AUTHOR AND EDITOR INFORMATION

Section 1 of 8  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Treatment
• Complications
• Future And Controversies
• References

INTRODUCTION

Section 2 of 8  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Treatment
• Complications
• Future And Controversies
• References

The treatment of aesthetically displeasing scars of the head and neck is challenging at times, although not without options. While removing one scar without leaving another is not possible, replacing an unfavorable scar with a more camouflaged one, or rendering an existing scar less noticeable, is possible.

By the time scar revision patients present to a physician, they have exhausted every means at their disposal to disguise the scar. These attempts at concealing the scar typically involve the use of cosmetics, clothing, and hairstyle modifications. While various treatments exist, none is perfect, and the cornerstone of any scar revision is a thorough understanding of the patients' dissatisfaction with their appearance and their expectations following treatment. Patients must understand that the best result may require multiple treatments and that initially, little improvement may be noticeable relative to the preexisting deformity.

Other considerations of paramount importance when considering scar revision include (1) whether the scar is in a position that compromises function and (2) if any revision might result in decreased function. As with any skin defect, the quality and availability of surrounding tissue must be assessed.^{1, 2}

The Medscape Dermatology Surgery Resource Center and Aesthetic Medicine Resource Center may be helpful.

History of the Procedure

According to ancient Egyptian writing, scarification for aesthetic reasons dates back to 1700 BCE. Throughout history, different cultures have used scarring as a depiction of one's affiliation with a particular group, its exploits, or stature. In most cultures now however, scars on the head and neck are perceived as undesirable, and patients often present to their physician requesting revision to render their scars less noticeable.

Problem

In general, scar revision techniques are either operative or nonoperative in nature. More aesthetically pleasing scars are those that are less noticeable. Intuitively, this includes matching the surrounding skin in color, texture, distensibility, and elevation. The characteristics of scars are important relative to their surroundings. For example, scars often have fewer dermal appendages or lack them altogether. In areas of hair-bearing skin, a scar's lack of hair follicles is particularly noticeable. In other areas with sparse hair follicles, this is a desirable attribute of scars.

Patient characteristics also play a large factor in scarring, as does the quality of closure and the cleanliness of the wound. Patients at the extremes of age often scar to a greater degree. Young patients are more prone to excessive scar formation, while elderly persons are more prone to poor healing, owing to diminished fibroblast activity. Individuals with connective-tissue disease, diabetes mellitus, or vitamin deficiencies or those who return to activity too early may experience healing complications that result in greater scarring upon final closure.

Wounds that are poorly closed, undergo dehiscence, have necrosis of the skin edges, or have edges that are poorly approximated are more likely to heal with unsightly scarring. Likewise, wounds that become infected or undergo foreign body reactions to sutures more frequently yield poor cosmetic results. Proper screening of patients prior to surgery, proper nutrition, good technique, and conscientious wound care dramatically favor faster wound healing and more aesthetic results.

Etiology

Before considering scar revision, the treating physician must have an understanding of wound healing and how scar tissue forms. Wound healing progresses in 3 phases: an inflammatory phase, a granulation phase, and the final, remodeling phase.

Inflammation is an immediate physiologic response to any injury to the body. In the skin, it serves the additional role of helping to contain and repel any organisms or foreign materials introduced into the tissues by a variety of traumas, including surgical incisions. The various mediators of inflammation are the first materials released in the wound, including activated complement, transforming growth factor-beta, circulating monocytes, tissue macrophages, neutrophils, platelets, clotting factors, and serum proteins, among others. Damaged collagen fibers promote platelet aggregation in the wound. Later, collagen provides the scaffold for wound healing as the major constituent of the extracellular matrix. This primary phase of wound healing typically lasts for 1-2 days.

The granulation or proliferative phase involves fibroblast proliferation within the wound bed. These cells are responsible for the production of the collagen extracellular matrix. Cytokines present in the wound bed at this time also promote the process of angiogenesis and the appearance of granulation tissue, a characteristic of the healing wound. Once collagen is laid down as an extracellular matrix and cells have grown on this scaffold, the wound enters the remodeling phase of wound healing.

