Postoperative Scar Management Using Laser Therapy for Breast Reconstruction With Latissimus Dorsi Flap

Abstract

Background

Postoperative scar formation is inevitable, and a gold standard management has not been established to date. Due to the fact long and large scar formation occurs in reconstructive surgery, this study analyzed the relationship between various factors in patients who received breast reconstruction using latissimus dorsi (LD) flap to investigate appropriate and effective management approaches.

Patients and Methods

Twenty-seven patients who underwent breast reconstruction between June 2014 and January 2015 received laser therapy on their LD donor site at the Kyungpook National University Chilgok Hospital. Scar evaluation was performed on both the surgical scar and intact skin on the contralateral side. Scar evaluation was conducted at five specific points, 2 cm from the midpoint of the scar on each side. Laser treatment was performed at 4-week intervals, and patients were then followed-up for 6 months. To assess scars, gross images were taken using the same settings. In addition, spectrophotometry was used for color assessment, durometer for texture and pressure evaluation, and Vernier calipers and height gauges for a more precise and objective approach.

Results

The mean age of the participants was 45.7 years, and the mean body mass index was 22.1 kg/m². The operator-evaluated scar scale scores were 107.2 and 97.3 in the experimental and control groups, respectively. In the patient-rated questionnaire, the scores were 62.3 and 59.4 in the experimental and control groups, respectively.

Conclusion

When analyzing early-stage postoperative scars based on various factors, laser therapy is considered a very useful scar management approach. Additionally, when performing reconstructive surgery, tension force is regarded as a significant factor to take into account since it affects scar widening.

The wound healing process can be broadly divided into three stages: inflammation, proliferation, and remodeling. When disrupted, it can result in scars that differ in color and texture from the surrounding healthy tissue. During the inflammation stage, macrophages stimulate the production of growth and chemotactic factors, promoting capillary bed formation via angiogenesis. These capillaries are naturally absorbed and regress once the wound has healed, and persistent stimulation and delayed capillary regression may persist erythema for prolonged periods. In such cases, an erythematous and indurated cutaneous scar may develop. In the later stages of remodeling, the collagen matrix matures and is regulated, and the tensile strength increases by 70%-80% and returns to baseline within 6-12 months. In this later stage, dysregulation may cause hypertrophic scars because of tensile strength (1). During the remodeling phase, macrophages are reported to stimulate myofibroblasts and fibroblasts, which are the main causes of wound contractures (2,3).

The primary focus has been on scars from severe burns in visible areas, such as the face and neck and keloid and hypertrophic scars that could significantly affect basic social interactions or cause functional impairments such as those on the joints and face. However, with recent improvements in the quality of life, people have become increasingly concerned with small scars, showing interests on scar treatment.

Various options for scar treatment have been proposed, including creams, adhesive silicone sheets, and laser therapy; however, currently, no universal consensus has been made on the timeliest treatment modality (4). Several laser types have been proposed, which can be broadly divided into two types. The first type is the non-ablative pulsed dye laser, which emits light at a wavelength of 595 nm, and this is very close to the absorption wavelength of hemoglobin (542 nm). This light heats hemoglobin within the blood vessels, thus leading to coagulation necrosis and creating a state of hypoperfusion and hypoxia. This process influences the formation and breakdown of collagen, ultimately improving scar erythema (1,5-8). The second is the ablative CO₂ laser, which was first introduced for scar treatment in 2003 by Huzaira et al. (9). To induce thermal damage, this laser improves scars by working on tissue water, thus promoting scar resurfacing. However, its high-energy levels have been reported to cause complications, such as pain, edema, persistent erythema, infection, post-inflammatory hyperpigmentation, and hypopigmentation (10). The non-ablative type 2940-nm Er:YAG fractional laser was introduced to mitigate these adverse events. This laser highly absorbs water in cells. It alleviates scars by causing thermolysis that leads to micro-wound healing (5,10). It delivers less energy than CO₂ lasers; thus, it is more suitable for the superficial layers of the skin with lower rates of adverse events.

After investigating the characteristics of scar formation at different stages and understanding the principles and features of laser treatment, a preliminary observation of 30 patients who did not receive laser therapy was conducted. Based on the patient questionnaires, complaints were related to scar erythema in the early postoperative period and scar contour 2-3 months later. Based on our understanding of the scarring process and actual responses from patients, we hypothesized that providing pulsed dye laser therapy early and Er:YAG fractional laser therapy later in the course would be beneficial for scar treatment and thus established a combination laser protocol accordingly.

