Scar Placement Research Articles

Circumvertical Mastectomy Incision

Different surgical incisions have been proposed for skin-sparing mastectomy in an attempt to better disguise the remaining scar. These techniques are more hidden than the Stewart incision but can still leave scars in visible places and can restrict the natural shape of the upper pole. They can also add complexity and time to the mastectomy, requiring extensive retraction that could damage the salvaged skin flaps to perform an adequate mastectomy. We present a circumvertical mastectomy incision technique, which limits the mastectomy scar to the inferior pole, provides natural lateral contour, superior pole fullness, and contributes to a more youthful breast projection. Between November 2011 and November 2012, 51 women underwent circumvertical AlloDerm/tissue expansion reconstruction at our institution by a single surgeon. The reconstruction was bilateral in 30 patients and unilateral in 21 patients for a total of 81 breasts. Of the 81 reconstructed breasts, 5 patients went on to require a latissimus dorsi flap for definitive reconstruction and 3 failed breast reconstruction for a completion rate of 96%. The goal of creating breast reconstruction results comparable to those of cosmetic breast surgery is becoming a reality. Circumvertical incision is a technique that can prevent visible upper hemispheric breast scarring, limit upper pole constriction by scar placement, and preserves or restores breast projection. Following the principles of aesthetic breast surgery and repositioning the mastectomy scar, one can reconstruct a breast with a more disguised scar, which can be hidden from the patient's downward gaze.

Voice outcomes following laser cordectomy for early glottic cancer: A physical model investigation

The voice effects following laser cordectomy for early glottic cancer are poorly described. We investigated the voice outcomes of subligamentous cordectomy of progressive anterior-posterior extent of excision. Physical phonatory modeling. The influence of vocal fold surgical defects and corresponding scar was experimentally investigated using a self-oscillating physical model of the vocal folds and compared with the baseline model without defects or scar. Results showed that increasing anterior-posterior extent of resection increased phonation threshold pressure and flow rate and reduced excitation of high-order harmonics, resulting in a more breathy and rough voice production. However, it was found that voice production was improved with the placement of scar, which increased both excitation of high-order harmonics and the harmonic-to-noise ratio. Although large anterior-posterior surgical resections resulted in progressive impact on vocal measures, a limited excision of the vocal fold cover surprisingly demonstrated minimal voice changes. Further investigations are required to define the acceptable extent of surgical resection that may result in optimal voice outcomes.

Response to “Going in the Wrong Direction With Monsplasty”

In their Letter to the Editor, Drs Davison and LaBove pose an interesting question regarding the optimal scar placement for monsplasty and advocate that vertical pull on the mons elongates the pubic area by raising the hairline. While in many massive weight loss patients, the mons region can have both vertical and horizontal excess, the vertical component is easy to manage, as long as the scar is based 6 cm above the anterior vulvar commissure. We agree that if this scar is placed too …

An Easy and Novel Method of Preoperative Laser-Assisted Marking for Body Lift Procedures

