Scar Revisions

Abstract

Scars pose a complex challenge to the reconstructive surgeon in the variability of their presentation and their effect on cosmesis and function. Numerous surgical and nonsurgical options exist for scar management, each with their respective advantages and disadvantages. Each treatment modality should be tailored to the patient to ensure enhanced outcomes. In this review, we discuss different scar presentations, scar management options, and the benefits and risks with undergoing these various treatment modalities.

Scarring is an unavoidable sequela for all trauma and surgical patients. Plastic surgeons have implemented a variety of strategies to optimize scar outcomes over the decades. While nonoperative modalities can be utilized to treat scars, surgical intervention may be employed primarily in the case of significant scarring or when less invasive methods are deemed ineffective. Advances in research and innovation have led to improvements in patient satisfaction and function, making the most complex scars manageable. ¹ In this review, we will address numerous scar presentations, their surgical and nonsurgical revision options, and the advantages and drawbacks of each of these treatment interventions.

Scar Assessment and Planning

Scar Assessment

Validated scales are useful for standardized scar assessment. Several scales have been developed for consistent comparison. The Vancouver Scar Scale clinically rates scars based on their pigmentation, pliability, vascularity, and height ( Table 1 ). ^{1 2} The Patient and Observer Scar Assessment Scale also clinically rates scars but allows for additional input by the patient on factors such as pruritus and discomfort ( Table 2 ). ^{1 3} Scale selection may be determined at the physician's discretion.

Table 1. The Vancouver Scar Scale.

Scar characteristic	Score	Definition
Vascularity	0	Normal
	1	Pink
	2	Red
	3	Purple
Pigmentation	0	Normal
	1	Hypopigmentation
	2	Hyperpigmentation
Pliability	0	Normal
	1	Supple
	2	Yielding
	3	Firm
	4	Ropes
	5	Contracture
Height (mm)	0	Flat
	1	<2
	2	2–5
	3	>5
Total score	/13

Table 2. The Patient and Observer Scar Assessment Scale.

Timing of Therapy

As scars transition into the remodeling phase, they become stronger due to the increase in type I collagen. By 4 to 5 weeks following surgery/trauma, the scar reaches approximately 60% of the original skin strength. At this time, scars should be evaluated for termination of preventative therapy or additional scar management. ^{4 5} Complete scar maturation does not occur until about 1 year postoperatively when scar strength reaches its peak at around 80% of original skin strength. ⁵ It is at this time that surgical scar revisions may be considered. ^{6 7} However, early revision after 8 to 12 weeks in adults, and 6 months in children, may be appropriate when scarring affects functionality. ⁶ Although young patients demonstrate increased healing capacity, a significant decrease in healing is not noted until age 50. ⁵

Nonsurgical Scar Revision

Dyspigmented Scars

Simple scar erythema may be targeted with topical therapy alone. Proposed topical treatments include moist exposed burn ointment (MEBO), onion extract (Mederma), and silicone sheeting/gel. ⁸ MEBO is a formulation that promotes maturation of keratinocytes, and has been shown to significantly improve the appearance of scars and increase healing times. ⁹ Onion extract has an inhibitive mechanism of action and decreases fibroblast proliferation and histamine release. While onion extract shows efficacy in vitro, demonstration of clinical efficacy is lacking. ^{1 8 9} Silicone is hypothesized to improve scar color via occlusion and hydration of the stratum corneum, and has been validated across several studies. ^{1 10 11 12} Laser therapy may be considered for erythematous scars unresponsive to conventional topical therapy. Pulsed dye laser (PDL) and intense pulsed light (IPL) laser are best suited for treatment of such scars. ¹³

Hyperpigmented scars may similarly be treated with topical and/or laser therapy. ⁸ Tyrosinase is an enzyme involved in melanin production, and inhibitors of this enzyme are used clinically to target hyperpigmentation. Hydroquinone, though once banned by the FDA due to carcinogenic concerns, is now classified as a safe agent and can be used topically for hyperpigmentation. ⁸ Other topical agents, including silicone and tretinoin, have shown efficacy in reducing postinflammatory hyperpigmentation. ^{6 8 12 14 15} Lasers may be used in conjunction with topical therapies. The IPL is best suited for treatment of scar hyperpigmentation. IPL utilizes infrared wavelengths to improve scar color. This is similar to its common use in treatment of Mongolian spots, melasma, and solar lentigines. ⁸ While other nonablative lasers may be used for hyperpigmentation, ablative lasers should be avoided, as these lasers may cause further hyperpigmentation as an adverse effect. ⁸ Laser therapy in darker skinned individuals may be particularly challenging due to the increased risk of dyspigmentation and scarring. ¹⁶ Fitzpatrick skin types I–III tend to have better results with laser treatment because there is less risk of unintentional absorption of light by epidermal melanin. However, lasers can still be used safely for scar revision in darker skinned individuals. ¹⁷ To prevent hyperpigmentation, intraoperative energy densities can be lowered with increased number of treatment sessions. If hyperpigmentation occurs secondary to laser therapy, topical bleaching and peeling agents may be used. ¹⁶