In this study, the scars were evaluated using the Kyungpook National University Hospital (KNUH) scar scale, a modified version of commonly used scar scales, namely, Manchester, Vancouver, and Stony Brook scar evaluation scales. In addition, objective assessments were conducted using devices as photospectrometers, durometers, digital Vernier calipers, and height gauges.

Patients and Methods

Patient characteristics and operation method. Postoperative donor site scars were assessed in 27 Korean patients who underwent breast reconstruction using latissimus dorsi (LD) myocutaneous flaps at the Kyungpook National University Chilgok Hospital. The procedure of the extended LD myocutaneous flap involved multiple steps. After total mastectomy by a surgeon, the LD flap and predesigned skin paddle of a specific size (5×15 cm) were marked using a template that represented the defect and were elevated and tunneled to the axillary area. Then, they were moved to the breast defect for reconstruction. The surgical site was closed by the same two plastic surgeons for all cases. Initially, a 2-0 vicryl suture was used to close the ends of the donor site with 1.5-cm spacing. After confirming the appropriateness of suture spacing, closure was continued using 4-0 vicryl sutures at the bottom half of the fascia and subcutaneous fat layer, whereas 5-0 vicryl sutures were used for the top half of the dermis and subcutaneous fat layer, aligning them as accurately as possible. The skin layer was closed layer-by-layer using 5-0 ethilon sutures, which indicated the completeness of the surgery.

The patients were not allowed to receive any other treatments while undergoing treatment in the present study. Their direction of breast cancer, flap weight/size, body mass index (BMI), underlying diseases, medications, dominant arm, occupation, surgical history, medical history (scar history, thyroid disease, and connective tissue disease), menopause status, and medication use were evaluated. Postoperative complications were also documented.

Scar management protocol. The study protocol for scar treatment was as follows. First, scar evaluation began on postoperative day 9 or 10, which was after total stitch off at the LD donor site. Subsequently, scar evaluations were conducted at outpatient follow-ups every 4 weeks to 6 months (Figure 1). Based on scar features and patient questionnaires, pulsed dye laser treatments were performed for scar erythema in the initial two sessions, and Er:YAG fractional laser treatments were performed in the following three sessions to improve scar contour. In addition, pressures at three sites were directly measured before closing the LD donor site to assess tension that could potentially affect the scar (Figure 2). A statistical approach was attempted using mean values to determine the relationship between the excision size and postoperative scar.

Figure 1. The KNUH evaluation protocol. Scar evaluation/recording began at the time of postoperative total stitch removal. Follow-up was performed at 4-week (1-month) intervals up to 6 months (Table III). KNUH: Kyungpook National University Hospital.

Figure 2. Intraoperative findings (e.g., flap size and donor site tension). After flap elevation, tunneling was performed to move the flap to the breast area. Next, the donor site midpoint and areas at 2-cm intervals from the midpoint on both sides were measured. Finally, tension was determined from the mean values.

After surgery, gross images were taken using the same camera settings (Nikon D7100, Minato, Tokyo, Japan/Lens: AF-S DX NIKKOR 18-200 mm f/3.5–5.6G ED VR II/lns aperture, exposure time, subject distance, and room lighting were kept constant for each patient) in the same location. For objective assessment, measurements were taken using objective devices at five locations, 2 cm on both sides of the midpoint of the scar on the donor site (Figure 3). Brightness and color were measured using a spectrophotometer (CM-700d; Konica Minolta Sensing Americas, Inc., Ramsey, NJ, USA). The elasticity of the scar texture was measured in international units using a durometer (RX-1000-A; ELECTROMATIC Equip’t Co., Lynbrook, NY, USA) (9-12). To assess scar size, digital Vernier calipers (WR100; Barry Wixey Development, Sanibel, FL, USA) were used to determine the extent of widening at five identical points where spectrophotometer measurements were taken. Hypertrophic scarring was determined using a height gauge (WR25; Barry Wixey Development).

Figure 3. Scar evaluation design. The red and blue lines indicate the postoperative scar and contralateral normal skin, respectively. Scar evaluations were performed in the same manner on the scar area and corresponding contralateral intact skin. A total of five areas were measured, including one spot each on both sides of the scar midpoint at 2 cm intervals.

