the clinical presentation, a high index of sus­
picion and early biopsy must be utilized by lower extremity physicians
when dealing with masses of the foot and ankle. All tissues removed
in the procedure are to be collected, labeled and sent for histopatho­
logical evaluation, and at no time should any materials be simply
discarded without examination.
History and physical examination
In order to attain an accurate diagnosis of a soft tissue mass, the
process begins with a thorough history and physical examination.
Information should be obtained about the first recognition of the
mass: Was it a slow onset or was its appearance rapid? What kinds of
symptoms are or have been present? Has the mass changed in size,
color, texture, or location? Was there any previous injury or treatment
to the area prior to the mass appearance? It is also important to review
the patient’s vocation and avocation activities and social habits to rule
out any connection to the condition. A complete systems review may
also be helpful in determining the causal source of the mass.
During the physical examination, it is important to report the visual
appearance of the mass, its exact location, and whether there is any
associated swelling, adjacent skin color change, pain, induration or
odor present. Palpation of the mass should determine the character
of the lesion with regards to firmness, fluctuance, mobility or tempera­
ture variations. At this same time, darkening the room and shining a
light directly against the mass may result in transillumination of the
mass. If the light passes completely through the mass, it generally
indicates that it is fluid-filled and not solid in character. Based upon
the information gained during this process, the next step is to order
the appropriate tests as needed.
Diagnosis options
Fluctuant or fluid-filled masses may be aspirated for clinical labora­
tory evaluations and pathology examinations. Biopsy of the soft tissue
mass is another recognized diagnostic and therapeutic approach to
©2012 Elsevier Ltd.
Foot and ankle benign soft tissue masses
G. Dock Dockery
Chapter
26

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
magnetic resonance imaging (MRI), tend to provide much greater
detail of soft tissue masses than the standard radiographic studies.
With MRI, a more accurate evaluation of the total extent of the mass
can be performed. This examination establishes exceptional soft
tissue contrast and is capable of direct multiplanar imaging in the
lower extremities. Relatively accurate identification of soft tissue
masses and the full extent of soft tissue, as well as bone involve­
ment, can be established with a high degree of reliability with the
MRI scan.
Treatment options
Leaving the mass alone is rarely the best option for most patients.
Conservative care plays a limited role in the treatment of some types
of soft tissue masses. For cystic or fluid-filled lesions, aspiration of the
lesion may be all that is necessary (Fig. 26.1). Other lesions may be
responsive to injection therapy with corticosteroid mixtures (Fig.
26.2) or with diluted alcohol injections (Fig. 26.3). Physical therapy
modalities may occasionally be useful for a few select conditions.
Whenever conservative care has failed or is not an appropriate choice
of management, surgical treatment is the next best option.
When a surgical procedure is considered for the removal of a soft
tissue mass, the first consideration is the incision placement. In a few
instances, a linear incision may be the most direct approach and
easiest technique to perform. However, serpentine or curvilinear
incisions may be more optimal, providing greater exposure and
many lesions. This may include incisional or excisional techniques.
Additional tests may include a hematology evaluation, sedimentation
rate and chemical analysis. Radiographs may be able to show an
increase in soft tissue density or calcifications within the mass. Special
studies, such as the computerized axial tomographic (CAT) scan and
Figure 26.1  Aspiration of fluid-filled lesions is sometimes all that is
necessary. The contents should be sent for culture and pathology
evaluations.
Figure 26.2  Corticosteroid and local anesthetic agent injections. (A)
Using a short-acting steroid to inject the retrocalcaneal bursa taking care
not to inject the tendon. (B) Intermediate or long-acting steroid injection
of plantar fibromatosis.
A
B
Figure 26.3  Dilute alcohol injections. (A) A lipoma at the anterior ankle
is injected with 0.5 cc of 4% alcohol solution. (B) A small medial plantar
fibroma is injected with 0.75 cc of 4% alcohol solution.
A
B

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| 26 |
has a very foul odor (Fig. 26.9). Cultures may test positive for patho­
genic bacteria but are usually culture negative.
Aspiration or incision and drainage procedures have an extremely
high recurrence rate with this particular lesion. Surgical treatment is
recommended with complete removal of the entire epidermal inclu­
sion cyst. The two main approaches are the direct incisional technique
and the fusiform excision procedure.
Direct incisional technique
This approach is for small-to-medium epidermal inclusion cysts. The
incision is linear or curvilinear adjacent to the cyst or within the RSTLs
or existing wrinkles over the cyst. In some small and encapsulated
cysts, the incision length can be shorter than the diameter of the cyst,
which allows for a potentially smaller scar but decreased visualization.
For medium cysts it may be necessary to make a larger incision adja­
cent to the lesion in order to gain full access (Fig. 26.10). The skin
incision is stopped at the level of the shiny white cyst wall and the
cyst is then carefully dissected free with blunt technique using curved
blunt-tipped scissors or the base of a scalpel handle. If the cyst wall
is accidentally breeched, the keratinous debris can be removed and
the cyst lining carefully extracted. In some cases, the cyst may have
adherent fat or fibrous tissue attached to the outer lining. If the cyst
has previously drained or been infected it may be more difficult
to shell out and additional sharp dissection may be necessary to
remove it.
Figure 26.4  Simple bursa excision. (A) An enlarged, inflamed and painful
bursa over the fifth metatarsal head. (B) The bursa is excised and layer
closure is performed on the incision.
A
B
preventing some of the scar complications noted with linear incisions.
In some cases the crescentic or fusiform excision may be a better
choice if it allows removal of an external lesion at the same time that
the mass is removed. The incisions should be planned to coincide
with the relaxed skin tension lines (RSTLs) whenever possible and, on
weight-bearing areas, incisions should be planned to avoid direct
pressure or weight.
As has been discussed in other chapters, knowledge of the anatomy
in the area of the procedure is essential as are meticulous dissection
techniques and tissue handling. All of the principles of incisional
planning and design, instrument techniques and specific procedures
discussed earlier will be helpful in soft tissue mass excision proce­
dures. Whenever a mass of any kind is removed there is a potential
for the creation of a dead space that has to be closed. In some cases
it will be wise to plan for a drain system to prevent seroma or
hematoma formation following excision of a mass. The conditions to
be discussed will include the bursa, epidermal inclusion cyst, fibroma
(plantar fibromatosis), ganglion, giant cell cyst, lipoma and pig­
mented villonodular synovitis. The general principles discussed may
be further applied to the numerous other soft tissue masses that are
not discussed in this chapter.
Bursa
In some cases, a bursa may become inflamed or painful and when it
does not respond to conservative care, it may need to be excised. A
bursa is a closed, flat, synovial-lined sac that is present in areas subject
to excessive friction or pressure. These sacs are located near joints or
where skin, muscle, and tendon move over bony prominences. Bursae
may be either adventitious (acquired) or anatomical. Pathological
bursae may represent either of those types, which have become
enlarged, thick-walled and distended from chronic irritation, inflam­
mation, infection, or increased pressure. Examination of these
inflamed bursae show that they are smooth to palpation, unilobular,
distended, erythematous, and usually tender.
Surgical excision of a bursa is usually straightforward and simple
(Fig. 26.4). It is generally recommended that the underlying structures
be examined during the bursa excision procedure to assure that there
are no exostoses or other bone enlargements present (Fig. 26.5).
Examination of the excised bursa may show that it is fluid-filled or
contains a thick gray caseous material (Fig. 26.6).
Epidermal inclusion cyst
The common lower extremity epidermal inclusion cyst, also known
as an epidermoid cyst, occurs secondary to traumatically or surgically
implanted epidermis within the dermis (Fig. 26.7). This grafted epi­
dermis then grows in the dermis, with accumulation of keratin within
the cyst cavity. There may also be foreign body fragments within the
buried tissue and that may cause more of an inflammatory reaction
to be present. Epidermal inclusion cysts may range in size from a few
millimeters to several centimeters in diameter. The cysts are common
on the plantar foot, around the digits, especially the hallux toenail,
and over the extensor hallucis longus tendon (Fig. 26.8).
Clinically, the mass is usually asymptomatic, slowly enlarging, firm
to fluctuant, dome-shaped, flesh-colored, yellowish or whitish in
appearance. They are not usually tender or erythematous by nature,
unless they become infected or inflamed in areas of direct pressure.
They may have a thin epidermal cover with small blood vessels (tel­
angiectasia) visible on the dome or they may have a very thick epider­
mal cover with overlying hyperkeratotic tissue. The lesion usually
grows very slowly and may spontaneously drain. If the lesion is punc­
tured or opened, it may extrude a thick, white keratin material that

360
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 26.5  Bursa excision. (A) Painful and enlarged retrocalcaneal bursa. (B) Side incisional approach with exposure of bursa. (C) Enlarged and intact
bursa is removed. (D) Prominent calcaneal bone is removed at the same time. (E) The deep layers are closed with buried sutures. (F) The skin is closed
with a combination of removable subcuticular and horizontal mattress sutures. (G) Appearance of incision 4 weeks postoperatively.
A
B
C
D
E
F
G

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| 26 |
Figure 26.6  Bursa excision. (A) Large inferior calcaneal bursa is excised.
(B) The enlarged bursa is collected and labeled and sent to pathology for
identification.
A
B
Figure 26.7  Epidermal inclusion cyst. This lesion is located on the plantar
ball of the foot and resulted from surgically implanted skin into the deep
tissue.
Figure 26.8  Epidermal inclusion cyst. A typical appearing cyst over the
extensor hallucis longus tendon.
Figure 26.9  Epidermal inclusion cyst. If punctured the cyst may extrude
a thick, white keratin material that may have a foul odor.
It is acceptable to evacuate the contents of the cyst before dissecting
the cyst wall free, as long as care is taken to prevent leaving behind
remnants of the wall or keratinous material. If portions of the wall or
the cyst contents are left behind, there is a higher risk of a foreign
body reaction or development of a new epidermal inclusion cyst.
Once the cyst is completely removed, the area should be inspected to
be sure there are no remaining fragments or connections to the skin
present. The wound is then flushed with sterile fluids and the tissues
are closed in layers to prevent a dead-space formation.
Fusiform excision
This technique is for the medium-to-large cysts or those in which the
overlying skin is thin, discolored or showing considerable telangiecta­
sia. This approach is also recommended when there is an obvious skin
lesion present overlying the cyst (Fig. 26.11). In these cysts, it is best
to use the fusiform, or crescentic, excision technique to obtain the best
cosmetic end-results (Fig. 26.12). The fusiform incision is placed over
the top of the cyst and the elliptical-shaped skin wedge is left con­
nected to the underlying cyst in the dermal or subdermal layer. The
skin is grasped with a forceps or hemostat and the cyst is carefully
blunt dissected free from the surrounding tissues (Fig. 26.13). Remov­
ing the wedge of skin along with the larger cysts helps keep the convex
deformity from becoming a concave defect of redundant skin once
the cyst has been removed. As with other excision procedures, the
wound is closed in layers. This same technique may be used if the cyst
has ulcerated or ruptured (Fig. 26.14).