Hypopigmented Scars

Hypopigmented scars may be treated with needle dermabrasion, topical agents, lasers, or medical tattoos. ⁸ Microneedling improves hypopigmentation by direct injury to the epidermis and dermis, resulting in postinflammatory hyperpigmentation. Topical bimatoprost, a prostaglandin analogue found to cause periorbital cutaneous hyperpigmentation as a side effect of glaucoma treatment, may also be used. Lasers can be considered for more invasive therapy. The excimer laser and other nonablative lasers are best suited for hypopigmentation. The excimer laser has a wavelength close to traditional narrow-band UVB light and is effective in the treatment of hypopigmentation, in addition to psoriasis and vitiligo. ^{18 19} Dermatography, or medical tattooing, may be used as a final alternative when other modalities fail to improve cosmesis. ²⁰

Atrophic Scars

Atrophic scars are difficult to treat given texture abnormalities that occur. Atrophic scars commonly result from an acute inflammatory process resulting in collagen destruction and subsequent dermal atrophy. Treatments for atrophic scarring include dermabrasion, chemical peels, fat grafting, laser therapy, and excisional surgery. ^{12 21 22 23}

Dermabrasion is one of the oldest techniques for scar resurfacing to improve contour and color match. Dermabrasion may be performed manually with sandpaper, mechanically with wire brush, or electrically with electrobrasion. The goal depth for dermabrasion is the papillary dermis and is appreciated clinically when punctate bleeding occurs. ¹² Lidocaine and epinephrine-soaked gauze may be applied after dermabrasion to alleviate pain and bleeding. Electrobrasion has the advantage of resulting in less profuse bleeding following tissue insult. Although a relatively simple and cost-effective revision technique, dermabrasion is highly efficacious. In a study by Nehal et al, dermabrasion was comparable in outcome to ablative CO ₂ laser. ²⁴

Chemical peels generally have a minor role in resurfacing scars and are best used as an adjunct to other scar revision techniques. ²⁵ When utilized, deeper peel agents such as pure phenol solution (88%) are recommended. ²⁵ Chemical peels have benefits including decreased skin laxity and coagulation of superficial blood vessels. ²²

The CO ₂ laser is most effective in the treatment of atrophic scars and has been shown to improve scars by 50 to 80%. ^{21 26 27} While early CO ₂ lasers resulted in high incidence of scarring due to excessive surrounding tissue thermal damage, newer pulsed lasers show superior results with decreased resultant scarring. The erbium laser can be used to produce a shallower level of tissue ablation, resulting in less postoperative erythema with a quicker recovery. However, this laser should only be used for mild-to-moderate atrophic scars.

Surgical excision of the atrophic scar may be considered when conservative measures have failed. Fat grafting may also be considered as an invasive option for atrophic scar revision. ²³

Striae Distensae

Striae distensae, commonly referred to as stretch marks, are a result of irregular elastic fibers and reduced collagen fibrils in the dermis caused by excessive tension. ²⁶ Striae distensae develop perpendicular to lines of tension. Newer striae appear as erythematous bands, while older striae are fibrotic and hypopigmented. In a review by Khansa et al, infrared, PDL, tretinoin, cocoa butter, and olive oil do not demonstrate reproducible success in prevention or treatment of striae. The best approach to striae, therefore, is surgical excision. ¹

