Hindawi Publishing Corporation Dermatology Research and Practice Volume 2010, Article ID 545796, 2 pages doi:10.1155/2010/545796 Editorial Scar Revision Hayes B. Gladstone, 1 Daniel Berg, 2 and Michel McDonald 3 1 Division of Dermatologic Surgery, Stanford University, Stanford, CA 94305, USA 2 Division of Dermatologic Surgery, University of Washington, 4225 Roosevelt Way NE, 4th Floor Dermatology, Box 354697 Seattle, WA 98195, USA 3 Division of Cosmetic Dermatology, Vanderbilt University Medical Center, 719 Thompson Lane Suite 26300, Nashville TN 37204, USA Correspondence should be addressed to Hayes B. Gladstone, [email protected] Received 31 December 2010; Accepted 31 December 2010 Copyright © 2010 Hayes B. Gladstone et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1. Introduction Scarring is the body’s natural response to a wound. Yet, this healing process can create significant functional and cosmetic problems. It impacts daily life and can create issues in self-esteem. Traditionally, the treatment of scars has been surgical. Despite meticulous surgical technique, scars still form. Revision may be in the form of excising the scar to create a “thinner” line, or the surgeon may perform a geometric broken line to create an illusion of natural creases. Lasers or mechanical dermabrasion can also be performed to minimize the scar. Lasers including the pulse dye laser has also been used intraoperatively and in the acute postoperative period to suppress scar formation. Topical treatments such as silicone may also help soften a scar. Yet the cicatrix still exists. Other types of scars such as those from inflammatory processes including acne create a skin topography that features alternating depressions and papules. There is no single satisfactory treatment for acne scars. Because of the complexity of this scarring process, a combined approach must be undertaken. Historically, dermabrasion has been performed. For Fitzpatrick Skin I, II, and III, conventional ablative laser resurfacing has been used. Despite many case series, it is not clear if the carbon dioxide laser or the erbium laser alone pro- vides a long-term significant improvement. More recently, fractionated resurfacing both nonablative and ablative have been shown to have some effect on subsets of acne scars. Subscision which manually breaks apart the acne scars is often combined with the laser treatment. Subscision can be performed with Nokor needles through small puncture sites, or more recently using a roller device that percutaneously disrupts the scar. Other techniques including punch grafting and excision may ameliorate acne scars. On the other end of the spectrum of acne and small surgical scars are those from burns. Because of the severe trauma of a burn, large deforming contractures can occur, or large areas of denuded skin. An artificial or natural skin substitute may need to be used foremost for coverage and protection from the environment, but also to minimize scars. Perhaps the reason that clinicians have difficulty in eradicating scars is because we do not quite understand the mechanism from a cellular and molecular basis. Break- throughs have been made in the past 20 years, particularly from fetal surgery and the discovery that fetal skin does not scar after wounding. The treatment implications of this type of research has still not been fully realized. Yet, it is no doubt that in the future, the prevention and treatment of scars will be in the form of targeted molecular therapies including the use of stem cells. 2. Mechanisms It is this contrast between healing in the womb and healing after birth that the authors Satish and Kathju discuss in their article entitled Cellular and Molecular Characteristics of Scarless versus Fibrotic Wound Healing. They review the biology of fetal wound healing including the role of growth factors, keratinocytes, and reepithelialization and gene expression. This article is an excellent primer for those
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Hindawi Publishing CorporationDermatology Research and PracticeVolume 2010, Article ID 545796, 2 pagesdoi:10.1155/2010/545796
Editorial
Scar Revision
Hayes B. Gladstone,1 Daniel Berg,2 and Michel McDonald3
1 Division of Dermatologic Surgery, Stanford University, Stanford, CA 94305, USA2 Division of Dermatologic Surgery, University of Washington, 4225 Roosevelt Way NE, 4th Floor Dermatology, Box 354697 Seattle,WA 98195, USA
3 Division of Cosmetic Dermatology, Vanderbilt University Medical Center, 719 Thompson Lane Suite 26300, NashvilleTN 37204, USA
Correspondence should be addressed to Hayes B. Gladstone, [email protected]
Received 31 December 2010; Accepted 31 December 2010
Copyright © 2010 Hayes B. Gladstone et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.