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
have a high recurrence after partial excision. The formation of plantar
fibromas results from proliferation of the aponeurosis of the sole,
primarily the medial septum and medial border of the central band.
The behavior of these lesions may range from simple local involve­
ment to severe infiltrative nodular activity. The nodules may be sin­
gular or multiple and they may be asymptomatic or painful. They may
be found on the lateral aspect of the foot, but are most common on
the plantar foot, usually the medial aspect. The cause of the fibroma­
tous lesions is unknown, but trauma, or repetitive micro-trauma,
seems to play a key role.
Fibromas may respond to either corticosteroid or dilute alcohol
injections (Fig. 26.17). Corticosteroid injections for small-to-medium
sized fibromas usually involve placing 0.5–1.0 cc of betamethasone
sodium phosphate or dexamethasone sodium phosphate into the
central portion of the lesion. For larger or firmer fibromas it may be
advisable to use 0.25–0.5 cc of triamcinolone acetonide, 10 mg/cc,
diffusely infiltrated intralesionally throughout the fibroma. The injec­
tion of steroid into fibromas may be mixed with a local anesthetic
agent, if necessary, to help reduce discomfort of the injection, but it
should not be mixed in a greater than 1 : 1 ratio. It may be helpful to
add a small amount (0.25–0.5 cc) of hyaluronidase to the steroid.
Hyaluronidase is a mucolytic enzyme that breaks down hyaluronic
acid (an ingredient of dense connective tissue), increasing the distri­
bution of drugs in the tissue spaces and facilitating absorption. Repeat
injections of the steroid or combinations may be performed in 4–6
weeks until the lesion begins to soften or shrink. Injections are
Fibromas
Fibromas usually occur in the deeper tissues and appear circum­
scribed, firm and encapsulated (Fig. 26.15). They are composed of
numerous bland fibroblasts. They may arise from fascia, muscle or
subcutaneous tissue (Fig. 26.16). They may regress spontaneously but
Figure 26.10  Incisional technique for removal of inclusion cyst. (A) A curvilinear incision is made adjacent to a medium-sized inclusion cyst that was
present over the medial ankle region. (B) The incision is carefully carried down to the cyst. (C) The cyst is blunt dissected free from attached tissues.
(D) The cyst is removed intact and measured. (E) The tissues are closed in layer fashion. In this case, the external lesion was also excised.
A
B
C
D
E
Figure 26.11  Fusiform excision drawn over typical inclusion cyst of
extensor hallucis longus tendon.

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Foot and ankle benign soft tissue masses
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discontinued if any skin changes, such as atrophy or discoloration,
are noted.
Fibromas may also be injected with a dilute alcohol solution com­
posed of 48 cc of local anesthesia, without epinephrine, mixed with
2 cc of dehydrated ethyl alcohol. This combination makes a 4%
alcohol by volume solution, of which 0.5–1.0 cc may then be injected
into the center of the fibroma. Hyaluronidase may also be added to
help diffuse the solution into the thick fibrous tissues of the fibroma.
Subsequent injections may be infiltrated throughout the mass and the
injection is followed by 5 min of ultrasound massage treatment. This
injection technique is repeated weekly for up to five visits, with addi­
tional softening and shrinking of the fibroma expected to be seen for
several months after the final injections. In most cases, the mass will
be much smaller with less discomfort and the patient will be satisfied
enough so that further treatment will not be necessary.
Surgical approaches for fibromas vary, but the most common are
the linear, curvilinear, serpentine, and the Z-plasty incision. When
there is mild-to-moderate involvement of the foot the linear, curvilin­
ear or serpentine incision technique is usually acceptable (Figs 26.18,
26.19). In some cases of small isolated fibromas, a Z-incision may
give good exposure with a smaller final incision (Fig. 26.20). However,
with multilobular or extensive involvement, the continuous or mul­
tiple Z-incisions is preferred (Figs 26.21, 26.22). Wide excision of the
fibroma with normal tissue borders should be attempted. Taking a
small section of the fibroma or doing a partial excision in cases of
Figure 26.12  Crescentic excision technique for removal of inclusion cyst.
(A) This modified fusiform excision is placed in such a way as to follow
the natural skin creases. (B) Initial closure with retention sutures.
Additional simple interrupted sutures will finalize the incision closure.
A
B
A
B
Figure 26.13  Fusiform excision of inclusion cyst. (A) The central area of
the cyst is outlined and the fusiform incision is drawn on the skin along
with the outline of the metatarsal head. (B) The skin wedge is left
attached to the underlying cyst, both of which are removed together.
(C) Final appearance at suture closure.
C

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
as the sutures have been removed, the incision site may be covered
with silicone gel sheeting for several weeks, thus reducing the ten­
dency for recurrence of the nodular fibrous tissue and decreasing the
risk of scar formation (see Chapter 28).
Ganglion cyst
Ganglionic cysts are chronic, soft-to-firm, fluctuant, painless to slightly
tender cystic lesions usually found over the dorsum of the foot (Fig.
26.23), ankle (Fig. 26.24) or lateral heel (Fig. 26.25). Less common
formations may be seen at the digits and plantar forefoot region. They
may be unilocular or multilocular cysts, which are often tense and
fixed to the underlying deep tissue. There are two main theories about
the pathogenesis of a ganglion cyst. The first, and most popular theory,
is that the ganglion is produced by a herniation of a tendon sheath
or joint capsule, and its connection with the parental lumen subse­
quently becomes closed off by constriction and postinflammatory
fibrosis. The trapped fluid is then encapsulated by the fibrous tissue
and the cyst results. The second theory is that they are the result of a
focal myxomatous degeneration of collagenous tissue resulting from
trauma.
Clinically, the majority of ganglion cysts are attached to the joint
capsule or tendon sheath and aspiration usually demonstrates a thick
mucinous jelly-like fluid (Fig. 26.26). Most ganglion cysts remain
Figure 26.14  Fusiform excision of ulcerated inclusion cyst. (A) A transverse fusiform incision is made around the cyst. (B) The skin and cyst are
removed as a unit. (C) Initial closure of incision.
A
B
C
Figure 26.15  Fibroma. Enlarging mass located around the first
metatarsal was confirmed as fibroma on pathology.
Figure 26.16  Fibroma. Located on the lateral plantar heel region.
Figure 26.17  Fibroma. Clinical response to intrasubstance injection with
4% alcohol. (This is the same patient as in Fig. 26.16.)
multilobular or extensive fibromas has a much higher failure rate than
wide excision.
Once the fibroma has been removed and the tissues closed in layer
fashion, a compression bandage is applied to prevent seroma and
hematoma formation and to reduce tension on the incision. As soon

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Figure 26.18  Fibroma: linear incision. (A) A small firm fibroma located on the side of the heel. (B) A linear incision is used to expose the fibroma. (C)
Clinical appearance of removed fibroma. (D) Final appearance of scar at 2 months postoperative.
A
B
C
D
A
B
Figure 26.19  Fibroma: Curvilinear incision. (A) Medial band fibroma approached with incision in non-weight-bearing arch. (B) Well-defined fibroma
removed intact.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 26.20  Fibroma: Z-incision. (A) A small single fibroma is marked and a Z-incision is planned. (B) The Z-incision gives good exposure to deep
tissues. (C) The fibroma and adjacent tissue are excised. (D) Initial stages of closure of the Z-incision.
A
B
C
D
(C) Initial closure of incision. (D) Final appearance at 6 months postoperative.
C
D
Figure 26.19, Continued

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| 26 |
A
B
C
D
E
Figure 26.21  Fibroma. Multiple Z-incisions. (A) A multi-nodular plantar fibroma along the medial arch. (B) Planned continuous Z-incision. (C) Excellent
exposure. (D) Another arm was added to the Z-incision for complete fascia removal. (E) Excised plantar fascia.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 26.22  Continuous Z-incision for plantar fibromas. In this modified
Z-plasty design, the central arm is not drawn but the Z is running in the
line of tension. This incisional approach gives great exposure and reduces
scar contracture during healing.
Figure 26.23  Ganglion cyst. A common location for ganglion cyst is the
dorsal aspect of the foot.
(F) Initial closure of continuous Z-incision. (G) Appearance of scar at 2 months postoperative. (H) Appearance at 1 year
postoperative.
F
G
H
Figure 26.21, Continued 
intact with activity and normal external pressures; however, occasion­
ally they spontaneously erupt and the clear, thick fluid disperses into
the surrounding tissues or leaks out externally (Fig. 26.27).
Treatment is not necessary unless the cyst becomes symptomatic
owing to its location or increase in size. The ganglion can usually be
surgically removed without rupturing the fibrous capsule (Fig. 26.28).
The placement of the initial incision is important and it should be a
linear or curvilinear approach without penetration of the ganglion
during the first cut (Figs 26.29, 26.30). Once the incision is developed,
the cyst can be bluntly dissected and freed from the fibrous and liga­
mentous tissue around the base. If the cyst should be ruptured during
the excision process, the viscous fluid should be wiped away and the
cyst completely removed along with all of its attachments. Recurrence
is common if the cystic lining is not completely excised. Once the cyst
is completely removed, any attachments to the joint or tendon are
ligated or cauterized to prevent recurrence. All bleeders should also
be cauterized or tied-off to prevent postoperative hematoma forma­
tion. Great care should be taken to avoid cutting or damaging adjacent
neurovascular structures that are commonly close by (Fig. 26.31).
In most cases, the ganglion excision will not leave a deep void like
some other space-occupying masses and the layer closure will be
easier. The skin is closed with the suture technique of choice and