The remodeling phase involves the reassortment of collagen fibers laid down in the preceding proliferative phase. Remodeling is the longest period of the wound healing process; it may continue for up to a year. However, 2-3 weeks is a more common interval for this final phase of wound healing. During this time, the net amount of collagen does not increase, but the formation of a more orderly arrangement of fibers helps to greatly increase the wound's tensile strength. When healed properly, the final wound strength reaches 70-80% of prewound strength.

Pathophysiology

The ideal scar is narrow and fills but does not eclipse the original volume of the wound bed. In fact, the wound often decreases in size upon healing due to contractile forces involved in scar formation. Occasionally, scar formation may be exuberant, as in the cases of hypertrophic scarring or keloid formation. Although discussed in detail in Keloid and Hypertrophic Scar, a brief mention of these unwelcome sequelae of wound healing is warranted.

Hypertrophic scars do not extend beyond the original boundaries of the wound laterally, but scar tissue may rise above the level of the surrounding skin. This commonly results in a very noticeable, irregularly contoured scar. A more extreme example of exuberant growth of scar tissue is the keloid. Keloid scars extend beyond the original borders of the wound, resulting in a raised and expanded scar relative to the original defect. These are often very noticeable, and they occur with increased frequency in persons with dark complexions. In both hypertrophic scars and keloids, components of the extracellular matrix are increased. Thus, while the number of fibroblasts present is normal, the cells present are apparently overactive in their wound healing response.

INDICATIONS

Section 3 of 8  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Treatment
• Complications
• Future And Controversies
• References

The indications for scar revision are often a matter of patient preference. Scars on the head and neck are distressing to most patients. However, certain aspects of a scar, such as the color or texture, may bother one patient more than another. Patients should be counseled that a scar-free revision is not realistic and that an optimal result is achieved only through cooperation between patient and physician.

CONTRAINDICATIONS

Section 4 of 8  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Treatment
• Complications
• Future And Controversies
• References

Cigarette smoking, nonsteroidal anti-inflammatory drugs, vitamin E, and isotretinoin should be stopped at the appropriate time prior to revision. Noninvasive or minimally invasive measures such as microdermabrasion and intralesional steroid injection can be performed as early as 3 weeks after revision of the scar, but many practitioners prefer to wait 6 weeks. When undertaking a revision, subtle problems should be treated conservatively first, before more aggressive interventions are used. Patients should be informed that the final maturation of the scar may take up to a year after revision. Above all, stress to the patient that scar revision merely replaces one scar with another in an attempt to improve the aesthetics of the area.

Complete restoration to the preinjury state is not possible under any circumstances, but the revised scar may be less detectable. A patient with realistic expectations is more likely to be satisfied with the final results of the revision procedures than a patient with unrealistic expectations.

TREATMENT

Section 5 of 8  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Treatment
• Complications
• Future And Controversies
• References

Medical therapy

Nonsurgical interventions

Nonoperative techniques for scar revision include topical applications to the scar tissue, materials injected within the lesion, augmentation of soft tissues, cryotherapy, laser therapy, and coloring involving makeup or tattooing. Each of these modalities has its advantages and disadvantages, and often more than one technique is used to aid in obtaining a more aesthetically pleasing result. Topical applications include the use of products such as silicone gels or sheeting, creams or salves, vitamins E and A (retinoic acid), herbal remedies, and others. These are the most widely used approaches by patients because they are easy to use and are of low cost. Depressed scars can be filled with temporary or permanent filler materials.

Silicone gel or silicone sheeting may be applied over healing wounds to promote scar improvement. Although this is somewhat effective in reducing scarring, no clear mechanism has been proposed. The improvement in scarring is purportedly due to the water retention in tissues beneath the occlusive silicone dressings. This effect is apparently independent of any compressive forces exerted by the dressing, and silicone gel offers the added advantage of not needing to be taped over the wound as does silicone sheeting. In vitro experiments have shown that this hydration decreases the production of collagen by fibroblasts and the production of glycosaminoglycans.

