Dogbites are an unfortunate risk to which all children are potentially exposed. Beyond the trauma of the experience, permanent scarring almost always occur which can leave lifelong marks to be seen by all if it occurs on the face. With millions of dog bites occurring per year, plastic surgeons are involved in a lot of repairs particularly when it has occurred on the face. Plastic surgery involvement is so significant that last week was Dogbite Prevention Week sponsored by the American Society of Plastic Surgery.

Having done many hundreds of facial dogbite repairs and secondary reconstruction, there are some very common trends. A disproportionate number occur in children from ages five to nine, the biting dog is rarely an unknown one, and many such injuries turn into legal and insurance issues. The common age of patient injury is a reflection of the naïve and innocent nature of that age and their view that dogs are playful and fun. Most dogbites occur in a family, neighbor or relative’s dog where the familiarity promotes unintentional behaviors that are predisposed to evoke their protective natures. Because many dogbites occur on the owner’s home, insurance battles are certain to ensue that frequently involve lawyers. It is not uncommon for me to see referrals from attorneys to evaluate dogbite scars and get an estimate on the cost of scar revision.

That being said, prevention of dogbite injuries can avoid many of these problems. These are the most significant ways to avoid a dogbite injury to a child. These are based on many of the reasons or circumstances I have heard that were given for what was going on when the injury happened.

1) Don’t play aggressive games with a dog. They may not see it as a game.

2) Don’t mess with a dog while eating or play keep away games with food. They are very protective of food and aggressive about getting it.

3) Do not jump on a sleeping dog or surprise it from behind. Give it plenty of warning that you are around.

4) Do not attempt to kiss a dog, particularly face-to-face. Dogs tend to strike defensively when confronted directly.

5) Do not hug, squeeze, or ‘pin’ a dog in any way. This is likely not to be interpreted as play to them.

6) Keep away from a dog with puppies or do not attempt to take a puppy away or get between a mother and her puppy.

7) Do not attempt to pet a dog, particularly an unfamiliar one, unless you let them sniff you first.

While some dogbites can just not be prevented or occur for no discernible reason, these behaviors which are common in children can unintentionally cause a defensive maneuver by a dog. Defensive maneuvers in dogs are usually a biting response and their nature is to go for the face and neck.

Dr. Barry Eppley

Indianapolis, Indiana

The treatment of problematic scars or the excessive buildup of scar tissue underneath the skin after surgery can be a very difficult problem. The most common treatment has been the use of intralesional injections using Kenalog. (triamcinolone acetonide) While this has proven effective for many scar problems, it does not always work and is associated with certain side effects, most commonly fat or skin atrophy. Some patients have been described as having resistance to Kenalog, although this probably has more to do with the quality of the scar than it does with some systemic drug resistance.

For those scar problems that do not respond to Kenalog treatment, there is an alternative injectable drug using5-flourouracil. 5-fluorouracil (5-FU) is an antimetabolic cytostatic drug that inhibits DNA formation. In laboratory cultures, 5-FU barely reduces collagen reduction in normal fibroblasts, but produces a drastic reduction in collagen formation in altered fibroblasts. It also seems to counteract the capacity of growth factor TGF-1 to stimulate collagen production.

There have been multiple recommended mixtures for 5-FU scar injections. One method uses a mixture of 0.9 ml of 5-FU 50 mg/ml and 0.1 ml triamcinolone 10 mg/ml per ml. Another mixture is composed of1cc of 50 mg of 5-FUand 10 mg of lidocaine 1%. These mixtures are used primarily because 5-FU injections can be painful. The pain can be alleviated by these dilution measures or by giving a local anesthetic block prior to 5-FU injections.No more than 3 mls are injected in a single session in order to prevent potential systemic effects derived from the use of 5-FU. Although 150mgs (3 mls) is far below the dose generally administered in cancer treatments. (thousands of mgs)

The treatment schedule is more frequent than that used for Kenalog, being done on a weekly basis over the first four weeks, and then every two weeks thereafter. On an average 5 to 10 injection sessions are needed to achieve the best result. Side effects seen with 5-FU injections are pain and stinging and bruising at the injection site.