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Foot and ankle benign soft tissue masses
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| 26 |
Figure 26.24  Ganglion cyst. A large ganglion cyst located on the lateral
ankle was previously misdiagnosed as a firm lipoma.
Figure 26.25  Ganglion cyst. This ganglion cyst off of the Achilles tendon
was very firm to palpation.
Figure 26.26  Ganglion cyst. If the ganglion is punctured or broken a
thick jelly-like fluid will frequently extrude.
Figure 26.27  Ganglion cyst. This ganglion on the lateral aspect of the
hallux would spontaneously erupt and drain a clear thick fluid.
A
B
Figure 26.28  Ganglion cyst. (A) Located on the medial aspect of the first
metatarsophalangeal joint. (B) Initial incisional approach.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 26.29  Ganglion cyst. (A) Lateral ankle ganglion. (B) Initial incision down to ganglion without cutting cyst wall. (C) Careful blunt dissection will
expose the extent of the ganglion. (D) The ganglion may be removed completely along with its attachments.
A
B
C
D
(C) Careful dissection exposes the ganglion cyst. (D) The ganglion cyst is removed intact.
C
D
Figure 26.28, Continued 
Steri-Strips. When the ganglion is removed from an area that has pres­
sure or weight on it, the sutures may need to remain intact for a longer
period of time than usual (Fig. 26.32). In most instances of plantar
incisions, the sutures are left in for a minimum of 3 weeks while the
patient remains non-weight bearing. Compression is kept over the site
for a total of 3 or 4 weeks from the time of surgery.
Lipoma
The lipoma is the most common soft tissue mass in the body and it
may be found on any part of the lower extremity, even on the digits,
but they tend to be prominent around the ankle region (Fig. 26.33).
The vast majority of patients affected by ordinary lipomas are women,
most often during the middle decades and the condition is more

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Foot and ankle benign soft tissue masses
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| 26 |
Figure 26.30  Ganglion cyst. (A) Curvilinear skin incision over dorsal ganglion. (B) Full exposure of ganglion cyst without penetration of cyst.
A
B
Figure 26.31  Ganglion cyst. (A) The incision is placed adjacent to the fluid-filled mass. (B) Due to the location of the cyst the incision transverses the
dorsum of the foot. (C) Close-up view showing careful attention to blunt dissection to prevent adjacent neurovascular injury. (D) Postoperative
appearance at time of Steri-Strip removal.
A
B
C
D
common in patients who are obese. These mesenchymally derived
lipomatous masses are generally solitary but may be multiple in
nature. The majority of lower extremity lipomas tend to be circum­
scribed and well-encapsulated and they usually have normal-appearing
overlying skin.
The two main types of lipomas are the superficial type and the deep
type. The superficial type is the most common and the one that
presents most often on the lower extremities. It is usually located
between the skin and the fascia layer. The deep type is unusual and
may be found in the trunk area and around major organs.
These rubbery, round or oval, subcutaneous nodules are almost
always asymptomatic, but many patients complain that these masses
cause difficulty in wearing certain items of clothing or shoes. A few
patients complain of discomfort if the lipoma is in an area where the

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
A
B
C
D
Figure 26.32  Ganglion cyst. (A) The plantar aspect of the ball of the foot is an unusual location for a ganglion cyst. The incision is planned in a
non-weight-bearing area. (B) Careful dissection will reveal the extent of the ganglion cyst. (C) The cyst is removed intact. (D) Skin closure is with a
combination of subcuticular, retention and simple sutures that can be removed in a staged program. (E) Final appearance of the scar at 6 weeks
postoperatively.
E

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Foot and ankle benign soft tissue masses
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| 26 |
Figure 26.33  Lipoma. Large well-formed lipomas are present around
both lateral ankles, making wearing certain shoe gear difficult.
A
B
C
Figure 26.34  Lipoma. (A) An adjacent linear incision is placed over an anterior ankle lipoma. (B) Skin hooks are used to give better exposure. (C) Blunt
and sharp scissor dissection is used to free the lipoma of adjoining tissue. (D) The lipoma is removed as one unit. (E) Skin closure with subcuticular
suture.
D
E
increasing symptoms as the mass presses against nerve tissue. It is
generally recommended that any lipoma >3 cm in diameter be
removed for biopsy purposes. Surgical removal of the majority of
lower extremity lipomas is simple and straightforward, as the mass
usually comes out intact; however, care should be taken to remove the
entire mass and any attachments at the time of surgery.
Smaller lipomas may be removed by a single small incision that is
one-third to one-half of the diameter of the mass. The incision is
carried down to subcutaneous layer and medial and lateral compres­
sion will express the mass out the opening. Gentle dissection with
blunt curved scissors may be necessary to remove the fibrous tethers
between the capsule and normal subcutaneous tissues (Fig. 26.34).
Direct palpation will ascertain complete removal. The incision is then
closed in layers and a compression dressing is applied until the sutures
are removed.
Medium-sized lipomas, or those located over neurovascular struc­
tures, may be removed with an adjacent incision technique (Fig.
26.35). The incision is placed adjacent to the mass in an area that will
be hidden or be away from the vital structures, and, if possible, within
the RSTLs. This incision is then gently undermined to expose the
lipoma, which is then carefully dissected free and removed. Hemos­
tasis is achieved and wound closure and compression are performed.
It is imperative to be aware of local anatomy to prevent nerve injury
and hematoma formation.
Larger lipomas on the lower extremities are also generally removed
by surgical excision, but newer forms of liposuction may be used to
increased size may press on an adjacent nerve. Lipomas may range
from a few millimeters to several centimeters in diameter. The com­
position of the lipoma is that of adipose tissue with a moderate
increase in the size of the individual fat cells.
Treatment of lipomas is based upon the patient’s complaint of
cosmesis or functional concerns and in a few cases, gradually

374
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
A
B
C
Figure 26.35  Lipoma. (A) Lateral foot lipoma. (B) Linear incisional placement allows careful dissection of lipoma. (C) Inspection of the wound shows
no residual lesion and undamaged neurovascular structures. (D) Intact lipoma after resection. (E) Final appearance of incision after suture closure.
D
E
reduce their size. The mass is first outlined with a skin marker before
anesthesia is injected. A curvilinear or fusiform incision is placed over
the mass and the incision is taken down to the encapsulated lesion.
The lipoma is grasped with forceps and carefully dissected free from
attachments and surrounding tissue using blunt curved scissors.
Hemostasis is performed and if there is excessive overlying skin
present, a larger fusiform excision of tissue may be necessary to prop­
erly close the wound. If there is continued bleeding or oozing that
occurs, it may be necessary to place a small surgical vacuum drain in
the deep wound for 24 h to prevent hematoma formation. Once
again, the tissues are closed in layers and a compression bandage is
applied until the sutures are removed.
As has been described for other plantar foot lesions, when a lipoma
is identified on the plantar weight-bearing aspect of the foot, it is
imperative to design the incisional approach in such a way as to avoid
placing the incision in a pressure area (Fig. 26.36). The tissues may
be compressed to easily identify the plantar crease lines and palpation
will reveal the underlying osseous structures so that the incision may
be placed in an area that lies within the skin creases and is non-weight
bearing. By following this simple method, and by using good surgical
techniques and postoperative management of non-weight bearing for
at least 3 weeks, the final scar should be excellent. Recurrence of
lipoma formation following total excision is very rare.
Pigmented villonodular synovitis
Pigmented villonodular synovitis (PVNS) is a benign proliferative
disorder that affects synovial-lined joints, bursae, and tendon sheaths.
Three primary types are recognized, which include the more common
diffuse, villous, pigmented form that affects the synovial lining of the
entire joint; the localized extraarticular tenosynovial tumors found
around the small joints and tendons of the hands and feet; and the
solitary intraarticular nodules. The localized form often occurs around
tendon sheaths and is termed giant cell tumor of tendon and the term
PVNS is generally used when the joint, and sometimes bone, is
involved, whether the form is localized or diffuse. The term pigmented
villonodular tenosynovitis (PVNT) is sometimes used to better
describe and represent the giant cell tumor of tendon.
In most cases of PVNS the patient presents with painless joint swell­
ing that had a slow progressive onset. Joint pain is slow to develop
and usually is rather mild for the amount of swelling that is present.
As the swelling progressively worsens there is accompanied loss of
range of motion of the involved joint and subsequent locking of the
joint. There may be an increase in the skin temperature around the
swollen joint in the later stages of development.
In contrast, patients presenting with PVNT, or giant cell tumor, first
notice a pain-free and slowly enlarging mass, usually involving the
long tendons of the ankle or the extensor tendon region of the foot

Chapter
Foot and ankle benign soft tissue masses
375
| 26 |
Figure 26.36  Lipoma. (A) When masses are located on weight-bearing surfaces the incisional planning is important. The tissues are compressed
together to identify the natural skin creases. (B) The incision is placed in the area of a natural crease and between weight bearing structures.
(C) Careful dissection and knowledge of the anatomical structures allows good exposure of the mass. (D) The encapsulated lipoma may be removed
intact. (E) Final skin closure is with a combination of suture techniques.
A
B
C
D
E
or toes (Fig. 26.37). The PVNT condition appears to be much more
common on the lower extremities than the joint or bone version of
the condition.
Imaging plays an important role in the diagnosis of this condition
and MRI appears to be the most accurate for confirming the diagnosis
and predicting the extent of the lesion (Fig. 26.38). Computed tom­
ography (CT), ultrasound and plain film radiography are much less
specific and the results are limited by the lack of specificity. Bone scans
do not play a strong role in the diagnosis of PVNS, however, areas of
bone erosion may result in increased radionuclide uptake and soft
tissue masses often demonstrate increased uptake on the blood pool
images.
The optimal treatment of all forms of PVNS and PVNT is complete
excision. In the localized form a simple excision is usually possible,
but in the diffuse forms a subtotal or total synovectomy must be
performed (Figs 26.39–26.42). More extensive excision may be neces­
sary if there is bone involvement, which may require later arthrodesis
of the involved joint if arthrosis develops.