Hypertrophic Scars

Numerous modalities exist for the management of hypertrophic scars. Intralesional therapy with corticosteroids, chemotherapeutic agents, calcium-channel blockers, and botulinum toxin type A are commonly utilized. ²⁸ Intralesional corticosteroids are more frequently employed, and function by inhibiting collagen synthesis and cellular division of fibroblasts. ²⁹ Chowdri et al established that weekly intralesional injections of corticosteroids in the postoperative period followed by monthly injections resulted in complete resolution of hypertrophic scars. ³⁰ Chemotherapeutic agents such as 5-fluorouracil (5-FU) have also demonstrated success in the treatment of hypertrophic scars by inhibiting fibroblast proliferation. ^{31 32} Fitzpatrick reported reduced pain and pruritus with improved pliability of the hypertrophic scar when injecting intralesional 5-FU. ³² Calcium-channel blockers, such as verapamil, potentiate collagen I breakdown by increasing collagenase secretion. ³³ Ahuja and Chatterjee observed that intralesional verapamil performed comparably to intralesional triamcinolone in the management of hypertrophic scars. ³⁴ Intralesional botulinum toxin type A may also be used to improve cosmesis of the overlying scar. ³⁵ Studies have demonstrated that botulinum toxin type A improves appearance by immobilizing the area surrounding the scar. ^{35 36}

Lasers are also implemented in the treatment of hypertrophic scars. PDL improves hypertrophic scarring by reducing the number of fibroblasts and enhancing the production of collagenase. ³⁷ Additionally, PDL can result in destruction of the microvasculature surrounding the hypertrophic scar. ³⁸ PDL has demonstrated superior outcomes among the different lasers available. ¹ Alster and Nanni observed that PDL treatment resulted in reduced erythema and pruritus with improved scar pliability and texture after an average of two to three sessions. ²¹ Fractional CO ₂ lasers (CO ₂ -AFL) are ablative lasers that serve as alternatives to the PDL. The mechanism of action of CO ₂ -AFL is the generation of microscopic dermal injury that results in collagen remodeling. ³⁹ Radmanesh et al showed that CO ₂ -AFL performed similarly to PDL for the treatment of hypertrophic scars with marked symptomatic and cosmetic improvement. ⁴⁰ While studies have demonstrated the efficacy of CO ₂ -AFL in adults, it has recently been reported that its use can result in improvement in texture, color, and pliability within the pediatric population as well. ^{39 40}

Keloid Scars

Keloid scars differ from hypertrophic scars in several ways. Keloids extend beyond the boundaries of the original wound, while hypertrophic scars remain within the borders of the original scar. At a histologic level, keloids contain thick type III collagen bundles that are absent in hypertrophic scars. ^{13 41} Keloid scars may appear slowly over months and will not regress spontaneously. On the contrary, hypertrophic scars develop more quickly over a period of weeks and may spontaneously regress over time. ⁴² Treatment of keloid scars involves a multimodal approach and requires more rigorous treatment as they have high rates of reoccurrence. Resection should be combined with adjuvant therapy as keloid excision alone is associated with a high rate of recurrence, ranging from 45 to 100%. ^{13 43}

Injections used in the treatment of keloids include intralesional corticosteroids and chemotherapeutic agents (imiquimod, mitomycin C, 5-FU, and bleomycin). Botulinum A can be used in a similar fashion to that described for hypertrophic scarring. Injections may be used either as monotherapy or as part of combination therapy. Intralesional steroids are considered the gold standard treatment. Triamcinolone is injected at a concentration of 2.5 to 20 mg for facial keloids or 20 to 40 mg for nonfacial keloids. ¹³ Triamcinolone has been shown to reduce scar volume and hinder recurrence by around 50% after surgical excision. ⁴³

Excisional scar revision may be employed for more severe keloid scarring. Radical excision may be considered for smaller lesions, with mass reduction as a consideration for larger or multiple keloids. ⁴¹ A Z-plasty or a W-plasty can be used to change the tension lines and alleviate any predisposition toward recurrent scar hypertrophy. ⁴²

Laser therapy may also be utilized in the treatment of keloids. PDL therapy is most often employed and is offered for 12 to 18 sessions, with 4 to 8 weeks between sessions. Al-Mohamady et al described a 55% improvement in Vancouver Scar Scale after only six treatments, with less improvement seen in older scars. ⁴⁴ Alster and Nanni was also able to demonstrate a reduction in associated pain and pruritis. ²¹ Ablative lasers have also been implemented for keloid treatment, though with higher recurrence rates. CO ₂ laser excision without adjunctive therapy demonstrates recurrence rates ranging from 74 to 100% at 1 year, but resulted in decreased blood loss and postoperative pain compared with scalpel excision. ⁴⁵ Ablative lasers may also be utilized to increase the bioavailability of topical scar therapies by increasing drug penetration beyond the stratum corneum in a treatment known as laser-assisted drug delivery. ¹³