One researcher performed the measurements to minimize error. Three measurements were taken for each patient, which was used as the average value. The same measurements were taken using the spectrometer and durometer on the normal tissues on the contralateral side. Then, the differences (Δ) were analyzed statistically (Figure 1). Erythema values were measured on the scar site and intact skin on the contralateral side using a spectrophotometer, and the difference was recorded. The slope of the difference was calculated to compare the degree of recovery between the control and intervention groups. A greater difference in the slope between the first and final f/u was interpreted as better scar healing.

Scar evaluation and treatment method. Three plastic surgeons assessed the scars using the KNUH scar scale, which was an integrated and modified version of several globally used scar scales, namely, Manchester, Vancouver, and Stony Brook scar evaluation scales (9,12,14,15). The control group included five patients who did not receive laser therapy. The scar scale was rated by both the operator and patient. They consisted of 12 and 7 questions with a total possible score of 120 and 70, respectively. Each question was rated on a 10-point Likert scale, and a higher score indicated better scarring (Table I).

Table I. KNUH scar scale (operator/patient).

Three plastic surgeons scored and evaluated the scars using the KNUH scar scale, which integrated and modified the Manchester scar scale, Vancouver scar scale, and Stony Brook scar evaluation scale. KNUH: Kyungpook National University Hospital.

The first three sessions consisted of pulsed dye laser therapy at 595 nm (Vbeam laser; Candela, Wayland, MA, USA) at a fluence of 7.0 J/cm², pulse width of 1.5 ms, and spot sizes of 7 mm. Treatment was carried out with pulses overlapping up to 10%. The next two sessions consisted of Er:YAG fractional laser therapy (MatriXell, 2940 nm, at a fluence of 1,100 mJ, and spot sizes of 6 mm) (Meditech, Seoul, Republic of Korea). The treatment area was cleansed with mild soap before each procedure, followed by the application of a topical anesthetic cream (Manecin, AstraZeneca, Wilmington, DE, USA) for 30 min. Because no laser parameters have been established for postoperative scar prevention, suitable parameters for the study were determined based on the comparative results of preliminary experiments using parameters, such as high energy with low density or low energy with high density.

Results

Breast reconstruction was performed using extended LD flaps in 27 patients with breast cancer. The mean age of the patients was 45.7 years, and the mean BMI was 22.1 kg/m². Fifteen patients had a right breast cancer, whereas 12 had a left breast cancer (Table II). Surgical site complications included seroma (n=7), hematoma (n=1), and necrotic change (n=4). The operator-evaluated KNUH scar scale score was 107.2 out of 120 in the intervention group and 97.3 out of 120 in the control group, and the patient-evaluated scar score was 62.3 out of 70 and 59.4 out of 70, respectively (Table III). To determine the relationships between the items, regression analysis was performed using IBM SPSS Statistics version 22.0 (IBM Corp., Armonk, NY, USA) package. The intraoperatively measured tension was significantly associated with texture elasticity as measured using a durometer, and scar erythema as measured with a spectrometer was significantly associated with the size of the excised skin paddle (p<0.05). In addition, the weight of the LD flap and BMI were significantly associated in patients with large breast volume (p<0.01) (Table IV).

Table II. Patient characteristics.

Patients with a medical history of keloid scars, hypertrophic scars, or previous connective tissue-related disease (dermatological disease) were excluded. Rt, Right; Lt, left.

Table III. Mean KNUH scar scale (operator/patient) and spectrometer values.

The laser-treated experimental group had a mean score of 107.2 points according to the KNUH scar scale, whereas the control group had a lower score of 62.3 points. In a direct survey of the patients, the experimental and control groups received mean scores of 97.3 and 59.4 points, respectively. The scatter plot slopes showed that the experimental group had a higher rate of improvement in the initially evaluated scar items. KNUH: Kyungpook National University Hospital.

Table IV. Multiple regression analysis of scar evaluation.

Statistically significant correlations were observed between the donor site tension and durometer-measured elasticity, between erythema and excised skin paddle size, and between the breast volume and LD flap weight or BMI. *p<0.05, **p<0.01. BMI, Body mass index; LD, latissimus dorsi.

