Scar revision treatment can kick off lasting relationship with aesthetic patients

Quick Read: Scar revision procedures can provide a low-risk entry point for new patients, an expert says, who adds that minimizing surgical scars requires sharp tools and careful technique.

Aspen, Colo. - Treating existing scars can help dermatologists and other core aesthetic specialists build lasting relationships with patients, says an expert who spoke at Cosmetic Boot Camp, held here.

Scars rank among the most common aesthetic concerns worldwide, says Daniel L. Kapp, M.D., a plastic surgeon based in West Palm Beach, Fla. Furthermore, he says that according to a survey performed by St. Louis plastic surgeon Leroy Young, M.D., more than 90 percent of people with scars would gladly do something about them if effective treatment is available (Young VL, Hutchison J. Plast Reconstr Surg. 2009;124(1):256-265).

In this regard, Dr. Kapp says, scar revision treatments are usually fairly straightforward. “Scars can always be made better - whether through surgery, nonsurgical methods or just giving someone a steroid injection or silicone sheeting.”

Aesthetic impact

Scar revision also yields high patient satisfaction and frequently boosts patients’ self-confidence. Accordingly, he says that when consulting with patients, “We need to ask them how they feel about their scars, because in general, people with scars live less happy lives than those who don’t (have scars). And this isn’t body dysmorphism,” because scars are visible. Besides, he notes, “Nearly everybody likes to talk about how they got their scars. So you get them talking about themselves, and they will talk themselves into allowing you to treat their scars.”

It’s also important to be upfront with patients about any scars that aesthetic surgeries will create. “After plastic surgery, patients will always have scars. I tell my patients that when they get their pants altered, their tailor uses the seams to hide the repair. Because the human body doesn’t have seams, I have to make one” after a tummy tuck, breast augmentation or other surgery.

The key to successful scar revision is choosing appropriate candidate scars, Dr. Kapp says. Regarding size, he notes that it’s usually very difficult to offer substantial improvement on scars that cover an entire arm or leg, for example.

“The ideal scars are flat and narrow, with good color match to surrounding skin,” he says. In the latter area, he usually waits one year - or 18 months in children - for any postsurgical redness to subside before treating scars.

Strategic scar location

To minimize surgical scars, Dr. Kapp says, “We try to hide our scars in strategic locations. When we perform a scar revision, we change the scar’s location” to one that offers natural camouflage, such as a junction between facial subunits.

With surgical technique, “It’s all about the tools, the sutures, careful tissue handling and precise approximation of the tissues.” Regarding tools of the trade, he says, “When I perform a facelift in a hospital, I use my own surgical tray from my office. I know exactly how many times that pair of scissors has been used to perform a facelift. I replace my scissors around every three to five years, depending on the scissors and what I use them for, because they don't last.”

With scalpels, he says, good technique requires using perpendicular incisions to minimize tissue trauma. To retract tissues, “I always use skin hooks. No matter how strongly you believe you’re just grabbing the dermis when you’re using an Adson forceps, you’re grabbing the full thickness of the skin,” Dr. Kapp says. “Skin hooks are the least traumatic way of lifting and elevating the tissue.”

Suturing considerations

Similarly, he says, “Suture matters. Suturing is not just about using a string to close a wound. The suture material and needle you use play very important roles.” For primary closures, he prefers Vycril (polyglactin 910, Ethicon) sutures because he finds them easy to use, and their braided construction helps hold fast.

“I usually use either Monocryl (poliglecaprone 25, Ethicon) or Prolene (polypropylene, Ethicon), and sometimes nylon. I like Prolene best because it’s easiest to remove.” For scar revisions, Dr. Kapp says he prefers sutures that dissolve by hydrolysis because they are unlikely to cause inflammation.

Regarding needles, “The best ones are laser-honed and sharp. A sharp needle may be used three times, or up to an hour and a half, depending on what you’re suturing,” before losing its edge.

Among newer techniques, Dr. Kapp says he does a fair amount of fat grafting for depressed scars. “I incorporate it with a little liposuction, so patients feel they're getting value added: an improvement of their scar, and a little liposuction. I also use a fair amount of acellular dermal matrix - I tend to prefer the bovine neonatal ones because they have high amounts of type 3 collagen. In my experience they seem to revascularize better, and I can place one underneath a depressed scar to elevate it.” In his opinion, he suggests that dermatologists could make more use of acellular dermal matrices for similar purposes.

Disclosures: Dr. Kapp reports no relevant financial interests.