Sir: We read with great interest the article “Simplifying Circumferential Body Contouring: The Central Body Lift Evolution” by Rohrich et al.1 The authors present the evolution of their technique and experience with the central body lift procedure in a greater than 12-year period and emphasize the key operative elements and strict safety guidelines that afford optimal results with minimal morbidity. We would hereby like to introduce a novel technique to facilitate the preoperative planning and marking concerning the body lift procedure in massive weight loss patients. Preoperative markings are set in standing position,2,3 and this sometimes implicates difficulties for the surgeon, especially in drawing straight vertical and horizontal lines, which later on will be the position of the horizontal scar on the typical position of the abdomen and the back. Scar placement is crucial and the result of a precise marking technique. In the massive weight loss patient, excess skin may make identification of the anatomical landmarks (which are often used for orientation to achieve symmetry) difficult.4 Kalbermatten et al.5 in 2009 suggested body taping to visualize the optimal position for skin incision. This technique makes preoperative marking objectively reproducible. The authors also postulated demands for a sufficient marking technique, which are all fulfilled by our new method too: minimal expenditure of time, congruence of marked and later resected area, and finally cost efficiency. In this Viewpoint, we present a new simple method of reproducibly defining the incision lines for body lift procedures with an available laser marking device (Fig. 1).Fig. 1: Laser device placed opposite the standing patient (Stanley XP180 Cross Line and Laser Plumb; Stanley Deutschland–HDL Industrievertretung GmbH).The patient is placed standing with hanging arms to avoid a tightening effect on the lateral trunk. The laser marking light lines (horizontal and vertical light) are turned on and the vertical light line is placed exactly on the anal cleft. The designated scar line is generally defined by placing the horizontal laser light approximately 2 cm below the upper impression of the underwear’s elastic strap. After marking of a median line, further vertical lines are drawn at a distance of 5 cm (2 inches) as far as the spina iliaca anterior superior by turning the patient. For defining the resection margins, skin is moved upward and downward using the tip of the index finger at each vertical line. Immediately before skin slips of the fingertip, a skin mark is set at the place where the vertical line and laser light intersect. This maneuver is started medially and continued to the lateral side as far as resection is planned. To complete the drawing of the inferior and superior incision line, these points are connected (Fig. 2).Fig. 2: Laser marking light lines (horizontal and vertical light) placed on the back of the patient.The use of this simple instrument allows placement of reproducible skin markings, pays respect to varying tissue mobility, and reduces time needed for preoperative skin marking. As a sighting device, the laser marking device gives the surgeon a secure instrument with which to draw precise lines that finally will result in a more precise positioning of the scar and thus a better postoperative outcome for the massive weight loss patient. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. No funding was received for this work. Lorenz Larcher, M.D. Hospital of St. John of God (Barmherzige Brüder) Salzburg (A) Department of Plastic, Aesthetic, and Reconstructive Surgery Academic Teaching Hospital Paracelsus Medical University Salzburg Karl Schwaiger Paracelsus Medical University Salzburg Florian Ensat, M.D. Gottfried Wechselberger, M.D., M.Sc. Heinrich M. Schubert, M.D. Hospital of St. John of God (Barmherzige Brüder) Salzburg (A) Department of Plastic, Aesthetic, and Reconstructive Surgery Academic Teaching Hospital Paracelsus Medical University Salzburg Salzburg, Austria

Breast Reduction Scars

Studies have shown that scarring is a primary reason for patient dissatisfaction with reduction mammaplasty. The authors prospectively evaluated patient preferences for the 3 most common breast reduction scar patterns: horizontal, vertical, and Wise. Sixty-six patients were recruited for the study before receiving their reduction mammaplasty consultation. Each patient was shown line drawings and postoperative photographs of the 3 breast reduction techniques and scored the scars on a modified 10-point Likert scale (1 = unacceptable; 10 = acceptable). The survey responses had no impact on the patients' medical care. A nonparametric Friedman test was used to compare the mean scores, and univariate generalized linear regression analysis was performed to adjust for confounding factors. Post hoc analysis was performed using the Bonferroni method. Significance was set at P < .001. Sixty patients completed the study. The mean preference ranking was significantly higher for the horizontal scar pattern versus vertical and Wise (P < .001). The mean score difference between the horizontal and Wise patterns was 2.982. The mean difference between the horizontal and vertical patterns was 2.27. There was no significant difference in preference between the vertical and Wise patterns. Linear regression analysis showed that age, body mass index, and torso/bra size had no significant effect on preference. To our knowledge, this is the first study designed to prospectively evaluate patient preferences regarding postoperative scars. Results indicate that the horizontal technique is preferable with respect to scar placement.