The results of intralesional injection with low concentrations of a solution of 5-FU and steroids has been shown over the past decade to be effective for reducing the production of collagen and aiding in the reorganization of scar fibers. 5-FU inhibits DNA synthesis and inhibits fibroblast proliferation inducing regression of keloids and hypertrophic scars. Intralesional 5-FU is associated with pain which is reduced by the addition of triamcinoloneor local anesthesia. To be most effective,5-FU injections need to be done when collagen and scar formation is actively being produced.

Dr. Barry Eppley

Indianapolis, Indiana

When topical therapies fail and the scar is unfavorable, resorting to scar revision is necessary. There is a lot to be said about time for scar maturation, but scars that are depressed, raised or excessively wide do not substantially improve as they heal in many cases. Many scars do not need an elaborate revision procedure and often simple linear excision and closure will suffice. This is particularly true for many scars on the trunk and the extremities.

But many facial scars are not improved by simple linear scar revision. The visibility of the face has a lot to do with the need for heightened scar revision outcomes as well as the location of the variable patterns of the relaxed skin lines of the face. For these reasons, better scar camouflage can be obtained through what is known as geometric, or non-linear, scar rearrangement. (GSR) A variety of GSR methods are known and they carry names that start with a letter followed by –plasty. Whether it be the classic Z-plasty or W-plasty or other combinations of the alphabet, the concept is to convert a straight line scar to a non-linear or irregular one.

The Z-plasty is a well known scar revision method that is easy to visualize. With a Z pattern in the middle of the scar, it is easy for patients to understand. The beauty of the Z-plasty is that it not only makes the scar irregular but also makes it longer. This is of great value in scars that have created skin tethers or contractures as they cross moving surfaces and concavities. Examples would be vertical scars of the upper eyelid, the inner area of the eye near the nose, the nostril rim, and the armpit. This lengthening benefit is also useful for contracted scars along the upper lip philtrum and the corner of the mouth. Scars around an orifice can also be helped with z-plasties including the oval nostril, a tracheostomy stoma scar, or those scars around or in the umbilicus.

The W-plasty scar revision turns the whole scar into an irregular ‘pinking shear’ pattern.Instead of a one or two areas with a Z pattern in a scar, the W-plasty turns the entire scar into a continuous zigzag pattern. The scar essentially becomes a series of alternating triangles. The theory is that an irregular line is harder for the eye to follow than a straight line. This is of great value in facial scars of the cheek, side of the face, or forehead in which there is no discrete skin fold or wrinkle in which to ‘hide’ the scar. While this does break up a linear scar, it also creates a regular pattern which may work against the concept of decreased visibility by making a regular pattern for the eye to follow, even if it is irregular.

For this reason, w-plasties are rarely done alone or throughout the entire scar. They are usually combined other patterns in what is a more sophisticated scar revision method known as geometric broken line closure. (GBLC) This method employs the W-plasty but with the addition of other shapes besides just triangular flaps of the W-plasty. The different shapes may be Ms or other shapes interspersed between the Ws. This makes the closure irregularly irregular and offers the best potential for maximal scar camouflage.The resulting scar is “irregularly irregular,” with the maximum potential for camouflage. This scar closure pattern, combined with sanding or dermabrasion later (no sooner than 2 to 3 months after), is the best bet for many scars that are in difficult or unfavorable facial locations.

Dr. Barry Eppley

Indianapolis, Indiana

Any interruption of the skin, whether from a fall on the ground, an accident on the job, or from the surgeon’s knife, prompts the complicated and not yet fully understood process of healing, the end result of which is a scar. However, the word “scar” often invokes the image of an unwanted deviation of the healing process, that which is a physical derangement from the smooth and non-discolored appearance of skin that it replaces.

As do the injuries from which they result, the appearance of scars can vary tremendously. Differing scar appearances are because the scars are different from each other. Different scar types are treated differently! Like all of medicine, successful treatment is based on establishing the diagnosis first. The wrong treatment method on a scar results in not only no beneficial effect but a waste of your time and money.

Hypertrophic scars appear as raised, wide,firm,and red to purple-colored scars that

remain within the physical boundaries of the original skin injury. They are more likely to

occur in wounds that cross natural lines of skin tension or an original open wound that

healed on its own. These can cause some itching and discomfort to the touch but may

improve with time.

