MARISIENSIS 2014

SOME METHODS OF THE SURGICAL AND CONSERVATIVE TREATMENT OF KELOID SCARSAUTHOR : ADRIANA BOȚAN, forth year medical student, UMF Tîrgu MureșCOORDINATORS: ADRIAN BOȚAN, M.D., Ph.D., Senior Consultant Plastic Surgeon & Chief, The Burn Centre & Plastic Surgery Department, Teaching Hospital of Tîrgu Mureș Medical SchoolDAN VIOREL COZMA, M.D., Ph.D., Assistant Professor of Surgery, Department of General Surgery, Teaching Hospital of Tîrgu Mureș Medical School

Background: Plastic surgery has evolved as a medical specialty at the beginning of the twentieth century, especially during and after the First World War, out of the necessity for treating burns and post-burn deformities. Different surgical proce-dures have been developed in time aiming to prevent and to cure the morphological and functional consequences of the scar in process.Objective: The aim of this clinical presentation is to emphasize some particularities in the surgical and conservative treatment of deforming scars.

This is a characteristic image of a keloid scar (following a scald) of the anterior neck; this 19 year old girl has a very supple and soft neck skin, allowing marginal excision followed by direct closure.

The large excision is followed by a wide undermin-ing of the anterior neck. The first step of the direct closure is represented by the insertion of nu-merous absorbable buried sutures.

The image above shows the large dimensions of the excised scar.

The final aspect after direct closure, with no skin traction and no tension on the sutures. The patient had to wear a customized permanent pressure garment and use silicone gel every day.

This image shows the hand of a 45 year old patient with a scar band of the first web following a full thickness flame burn.

The most usual procedure to deal with such scars is to create a simple or multiple Z-plasties. The top of the scar is vast divided by a long incision which is the main branch of the Z-plasty.

A large undermining of both sides of the incision is performed.

The other two branches of the Z-plasty are then dissected and placed in the new position.

As it was previously emphasized, for the best flap survival, it is very important to perform an exten-sive dissection of the whole web space between the subcutaneous tissue and the superficial fas-cia.

The two triangular flaps thus obtained are eventually crossed and sutured into the new position.

The image from above shows a mutilating scar (following a full thickness scald by hot sunflower oil); one can see the deforming scars of the eyelids creating ectropion and lagophtalmy.

The terrible scar and the ectropion can be better seen in the image above.

The ectropion is very dangerous because it may develop corneal ulcer and loss of vision. One can see the severe distortion of the superior ciliary margin of the right eye.

The eyelids have been dissected, the scar removed and the remaining defect has been covered by full-thickness skin grafts harvested from the groin region; all grafts are placed directly on the orbicularis muscle.

Special bolster dressings (tie-over) soaked in paraffin have been placed above the full-thickness skin grafts.

10 days later all sutures and the bolster dressings have been removed ; one can see the good palpe-bral closure following the blepharoplasty.

In the image above one can see the good cosmetically and functional aspect of the eyelids.

The palpebral skin and the ciliary (eyelash) margins are now in a good functional position.

The image above shows a 56 year old patient with a huge (iatrogenic) paratherapeutic keloid of the right earlobe.

These keloids (on the ear, the anterior chest and shoulder) must be treated only in a conservative way because every aggressive surgery is always leading to another scar, greater and more invasive; that is why the scar is infiltrated with a mixture of triamcinolone (Kenalog) and lidocaine. The injection is done under high pressure until all scar tis-sues are flattening and blanching.

Such infiltrations (Kenalog 30 mg and lidocaine 20 mg) are performed every six weeks until the scar progressively regresses.

This case is still in process, but we can see a very good result at six months after the first infiltration.

Results

Surgical treatment is preferred for those cases where the postoperative result is considered to be superior to the initial aspect. Surgical techniques are applied only to old, neglected scars (hypertrophic scars are submitted only for conservative treatment). The regions where conservative treatment is mandatory are known as “noli me tangere” (the retroauricular, presternal and deltoid regions), invasive surgical techniques must be avoided at all costs.

Conclusions

Scar management (especially for post-burn deformities) is an arduous process requiring long term follow-up and a perfect collaboration between patient and physician. Even after the reconstructive intervention, monitoring and conservative treatment of the surgical result is mandatory. Preventing scar development through various techniques (frequent light and deep massages, special topical gels, wearing of pressure garments) is the cornerstone of all therapeutic procedures involved in scar management.

Bibliography:

Boțan A. Some Principles of Keloids Management. Proceedings of SASME International Congress, Francavilla al Mare, Italay, May 8-10 2010.Newsome R.E.,Tandon R. Wound Healing, Keloids. eMedicine Specialties – Plastic Surgery; 2009, June 26.Snow S.N., Oriba H.A. Scalpel Sculpting. Harahap M.(ed.), Surgical Techniques for Cutaneous Scar Revision. Marcel Dekker Inc; 2000 p.149-169.Haneke E. Fusiform Excision and Serial excision. Harahap M.(ed.), Surgical techniques for Cutaneous Scar Revision. Marcel Dekker Inc; 2000 p.359-380.Harahap M., Marwali R.P. The Overlap Technique. Harahap M.(ed.), Surgical techniques for Cutaneous Scar Revision. Marcel Dekker Inc; 2000 p.349-358.