Commentary on: What Do Patients Want? Technical Quality Versus Functional Quality: A Literature Review for Plastic Surgeons

Ms Smith, your patient of many years, is beaming as you walk into the examination room. After a brief exchange of pleasantries, she seamlessly transitions into a request for removal of some obviously benign skin lesions. As she talks, you struggle to listen, mesmerized by the bizarre face addressing you. A lateral sweep, tethered ear lobes, inexplicable scar placement, and malpositioned fat grafts seem to be only the start. “Oh, you’ve noticed I finally got that face-lift we’ve been discussing for years,” she exclaims through plethoric, distorted lips. “Isn’t it great?” She drones about the work of her “cosmetic surgeon, Dr Wannabee,” how nice the staff was, and the great price she was given (“Thousands less than you quoted me!”). You know that, in actuality, Dr Wannabee is not certified by any legitimate board, didn’t even finish residency (a nonsurgical one, at that), and operates in a noncertified office facility. Through the years, you have seen many poor results from Dr Wannabee, yet the practice seems to prosper, at least as evidenced by a perpetual barrage of advertising. Disappointed, you ask yourself why Ms Smith made what, to you, is such a poor choice, why she is seemingly happy with clearly inferior results, and—most personally distressing—why she did not select you to do her face-lift. Dr Fiala’s excellent article, “What Do Patients Want? Technical Quality Versus Functional Quality—A Literature Review for Plastic Surgeons,” provides us with keen insights into the potential origins of such a scenario.1 As surgeons, we have striven for years to develop, refine, and perfect our technical quality (TQ). However, as the author clearly illustrates, patients are generally poorly equipped to judge TQ. This is not particularly surprising, given that even highly skilled and experienced aesthetic surgeons may not always agree on TQ measures like aesthetic …

Canadian Society of Plastic Surgeons Société Canadienne des Chirurgiens Plasticiens

The presenter will discuss the evolution of his facelift practice. Fit the operation to the patient is the basic premise. The concept of dealing with the deep layered support will be discussed and representative results will be shown. Unsatisfactory results and complications will be addressed. Helpful techniques learned from performing almost 5000 facelifts will be shown. Learning Objectives: The presenter will review facial rejuvenation techniques as they have evolved over the past 40 years. Participants will be able to evaluate scar placement, compare the various techniques to fit the operation to the patient and understand the management of complications. Can J Plast Surg. 2012 Summer; 20(2): 109–140. » 01 Measuring Quality of Life in Facial Aesthetic Patients: Field-Testing of a New Modular System (The Face-Q) Can J Plast Surg. 2012 Summer; 20(2): 109. 01 Measuring Quality of Life in Facial Aesthetic Patients: Field-Testing of a New Modular System (The Face-Q) A Scott, S Cano, A Klassen, R Warren, N VanLaeken, and A Pusic Copyright and License information ► Copyright ©2012 Canadian Society of Plastic Surgeons. All rights reserved Abstract PURPOSE: In aesthetic surgery, the assessment of patient-reported outcomes (PRO) is especially pertinent to clinicians as patient satisfaction and quality of life are the predominant considerations determining success. In order to measure the impact of these procedures, well-developed and validated questionnaires are needed. The purpose of this study was to develop a new PRO measure to evaluate patient satisfaction and quality of life following facial cosmetic procedures. The main scale: ‘Satisfaction with face overall’ will be presented.

Aesthetic Sculpting for the Natal Cleft and Buttock Lift Using an Innovative Periosteal-Dermal Suture Suspension Technique

Natal cleft contouring poses a reconstructive challenge. Buttock aesthetics and the need for careful scar placement are part of the challenge faced by plastic surgeons. Various steps of the reconstructive ladder can be used with varying outcomes. We report a patient who underwent natal cleft reconstruction using a new suture technique and had a cosmetically pleasing outcome.

Monoblock Thoracobrachioplasty in Males: A Proposed Technique Mimicking the Pectoral Fold