Keloids are also raised, reddish-purple, nodular scars that are usually firmer than hypertrophic scars.Keloids are the result of uncontrolled scar healing that the body does not stop once the wound is healed. The difference between keloids and hypertrophic scars is that keloids extend beyond the boundaries of the original injury site, encroaching upon surrounding uninvolved healthy tissue. Keloids can result from seemingly innocuous activities such as ear piercing and tattoos and unlike hypertrophic scars, keloids do not regress over time. While keloids can occur in all skin types, they are generally more common in darker skin.

Stretch Marks are linear bands of wrinkled skin that most frequently result from rapid weight loss or weight gain, for example following pregnancy, and tend to appear in areas like the abdomen, breasts, thighs, and hips. Initially, they tend to be red or purple, but often fade to white over time. They are essentially ‘partial tears’ on the underside of the skin from overextension.

Depressed Scars (atrophy) are due to the irreversible damage of the skin from the injury where the amount of scar formed is less thick than that of the surrounding normal skin. The level of the scar (thickness) is less than that of the surrounding skin. They can occur from a multitude of inciting events such as acne lesions, burns, or skin avulsive injuries from trauma. Trying to apply makeup to conceal depressed scars actually worsens their appearance as makeup enhances the textural variations.

Acne scars are a variety of depressed scars that have occurred due to loss of skin thickness from the body’s inflammatory response to a plugged sebaceous follicle. The inflammatory reaction (infection) results in thinning of the skin even though scar tissue has formed. Acne scars appear in a variety of shapes, which are important to distinguish, as they are often treated differently.

Icepick scars are usually narrow, sharply demarcated tracts that are wider at the surface and taper as they extend through the skin. Rolling scars are more superficial, wider, and produce an uneven appearance in the skin. Boxcar scars are round- to oval-shaped skin dimples with sharp margins and are wider than icepick scars.Most tend to have diameters from 2.0 – 4.0 mm.

Burn Scars are unique in that they have a very thin and atrophic underlying dermis. They are quite stiff and inflexible and do not heal well when cut and sutured. The fat layer underneath them is frequently gone or thinned due to the initial heat of the original injury. The burn scar can appear smooth and almost ‘glass-like’.

Scar diagnosis is critical to selecting the proper scar revision approach. These simple descriptions may help one better describe and identify their scar problem.

Dr. Barry Eppley

Indianapolis, Indiana

Background:  Scars are a common patient concern, whether they be slight or significantly disfiguring. While scar treatments and therapies abound, significant scarring requires some form of surgical scar revision. Lacerations and traumatic wounds are particularly prone to hypertrophic scar formation, the most common type of raised and disfiguring scars. While less commonly seen on the face, hypertrophic scars can develop under two healing situations. One is when a laceration crosses a facial transition zone, such as the jaw line. The other is when an open facial wound is allowed to or can only heal by secondary intention. Abrasions, burns and other partial thickness wounds are particularly prone to abnormal scar formation

This is a 22 year-old female who was originally involved in a motor vehicle accident in which she was thrown from the car. She sustained multiple long facial lacerations including a deep abrasion from the left side of her face down into the neck. Her original care was unclear although she may have received suturing of some of her facial wounds. She went on to heal and came in for scar revision 18 months after the accident. Besides the numerous persistent red and prominent scars, she had a large scar contracture across the left jaw line. It was painful and tight and limited her from turning her head to the right.

She underwent revision of all of her scars in a single operation. Some basic plastic surgery scar principles were used. Scar revision of most facial scars is best done by changing the line or orientation of the scars. While you can’t change the direction of scars, you can make them more narrow and not a perfectly straight line. This is the principle of the running w-plasty, it changes a straight line into more of a pinking shears pattern. This is useful if the scar runs obliquely or perpendicular to the natural lines of skin tension. This is known as geometric scar rearrangement. Z-plasties are done when the scar is contracted and needs lengthening. This is of particular need in many scars that cross the jaw line, a transition zone between the face and the neck which differs in both skin thickness and exposure to stretching.