376
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 26.37  Pigmented villonodular tenosynovitis or giant cell tumor.
The patient noticed a very slowly enlarging mass over the top of the left
foot.
Figure 26.38  Magnetic resonance imaging (MRI) of pigmented
villonodular tenosynovitis or giant cell tumor. An MRI scan is very useful
in delineating the size and location of the mass. (A) Mass located on
plantar ball of the foot with an extension around the second metatarsal.
(B) Position of the mass is seen on side view.
A
B
A
B
C
Figure 26.39  Pigmented villonodular tenosynovitis or giant cell tumor.
(A) Incisional approach to a soft tissue mass located over the dorsum of
the foot. (B) Initial exposure shows a well-organized, pigmented and
vascular appearing lesion over the extensor tendons. (C) Careful blunt
and sharp scissor dissection starts to free the mass away from the
attached structures. Care is taken to prevent injury to adjacent
neurovascular structures.

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Foot and ankle benign soft tissue masses
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| 26 |
(D) The mass is removed intact. (E) The deep layers are each closed and the skin is closed with subcuticular suture and
Steri-Strips. (F) Appearance of incision at 2 weeks postoperative.
D
E
F
Figure 26.39, Continued 
A
B
C
D
E
F
Figure 26.40  Pigmented villonodular tenosynovitis or giant cell tumor. (A) Large mass on anterior right ankle. (B) Curvilinear incision placed over the
area. (C) Careful dissection reveals large mass around anterior tendons. (D) Mass completely surrounds the anterior tibial and extensor hallucis longus
tendons. (E) The mass is dissected free of the tendons and other attachments. (F) All sections of the mass are completely removed.

378
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 26.41  Pigmented villonodular tenosynovitis or giant cell tumor. (This is the same case as in the MRI scan in Fig. 26.38.) (A) The incision for the
plantar ball of the foot mass is made in the non-weight-bearing area. (B) The mass is dissected away from the tendons. (C) The mass is carefully
excised and the deep layers are inspected for additional abnormal tissue. (D) The entire mass is removed, measured and sent to pathology for
identification. Layer closure is performed and the skin is closed with combination sutures.
A
B
C
D
(G) A deep vacuum drain is placed into the wound and exits away from the incision. The tissue layers are carefully
separated. (H) The deep layers and retinaculum layer are closed. (I) Final incisional appearance after subcuticular closure. Additional retention and
simple sutures will be applied for final closure.
G
H
I
Figure 26.40, Continued 
General postoperative considerations
The application of a deep-wound vacuum drain should be considered
any time a large mass has been removed or there is persistent oozing
or bleeding during the procedure. Proper closure of the deep layers,
retinaculum and the skin is necessary to provide a good end-result in
all cases of soft tissue mass excision. Whenever complete closure is
not possible, deliberation should be given for other methods such as
rotational flaps, skin grafts, removal of bony prominences or xenografts
to improve closure of the incision. It is important to minimize the

Chapter
Foot and ankle benign soft tissue masses
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| 26 |
A
B
C
D
E
F
Figure 26.42  Pigmented villonodular tenosynovitis or giant cell tumor. (An alternative incisional approach to the case in Fig. 26.41.) (A) A large soft
tissue mass located on the ball of the right foot. (B) Incisional design with curvilinear pattern at distal ball away from weight-bearing. (C) Dissection
through tissue layers exposes the extent of the mass. (D) Soft tissue dissection of the mass is carried out with care to preserve the normal anatomical
structures. (E) Initial incision closure. (F) Appearance at 3 weeks postoperative. (G) Continued healing at 6 weeks postoperative.
G
tension on the incision during closure. Vertical or horizontal retention
sutures of large diameter may help to maintain closure of an incision
with increased tension present. Buttress sutures also provide addi­
tional closure while reducing wound tension. The application of
compression dressings and 14-inch sterile felt pads over the incisions
helps to prevent excessive edema, seroma and hematoma formation
following excision of masses.
Staging the removal of sutures also allows the incision to heal more
completely before final suture removal. Obviously, those incisions
with increased tension or incisions on the plantar aspect of the
foot require additional healing time than similar incisions on
non-weight-bearing surfaces. In most cases, it is recommended to
keep plantar incisions non-weight-bearing for a minimum of 3 weeks
before the sutures are removed and weight bearing is allowed. Addi­
tional protection of the incision may be useful following suture
removal. This may include padding the area, providing aperture
cutouts in insoles, using cushioned inserts, and protective casts or
postoperative shoes.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
CONCLUSION
Because of the large number of diverse types of soft tissue masses that
may be encountered in the lower extremities, it is essential that the
surgeon be familiar with both the common and uncommon types that
can exist. This is the only way that reliable steps can be taken to care­
fully assess each cyst or mass preoperatively and select the most suc­
cessful form of treatment for each individual case. In all cases,
regardless of the size of the lesion excised, the tissue removed should
be sent to pathology for a complete histopathology examination and
identification.
FURTHER READING
Ahn, J.H., Choy, W.S., Kim, H.Y., 2010.
Operative treatment for ganglion cysts of the
foot and ankle. J Foot Surg 49 (5), 442–445.
Azam, A., Rajagopalan, S., Niezywinski, W.A.,
2007. A rapidly expanding massive lipoma
to the toe. J Foot Ankle Surg 46 (6), 499–501.
Bachhal, V., Rangdal, S., Saini, U., et al., 2011.
Giant cell tumor of distal phalanx of great
toe. A case report. Foot (Edinb) 21 (4),
198–200.
Bakotic, B.W., 2001. Metastatic malignant
melanoma to the foot and ankle. J Foot
Ankle Surg 40 (2), 118.
Bakotic, B.W., 2006. Tumors of the skin of the
lower extremity. In: Levy, L.A., Hetherington,
V.J., Bakotic, B.W. (Eds.), Principles and
Practice of Podiatric Medicine, second ed.
Data Trace Publishing, Brooklandville, Chs
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Bakotic, B.W., Borkowski, P., 2001. Primary
soft tissue neoplasms of the foot: the
clinicopathologic features of 401 cases.
J Foot Ankle Surg 40, 28–35.
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et al., 2002. Soft tissue tumors of the lower
extremities. Radiol Clin North Am 40,
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Bancroft, L.W., Peterson, J.J., Kransdorf, M.J.,
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Bart, R.S., Kopf, A.W., 1979. Techniques of
biopsy of cutaneous neoplasms. J Dermatol
Surg Oncol 5, 979–983.
Bos, G.D., Esther, R.J., Woll, T.S., 2002. Foot
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CHAPTER CONTENTS
Introduction
381
Occlusive dressings
381
Traditional dressings
382
Negative pressure dressing
384
Conclusion
386
INTRODUCTION
No ideal surgical dressing exists and the use of each material available
should be based on the needs of the wound at the various points of
healing. Wound healing is a dynamic process that changes frequently
and the type of dressing that is required will change as the phases
transpire. Surgical and wound dressings were once thought primarily
as protective barriers or wound covers to prevent contamination or
further trauma to the wound. With the advent of new semisynthetic
and biosynthetic dressings, the emphasis has shifted the role of dress­
ings to one of assistance of healing.
Many original concepts of the wound-healing environment have
also changed over the course of the last century. It was formerly
thought that a large amount of oxygen exchange was vital for wound
healing and that the dry eschar over a desiccated wound acted as
a biological barrier to prevent infection so the wound could heal
(Fig. 27.1). It is now understood that the optimal oxygen tension for
fibroblast and vascular proliferation is quite low, 5–10 mmHg, and
that moisture found in wound exudate or found under an occlusive
dressing actually speeds the process of epithelialization and wound
contracture.
Skin grafts and in some cases, skin flaps with random blood supply
have an added component of complexity in which the newly placed
skin must conform as fully as possible to the recipient site for ade­
quate blood perfusion to occur. This usually requires specialized dress­
ings to apply uniform pressure to the overlying skin that not only
promotes conformity but also reduces motion between the graft and
the recipient bed. The optimal pressure applied by the dressing is
between 15 and 30 mmHg. Pressure less than this may result in poor
graft contact with the underlying wound bed, and seroma or hematoma
formation; pressure greater than this will result in occlusion of blood
flow in the capillaries and graft necrosis.
OCCLUSIVE DRESSINGS
The adherence of a dressing to a wound is not synonymous with an
occlusive dressing nor is it beneficial. Some adherent dressings become
mechanically connected to the wound by the fibrin or protein exudate
and thereby incorporated directly into the wound. Difficulty develops
when the dressing is changed and the newly formed epithelium is
stripped from the wound bed, disrupting the healing process. This can
be prevented with the use of a non-adherent dressing applied directly
to the wound bed or the incisional closure.
An occlusive dressing on the other hand has been shown to greatly
accelerate epithelialization and decrease healing times with enhanced
wound contracture by maintaining a moist environment in contact
with the wound. Occlusive dressings have been shown to increase
re-epithelialization rates by 30–50% over non-occlusive dressings and
increase collagen synthesis by 20–60%. There are many types of occlu­
sive dressings available (Table 27.1). The resulting moist wound envi­
ronment was once thought to harbor large bacterial counts and
promote infection and was, therefore, discouraged as wound coverage.
While it is true that the bacterial counts underneath an occlusive dress­
ing far exceed what is classically defined as an infection, in actuality,
there is not an increased rate of clinical infection seen. Increased rate
of epithelialization and rapid healing with more organized fibroblast
infiltrate are consistently seen, despite the increased presence of bac­
teria at the wound site. The possibility of infection may still exist as
in any wound but the occlusive dressing has been shown to be a safe
and effective way to promote healing with no clinical evidence of
infection.
A surgeon must initially become accustomed to the foul-smelling
odor and large amount of exudate that may accumulate beneath the
occlusive dressing and understand that this does not equate with
infection. The clinical appearance of the wound and the associated
signs and symptoms are the best guides to assessing the wound for
©2012 Elsevier Ltd.
Surgical dressings
Mary E. Crawford
Chapter
27