Other petroleum-based ointments also provide this occlusive effect, promoting hydration and improving scar appearance. Creams and salves of different varieties are widely used in the treatment of scars. Topical applications including vitamin A have been shown to improve the aesthetic properties of scars. Vitamin A as applied to the skin is 0.05% retinoic acid and is an effective resurfacing agent. Scars exposed to retinoic acid are typically less irritated, less elevated, and softer. The topical route of administration is preferred because the systemic toxicity of vitamin A is more easily avoided than with oral intake of the vitamin.

Despite popular opinion, applications containing vitamin E have been shown in double-blinded studies to result in no improvement in the cosmetic appearance of surgical scars compared with placebo. Vitamin E penetrates deeply into the dermis and has an antioxidant effect. If applied to a wound in the early stages of healing, the recovery of tensile strength may be adversely affected. Lastly, creams or salves containing herbal remedies have been shown to be largely ineffective in changing the attributes of scars, or at best, are of unproven efficacy.

Intralesional injections allow for greater penetration of the scar by the therapeutic agent and for delivery of greater concentrations locally than with topical or systemic administrations. The 2 most common intralesional injections are corticosteroids and antimitotic agents. Intralesional corticosteroid injection has been extensively studied and proven to reduce the size of hypertrophic scars and keloids. Steroids exert several effects on healing scars, including reducing fibroblast populations, reducing the formation of new vasculature, and decreasing fibrosis.

Intralesional steroidal therapy every 4-6 weeks is often used following scar excision to prevent a reoccurrence of unsightly scarring. Intralesional corticosteroid injection is the common standard used in research to establish the relative effectiveness of new agents for scar revision. However, intralesional steroid injections are not without potential adverse effects, including changes in coloration of the scar tissue, the development of telangiectasis in the overlying skin, and the formation of granulomas.

Antimitotic agents such as 5-fluorouracil or bleomycin are used intralesionally to inhibit proliferation of scar tissue. These agents are contraindicated in pregnancy.

Cryotherapy involves the freezing of tissue with liquid nitrogen. The mechanisms of action are cell death and sloughing. Liquid nitrogen is applied either in spray form or directly with a cotton applicator. Immediately after application, the area becomes edematous, and cell death ensues. The resulting scar, if managed well, may provide a more aesthetic result.

Laser therapy has progressed significantly since it was first used to treat skin lesions. Laser is an acronym for light amplification by stimulated emission radiation. Laser light that is absorbed heats the tissue and coagulates or ablates it. Pulsed-dye laser systems are often used because they have been shown to result in long-term improvements in the appearance of scars, whereas continuous carbon dioxide lasers and Nd:YAG lasers have had shorter-term successes. The wavelength used is 585 nm, which is vasculature specific. This ablation within the scar tissue helps to decrease the height of the scar and to render the tissue of the scar softer. When performed correctly, the damage caused by the laser is limited to the underlying dermis; the epidermis is largely not affected. Because the skin barrier is not breached, infection rates are low. Hyperpigmentation can be reduced with laser therapy in some cases.

In scars that are significantly depressed relative to surrounding tissue, some filler material may be added to correct the contour deformity. For this method to be effective, the skin must be pliable. Consequently, soft tissue augmentation works poorly in heavily fibrotic areas. Collagen injections or fat transfers can be introduced into areas of depressed scar to elevate the skin and make the area less noticeable. These biologic tissues are derived from autologous or allogenic sources.³

Collagen is obtained from processed dermis, while lipocytes needed for fat transfers are obtained via liposuction prior to augmentation. Bovine collagen is also used, with the peptide ends of the collagen molecules cleaved enzymatically to diminish their antigenicity. A disadvantage of this material is that skin testing is required before injecting bovine collagen because 1-4% of patients have hypersensitivity responses. Collagen preparations used in the skin include Zyderm I and Zyderm II. Zyderm I is a 35-mg/mL collagen used in areas of thin skin, and Zyderm II is 65-mg/mL collagen used in areas of thicker skin. Collagen and fat injections last only a few months, and repeated injections may be necessary for correction of scar contour deformity. Other filler materials such as hyaluronic acid derivatives (eg, Juvederm, Restylane, and Perlane) can be used and do not require any skin testing.