Over 500 skin sutures were placed in doing these comprehensive facial scar revisions. They were removed one week later and replaced with topical glue to allow further healing. She was lost to follow-up  but reappeared nearly two years later. Her scars had adequately faded and the final results of the initial scar efforts could be seen. While I thought some further scar improvements could be obtained, she declined any further scar work.

Case Highlights:

1)      Traumatic facial lacerations and wounds are prone to develop hypertrophic scars. Such scars can only be improved by surgical treatment.

 2)      The use of a combination of straight line closure and geometric rearrangement for facial scar revision is used based on scar orientation to the relaxed skin tension lines.

3)      Most facial scar revisions will require some form of touch-up which can include laser resurfacing and/or treatment of persistent redness. Such considerations should wait at least six months after the initial scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

A common term that is used in plastic surgery, and one that patients know little about, is a dog-ear. It is an uncomplimentary and perhaps misleading name for a common plastic surgery deformity. Patients may become aware of it when they learn they have it and may need to do something about it for the best cosmetic result.

This skin deformity denotes the bunching of skin at the end of an incision after wound closure. It is the result of an excess of skin that bunches up like a standing cone at the tail of the wound. Technically, it occurs when separated wound edges are closed that are separated at an angle. It can appear everted and protruding from the skin edges or it can be inverted and depressed below the skin surface. I don’t know how it got the name of dog-ear but it has even been called a pig-ear. Depending upon how you it presents (raised and above the skin or inverted below the skin), I guess it appears as the front or back of dog or pig’s ear. Interestingly, this is the only known plastic surgery skin deformity that is actually named after an animal.

Dog-ears commonly occur at the tail ends of a long wound closure after an ellipitical excision of tissue. In body contouring where large amounts of tissue are excised, they are not rare. Frequently, they occur after abdominoplasties, breast lift and reductions, and any other large elliptical skin removals. We look carefully for them at the time of surgery since we know they do occur. When seen, they are excised and closed so that incision lays flat. This often will extend the length of the incision somewhat.

Despite treating obvious dog-ears at the time of surgery, they may still appear after surgery even if they are not obvious during surgery. This is the result ofskin relaxation and settling. Patients notice them and ask if this fold or cone of skin will settle down. Once seen, it is fair to say…no. But it is worth waiting for at least three months after surgery to make sure that the size of the dog-ear does not get bigger as all swelling eventually subsides.

Dog ears can only be improved by their excision. By removing the extra skin and some underlying fat, the tail of the incision will lay flat. It is important to remember that a dog-ear is often more than just skin. So during its excision, a generous amount of surrounding fat may need to removed as well. This is particularly true at the ends of tummy tuck incisions.

Dog-ears are a frequent, but minor, cosmetic incision deformity that may require scar revision. While it can be unsettling for patients to discover a dog-ear after surgery, they can happen in the best planned and closed wound. They can be easily solved as an office procedure under local anesthesias in most cases with no need to limit most activities afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

Most grafts for hair restoration come from the back of the head or the occipital region. This is most commonly done with a horizontally-oriented excision, resulting in a straight-line closure from one side of the occiput to the other. Most hair transplant donor scars have a width of just a few millimeters, but wide donor scars do occur in a few patients leaving a new visible bald area that can be easily seen from behind.

Wide occipital scalp scars can be difficult to treat. They are the result of either too wide of a donor strip removed, poor laxity of the donor site due to prior harvest(s), or poor skin closure techniques.  Widened scars can be improved in only two ways. They can be re-excised and closed to make the scar more narrow or the scar itself can under hair transplants to make it less visible.

Scar excision should be the first approach (provided that it hasn’t already been tried) but the method of skin closure needs to be different. The key lies in the manipulation of the deeper tissues. Adequate superior underlining needs to be done in the subgaleal plane as the upper scalp area is the most likely to be adequately mobilized. Once adequate scalp is loosened, tension needs to be reduced on the upcoming skin closure through galeal or fascial closure. The tension needs to be placed in this deeper layer, not on the skin. In some cases, the galea needs to have relaxing incisions in it for adequate movement. The goal is to get the scalp hair-bearing skin edges to lie loosely together. If the skin has to be pulled together tightly to get it closed, there is a good change the scar will re-widen significantly.