382
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Most topical antibiotics provide little protection against bacterial inva­
sion but do provide adequate wound hydration without occlusion.
Care must be exercised with the use of topical antibiotics due to the
possibility of contact sensitivity and wound complications, especially
with neomycin-based products. An alternative to the topical antibiotic
is a medicated semi-occlusive Tulle dressing. A Tulle dressing incor­
porates gauze dressing impregnated with soft white paraffin, an anti­
biotic or an antiseptic agent such as chlorhexidine or povidone-iodine
(Fig. 27.3). A scarlet red ointment dressing is a non-adherent dressing
in white petrolatum, lanolin and olive oil on fine mesh gauze that is
thought to promote re-epithelialization (Fig. 27.4). It is usually held
in place with OpSite™ (Smith & Nephew United, Largo, FL) or Tega­
derm™ (3M Nexcare, New York, NY) dressings to help reduce motion
at the graft site.
There is a great deal of controversy surrounding the use of an anti­
septic agent, either applied directly to, or incorporated into, a Tulle
dressing. Many of the antiseptic agents, such as povidone–iodine, have
possible infection and include edema, tenderness, increasing ery­
thema, fever, lymphadenopathy, and elevated white cell count.
The putrid exudate present in an occluded wound may also exhibit
healing components. Recent research has found growth-regulating
peptides, epidermal and platelet-derived growth factors and fibroblast-
derived growth factors in the exudate that enhance wound healing and
may explain why there is such rapid epithelialization present with an
occlusive dressing. Also, as previously explained, the oxygen tension
required for fibroblast and vascular proliferation is quite low and the
occlusive dressing does not impede the exchange of oxygen or pro­
hibit wound healing as originally thought. Another benefit of the
occlusive dressing is decreased postoperative pain experienced by the
patient, especially at a skin graft donor site. There appears to be a
decrease in the inflammatory response thereby decreasing erythema,
pain and tenderness. Occlusive dressings are, however, contraindi­
cated for clinically infected wounds and are used cautiously in the
immunocompromised patient.
TRADITIONAL DRESSINGS
As there is no single ideal dressing available, a combination of materi­
als are often incorporated together in layers, each layer consisting
of a different material and each layer contributing to the various
requirements of a particular wound. The concepts discussed above
regarding the maintenance of a moist environment are kept in
mind when developing a layered composite dressing. In a surgical
incisional closure, the first layer is a non-adherent layer against the
wound to prevent the dressing from incorporating into the wound as
well as promote epithelialization and minimize trauma to the incision
(Fig. 27.2).
If a surgical wound is healing by secondary intention, the wound
bed should be kept moist, while allowing for the absorption of excess
exudate and for the oxygen exchange required for fibroblast and vas­
cular proliferation. Different non-adherent dressings are available. The
simplest is the application of antibiotic ointment directly to the site.
Figure 27.1  Postoperative incisional wound with dark desiccated eschar.
Figure 27.2  Silk dressing over surgical flap.
Figure 27.3  Tulle dressing with non-adherent material.

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and debride the wound, but, as with other agents, this should be
replaced with a moist wound environment once all necrotic tissue is
eliminated. If there is a large amount of exudate or bleeding expected
at the wound site, other non-adherent but absorptive products can be
used on the wound bed. These products include the hydrocolloid
dressings, which encourage granulation tissue formation and reduce
pain; the alginate dressings, which stimulate platelet aggregation and
absorb excess exudate forming a hydrophilic gel over the wound
surface; or the oxidized cellulose dressing, which is capable of absorb­
ing many times its weight in exudate and blood, but may promote
infection. Regardless of the material selected, the purpose of the non-
adherent dressing is the same, to provide a moist environment to
allow for epithelialization that is not damaged when the dressing is
removed and to allow the excess exudate to pass through to prevent
maceration.
Once the non-adherent layer is applied, the next layer of the dress­
ing is the absorbent material. This layer serves as a wick to remove
excess exudate from the wound surface, to decrease risk of infection
and to deter crust formation on the wound edges. The absorbent layer
can consist of gauze pads or cotton balls and should be changed once
they become saturated with exudate (Fig. 27.5). If applied correctly,
the absorbent dressing will transmit and distribute pressure to the
wound surface in a uniform fashion and aid in hemostasis and pre­
vention of hematoma or seroma formation.
Table 27.1  Occlusive wound dressings and their uses, advantages and disadvantages
Classification
Composition
Indications
Examples
Advantages
Disadvantages
Films
Polyurethane or
co-polyester
with adhesive
backing
Split skin graft donor
sites, superficial burns,
wounds with minimal
drainage
OpSite,
Bioclusive
Dermafilm
Tegaderm
Transparency for wound
inspection, fluid
retention, decrease
wound pain at donor site
Fluid retention if excess
drainage, may adhere to
wound, does not debride
wound
Hydrocolloids
Contain hydrophilic
colloidal particles
bound to
polyurethane foam
Acute, chronic or
full-thickness wounds,
pressure or stasis
ulcers
DuoDerm,
Actiderm,
Tegasorb,
Cutinova hydro
Debrides wound, absorbs
exudates, does not
adhere to wound, gel
creates moist wound
healing
Cost, opaque dressing, gel
leakage, foul smell
Hydrogels
Contain 80–90%
water. Cross-linked
polymer
Acute, chronic partial
thickness exudative
wounds
Biofilm,
Cutinova gel
Elastogel
Vigilon
Diminishes wound pain,
does not adhere, good
for exudative wounds,
semitransparent
Non-adhesive, cost,
requires frequent dressing
changes every 1–3 days
Foams
Either hydrophilic or
hydrophobic,
non-occlusive,
polyurethane or gel
film coated
Acute, chronic partial
thickness exudative
wounds that require
mechanical debriding
Epigard
Cutinova plus
Lyofoam
Allevyn
Debrides wound and
absorbs exudates
Cost, opaque, may
become incorporated into
wound, frequent dressing
changes
Calcium alginate
Non-woven
composite of calcium
alginate
Partial thickness
wounds with high
exudates, full
thickness wounds,
stasis ulcers
Sorbsan
Kaltostat
Algosteril
AlgiDerm
Highly absorbent, good
for full-thickness wounds,
gel creates moist healing,
reduced frequency of
dressing change
Cost, foul smell, not ideal
for dry wounds, may
become adherent,
non-adhesive
Biobrane
Silicone rubber with
porcine collagen and
nylon bilaminate
Partial thickness
wounds, superficial
burns, split-thickness
graft donor sites
Biobrane
Flexible for irregularly
contoured wounds
Cost, may become
incorporated, contains
silicone, may have higher
rate of infection
N-terface
Monofilament plastic
Immobilizing graft
sites, partial-thickness
wounds
N-terface
Transfers exudates to
outer membrane,
non-adherent
Cost, requires secondary
dressing, may cause fluid
accumulation
Modified from Kannon, G., Garrett, A., 1995. Moist wound healing with occlusive dressings: a clinical review. Dermatol Surg 21, 583–590.
Figure 27.4  Scarlet red ointment dressing and Tegaderm™ cover.
been reported to decrease wound strength and decrease rates of epi­
thelialization and exhibit fibroblast toxicity. Some surgeons utilize
these agents to effectively cleanse and debride a wound but they
should be discontinued once all necrotic tissue is removed to avoid
harm to newly forming epidermal cells.
Normal saline is often incorporated into a dressing as a wet-to-wet
or wet-to-dry dressing to function as a wick to remove excess exudate

384
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
improving split-thickness skin graft take and healing of skin graft
donor sites. Especially in cases of lower limb wounds, there has been
reported a significant improvement in the overall take of the skin
grafts in difficult irregular anatomic areas. Studies have shown that
negative pressure dressing at 100 mmHg creates an environment that
promotes wound healing by increasing blood flow, improving oxy­
genation, increasing granulation tissue formation, removing excess
interstitial fluid and reducing bacterial contamination. In cases involv­
ing a skin graft, there is also enhanced conformity of the graft to the
recipient bed and prevention of graft motion and shearing with nega­
tive pressure. Even the appearance of the graft was noted to be quali­
tatively better when negative pressure was utilized rather than a
traditional bolster dressing. The cost of negative pressure dressings
The pressure layer is occasionally separate but can be incorporated
as part of the absorbent layer. Pressure application layer is highly
useful in wounds with a large dead space, in instances where a large
skin flap requires pressure to avoid hematoma or seroma formation,
in any surgery where bleeding was excessive or difficult to control,
or in surgical procedures where excessive swelling is to be expected
postoperatively. The layer can be composed of gauze or cotton balls,
but can also include dental rolls or non-adhesive felt to provide
even pressure over a broad area. One inexpensive but very effective
means of creating a pressure layer is with handmade cotton balls from
commercial cast padding material (Fig. 27.6). The technique for
applying the handmade cotton balls is very simple and straightfor­
ward (Fig. 27.7).
Overly excessive pressure or unevenly distributed pressure should
be avoided especially in cases involving a skin flap or graft or digital
procedures as the vascular supply may become compromised. A
bolster dressing involving dental roll for smaller full-thickness skin
grafts or felt for large grafts can be applied directly to the graft recipient
site over the non-adherent layer to provide uniform pressure directly
to the graft. The bolster dressing usually consists of a thick layer of
antibiotic ointment on the graft, followed by a non-adherent dressing
layer and then a bulky material such as the dental roll or felt to com­
press the graft to the recipient base. The bolster material is usually
saturated in mineral oil to prevent drying and then tied into place
(Fig. 27.8). This is then covered with fluff gauze and tape and usually
not removed for up to 1 week, unless extenuating circumstances
develop. All layers are then secured to the site with small elastic adhe­
sive bandages, tape (usually hypoallergenic paper tape), or rolled
gauze, such as Kerlex or Kling.
Other forms of pressure dressings include foam rubber, poly­
urethane foam, sponge bolster, and even silicone gel sheeting over flat
or convex surfaces has been shown to effectively apply uniform pres­
sure to a graft site to prevent motion and promote revascularization
of the graft.
NEGATIVE PRESSURE DRESSING
The use of topical negative pressure has been shown to improve
wound healing in a variety of clinical and surgical settings, from
chronic diabetic wounds to preparing wound beds for skin grafting
or flap closure (see detailed discussion on negative pressure dressings
in Ch. 29). More recently, negative pressure has been utilized for
Figure 27.5  Absorbent layer of gauze pads making up composite
dressing. Other materials such as cotton or felt may be used as well.
Figure 27.6  Pressure dressing over the non-adherent material can be
fabricated from commercially available cast padding in place of premade
cotton balls. (A) Sterile medical grade commercially available cotton balls
and sterile cotton cast padding within their packaging. (B) Appearance
after opening and preparing the cotton padding into handmade balls.
Note the large volume of handmade cotton balls that can be fabricated
from one roll of cotton cast padding.
(Courtesy of Dr Thomas Roukis.)
A
B