Other options in soft tissue augmentation are processed acellular dermal matrix materials. These are widely available. They are treated to remove cells; therefore, they carry a very low risk of prion-related disease transmission. The processed acellular dermal matrix materials last longer than collagen or fat injections, but the dermal matrix must be implanted.

All of these are temporizing measures and do not provide long-term correction of the depressed scar. Permanent implants consisting of Gore-Tex, Softform, or Silastic (polytetrafluoroethylene) are long-lasting options. Hyperemic scars can be treated with nonablated lasers (pulse light).

Dermabrasion is a good technique for slightly raised scars. Dermabrasion does not treat the scar itself; it planes-down the surrounding skin, which makes the raised scar less noticeable. The skin is planed or sanded with a dermobrader, stripping away layers of the superficial dermis and epidermis. Regeneration of these layers then proceeds from the dermal appendages. The effects of dermabrasion are very operator dependent. Variations in abrasion either more superficially or too deep produce either a suboptimal effect or greater scarring, respectively. Because portions of the dermis are removed and the skin barrier is breached, dermabrasion has an associated risk of infection. Patients must be questioned about a previous history of herpes simplex infection, isotretinoin use, or previous surgeries in the affected area. Ablative lasers (eg, carbon dioxide, erbium) can also be used to decrease raised scars.

Surgical therapy

Surgical interventions

For longer-term results, surgical intervention is often a better option. Surgical treatments include fusiform scar excision, shave excision, partial or serial excisions, local flap coverage, skin grafting, and pedicled or free flaps. In all surgical closures in the skin, care should be taken to evert the skin edges slightly so that upon healing and wound contracture, the scar will be level with the surrounding skin. In closing the wounds, tension should be avoided and should not cross the joint line in linear fashion.

Fusiform excision involves incision around the scar in an elliptical pattern, and the ellipse is then removed. The resulting surgical scar should be thinner and more easily hidden. Care should be taken to reorient the scar if need be when using fusiform excision. In this manner, the scar can be brought to lie in the relaxed skin tension lines of the skin, placing the wound such that it is subject to forces primarily along its axis. Forces counter to the long axis of the wound serve to prolong healing time, widen the scar, and yield a less aesthetic final result.

Some patients may have scars that are too large to be excised in one sitting, and they may have insufficient available skin for local skin flap closure. An ellipse can be excised from the center of the scar, removing as much as possible while still allowing for primary closure. The sides of the wound are undermined in order to close the defect. After several consecutive operations, the scar tissue should have been nearly removed, so that in the final surgery, an ellipse can be designed to remove all scar tissue present. The result is a thin surgical scar where a wide scar had been. If scars are too wide, staged excision can be considered.

Tissue expanders can be placed around the scar to provide more skin and allow for greater excision of scar tissue while facilitating primary closure. Indications for tissue expansion in scar revision of the head and neck are an inadequate quantity and quality of surrounding skin or a determination by the surgeon that too great a morbidity would be associated with local flap revision of the scar. Because the skin of the head and neck is thinner than elsewhere on the body, the recommendation is that no larger than 400 mL be used in tissue expansion in these areas.