Once good mobilization and galeal closure is done, the skin can be either put together as a straight line again or changes to an interdigitating w-plasty pattern. That is a matter of intraoperative judgment. Geometric skin closures can not only help reduce skin tension but they change an easily followed straight line into a less obvious scar pattern.

The skin closure can also be done using a classic trichophytic technique. This is a common plastic surgery method that has long been used in facial procedures done near the hairline such as facelifts and browlifts. A small piece of one wound edge, as well as the corresponding hair, is removed. (but not the hair follicles) When the wound heals, the buried and partially cut hair shafts will end up growing through the scar. This will take several months to see the new hair growing up through the scar.

Hair transplants are an ironic approach to improvement of the wide donor scar, but it can be effective. The question is where can the hair grafts be satisfactorily harvested? A large number are not needed, usually 25 to 50. Some have advocated other scalp donor areas around the scar and a few use chest hair through a 1mm punch method. Transplants, in my opinion, should be reserved only as a last-ditch method as scar revision will usually suffice for adequate improvement.

Dr. Barry Eppley

Indianapolis, Indiana

1.      I recently had a car accident and have a very ugly scar on my forehead. Will scar revision help me? The revision of scars  is rarely done prior to 6 months following an injury. This is simply because  it is too early to intervene as the tissues have not sufficiently softened to handle being surgically manipulated. Another reason is that scar revision prior to nine to twelve months following your injury can also be too early is because scars change in appearance over time.. A scar that initially looked terrible can almost completely fade as it matures and settles down.

In some scars that appear to be healing poorly (wide, irregular, misaligned skin edges), scar revision before six months may be done. It is the progress of a scar over time that determines whether early or delayed scar revision may be beneficial.

Today’s plastic surgery techniques also allow for scar manipulation to be done as it progressively heals. It is wise, therefore, to see a plastic surgeon and have your scra followed as it heals. Certain methods may help a scar heal better along the way. For example, if the scar thickens, it can be treated with injectable steroids to reduce any unwanted hardness or fullness. If the scar stays red for too long, it can be treated with pulsed light therapy to lessen the undesirable redness. If the scar becomes darker due to  sun exposure or your natural darker skin color,topical bleaching products may help the darker color fade.

2. Does Cocoa Butter or Vitamin E really work to improve scars?

There is no doubt that these two topical creams or oils have a historic belief that they are helpful for scar reduction. I have seen many patients over the years in my Indianapolis plastic surgery practice that have recounted stories of their relatives or even themselves that have seen the benefits of using them on scars and stretch marks. Despite these long-held beliefs, scientific studies have shown that they are largely urban myths. While good scientific studies in scar revision are largely  lacking, a few scientific studies that have been done have shown that these treatments provide no improvement at all in an incision or scar. In fact, Vitamin E oil has been shown that it may actually slow wound healing. (this doesn’t mean that it makes scars worse, just that it does not make them better) Therefore, the use of these topical creams is mainly psychotherapeutic, not clinically effective.

3. What causes scarring and why is it noticeable? A scar is the result of the natural process of wound healing. The body does not always heal a wound with exactly the tissue that was cut or lost. Rather it mends and replaces injured tissue with on-specific collagen tissue to bind it back together. Whether the amount of scar tissue that is formed is a little or a lot depends on a lot of factors, such as the size of wound, how close the skin edges where as it heals, and the mechanism of injury. (e.g., incision, burn etc.) How much and what type of scar tissue that forms will have a significant impact on how much the scar is seen. There are other factors, beyond how the wound has healed, that also influences how a scar looks. A scar can be noticeable because it is a straight line that your eye can easily follow. Another reason a scar is visible is that the scar is darker or lighter than the surrounding skin color. Dark color may fade over time. A white scar, however, will not change color and is a permanent visible contrast to your surrounding pigmented skin. A scar may be visible because it is at a different level to that of the surrounding, It may be raised or indented, causing a visible contour deformity. Lastly, a scar may be adhered (scarred to) a nearby structure which causes it to move abnormally or be tethered as it tries to move. This causes visible distortion of both the scar and the normal structure during movement.

