1. Formation and Revision of the Cicatrix Herve’ LeBoeuf, MD Karen Calhoun, MD

2. Tension Lines l Langer’s lines l Relaxed Skin Tension Lines Unique to each patient Frequently perpendicular to muscle Different from “wrinkle lines” Identified by pinching the skin l Straith, Kraissl, Bulacio

3. Wound Healing l Neovascularization l Inflammation l Epithelialization l Granulation l Contraction l Remodeling

4. Preoperative Management l Debridement & Irrigation l Instrumentation l Anesthesia l Incision planning l Patient consultation

5. Intraoperative Precautions l Incision placement l Undermine where necessary l Meticulous hemostasis l Dead space obliteration l **Dermal closure** l Suture type & placement l Anti-tension taping of wound

6. Postoperative wound care l Topical emollients for moisture l Frequent cleaning with H2O2 l Early dermabrasion of irregular wounds l Avoidance of sun, water l Steroid creams, retinoids, etc.

7. Goals of scar revision l Flat scar, level with surrounding skin l Good color match with local tissue l Narrow l Parallel to the patient’s RSTL l Absence of straight, unbroken lines

8. Scars that may benefit... l Those interrupting a facial aesthetic unit l Webbed or pin cushion scars l Hypertrophied or widened scars l Those adjacent to a favorable site l Long scars perpendicular to RSTL l Aesthetically or functionally distorting

9. Excisional techniques l Fusiform excision with or without M-plasty Rotational flaps Tissue expanders l Repositioning of scars l Partial serial excision of larger scars

10. Altering scar polarity l Classic Z-plasty l Multiple “running” Z-plasties l W-plasty l Geometric Broken Line Closure l Early dermabrasion with the irregular closures and hypertrophied scars

11. Nonsurgical revisions l Steroids -- Injectables and creams l Estriol and tretinoin with iontophoresis l Silicone gel sheeting and tocopherol l Ultrapulsed CO2 laser resurfacing l Injectable fillers: Zyderm, Zyplast, Fibrel, autologous fat, Autologen, Silicone, etc. l Cosmetics