A growing number of men with massive weight loss are seeking improvement of arm deformity extending through the axilla and on to the chest. Although contouring techniques addressing the male arm and anterior chest deformities as separate entities have been described, when a combination of those techniques is performed, the surgical outcomes may lead to improper placement of the resultant scars. The authors propose an upper body-contouring treatment by monoblock thoracobrachioplasty aimed at correcting chest, axilla, and arm deformities in men through a single continuous incision, resulting in a thoracic scar placed right on the pectoral fold. The described surgical approach provides excellent chest contour and simultaneously addresses the upper extremity and axillary contour deformities in men after massive weight loss. The final position of the scar on the thorax corresponds to the inferior pectoral groove, resembling the division of two aesthetic units in the thorax and resulting in anatomically favorable scar positioning. A limitation of this proposed technique is the potential retraction of the axillary part of the continuous scar that may need revision. Careful preoperative evaluation and markings followed by intraoperative skillful handling are needed to prevent complications. The procedure appears relatively simple and easy to perform but requires a learning curve for previewing the ideal positioning of the resultant scar to obtain aesthetically favorable results. Monoblock thoracobrachioplasty mimicking the pectoral fold is a treatment option to be added to the armamentarium of techniques for postbariatric male patients.

An Algorithmic Approach to Breast Reconstruction Using Latissimus Dorsi Myocutaneous Flaps

Innovative surgical techniques developed by surgical oncologists have changed the landscape of mastectomy defects. Latissimus dorsi myocutaneous flap-based breast reconstruction provides a reliable foundation for breast reconstruction. The purpose of this study was to evaluate differential skin island designs with latissimus dorsi myocutaneous flap breast reconstruction, and to develop an algorithmic approach to breast reconstruction that is applicable to a broad spectrum of mastectomy defects. In this study, the authors retrospectively reviewed data of patients who underwent latissimus dorsi myocutaneous flap reconstruction following unilateral or bilateral mastectomies between February of 2001 and April of 2005. Patients were selected to undergo reconstruction under the following circumstances: (1) previously irradiated tissue, (2) body mass index greater than 30, (3) current tobacco use, (4) previous abdominopelvic surgery, and (5) patient preference. Patients were divided into three groups based on defect present: intact inframammary fold with skin deficit, intact inframammary fold without skin deficit, and absent inframammary fold with or without skin deficit. Differential skin island design was customized to the presenting mastectomy defect to optimize results and minimize donor-site scaring. Fifty-four patients underwent 64 latissimus dorsi myocutaneous flap reconstructions. Aesthetic outcomes and donor-site scar placement differed between groups. The authors have developed an algorithmic approach to latissimus dorsi myocutaneous flap breast reconstruction. Through critical evaluation of mastectomy defects, reconstructive breast surgeons can tailor skin island orientation, minimize donor-site scarring, enhance cosmetic outcomes, and provide a durable and natural aesthetic outcome in breast reconstruction with the latissimus dorsi myocutaneous flap.

Internal Pedicle Shaping to Improve Aesthetic Results in Reduction Mammaplasty

Reduction mammaplasty has been performed utilizing various techniques to achieve reduction in breast volume and to enhance aesthetic shape. The conventional inverted T-scar method is the most widely used technique in breast reduction given its predictability and versatility [1]. Nonetheless, newer surgical techniques have been developed in order to optimize outcome while minimizing associated complications. Pedicle types include inferior, central, superior, lateral, and bipedicle, all of which maintain the blood supply and innervation to the nipple-areola complex [2]–[6]. Cosmetically acceptable placement of scars, although debated, has also been emphasized through additional technical modifications including short scar periareolar inferior pedicle reduction mammaplasty (SPAIR), vertical mammaplasty without inframammary scar, or no vertical scar breast reduction [7]–[10].

The Influence of Subfascial Transaxillary Breast Augmentation in Axillary Lymphatic Drainage Patterns and Sentinel Lymph Node Detection