4.  How can scar revision surgery make it look better?

Scar revision is a surgical approach to scar improvement. Fundamentally, it is about cutting out the scar and putting it back together. How it is put back together is different based on the type of scar and its location on the body.

Straight Line Repair. For some scars, it is as simple as cutting it out and putting it back together in the line or orientation that it lays. This can be very effective for scars that already lie along the relaxed skin tension lines of their locations. Some scars are simply too wide or depressed and need to be made thinner and more even with the surrounding skin. This is often how scars on the body (below the neck) are done.

Geometric Broken Line Repair.  (GBLR) The concept of GBLR is to cut out a scar and put it back together in an irregular pattern, not a straight line. By doing so, it makes it harder for the eye  to follow the scar line thus making it less noticeable. Using precise and randomly alternating squares, rectangles, triangles, and trapezoids that measure between 3 to 5 mm and that interlock with one another, the scar is transformed from a straight line into a very difficult to follow  zig-zag appearance. In some cases, a superficial skin resurfacing treatment (laser or mechanical dermabrasion) is done several months later.Z-plasty Repair  A z-plasty involves changing the scar from a straight line into a z-pattern. This accomplishes several scar benefits. It redirects the forces of tension and also lengthens a contracted or shortened scar. By irregularizing a straight line, it also serves to make it more difficult to see the scar and thereby camouflage it.
W-plasty Repair. The w-plasty serves to irregularize a straight line and creates a ‘pinking shears’ effect. It breaks up the entire straight line of a scar.

5. s there any way to make scars look better without cutting them out? For scars that have some minor contour deformities, ‘sanding’ is one approach. This can be done using mechanical dermabrasion or laser resurfacing. For scars that have some minor amounts of depression or indentation, injectable fillers can be used to raise the scar. Unfortunately, no currently available filler is permanent.

6. What is the difference between a keloid and a hypertrophic scar? 

These two types of scars are commonly confused. I have seen lots of scar patients who thought they had a keloid when they did not. A keloid is a scar that grows beyond the boundaries of the original margins of the scar. A hypertrophic scar, on the other hand, is a very thick or widened scar but it stays within the edges of the scar. As a general rule, keloids rarely form on the face. The face is defined as the area in front of the ears and not involving the scalp and the neck. The areas where keloids are often distributed include the earlobes after ear piercing, the neck after shaving, and the back of the head after hair trimming and most often are found in African-Americans or darker complected races. Keloids manifest and may continue to grow after a very minor insult like an ingrown hair or after shaving. Hypertrophic scars usually arise from a real injury of some kind and tend not to continue to grow. This distinction is very important as the treatment for these two scar types can be quite different. Keloids are well known to be difficult to treat and often require multiple treatments and surgeries for improvement. 

Dr. Barry Eppley

Indianapolis, Indiana

Surgical incisions and the scars they create are a concern for many patients. Nowhere is this more true than in the plastic surgery patient. Because it is a cosmetic procedure, most people ask how to take care of new scar so that it ultimately looks as obscure as possible.  This raises the important question of…does anything one does early change how a scar may look later?

This may seem like a silly question with an obvious answer of…of course it does! But such a simple answer belies a much more complex issue. How scars turn out is affected by a large number of factors including how the incision was made, is the wound closure under tension, how the incision was closed, age and race of the patient, skin type and thickness,  and location on the body…to name the major influencing factors. The interplay of all these factors will be responsible for how a scar looks.

These factors are so significant that, quite frankly, anything put on top of a scar or used to treat it from the outside after surgery is trivial by comparison. While time and the mature healing of the scar tissue plays the greatest influence in the ultimate appearance of a scar, there are a variety of things a patient can do to affect both the speed of scar fading and how it may eventually look.

But first, not all incisional scars made in plastic surgery will benefit from early scar therapy. Location of the scar determines the merits of treating it. Eyelid (blepharoplasty) incisions, for example, heal so well that any such treatments are not needed and are also impractical to apply. This also applies to many facial incision areas such as that of a rhinoplasty, browlift, ear surgery, and a chin implant. Once could debate about the scars that run around the ears in a facelift but the more ‘visible’ frontal scar is worthy. Almost all body scars, particularly those from breast and abdominal surgery, will benefit.  