Radiation therapy may be used as an adjunct for treatment of keloid scars and is initiated within 3 days of keloid excision. Radiation treatment damages proliferative fibroblasts directly to prevent reoccurrence of scar tissue, with success rates ranging from 67 to 98%. ^{1 41} Radiation therapy poses theoretical risks of inducing malignant tumors in surrounding tissue, though very few cases are reported in the literature. ^{1 13 41} Total radiation dose administered is therefore an important consideration. Ogawa suggests that less than a total of 20 Gy should be given over several therapeutic appointments. ^{1 41}

Cryotherapy may be utilized as a monotherapy or multimodal approach to keloid management. This modality acts on scar tissue to reorganize collagen and reduce scar-forming growth factors. ¹³ Cryotherapy can be offered in the form of contact, spray, or intralesional administration. ^{13 41} The use of cryotherapy is typically reserved for smaller areas as it may induce severe pain and blistering. ^{13 41} Studies have shown an average volume reduction in keloids of 51.4 to 67.4%, with recurrence rates ranging from 0 to 24% after 6 to 18 months. ¹³

Surgical Scar Revision

Surgical Principles

Surgical intervention for scar revision can serve as a primary treatment option or can be performed when nonsurgical modalities are ineffective. ⁴⁶ The ideal scar presents with minimal discoloration and similar texture and contour to the surrounding unaffected skin. It should also remain parallel to naturally occurring lines, such as relaxed skin tension lines (RSTLs) ^{47 48} It is imperative that the patient understand the goal of scar revision is not to eliminate the scar altogether. ^{7 47 49} Understanding the subjectivity of how a scar may be perceived by the patient may also help the surgeon tailor management to the needs of the patient. ⁴⁹

Timing of the revision is crucial in attaining the ideal scar. Scars generally require up to 1 year to fully mature. ^{4 47 48 49} If the revision is performed prior to complete maturation of the scar, there is increased risk for recurrence and poor healing, possibly resulting in a worse outcome. ⁷ There are particular circumstances in which the surgeon will conclude that there is low potential for further improvement due to the severity of the scar deformity. In these cases, one may consider performing the surgical revision prior to 1 year. ^{47 48 49} Shockley termed this the “plateau phenomenon.” ⁴⁸ With no significant change to the scar after 3 months, surgical revision may be performed. ⁴⁸ In addition, scars that result in functional disability may be revised prior to 1 year following a risk/benefit assessment.

Serial Excisions

Serial excisions are a reasonable surgical option for large scars that are surrounded by poor tissue laxity ( Fig. 1 ). ^{50 51} Prior to the initial incision, the surgeon must devise a plan regarding the desired final position of the revised scar. ⁵² Ideally, the scar should be located either within the hair-bearing areas, following the hairline, or along the RSTLs. ⁵⁰ Depending on surgeon preference, the initial incision can be made either centrally or peripherally. ¹² The subsequent excision should take place 8 to 12 weeks following the previous procedure to allow for appropriate skin healing and physiologic skin changes. ⁵⁰ It is important that the superficial wound be closed under moderate tension. ⁵² The skin responds to this stress via both stress relaxation and creep. Intraoperatively, mechanical creep serves a vital role during wound closure for each excision, while biological creep and stress relaxation function to provide increased tissue availability for subsequent operations. ^{50 51 52}

Fig. 1.

A patient who underwent serial scar excision of the face. ( A ) The scar/lesion before serial excision. ( B ) The scar/lesion 2 months postoperatively after the first excision. ( C ) The scar/lesion 10 months postoperatively after the second excision.

