The key to surgical scar treatment is to remove the scar while preventing the development of new scarring. The surgical treatment of keloid scars requires the use of different surgical treatment principles and methods according to the characteristics of different keloid scars.
1. Superficial scar
(1) Treatment principle: If the scar does not affect the aesthetic appearance, surgery is generally not given; if it occurs on the face or exposed area and causes psychological burden, surgery can be chosen, but it should be treated with caution because new scars will occur after surgery, which may not be satisfactory to patients.
(2) Surgical methods.
① When the width of the scar is <2cm, one-time surgical excision and direct suturing, with appropriate Z-formation, changing the direction of the incision to conform to the skin pattern as much as possible.
②For scar width of 2-5cm, the scar can be excised and sutured in 2-3 times, the first few surgeries should try to make incisions within the scar, and the last surgery should pay attention to changing the direction of the incision to be in line with the skin line as much as possible.
③ If the scar width is >5cm, it is best to treat it with skin soft tissue expansion, the aesthetic effect will get better repair.
④For flat scars caused by acne, it is better to use dermabrasion if the area is wide, and scattered small amounts can be improved by removing the raised skin at the edge of the “pit” with ultra-pulsed CO2 laser.
(⑤ For those with flat forearms, a roller cutter is more effective than excision and suturing.
(6) Generally, free skin implants are not chosen for scar removal.
2.Depressed scar: divided into superficial depressed scar and deep depressed scar.
(1) Treatment principle: superficial depressed scar treatment is the same as superficial scar, while deep depressed scar, in addition to excision of scar and release of tissue adhesions, different methods are used to fill the defect according to the degree of depression.
(2) Surgical methods: The former can be done by grinding, excision suture, ultra-pulse CO2 laser, collagen injection or fat particle injection. For simple linear depressed scar, the superficial epithelial tissues can be excised and the deep scar tissues can be preserved, and the two edges can be pulled together and sutured layer by layer on the preserved scar. In the latter case, depending on the situation, the scar is completely excised, the tissue adhesions are loosened, and autologous tissues such as free dermal fat flap, tipped dermal fat flap, fat particle injection, bone or cartilage are transplanted in the depression, or appropriate tissue substitutes such as silicone rubber, artificial bone, Plexiglas, expanded PTFE are filled in, and local flap transfer is often used to cover the wound.
3.Linear, bridge and superfluous scar
(1) Treatment principles.
①Linear scar: excise the scar, change the direction of incision and tension if necessary.
②Bridge-like and superfluous scar: comprehensive consideration, excision of scar and repair of appearance.
(2) Surgical methods.
①Linear scar: direct excision and suture, or “W” or Z-formation, the operation should pay attention to subcutaneous free tension reduction and prevention of flap tip blood flow obstruction due to too small flap angle.
②Bridge and superfluous scar: a few simple bridges and superfluous skin can be excised and sutured directly; for larger complex bridges and superfluous skin, the rolled-up skin should be cut and flattened to form a double-tipped or single-tipped flap to repair the scar after excision.
4.Atrophic scar
(1) Treatment principle: according to the size of the scar, it is decided whether the scar should be directly excised and sutured, or repaired by skin grafting or flap grafting.
(2) Surgical method: According to the scar site, area and size, direct excision and suturing, scar excision and flap transfer and skin soft tissue expansion are appropriate methods.
5.Proliferative scar
(1) Treatment principle: If there is no special reason, early stage (proliferative stage) should be preceded by non-surgical treatment to inhibit scar proliferation, and surgery can be given in special cases such as lower lid ectropion, small mouth deformity and severe contracture deformity of joints. In most cases, surgery should be performed after the scar has matured and softened. The principle is to remove the scar, fully release the contracture, correct the deformity, and repair the wound with a skin slice or flap graft.
(2) Surgical methods: According to the site, area and size of the scar, appropriate methods such as direct excision and suturing, scar excision and skin grafting or flap transfer, skin and soft tissue expansion, and scar skin replantation should be chosen. For example, for cases with wide scar area and lack of skin source, only excision or partial excision of the scar can be performed, only seeking contracture release and repairing the trauma with skin flap transplantation. For hyperplastic scars in special areas such as face and neck, joints, etc., the effect of simple excisional skin grafting is often unsatisfactory, and the use of skin flap transfer is more effective for repair.
6.Contracture scar
(1) Treatment principle: cut or excise the scar, completely loosen the contracture, change the direction and position of the tension line, and repair the wound with skin slice or flap graft to restore function and shape. In general, for mild contracture, not deep scar and non-articular area, medium-thickness skin flap grafting is more suitable. For deep scar contracture, it is often difficult to determine the location and extent of the scar and deep adhesions before surgery, so it is necessary to make a thorough study before surgery, carefully design the surgical plan, choose the surgical approach, explore clearly during surgery, and then decide on the treatment plan.
(2) Surgical methods: for small scope, Z-formation, multi-Z-formation, five-flap formation, W-formation, V-Y or Y-V and other flap repair can be used. For severe contracture and larger scope, if the flap cannot cover the entire wound after displacement, skin soft tissue expansion, free skin flap or free flap grafting can be used for repair.
Complete release of the contracture is the key step in surgical treatment. Generally, an incision is made perpendicular to the longitudinal axis of the contracture to release it, and the scar is peeled along the division between the scar and the deep normal tissue until the contracture is completely released. Sometimes it is also necessary to perform auxiliary procedures such as tendon lengthening, capsulotomy, and joint ligament excision to achieve full release. During the release, appropriate external force can be applied, but do not use violent pulling to force the joint to reset, in order to avoid lacerations or fractures of nerves, blood vessels and other tissues. For those who cannot be reset at once, postoperative traction, arthroplasty or fusion can be performed according to the situation.
7.Keloid
(1) Treatment principle: surgical treatment of keloid must be cautious and should avoid surgery alone, but should adopt a comprehensive treatment mainly based on surgery.
(2) Treatment methods: preoperative radiotherapy + surgical excision, surgical excision + postoperative radiotherapy, surgical excision + postoperative drug injection therapy, intra-scar excision, etc. Attention should be paid to minimize the tension of the skin edge during surgical excision and suturing, and adopt the surgical methods of skin soft tissue expansion, skin slice or skin flap transplantation if necessary.
8.Keloid cancer
(1) Treatment principle: At present, it is advocated that for chronic non-healing ulcers, deep tissues should be repeatedly excised from multiple parts for pathological examination and early diagnosis of cancer; once the scar cancer is diagnosed, the lesion should be excised by surgery as early as possible, together with radiotherapy or chemotherapy if necessary.
(2) Treatment method: complete excision of the cancerous ulcer and its deep involved tissues along the 2cm edge of the lesion, and surgical repair of the wound by skin slice or skin flap graft according to the wound condition after excision of the cancerous tissues. For amputation of scar cancer occurring in the limbs, a cautious attitude should be taken because the malignancy of scar cancer is low, even if there is enlargement of inguinal lymph nodes, it is not necessarily caused by cancer metastasis, and there is still a possibility of limb preservation.