Before any of these scar strategies are implemented, it is important that the incision be healed. This means no open areas, sores, or spitting sutures. The epithelium (outer layer of the skin) must be closed so that the deeper layers of the skin and the wound are protected. This is necessary to prevent trapping bacteria causing infection or impeding further healing. Delayed wound healing is one factor that is well known to adversely affect scar appearance. For most incisions, this will be around three (3) weeks but the completeness of healing may make that time frame longer or shorter.

Early scar treatment can involve one of three methods; a topical cream or solution, occlusive taping, and light energy therapies. While there are proponents for each approach, it is important to understand that there is no proven science that has yet shown one to be better than the other. Cost, availability, ease of use and plastic surgeon recommendations are as important, if not more so, than any advertisement or promotional material.

Topical scar solutions come in a variety of serums, gels, and balms. All of them contain some form of silicone. How silicone exactly works for scar improvement is not really known but its effectiveness is widely accepted. Some preparations contain other ‘active’ agents including Vitamin E, mild strengths of hydrocortisone, CoEnzyme Q10, copper peptides, etc. Whether any significant differences exist between what one can purchase in a drugstore, on the internet, or in a doctor’s office is speculative. Their advantages are that they are easy and convenient to apply.

A wide variety of silicone gel sheeting, patches, and strips exist. Some can be cut into any shape and others come in preformed shapes that conform to breast and abdominal scars. Their use is more economical for the long scars that result from body surgery even though their ability to stay in place is more cumbersome than topical solutions. They also have the added value of applying some low-grade continuous pressure and occlusion, which may be of more value than any effect silicone may provide.

Light scar therapies consist of either pulsed light (e.g., IPL, BBL) and use of low power laser wavelengths specific for red colors. Each type has a similar purpose, to lessen scar redness that may occur or help get rid of it sooner than what time alone would do. They may also lessen the amount of excessive scar formation which can make some scars wide or raised. This is the most expensive form of preventative scar treatment because it emanates from an expensive device.  I usually only use this approach after revision of a problematic scar or in scars that begin to acquire some early unfavorable characteristics.

How long should prophylactic scar therapy  be used? There is no exact answer but its benefits are best realized in the first three months after surgery.  

Dr. Barry Eppley

Indianapolis, Indiana

Unsightly neck scars from a previous tracheostomy are not uncommon. The prominent location in the center of the neck and the nature of the placement and removal of the tracheostomy often leaves a visible depressed scar. The classic appearance is that resembling an umbilicus with the circular skin edges tethered down to the deeper tissues. Some call this a tracheal tug but its origin is that soft tissue (fat) is lost between the skin and the underlying strap muscles and trachea.

A depressed tracheostomy scar can really be revised within the first three months after the tube has been removed. While some advocate waiting until the scar is mature (greater than six months), there is really little benefit to such a delayed approach. The reconstructive techniques needed are not adversely effected by an immature scar. It is understandable why a patient would like to shed as soon as possible any physical signs of the experience.

A tracheostomy scar revision has to employ several concepts to be successful. The skin edges (tracheal tug) must be widely released, the lost deep tissue must be filled in and the skin closure must be tension-free and lie horizontally along a natural neck skin fold. The hardest one to achieve of these three is the fill of the underlying tissue deficit. There are a variety of techniques for replacing this lost tissue including scar de-epithelialization, dermal-fat grafts or acellular dermal grafts. (allogeneic grafts) If the tracheostomuy scar is fairly shallow, the skin edges can be de-epithelized and turned down for a little tissue fill. For deeper tracheostomy scars, however, more bulk is needed. While some use local muscle flaps, I find more bulk comes from a dermal-fat graft. While this requires a donor site and a scar, its consideration should be high if other trunk scars already exist. (which can be used for the harvest site)

Tracheostomy scar revision can be done under local anesthesia, if desired, as a simple outpatient procedure. A fine line red scar will exist for awhile but the final goal of a pencil line thin scar can usually be obtained in most cases.  It is necessary to completely resolve the skin adherence to the trachea to significantly improve scar appearance in this very noticeable location.

Dr. Barry Eppley

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