Serial excisions have numerous benefits that make it an excellent surgical option for large scar revisions. When performing serial excisions, the surgeon makes use of the surrounding tissue to reapproximate the wound edges. Therefore, the resulting scar incorporates well within the adjacent tissue without creating a jarring appearance. ^{12 50 51} This technique is also advantageous because it allows for reorientation of the scar in a direction and position that can result in a well-hidden scar without the use of a donor site. ⁵⁰ By definition, this technique is disadvantaged by requiring multiple procedures. ^{12 50 51} If more than two excisions are necessary, tissue expansion can be used as an adjunct to generate additional tissue within the desired area. ^{50 51}

Z-plasty

The Z-plasty is a rotational transposition flap that has specific indications for its use. ^{47 48 53} It is capable of diffusing significant tension and reorienting the scar. Consequently, this technique is primarily performed to manage webbed scars, contracted skin, poorly oriented scars, ectropion, and eclabium. ^{12 49 54} The Z-plasty has also demonstrated success in the management of mild-to-moderate keloids with adjunct treatments including postoperative radiation, silicone tape stabilization, and steroids. ^{55 56}

The Z-plasty is capable of reducing tension surrounding the scar, lengthening the scar, and reorienting ill-positioned scars. ¹² The technique begins by creating an incision along the longitudinal length of the scar known as the central limb. The two peripheral incisions are placed at angles of the surgeon's choosing at the distal ends of the central limb. ^{47 48} The angle of these incisions alters the final length of the scar. For example, a 30-degree angle will lengthen the scar by 25%; a 45-degree angle by 50%; and a 60-degree angle by 75%. ^{12 46 47 48 49} Generally, the three incisions are of equal lengths. The two triangular pedicle flaps formed are transposed, redirecting the scar perpendicular to its original position ( Fig. 2 ). ^{47 53} For longer scars, multiple Z-plasties can be applied using either an interrupted or a serial technique ( Fig. 3 ). When treating keloids, excision of the scar should take place prior to Z-plasty. After removal, the wound edges are loosely reapproximated to create the central limb, and Z-plasty is performed. ^{55 56}

Fig. 2.

Z-plasty illustration. ( A ) Incisions created during this technique show the central limb along the length of the scar and the two peripheral limbs 1 and 2 that will create flaps A and B. Arrows demonstrate the direction in which the flaps will be transposed. ( B ) Transposed flaps loosely reapproximated demonstrating the change in direction of the scar relative to its original position. ( C ) Transposed flaps sutured into final position.

Fig. 3.

A patient who underwent Z-plasty for scar revision. ( A ) Before the revision demonstrating significant flexion contracture of the right knee. ( B ) Preoperative markings illustrating serial Z-plasty. ( c ) Immediate postoperative result allowing full extension on the right lower leg.

The benefits of this technique include reorientation of the scar parallel to RSTLs, lengthening of the scar, and interruption of the scar. ^{12 47 48 54} By interrupting the scar, different vectors of pull are generated that may camouflage the long-term postoperative appearance. ⁴⁸ Additionally, the Z-plasty incisions largely remain within the scar itself with minimal disruption of healthy surrounding tissue, unlike the W-plasty (discussed next). Nonetheless, a marked disadvantage of the Z-plasty is the potential to produce an even larger conspicuous scar. ^{12 48 49 53} Ratnarathorn et al reported that the participants of their study preferred the appearance of linear scars to irregular scars created by Z-plasty. ⁵⁷

W-plasty

The W-plasty functions as an advancement flap that creates an irregular scar from one that is linear ( Fig. 4 ). ^{17 48 58} Similar to the Z-plasty, it is performed to reorient poorly positioned scars relative to the RSTLs. ^{54 58} However, this technique is also used to treat scars along curved surfaces such as the inferior mandibular border, at transitional areas such as the hairline, and along concave surfaces prone to webbing and cicatricial healing. ^{17 48 58 59}

Fig. 4.

W-plasty illustration. ( A ) Incisions created during this technique demonstrate circumferential obliquely oriented lines around the original scar, which will be excised before reapproximating the skin edges. ( B ) Skin edges are reapproximated for appropriate skin closure to create an irregular scar from one that is linear.

The W-plasty is an excisional procedure that results in triangular flaps that are advanced for wound closure. Notably, this technique should be performed at anatomical locations with considerable tissue laxity to prevent significant tension upon advancement. ^{17 48} The W-plasty is designed by creating oblique peripheral incisions circumferentially around the scar, with each limb of the flap measuring between 3 and 5 mm. ⁵⁸ The scar is then excised along the perimeter of the initial incision, resulting in numerous triangular flaps all separated by an open wound. It is important to note that there are various ways to create the initial incision. The incision will dictate the shape of the triangular flaps and can result in either equilateral, isosceles, or scalene triangles. Goutos et al described their indications for each of these techniques, proposing the use of equilateral and isosceles triangular flaps for scars positioned along a curved surface with poorly delineated RSTLs and scalene triangular flaps for scars positioned near distinct RSTLs. ⁵⁹ On the distal ends of the scar, the use of a more acute angle of approximately 30 degrees should be considered to reduce the risk of standing cone deformities. ^{17 48 58 59} The adjacent tissue must then be undermined to reduce tension prior to flap advancement. The triangular flaps are advanced with the tip of one flap fitting within the space between the base of two triangular flaps on the opposite side of the wound. ⁵⁹