Another useful technique in scar revision is shave excision. Shave excision is especially useful in scars that are unsightly by virtue of their elevation relative to surrounding tissue. The elevated portion of the scar is shaved off in a parallel plane to the surrounding skin, and the wound is dressed to help prevent reoccurrence. Compressive-type dressings or silicone dressings are helpful in this regard.⁴

When normal tissue surrounds a scar in sufficient quantity, local flaps can be used to fill defects left after scar excision, to move scars into areas that are less noticeable, or to break up the lines of a scar. Local flaps should also be planned so that the scars come to lie in the relaxed skin tension lines of the body or lie along the borders of the aesthetic units of the face for optimal camouflage of the scar. Scars perpendicular to the relaxed skin tension lines or those crossing aesthetic units of the face are usually very noticeable. Local flaps are discussed in detail in Advancement Flaps, but 2 flaps deserve mention here. The Z-plasty and W-plasty can be used to break up a linear scar into smaller components and to change the orientation of a linear scar, making it less noticeable. The resulting scar is longer but more camouflaged than the original.

The Z-plasty is a double transposition flap and may be used in the revision of scars and scar contractions. The Z-plasty elongates the operated tissues. The design involves the exchange of 2 adjacent triangular flaps with a central limb and 2 limbs oriented to resemble a Z. The length of the central limb dictates the absolute gain in length after Z-plasty, while the angles chosen determine the percent of length increase. The typical Z-plasty has 60° angles, resulting in a gain in length of 70% relative to the central limb. The angles may range from 30-90°, providing gains in length of 25% and 120%, respectively. However, these gains are theoretical. Therefore, smaller gains are seen in practice, owing to restrictive skin factors.

Because the Z-plasty also requires normal adjacent skin, it is a poor choice for the correction of burn wound contractures. However, the gain in length provided by the Z-plasty is well suited to other scar contractures, and the changed axis of the final scar often provides a more aesthetic result in facial scar revision. In plotting a Z-plasty, the final position of the central limb is planned first. This portion of the new scar is perpendicular to the original central limb incision and should lie parallel to relaxed skin tension lines. Consecutive Z-plasties result in further transposition of skin and obliteration of straight-line scars. Sequential Z-plasties create transverse shortening and lateral tension on the wound.

The W-plasty is also used to change the orientation of portions of a linear scar, although many smaller triangular flaps are interposed among one another. The base of each triangle is adjacent to the base of the triangle opposed to it. Unlike the Z-plasty, the W-plasty does not confer any gain in length to the contracted scar line. The W-plasty increases rather than decreases lateral tension, and skin must be sacrificed in its construction. Therefore, the procedure should only be undertaken in areas of scar with excess adjacent skin. At the ends of the scar to be revised, the triangles should sequentially diminish in amplitude.

Z-plasties and W-plasties are creative techniques for breaking up a scar and making it less noticeable. Other so-called geometric broken-line closures often result in a geometric scar that looks unnatural and confers little or no improvement in the scar and should therefore be avoided in favor of easier, more effective closures such as Z-plasty, W-plasty, or local flaps.

Another type of unaesthetic scar is the trap-door deformity, or pincushioning. This phenomenon may occur in instances of a healed curvilinear wound. The center of the tissue becomes elevated relative to the surrounding skin. Correction of the pincushion deformity should not be performed until the maturation of the scar is complete. Techniques for revision of this deformity are excision of the old scar, defatting of the flap, and closure with Z- or W-plasty to provide a more cosmetic result.

COMPLICATIONS

Section 6 of 8  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Treatment
• Complications
• Future And Controversies
• References

The complications of scar revision are dehiscence, infection, and local effects such as erythema. The complication patients are most concerned with is recurrence of the original unaesthetic scar.

FUTURE AND CONTROVERSIES

Section 7 of 8  

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Treatment
• Complications
• Future And Controversies
• References

Revision of scars of the face and neck is particularly important to patients. Scars can be aesthetically displeasing, but in some areas, form and function should be taken into consideration and should not be compromised. It requires a thorough understanding by the surgeon of the patient's dissatisfaction with the scar and a thorough understanding of the patient with regard to options in revision and realistic final results. As with other cosmetic procedures, the main goal is to make the patient more comfortable with his or her appearance, even though the deformity may not be completely alleviated. Teamwork between the physician and patient helps ensure the optimal result in scar revision. A successful scar revision can bring great satisfaction to both parties and improve the doctor-patient relationship.