The transaxillary approach plays a useful role for breast augmentation due to scar placement in a less visible position. However, the future impact of the procedure on the lymphatic drainage patterns and sentinel lymph node (SLN) detection remains controversial. To date, no information is available regarding the feasibility of SLN identification in patients with previous transaxillary breast augmentation (TBA). Twenty-six patients underwent primary TBA. Mean follow-up was 8.3 months. All patients were submitted to lymphoscintigraphy (LSG), with a dose of 0.1 mCi 99m-technetium-labeled dextran 1 week before (preop-LSG) and 10 days (Po10 days-LSG) after TBA. Preop-LSG was successful in all patients. Mean number of SLN detected was 2 per patient (range, 1 to 4) in the right axilla and 2.2 (range, 1 to 5) in the left. In Po10 days-LSG, SLN detection was successful in 92.3%. Mean number of SLN detected was 2.3 per patient (range, 0 to 7) in the right axilla and 1.8 (range, 0 to 6) on the left. Two patients (7.6%) failed to reveal the accumulation of radioactivity in Po10 days-LSG. Comparing bilaterally, in the number of SLN detected (P = 0.838) and the SLN uptake (P = 0.067) between Preop-LSG and Po10 days-LSG, no significant differences were observed. No major complication was noted. The initial data illustrate that SLN detection in the setting of prior TBA is feasible in a great part of patients. Additional long-term studies are necessary to investigate the accuracy of SLN biopsy in subgroups of breast cancer patients with previous breast implants.

The psychological impact in children of using Microskin, a novel spray-on semi permanent cover for mature scars from burns

Objective: To examine the impact in young people on self esteem, behaviour, body image, peer relationships and family function, of using a new product to cover mature scars from burns. Methods: 20 young people with a range of severity of burn and a variety of placement of burn scars were randomised to the Microskin use group or to waitlist. Assessments on a range of variables were taken on entry to the study and at 6 weeks after usage began. Results: Remarkable improvements are reported in self-esteem, behaviours, body image, peer relationships and family function as well as social behaviour, Conclusions and implications for discussion: This remarkable new product appears to be able to assist young people to come to terms with permanent mature scars from burns. Reductions in social anxiety, as well as surprising improvements in a range of internal psychological functioning, and family dynamics suggest that the product should be made more easily available, Further studies are planned to support the current evidence from the pilot study.

The Grid/Staple Adjunct to Abdominoplasty

A variety of designs have been described for skin resection in abdominoplasty, but all have in common the need for intraoperative modification. Comparison of the different techniques is problematic because the actual skin resection may differ from the preoperative design. In addition, it may be difficult to achieve a symmetrical result, given the shifting bulk of the skin and soft tissue and the differences between the upright and supine patient. This article describes a standardized grid pattern drawn on the abdomen preoperatively that promotes symmetry and allows postoperative determination of the exact extent of skin resection. Preliminary stapling fundamentally changes the sequence of the procedure by eliminating the conventional first step of flap elevation. The technique was used on 31 patients from January of 2004 through May of 2005. Body mass index ranged from 19.1 to 33.1, with an average of 24.4. All procedures were performed under general anesthesia in an accredited office operating facility on an outpatient basis. Details of the technique and representative cases are shown. Use of the grid pattern allows more meaningful comparison of different techniques and gives the surgeon more insight into his or her own technique. When combined with temporary intraoperative skin stapling, it maximizes symmetry of the results, facilitates precise scar placement, and minimizes the need for modifications such as chasing dog-ears. Stapling also allows identification of the proper amount of safe tissue resection at the beginning of the procedure, allowing the redundant tissue to be removed without first being elevated as a cumbersome flap.

Excision of Subcutaneous Facial Cysts and Lipomas Using Cosmetic Approaches

The excisional biopsy of subcutaneoous facial cysts and lipomas can be problematic due to the high esthetic nature of the affected area. Remote scar placement has advantages in allowing access to subcutaneous pathology while placing incision lines in cosmetic locations. This article will review excisional biopsies of subcutaneous facial cysts and lipomas using cosmetic approaches. Patients with superficial facial cysts or lipomas undergoing excisional biopsies utilizing contemporary cosmetic surgery approaches (rhytidectomy, lower blepharoplasty, and submental) with tumescent anesthesia and either intravenous sedation or general anesthesia. All patients had successful removal of superficial facial pathology with good cosmetic results. The use of contemporary cosmetic surgical approaches for the excisional biopsy of superficial facial cysts and lipomas provides adequate surgical access, a cosmetically acceptable result, and is well-tolerated by patients.