While the benefits of the W-plasty mirror those of the Z-plasty, the shortcomings of this procedure are unique to the nature of this technique. The W-plasty is valuable for its ability to reorient scars parallel to RSTLs. ^{43 47 48 54 58 59} The irregular scar may also camouflage its appearance to the human eye. However, there is still concern that by breaking up the scar along different vectors, the appearance may alternatively be more conspicuous. ^{17 48 58} Unlike the Z-plasty, the W-plasty requires excision of the scar and thus skin tension may develop. ⁵⁸

Geometric Broken Line Closure

Geometric broken line closure (GBLC) is another excisional technique that results in an advancement flap ultimately creating a randomly irregular scar. It is designed to reorient long scars that are directed away from RSTLs ( Fig. 5 ). ^{17 43 46 47 48 58}

Fig. 5.

Geometric broken line closure (GBLC) illustration. ( A ) Two concentric lines are drawn equal distance from the scar. ( B ) Geometric shapes including squares, rectangles, and semicircles are randomly drawn within the boundaries of these concentric lines. ( C ) Excisions are made along the randomly outlined shapes followed by skin approximation by interdigitation of the geometric shapes.

This method of scar revision follows a similar design to the W-plasty, though it is more sophisticated in technique. ⁵⁸ Before performing this procedure, ensuring sufficient skin laxity within the surgical field is important to prevent postoperative skin tension. ¹⁷ Once confirmed, a line should be drawn circling the scar. A second line should be outlined about 5 mm away from the original line, creating an inner and outer concentric line surrounding the scar. Geometric shapes, including squares, rectangles, and semicircles, are designed in a random order within the borders of the two concentric lines. The surgeon should attempt to create lines within the RSTLs. ^{17 43 48 58} Similar to the W-plasty, creating 30-degree angles at the distal ends of the scar can reduce the risk of forming standing cone deformities. ^{17 48} Incisions through the outlined shapes should be performed, followed by excision of the skin. The deep tissue layers should also be undermined to allow for tension-free closure. ^{43 47 49 58} The irregular skin flaps on opposite ends of the wound interdigitate to create a randomly irregular scar. ^{17 43 48 58}

Advantages and drawbacks of GBLC reflect the nature of how this technique is performed. The eye is less capable of following irregular lines when compared with linear lines. Consequently, the revised scar will be less conspicuous. ^{17 48 58} A disadvantage to this procedure is that it may result in excessive skin tension following excision. ^{17 48} Other drawbacks to GBLC are its complicated technique and longer operation times. ⁵⁸ The surgeon should preoperatively plan the procedure thoroughly for a smooth and efficient intraoperative course. ^{17 58}

Fat Grafting

Klinger et al documented the first use of autologous fat grafting for scar revision. ⁶⁰ Fat grafting has consistently demonstrated improvements in scar appearance, as well as improvement in pain and pruritis. ⁶¹ The procedure is postulated to work through adipose-derived stem cells, which promote epithelial hyperplasia and angiogenesis through the release of growth factors. Histological evaluation after autologous fat grafting shows skin that is more resemblant of nonscarred tissue with organized collagen deposition, vascularization, and reappearance of the papillary dermis. ⁶¹

Liposuction is most commonly utilized to obtain tissue graft for autologous fat grafting in scar revision. Lipoaspirate is injected into the dermal–hypodermal junction of the scar, with needle subcision promoting scar release at the same time. Klinger et al suggest that 1 mL of aspirate should be injected for each 3.5-cm ² scar surface area. ⁶⁰ The procedure may require multiple sessions, with volume filling in the first session and further scar quality improvement in the second session. ⁶²

Conclusion

Scars pose a complex challenge to the reconstructive surgeon in the variability of their presentation and their effect on cosmesis and function. Both surgical and nonsurgical modalities exist for the management of scar formation, each with unique indications depending on the scar type and location. As revision therapies continue to evolve, the plastic surgeon must remain adaptable and knowledgeable to provide quality care and enhanced patient outcomes.

Funding Statement

Funding None.