REFERENCES

Section 8 of 8

• Authors and Editors
• Introduction
• Indications
• Contraindications
• Treatment
• Complications
• Future And Controversies
• References

1. Alster T, Zaulyanov L. Laser scar revision: a review. Dermatol Surg. Feb 2007;33(2):131-40. [Medline].
2. Alster TS, Lupton JR. Nonablative cutaneous remodeling using radiofrequency devices. Clin Dermatol. Sep-Oct 2007;25(5):487-91. [Medline].
3. de Benito J, Fernández I, Nanda V. Treatment of depressed scars with a dissecting cannula and an autologous fat graft. Aesthetic Plast Surg. Sep-Oct 1999;23(5):367-70. [Medline].
4. Gold MH, Foster TD, Adair MA, Burlison K, Lewis T. Prevention of hypertrophic scars and keloids by the prophylactic use of topical silicone gel sheets following a surgical procedure in an office setting. Dermatol Surg. Jul 2001;27(7):641-4. [Medline].
5. Alster TS, Lewis AB, Rosenbach A. Laser scar revision: comparison of CO2 laser vaporization with and without simultaneous pulsed dye laser treatment. Dermatol Surg. Dec 1998;24(12):1299-302. [Medline].
6. Borges AF. Timing of scar revision techniques. Clin Plast Surg. Jan 1990;17(1):71-6. [Medline].
7. Chen JS, Shack RB, Reinisch L, Spector N, Zinsser JW, Weisberg NK, et al. A comparison of scar revision with the free electron and carbon dioxide resurfacing lasers. Plast Reconstr Surg. Oct 2001;108(5):1268-75. [Medline].
8. de Noronha L, Chin EW, Menini CM, Knopfholz J, Rampazzo JC, Graf R. Histopathologic and morphometric evaluation of the skin abnormalities induced by erbium:YAG and carbon dioxide lasers in 10 patients. Plast Reconstr Surg. Oct 2001;108(5):1380-8. [Medline].
9. Engrav LH, Gottlieb JR, Millard SP, Walkinshaw MD, Heimbach DM, Marvin JA. A comparison of intramarginal and extramarginal excision of hypertrophic burn scars. Plast Reconstr Surg. Jan 1988;81(1):40-5. [Medline].
10. Frileck SP. Scar revision. Ann Plast Surg. Feb 1980;4(2):138-43. [Medline].
11. Goldberg D, Metzler C. Skin resurfacing utilizing a low-fluence Nd:YAG laser. J Cutan Laser Ther. Jan 1999;1(1):23-7. [Medline].
12. Goldberg DJ. Wheeland RG, ed. Cutaneous Surgery. ed. Philadelphia, Pa: WB Saunders; 1994:410-16.
13. Goldberg DJ. New collagen formation after dermal remodeling with an intense pulsed light source. J Cutan Laser Ther. Jun 2000;2(2):59-61. [Medline].
14. Goldberg DJ, Samady JA. Intense pulsed light and Nd:YAG laser non-ablative treatment of facial rhytids. Lasers Surg Med. 2001;28(2):141-4. [Medline].
15. Goldberg DJ, Silapunt S. Hair removal using a long-pulsed Nd:YAG Laser: comparison at fluences of 50, 80, and 100 J/cm. Dermatol Surg. May 2001;27(5):434-6. [Medline].
16. Goldberg DJ, Silapunt S. Histologic evaluation of a millisecond Nd:YAG laser for hair removal. Lasers Surg Med. 2001;28(2):159-61. [Medline].
17. Goldberg DJ, Silapunt S. Histologic evaluation of a Q-switched Nd:YAG laser in the nonablative treatment of wrinkles. Dermatol Surg. Aug 2001;27(8):744-6. [Medline].
18. Jeong JT, Kye YC. Resurfacing of pitted facial acne scars with a long-pulsed Er:YAG laser. Dermatol Surg. Feb 2001;27(2):107-10. [Medline].