Chapter
Surgical dressings
385
| 27 |
Figure 27.7  Application of postoperative dressings following split-thickness skin grafting using
sterile handmade cotton balls. (A) Following skin graft, a petroleum-impregnated dressing is
applied. (B) The dressing is stapled to the underlying native skin about the perimeter of the graft.
(C) Sterile handmade cotton balls are placed on the petroleum-impregnated dressing over the skin
graft. (D) The edges of the petroleum-impregnated dressing are then folded over the cotton
padding under slight tension and stapled together to secure the bolster dressing.
(Courtesy of Dr Thomas Roukis.)
A
B
C
D

386
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 27.8  Bolster dressing tied into place over skin flap. This is then
covered with final dressings of Kling or Kerlex gauze.
however, must be considered in addition to its benefits when consid­
ering options for postoperative wound care.
CONCLUSION
It is not always necessary to have all the layers of a composite dressing
present in a bandage and this depends on the characteristics of each
wound. Some wounds may require nothing but a non-adherent layer
and an outer bandage while other more complex wounds and skin
flaps may require all layers for the best possible outcome. As the
wound progresses through the many phases of wound healing, the
surgeon must assess the wound status and alter the dressing as neces­
sary to allow for optimal healing. In an open wound with no obvious
infection or necrotic tissue, the occlusive dressing is far superior com­
pared to a dressing that would allow desiccation of the wound. This
environment, however, is not always optimal for foot and ankle
surgery. A closed surgical lower extremity wound will usually require
a composite dressing including a non-adherent bandage, an absorp­
tive layer to remove excess blood or serous drainage from the surgical
site and a gauze roll for security of the dressing. Special dressing con­
sideration of skin grafts with uniform pressure applied to the graft site
to provide immobilization and increased vascularization is also noted.
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Surgical dressings
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CHAPTER CONTENTS
Introduction
389
Definitions
389
Normal scar tissue
389
Widespread scar
389
Suture tracks
390
Hypertrophic scar
391
Keloid scars
392
Other types of scars
393
Treatment
394
Pressure therapy
394
Intralesional steroid injections
394
Dilute alcohol injection
394
Other injections
395
Combined treatment
397
Silicone gel sheeting
397
Laser therapy
398
Surgical therapy
398
Scar prevention
400
Conclusion
407
INTRODUCTION
Scars are the inevitable result of injury to the skin, whether inten­
tional, as with surgery, or accidental. The final scar that forms second­
ary to the reparative process is variable and never completely
predictable. Scars are classified by color, texture, pattern, and overall
presentation. General categories include: normal scar, widespread
scar, suture tracks, hypertrophic scar and keloid scar. Each of these
may be depressed, elevated, hypopigmented or hyperpigmented in
appearance. While many patients are unconcerned by their scars,
others are extremely upset by the appearance of their scars. Scars may
also cause functional limitations or they may be painful. For these
reasons, there exists a need to define, understand, and appropriately
treat scars when the need arises.
DEFINITIONS
Normal scar tissue
The normal healing process that the skin undergoes following injury
is called the scar process. Full-depth breaks through the skin heal by
scar formation. A normal scar, however, is thin, soft, near-normal
color, and asymptomatic (Fig. 28.1). A normal immature scar shows
a proliferation of fibroblasts in a loose myxoid stroma running paral­
lel to the skin surface. Blood vessels are prominent. As the scar matures
over a few weeks to a month, mature eosinophilic collagen is laid
down, and fibroblasts decrease in number. The blood vessels begin to
rapidly decrease in size and numbers during the final repair process.
The thickness, color and size of the scar all diminish as maturation
continues (Fig. 28.2).
Widespread scar
The stretched, or widespread, scar appears when the fine fibrous con­
nections of the surgical scar slowly expand and widen. This usually
starts at around 3 weeks after surgery and when mature may show
transverse bands along the course of the scar. These scars are charac­
teristically flat, widened, pale, soft, and asymptomatic (Fig. 28.3).
They may also be described as being atrophic or hypopigmented scars
and, on very rare occasions, may be hyperpigmented. Typically, there
is no elevation, thickening, or nodularity in the widespread scar,
which differentiates it from the hypertrophic scar. Occasionally, this
type of scar will be found in association with underlying nerve damage
or traumatic neuroma formation.
Widespread scars can be successfully excised and protected during
the healing process to provide a greatly improved result. As with other
scar revision, the patient must understand that the same abnormal
scar may recur and that other possible risks, such as infection or scar
worsening, are still present. With proper planning and execution most
©2012 Elsevier Ltd.
Scars
G. Dock Dockery
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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
widespread scar revisions will be successful and the patient will be
pleased with the final result.
Suture tracks
Suture tracks occur when the epithelium grows along skin sutures
before they dissolve or are removed postoperatively. These small
sinuses subsequently fill with desquamated keratin, producing
unsightly marks. The likelihood that wound closure will leave suture
tracks depends upon a variety of factors, including the size and com­
position of suture materials and host conditions influencing wound
vascularity (Fig. 28.4).
Ways to avoid suture tracks and similar scar problems involve
avoiding wound healing by secondary intention, cautious topical anti­
biotic application, appropriate planning of incisions, careful execu­
tion of incisions, avoiding wound suture under tension, layered
wound repair, use of appropriate suture size and needle, everted
wound edges, use of adjuncts such as skin tapes and soft tissue adhe­
sives, and early suture removal in a staged fashion. Useful suture
techniques include deep dermal sutures with buried knots, simple
interrupted sutures, vertical mattress sutures, horizontal mattress
sutures, subcuticular sutures, continuous over-and-over sutures and
far-near near-far pulley sutures (see Chapter 9).
Figure 28.1  A normal scar formation around the medial aspect of the
first metatarsophalangeal joint following bunion surgery. The scar is soft
and non-tender.
Figure 28.2  (A) Normal scar formation on the lateral lower leg.
(B) Normal scar on lateral foot with natural skin lines. Both scars
are very thin, soft and asymptomatic.
A
B
Figure 28.3  A widespread scar. The scar is usually widened, pale, soft
and asymptomatic. (A) Widespread scar on posterior calf following a
gastrocnemius recession procedure. (B) Close-up showing the typical
transverse bands with widening of the scar and pale coloration.
A
B

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Hypertrophic scar
The hypertrophic scar is the result of an unchecked proliferation of
fibrous tissue following injury to the skin. The hypertrophic scar
remains confined to the site of the original skin injury, unlike the
keloid, and is usually linear in nature following the original surgical
incision. In a hypertrophic scar, whorls of young fibrous tissue and
fibroblasts with a haphazard arrangement produce a marked thicken­
ing of the dermis. Focal areas of mature collagen are admixed with
areas in which a myxoid stroma is present.
There is a significant increase in blood vessels within the hyper­
trophic scar and electron microscopic studies show an increase in
both partially and totally occluded blood vessels. This increase in
blood vessels tends to remain for extended periods of time and
frequently can be seen as telangiectasia in the top of the elevated
hypertrophic scar. The hypertrophic scar is usually pink, red or purple
in color and may be raised, inflamed, itchy, and even painful (Fig.
28.5). Early motion around a healing scar may create hypertrophic
scar formation in the part of the scar that is mobile (Fig. 28.6). Hyper­
trophic scars may improve without treatment; however, this may take
many years.
Figure 28.4  Suture tracks. (A) Incision closed with large gauge non-absorbable sutures. (B) Scar at 6 weeks, with visible tracks. (C) Another case of
tracks following closure with a running non-absorbable suture left in for 4 weeks. (D) Suture tracks are formed when the sutures are left in place too
long and epithelialization occurs along each suture puncture site.
A
B
C
D
Figure 28.5  Hypertrophic scar showing thickening, increased color, and
small visible blood vessels located over the medial aspect of the foot.