The Feasibility of Sentinel Lymph Node Detection in Patients with Previous Transaxillary Implant Breast Augmentation: Preliminary Results

Transaxillary breast augmentation has gained popularity because of the good aesthetic results and scar placement in a less visible position. As breast-augmented patients age, an increasing number of breast cancer cases can be expected. Sentinel lymph node detection (SLND) is a well-established technique in breast cancer. To date, no information is available regarding the feasibility of SLND for patients with previous transaxillary implants. A 28-year-old women with bilateral breast hypoplasia underwent a bilateral breast augmentation by the transaxillary approach. One week earlier, SLND was accomplished through two periareolar injections of 0.1 mCi 99m-technetium-labeled fitate and lymphoscintigraphy. A 3.5-cm-long axillary incision was performed, and the dissection continued through the subfascial plane to create the implant's pocket. A silicone gel implant (215 g round, low-profile, textured Silimed) was inserted. A satisfactory aesthetic result was obtained. Two postoperative lymphoscintigraphies were performed (15 days and 7 months after surgery) with satisfactory SLND. No complication was noted. The initial data show that SLND in the setting of prior breast implant augmentation through the transaxillary approach is feasible. Additional prospective studies and larger clinical series are necessary to analyze the accuracy of SLND for patients with previous breast implants.

Re: Incision Scar Placement and Persistent Eyelid Compartment Edema

Re: Incision Scar Placement and Persistent Eyelid Compartment Edema

Aesthetic subunits of the breast.

Surgery for breast cancer has traditionally addressed the breast as if it were a geometric circle with associated quadrants. Cosmetic reconstruction should not follow geometric patterns but should emphasize perceived contour and normal clothing lines. Similar to nasal reconstruction, a subunit principle in breast reconstruction planning may significantly improve the appearance of the result. To better identify the most aesthetic subunits for breast reconstruction, 10 years of autogenous reconstruction in 264 patients was reviewed. Various patterns of breast subunits were identified. The more favorable subunits of the breast in terms of postoperative appearance and camouflage of scars included the nipple, areola, and expanded areola subunits. For larger skin defects, the best subunits were the inferolateral, lower half, and a total breast subunits. Dividing the breast into reconstructive subunits that are to be replaced as a whole rather than as a patch gives superior results. Photographed examples of aesthetic subunits illustrate the placement of scars along natural lines that maximize the advantages of camouflage afforded by clothing.

The Art of Repair in Surgical Hair Restoration Part I

BACKGROUND An increasingly important part of many hair restoration practices is the correction of hair transplants that were performed using older, outdated methods, or the correction of hair transplants that have left disfiguring results. The skill and judgment involved in these repair procedures often exceed those needed to operate on patients who have had no prior surgery. The use of small grafts alone does not protect the patient from poor work. Errors in surgical and aesthetic judgment, performing procedures on noncandidate patients, and the failure to communicate successfully with patients about realistic expectations remain major problems. OBJECTIVE This two-part series presents new insights into repair strategies and expands upon several techniques previously described in the hair restoration literature. The focus is on creative aesthetic solutions to solve the supply/demand limitations inherent in most repairs. This article is written to serve as a guide for surgeons who perform repairs in their daily practices. METHODS The repairs are performed by excision with reimplantation and/or by camouflage. Follicular unit transplantation is used for the restorative aspects of the procedure. RESULTS Using punch or linear excision techniques allows the surgeon to relocate poorly planted grafts to areas that are more appropriate. In special situations, removal of grafts without reimplantation can be accomplished using lasers or electrolysis. The key elements of camouflage include creating a deep zone of follicular units, angling grafts in their natural direction, and using forward and side weighting of grafts to increase the appearance of fullness. The available donor supply is limited by hair density, scalp laxity, and scar placement. CONCLUSION Presented with significant cosmetic problems and severely limited donor reserves, the surgeon performing restorative hair transplantation work faces distinct challenges. Meticulous surgical techniques and optimal utilization of a limited hair supply will enable the surgeon to achieve the best possible cosmetic results for patients requiring repairs.

Liposuction and Scar Placement

A simple methodology is described that addresses liposuction procedures and the placement of scars. Natural body creases are employed to disguise scarring.