19. Kaplan B, Potter T, Moy RL. Scar revision. Dermatol Surg. Jun 1997;23(6):435-42; quiz 443-4. [Medline].
20. Kiliç A, Kiliç A, Emsen IM, Ozdengil E. Lip scars camouflaged using microhair transplantation on male patients. Plast Reconstr Surg. Nov 2000;106(6):1340-1. [Medline].
21. Kwon SD, Kye YC. Treatment of scars with a pulsed Er:YAG laser. J Cutan Laser Ther. Mar 2000;2(1):27-31. [Medline].
22. Langdon RC. Regarding dermabrasion for acne scars. Dermatol Surg. Nov 1999;25(11):919-20. [Medline].
23. Lent WM, David LM. Laser resurfacing: a safe and predictable method of skin resurfacing. J Cutan Laser Ther. Apr 1999;1(2):87-94. [Medline].
24. Leung KS, Sher A, Clark JA, Cheng JC, Leung PC. Microcirculation in hypertrophic scars after burn injury. J Burn Care Rehabil. Sep-Oct 1989;10(5):436-44. [Medline].
25. Manuskiatti W, Fitzpatrick RE, Goldman MP. Energy density and numbers of treatment affect response of keloidal and hypertrophic sternotomy scars to the 585-nm flashlamp-pumped pulsed-dye laser. J Am Acad Dermatol. Oct 2001;45(4):557-65. [Medline].
26. Manuskiatti W, Fitzpatrick RE, Goldman MP. Treatment of facial skin using combinations of CO2, Q-switched alexandrite, flashlamp-pumped pulsed dye, and Er:YAG lasers in the same treatment session. Dermatol Surg. Feb 2000;26(2):114-20. [Medline].
27. McCraw JB, McCraw JA, McMellin A, Bettencourt N. Prevention of unfavorable scars using early pulse dye laser treatments: a preliminary report. Ann Plast Surg. Jan 1999;42(1):7-14. [Medline].
28. McGillis ST, Lucas AR. Scar revision. Dermatol Clin. Jan 1998;16(1):165-80. [Medline].
29. Sarwer DB, Whitaker LA, Pertschuk MJ, Wadden TA. Body image concerns of reconstructive surgery patients: an underrecognized problem. Ann Plast Surg. Apr 1998;40(4):403-7. [Medline].
30. Sawcer D, Lee HR, Lowe NJ. Lasers and adjunctive treatments for facial scars: a review. J Cutan Laser Ther. Apr 1999;1(2):77-85. [Medline].
31. Shim E, Tse Y, Velazquez E, Kamino H, Levine V, Ashinoff R. Short-pulse carbon dioxide laser resurfacing in the treatment of rhytides and scars. A clinical and histopathological study. Dermatol Surg. Jan 1998;24(1):113-7. [Medline].
32. Snow SN, Stiff MA, Lambert DR. Scalpel sculpturing techniques for graft revision and dermatologic surgery. J Dermatol Surg Oncol. Feb 1994;20(2):120-6. [Medline].
33. Staindl O, Chmelizek-Feurstein C. [Scars and scar revision]. HNO. Jun 1983;31(6):183-92. [Medline].
34. Walia S, Alster TS. Prolonged clinical and histologic effects from CO2 laser resurfacing of atrophic acne scars. Dermatol Surg. Dec 1999;25(12):926-30. [Medline].
35. Whitaker DC, Smith AC. A caution in the evaluation of scar revision. J Am Acad Dermatol. Feb 1993;28(2 Pt 1):269-70. [Medline].
36. Yang JY. Intrascar excision for persistent perioral hypertrophic scar. Plast Reconstr Surg. Dec 1996;98(7):1200-5; discussion 1206-7. [Medline].
37. Zide MF. Scar revision with hypereversion. J Oral Maxillofac Surg. Sep 1996;54(9):1061-7. [Medline].

Article Last Updated: Oct 1, 2008