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Most hypertrophic scars can be excised and protected during the
healing process to give a much-improved appearance. It is important
to use delicate tissue handling during the procedure and adequate
suture closure at the completion of the procedure. It is wise to main­
tain compression and decreased mobility to the area for at least 3
weeks following scar excision.
Keloid scars
Keloids appear as firm, mildly tender to painful, pruritic, bosselated
tumors occurring at the site of previous skin injury or surgery (Fig.
28.7). The prolific keloid scar invades the surrounding normal skin
and is usually worse in areas where the skin is under tension or is
thickest (Fig. 28.8). They may also proliferate to an excessive amount
with continued irritation or pressure (Fig. 28.9) or following minor
injuries or procedures (Fig. 28.10). The borders are usually well
demarcated, but may be irregular or bizarre in outline. Keloids are
often associated with pain and hyperesthesia as well as pruritus.
Keloids show an increased level of histamine that may contribute to
the pruritus and pain associated with these scars. They are usually
hyperpigmented with red-to-purple coloration. Dark-skinned indi­
viduals and patients with blood group A are more susceptible to
Figure 28.6  Hypertrophic scar at an area of motion over the first
metatarsophalangeal joint. Early motion around the scar has a tendency
to produce hypertrophic scars in some patients.
Figure 28.7  Keloid scar. Multiple large keloid scars which formed after
an injury. The original incision sites were much smaller indicating that the
keloid moved into normal adjacent tissue.
Figure 28.8  Keloidal scar at the posterior Achilles region following
surgery. Note the lower portion thickening where flexion occurs. The scar
has advanced significantly into the neighboring normal tissues.
Figure 28.9  Keloid scar. Significant proliferation is noted in medial arch
keloid following a minor injury. Continued irritation or motion may cause
the keloid to continue spreading. (Courtesy of Dr Stephen J. Miller.)
keloid formation. It may be advisable to ask surgical candidates to see
previous surgical scars prior to surgery to check for keloid formation
(Fig. 28.11).
Surgical cure rates are much poorer for the keloid scar than for both
the widespread scar and the hypertrophic scar. The response to

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treatment also varies markedly by the anatomical location and from
patient to patient.
Other types of scars
Depressed. Depressed scars, either linear or geometric, occur when early
wound healing conditions are less than ideal (Fig. 28.12). Wound
seroma, hematoma and infections all potentially lead to depression
under healing skin incisions. Severe depression of scars commonly
results from incisions closed under too much tension. Additionally,
depressed scars may result from loss of subcutaneous fat. Elevating
Figure 28.10  A large keloid scar that formed after a minor injury. The
original scar site was much smaller, indicating that the scar advanced into
normal adjacent tissue.
Figure 28.11  Keloid scar on elbow. The surgical candidate was
examined for previous scars and the keloid on the elbow was identified.
This may help the surgeon in incision planning and postoperative incision
protection.
Figure 28.12  Depressed scar resulting from excessive removal of
subcutaneous and deep tissue.
Figure 28.13  Hyperpigmented scar. These surgical scars were both
elevated and hyperpigmented and occurred in a patient with a known
problematic scar history.
depressed scars may require tissue augmentations or, in some cases,
flap or excisional procedures.
Hyperpigmented. Hyperpigmentation refers to areas of skin where
an excess of melanin has been produced and formed deposits, causing
skin scars that appear darker than the surrounding skin (Fig. 28.13).
Hyperpigmentation is classified as focal or diffuse. Focal hyper­
pigmentation commonly appears in isolated scars while diffuse
hyperpigmentation involves larger areas of darkened skin. Most hyper­
pigmented scars are also elevated. Both types of scar hyperpigmenta­
tion can be caused by burns, reactions to sutures or medications or
skin infection at a surgical site. Sun exposure to the incision area
during the early days following a procedure may also cause an increase
in pigmentation of the healing scar.
Hypopigmented. Hypopigmentation is the opposite of hyperpigmen­
tation and often occurs after any sort of inflammation of the incision
site. This is also known as post-inflammatory hypopigmentation
(Fig. 28.14). When the skin is cut, the surrounding area often becomes

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Pressure therapy
Constant compression of hypertrophic or keloid scar tissue has proved
to be beneficial in preventing regrowth after surgical excision. This
compression may need to be applied for several months to be effec­
tive. Specially designed elastic compression stockings or garments may
be custom-made to fit the area of keloidal scars. The results of this
treatment alone are very inconsistent.
Intralesional steroid injections
Intra-scar injections of local anesthetic agents and steroid solutions
given every few weeks will stop the proliferation of fibroblasts and the
growth of hypertrophic and keloid scars. The treatment is not recom­
mended for the widespread scars. Careful usage of intralesional scar
injections will lead to significant flattening, softening and decrease in
pigmentation in most instances (Fig. 28.16). Care must be taken to
prevent the formation of atrophy and hypopigmentation with multi­
ple steroid injections, which may be as much of a problem for the
patient as the previous scar before treatment.
Hypertrophic and keloidal scars are treated with triamcinolone dia­
cetate 10 mg/cc suspension injections, administered by syringe with a
114-inch, 25-gauge needle. The steroid is mixed with equal parts of
local anesthetic agent and deposited along the course of the scar. The
scars are injected with 0.25–0.5 cc of the mixture, depending upon
their size and shape, to obtain the desired results of a smaller, thinner
and less symptomatic scar (Fig. 28.17). Side effects and complications
are high and include pain, atrophy, telangiectasia formation, hypop­
igmentation, necrosis, ulceration, perilymphatic atrophy or hyperpig­
mentation (Fig. 28.18).
Dilute alcohol injection
Hypertrophic and keloid scars may also be injected with a 4% alcohol
solution in a similar manner as outlined for the steroid injection. The
dilute alcohol solution is composed of 2 cc of ethyl alcohol (pure
dehydrated sterile ethanol) combined with 48 cc of 0.5% bupivacaine.
This preparation is then a 4% solution of alcohol by volume.
inflamed as the body attempts to repair the damaged area. The inflam­
mation can damage healthy cells, however, including melanocytes.
Damaged melanocytes produce less melanin, which can result in
hypopigmentation within the healed scar. Often these hypopigmented
areas have an irregular outline but may be totally within the scar itself.
Although it is possible for all of the melanin in the cells to be elimi­
nated, in most cases, the loss of pigment is only partial. In areas in
which the skin has become scarred, the hypopigmented region often
encircles the scar.
People with dark skin are more likely to suffer from post-
inflammatory hypopigmentation. This is primarily because the darker
skin will provide more of a contrast with even mildly depigmented
regions compared to lighter skin. This is also a condition that may
occur when the postoperative incision is injected with a local anes­
thetic agent and steroid after final closure of the incision. Treatment
of hypopigmented scars is very difficult and may require multiple
modalities to make it appear more normal in coloration.
Irregular. The irregular scar is one that may show depression, thin­
ning, elevation, hyperpigmentation or hypopigmentation all within a
single scar (Fig. 28.15). This irregularity may occur when more than
one suture material or one suture technique is utilized in a single
incision closure.
TREATMENT
Considerable treatment options are available to improve or resolve
scars. The response to each form of treatment depends on individual
characteristics of the skin, the location of the scar, the type of scar
being treated, the quality of the tissue surrounding the scar, motion
occurring around the scar and the general health of the patient. There
does not appear to be a consensus on which treatments are preferable
for the different types of scars, but there does appear to be a general
agreement that symptomatic hypertrophic, hyperpigmented and
widespread scars may respond the best to treatment and that hypop­
igmented and keloidal scars respond the least favorable to all forms
of treatment. A scar treatment algorithm may be useful in determining
the best approach for scar management (Table 28.1).
Figure 28.14  Hypopigmented scar. This scar was elevated, firm and over
1 year old.
Figure 28.15  Irregular scar. This scar shows areas that are depressed and
adherent, normal in appearance and elevated and hyperpigmented. In
this case, the incision was closed by three different people, the surgeon,
the resident, and a medical student. Tissue handling and suture
technique surely played a role in the outcome of the incision (see also
Fig. 28.40).

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Prior to injection with the dilute alcohol solution, the scar should
be manually manipulated or treated with ultrasound to help make
the penetration of the needle easier. Small amounts of the alcohol
solution are deposited along the course of the scar at weekly intervals
(Fig. 28.19). The volume of dilute alcohol injected into each scar
varies depending upon the size and firmness of the scar, but generally
ranges from 0.25–0.5 cc per scar. Many scars will decrease in thick­
ness, elevation, firmness and symptoms after one or two injections.
Those scars that are pruritic or painful will usually respond relatively
quickly, but it may take longer for keloid scars to respond.
Table 28.1  Scar treatment algorithm

Modified from: Thomas, J.R., Mechlin, D.C., 1983. Scar revision. In: Holt, G.R., Mattox, D.E., Gates, G.A. (Eds.), Decision-making in otolaryngology-head and neck surgery.
BC Decker, Philadelphia, p. 104.
Unacceptable scar
Maturation phase
Surgical excision
Steroid injection
Distorted landmark
Large
Yes
No
No
Yes
Yes
No
Small
Effacement
Hypertrophic or
Keloid scar
Pressure or
Silicone gel
Dermabrasion or
laser resurfacing
Geometric broken
line or W-plasty
Grafting fat/dermis
collagen or
filler material
Moderate width
Depressed
Slight elevation
Shave excision
Z-plasty
> 1cm
Excise
Reposition scar
Scar contracted
Within RSTL
Serial excision
Local flap
or skin graft
Large width
Wide or
Malpositioned scar
Side-effects from dilute alcohol injections into hypertrophic and
keloid scars are very rare but may include thinning of the skin, numb­
ness or pain.
Other injections
Recombinant interferon-gamma
Intralesional scar injection with recombinant human IFNγ 0.1–0.5 mg
may be performed once a week for 3–5 weeks and has been shown
to make major improvement in keloid and large hypertrophic

396
Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
Figure 28.16  Intra-scar steroid injection. (A) A raised, thickened and pigmented symptomatic hypertrophic scar. (B) Following careful intra-scar
injection of local anesthetic and triamcinolone diacetate. Note the thinning and flattening of the scar achieved as well as the hypopigmentary changes
within the scar.
A
B
Figure 28.17  Intra-scar injection with equal amounts of triamcinolone
diacetate and local anesthetic agent.
Figure 28.18  Significant atrophy and hyperpigmentation changes in a
scar injected with triamcinolone.
scars. IFNγ has untoward adverse effects, including low-grade fevers,
a flulike illness for 48–72 h after injection, and pain on injection.
5-Fluorouracil
5-Fluorouracil (5-FU) is a pyrimidine analog that is converted intracel­
lularly to a substrate that causes inhibition of DNA synthesis by
competing with uracil incorporation. Intralesional keloid injections
of 1.5 mL of 5-FU (500 mg/10 mL) weekly for 12 weeks or intrale­
sional keloid injections of 1.6 mL of 5-FU plus 0.4 mL Celestone
Soluspan, every 2 weeks for six visits, has been shown to be effective
in reducing keloid scars. The overall efficacy is not better than other
modalities and significant side-effects such as ulceration and hyper­
pigmentation make topical 5-FU less appealing than other treatments
available.
Verapamil hydrochloride
Verapamil is a calcium channel blocker that blocks the synthesis
and secretion of extracellular matrix molecules (e.g. collagen, GAGs,
fibronectin) and increases fibrinase. Intralesional keloid injection of
verapamil 2.5 mg/mL at weekly intervals, has been shown to reduce
keloids but the results were greatly improved when the injections were
combined with topical silicon gel sheeting at the same time. Side-
effects are dose-related and generally very mild but include itching
and burning at the injection site.