Discussion

Surgical site scarring is an inevitable process. Recently, various methods have been evaluated to reduce patient concerns and help with their daily living, including scar ointments, sunblock agents, silicone sheet adhesives, tape, and laser therapy. Of these methods, combination therapy involving laser therapy has grown in popularity (5,16). Surgical site scarring presented with two major issues over time (7), that is, scar pigmentation and contour becoming raised or depressed when compared with the surrounding normal tissue. To take a stepwise approach to these two issues, the wound healing process was reviewed, and patient surveys were conducted. The results revealed that complaints were primarily related to color differences caused by hypervascularity in the early stages. However, as time passed, complaints focused on contours caused by scar hypertrophy, depression, and widening. Thus, in this study, we initially performed pulsed dye laser therapy to address color changes in the early stages, such as erythema, and subsequently used fractional erbium YAG laser therapy to improve the scar (5-8). The patients were followed-up for 6 months, and the degree of improvement was assessed using objective instruments (spectrophotometer, durometer, and digital Vernier calipers) and subjective questionnaires for patients and evaluations by operators (17,18). For the operator evaluations, the KNUH scar scale was developed by integrating some commonly used scar scales, namely, the Manchester, Vancouver, and Stony Brook scar evaluation scales (5,12-15). Then, regression analysis was conducted to statistically analyze each item, and the associations among the items were analyzed based on their p values. The results indicated that the intervention group had improvements in scar erythema as compared with the control group. The KNUH scar scale also confirmed higher-quality scar scores in the intervention group that underwent combination laser therapy (Table III).

Statistically, higher intraoperative tension pressure at the donor site contributed to reduced texture elasticity, and larger skin excisions were a significant prognostic factor for increased scar erythema (p<0.05). Although higher tension appeared to be associated with scar widening, results were not statistically significant, and the slope data obtained by plotting showed negative slopes, contrary to common expectations (Figure 4). Furthermore, in patients with larger breast volumes, a significant association was found between BMI and the weight of the LD flap. Therefore, in cases where surgeons derived large areas of the skin for excision, patients should be warned preoperatively about the risk for donor site scarring. Moreover, given that patients with relatively larger breast volumes were likely to have heavier LD flaps, the operator could predict the extent of LD excision or need for additional silicone implant insertion.

Figure 4. Distribution of tension and scar widening. The x-axis presents the tension measured during the closure of the donor site. The y-axis is the final measurement of the scar width. The slope was calculated as −0.54, contrary to expectations.

Contrary to our hypothesis, scar widening was not significantly associated with intraoperative donor site tension. In addition, patients not only complain about color differences related to scar erythema early after surgery, but also about scar contour in the later stages. Thus, we used objective devices to assess erythema (spectrometer) and scar contour (durometer for scar elasticity) as per the KNUH scar protocol. Then, we visualized the changes in the average values through a graph. As the baseline values for skin color and elasticity differed according to personal characteristics, the amount of changes was analyzed. The graphs showed that in the early stages, the intervention group had quicker improvements in erythema and durometer values in the later stages when compared with the control group, thereby confirming that the intervention group had better scar healing (Figure 5).

Figure 5. Degree of scar evaluation change according to the KNUH scar protocol over time. Differences in erythema values measured with a spectrometer between the scar and normal tissue on the contralateral side are presented as E-red and C-red, respectively. Elasticity values measured using a durometer between the scar and normal tissue on the contralateral side are expressed as E-duro and C-duro. KNUH: Kyungpook National University Hospital.

Thus, research on continuous combination laser therapy and follow-up in more surgical sites is needed in larger study populations of diverse age groups. Studies should examine the relationship between laser parameters and initial skin evaluation values to establish a protocol and statistically verify the results. Therefore, to determine the specific modalities that produce a synergic effect, the addition of silicone sheets or scar care ointments to laser therapy will be studied in the future.

Conclusion

The results of the study objectively confirm that laser therapy helped improve postoperative scarring and identified statistically associated parameters. Based on our understanding of the pathophysiology of scars, the use of pulsed dye laser in early postoperative stages and fractional erbium YAG laser, later in the course, to improve the scar contour yielded satisfactory objective and subjective results in scar healing. In addition, tension force has been confirmed to have an effect on scar widening, considered a crucial factor to be taken in mind during reconstructive surgery.

Conflict of Interest

No potential conflicts of interest relevant to this article were reported.

Authors’ Contributions

Joon Seok Lee: Conceptualization, Data curation, Writing. Hyun Su Kang: Conceptualization, Formal analysis, Writing. Jongmoo Park: Data curation. Jeong Yeop Ryu: Methodology. Kang Young Choi: Methodology. Ho Yun Chung: Formal analysis, Data curation. Byeongju Kang: Methodology, Data curation. Jeeyeon Lee: Project administration. Ho Yong Park: Conceptualizaiton, review & editing. Jung Dug Yang: Formal analysis, Conceptualization, review & editing.

Acknowledgements

This work was supported by Biomedical Research Institute grant, Kyungpook National University Hospital (2014).