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Figure 28.19  Dilute alcohol injection of a hypertrophic and painful scar
at the anterior lateral aspect of the ankle. The 4% solution is injected
weekly until the desired results are obtained.
instrument (CryoProbe, H&O Equipments, Inc., Mount Pleasant, SC,
29464) until the scar turns white. As the scar thaws, it turns pink
and becomes edematous. During the thaw phase, each segment of the
scar is injected with 10 mg/cc of triamcinolone acetonide 0.5–1.0 cc,
depending upon the size of the scar. Successful injection is seen by
blanching of the thawed pink edematous scar. Three or four injections
are usually required at 4–6-week intervals. As the scar begins to soften
(and after the second injection), the concentration of steroid may be
reduced to 5 mg/cc. Compression bandages applied over the scars
after freezing and injections appear to increase the desired results and
speed the response rate.
Silicone gel sheeting
Although the mechanism of action of silicone gel sheeting (Cica-Care,
Smith & Nephew United, Inc., Largo, FL 34649–1970) still remains
unknown, an improvement in the size, texture, color, and thickness
of keloidal and hypertrophic scars occurs with the use of this material
when it is applied topically (Fig. 28.20). Widespread scars will also
respond to topical silicone gel sheeting therapy and noticeable changes
will include a decrease in pigmentary changes, decrease in scar width
and overall improvement in appearance (Fig. 28.21). There is a very
high success rate with this technique in all scars, with the hypertrophic
scar responding the best followed by the widespread scar and then by
the keloid. As with all other treatments, the keloid scar takes longer
and gets less overall improvement.
Combined treatment
The combined use of cryotherapy and intralesional injections of
triamcinolone acetonide 10 mg/cc is superior to either freezing alone
or injection alone. This combined treatment involves freezing the
scar with liquid nitrogen applied with a cotton swab or cryosurgical
Figure 28.20  Silicone gel sheeting therapy.
(A) Thickened, hyperpigmented and symptomatic
scar over a fifth toe revision surgery site.
(B) Appearance after 2 months of topical
silicone gel sheeting therapy.
A
B
Figure 28.21  Silicone gel sheeting therapy.
(A) An old widespread scar over the anterior
ankle before treatment. (B) After silicone gel
sheeting treatment for 2 months.
A
B

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
and keloid scars. The hypertrophic scar and the atrophic scar may
also be treated with the ablative pulsed carbon dioxide laser or the
Er:YAG laser.
Surgical therapy
Hypertrophic scars may be successfully excised with a low recurrence
rate if there is no resulting tension on the incision upon final suture
closure (Fig. 28.23). Undermining the area of scar excision and inject­
ing the surgical site with local anesthetic agent mixed with a small
There are several additional important findings noted with silicone
gel sheeting treatment of scars: the younger patients, under age 18,
have much faster and more responsive results than do adults; the sili­
cone gel sheeting is effective in prevention of both hypertrophic and
keloid scarring in known scar formers; compression with the silicone
gel sheeting is not necessary for good results; later recurrence of scar­
ring does not occur; and most sensitive and tender scars will return
to near-normal sensation after being treated with silicone gel sheeting
for at least 1 month (Fig. 28.22). Complications and side-effects of
scar treatment with topical silicone sheeting are relatively few and very
minor or transient in nature.
Laser therapy
There are several laser systems available that permit successful treat­
ment of various types of scars. The 585-nm flashlamp-pulsed dye laser
remains the gold standard for laser treatment of hypertrophic scars
Figure 28.22  Silicone gel sheeting therapy. (A) A very symptomatic
bunion scar before silicone gel treatment. (B) After treatment for
2 months.
A
B
A
B
C
Figure 28.23  Excision of hypertrophic scar. (A) Initial appearance of
painful hypertrophic scar. (B) Excision of scar with wide undermining.
(C) Initial suture closure of incision.

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(D) At 2 months postoperative and before silicone gel sheeting treatment. (E) Silicone gel sheeting has been applied.
(F) Covered with flexible cloth tape. (G) Appearance after 6 weeks on silicone gel sheeting treatment.
D
E
F
G
Figure 28.24  Fusiform excision of scar. (A) Painful transverse scar on heel. (B) Fusiform excision of scar with undermining and multiple simple
interrupted sutures close incision without tension.
A
B
Figure 28.23, Continued 
amount of soluble corticosteroid solution, followed by postoperative
compression dressings, usually provides an excellent result. Whenever
possible, a simple fusiform excision is the best approach (Fig. 28.24),
although complex excision techniques, such as W-plasty (see Fig.
16.35), a variation of the W-plasty called the short wavy incision
method (SWIM) (Figs 28.25, 28.26) or the geometric broken line
closure (GBLC) (Fig. 28.27), may be necessary for some long or
irregular appearing scars (see Fig. 16.38).
Widespread scars respond equally well with excision. There should
be good margins of normal skin after the scar is excised since the tissue
at the level of the scar may be fragile and difficult to suture. In cases
where there is underlying nerve damage or neuroma formation, the

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Lower Extremity Soft Tissue & Cutaneous Plastic Surgery
nerve can be revised at the same time as the scar (Fig. 28.28). Unusu­
ally shaped widespread scars may be excised in different patterns to
fit the relaxed skin tension lines (RSTLs) in flexion skin creases and
in some cases atypical closures result (Fig. 28.29).
In contrast, almost 100% of keloids can be expected to recur within
4 years of surgical therapy. Because of the high failure rate, and the
fact that many keloids return larger and more involved after surgery,
this treatment is best avoided in areas of flexion, tension, or pressure.
It may be advisable to excise or revise large keloid scars with more
advanced excisional procedures and then begin treatment with one or
more of the non-surgical treatments early postoperatively to decrease
recurrence.
SCAR PREVENTION
The prevention of excessive scar formation is the ultimate goal of any
reconstructive surgery. In many cases, using proper incisional tech­
niques and tissue handling during the initial stages of surgery, can
Figure 28.25  Short wavy incision method (SWIM) demonstrated on pig
foot. This is a modification of the W-plasty using smooth, wavy lines
instead of the W incision to remove a scar. (A) The short (around 1.0 cm
long) waves are created on either side of a scar. (B) Final closure of the
incision resulting in a wavy line instead of a linear line.
A
B
Figure 28.26  Short wavy incision method (SWIM). (A) Long
hyperpigmented scar. (B) Postoperative following short wavy incision
method of correction. (From: Hyakusoku H, Ogawa R. The small-wave incision
for long keloids, plastic and reconstructive surgery. Wolters Kluwer Health. Courtesy
of Dr Rei Ogawa.)
A
B

Chapter
Scars
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Figure 28.27  Geometric broken line closure (GBLC) demonstrated on pig foot. (A) GBLC drawn around an imaginary linear scar. (B) The lesion is
carefully excised. (C) Final closure of GBLC showing the irregular pattern created by this design (see Fig. 16.38).
A
B
C
sutures, instead of tissue forceps to lift the edges for undermining or
suturing (Fig. 28.32). Whenever possible, it is also better to place
the suture needle through the incision site at 90° rather than on a
biased angle for all external suture techniques (Fig. 28.33). When
closing with subcuticular or buried sutures, it is likewise helpful
to avoid manipulating the skin with forceps during this process
(Fig. 28.34).
Final closure can be achieved by a variety of skin-suture techniques.
In some cases, the skin can be closed with subcuticular sutures alone,
while in others there may be need for additional aid from Steri-Strips
(Fig. 28.35). The Steri-Strips are placed at each end of the incision and
then individually placed along the incision. If the incision is slightly
elevated on one side or the other, the Steri-Strips may be applied to
correct this by starting on the low side and crossing over to the high
side. This will equalize the heights of both sides. It is generally not
recommended to apply several Steri-Strips at one time, since this will
have a tendency to bring one side over the other creating an unequal
side-to-side relationship. The Steri-Strips may be applied with atrau­
matic tissue forceps to prevent the sticky backing from adhering to the
surgical gloves (Fig. 28.36). The Steri-Strips should be placed perpen­
dicular to the incision line, especially in curved incisions (Fig. 28.37).
facilitate this objective. Additional methods that help to prevent
tension, swelling and injury to the incision during and immediately
after surgery, include marking the incision with crosshatches accu­
rately to realign and close the incision, using skin hooks and rakes
instead of forceps to lift the wound edges, applying good suture
closure methods, using Steri-Strips or buttress sutures to secure the
incision, placing vacuum drains into wounds with potential large
voids or drainage problems, timing suture removal with wound
healing, using compression dressings and protective casts to prevent
injury to the incision, and leaving wounds alone long enough to
complete healing.
Making a precise, perpendicular, single, linear incision with one
sweep of the surgical scalpel blade creates a smooth incision without
jagged edges or skived borders (Fig. 28.30). For more precision, the
incision line should be drawn out with a skin marker and several
cross-hatch marks are placed across the incision (Fig. 28.31). This
allows very accurate placement of the incision and exact repositioning
of the incision edges at closure.
During the surgical procedure it is advisable to decrease the han­
dling of the skin edges as much as possible. This can be accomplished
much of the time by using skin hooks or small rake retractors, or even