1. Introduction
Scarring is the body’s natural response to a wound. Yet,this healing process can create significant functional andcosmetic problems. It impacts daily life and can createissues in self-esteem. Traditionally, the treatment of scarshas been surgical. Despite meticulous surgical technique,scars still form. Revision may be in the form of excisingthe scar to create a “thinner” line, or the surgeon mayperform a geometric broken line to create an illusion ofnatural creases. Lasers or mechanical dermabrasion can alsobe performed to minimize the scar. Lasers including thepulse dye laser has also been used intraoperatively and inthe acute postoperative period to suppress scar formation.Topical treatments such as silicone may also help soften ascar. Yet the cicatrix still exists.
Other types of scars such as those from inflammatoryprocesses including acne create a skin topography thatfeatures alternating depressions and papules. There is nosingle satisfactory treatment for acne scars. Because of thecomplexity of this scarring process, a combined approachmust be undertaken.
Historically, dermabrasion has been performed. ForFitzpatrick Skin I, II, and III, conventional ablative laserresurfacing has been used. Despite many case series, it is notclear if the carbon dioxide laser or the erbium laser alone pro-vides a long-term significant improvement. More recently,fractionated resurfacing both nonablative and ablative havebeen shown to have some effect on subsets of acne scars.Subscision which manually breaks apart the acne scars isoften combined with the laser treatment. Subscision can be
performed with Nokor needles through small puncture sites,or more recently using a roller device that percutaneouslydisrupts the scar. Other techniques including punch graftingand excision may ameliorate acne scars.
On the other end of the spectrum of acne and smallsurgical scars are those from burns. Because of the severetrauma of a burn, large deforming contractures can occur,or large areas of denuded skin. An artificial or natural skinsubstitute may need to be used foremost for coverage andprotection from the environment, but also to minimize scars.
Perhaps the reason that clinicians have difficulty ineradicating scars is because we do not quite understandthe mechanism from a cellular and molecular basis. Break-throughs have been made in the past 20 years, particularlyfrom fetal surgery and the discovery that fetal skin does notscar after wounding. The treatment implications of this typeof research has still not been fully realized. Yet, it is no doubtthat in the future, the prevention and treatment of scars willbe in the form of targeted molecular therapies including theuse of stem cells.
2. Mechanisms
It is this contrast between healing in the womb and healingafter birth that the authors Satish and Kathju discuss intheir article entitled Cellular and Molecular Characteristicsof Scarless versus Fibrotic Wound Healing. They reviewthe biology of fetal wound healing including the role ofgrowth factors, keratinocytes, and reepithelialization andgene expression. This article is an excellent primer for those
2 Dermatology Research and Practice
interested in fetal wound healing. Occleston et al. build uponthe understanding of the mechanisms of scarring in theircomprehensive article entitled Therapeutic Improvement ofScarring: Mechanisms of Scarless and Scar-Forming Healingand Approaches to the Discovery of New Treatments. Theseauthors point out that scar-free to scar-forming healing reallyis a continuous spectrum. They discuss preclinical examplesof wound healing and how this translates to humans. Froma treatment standpoint, they elucidate the mechanisms of aprophylactic scar treatment.
2.1. Molecular Treatment of Scars. It is has long been under-stood that TGF B plays an important role in wound healingand scarring in human beings. In their fine manuscript enti-tled Therapies with Emerging Evidence of Efficacy: Avoterminfor the Improvement of Scarring, Bush et al. evaluate therole of TGF B3 as a potential therapeutic agent. Echoing,the previous paper, these authors emphasize the importanceof prophylactic treatment after surgery in order to reducesubsequent scarring. They describe the successful Phase I/IItrials of this biologic agent. However, the Phase III trials (notpublished here) have been disappointing, so the march goeson for the optimal prophylactic biologic agent. Nevertheless,the success of the company’s early trials may shed additionallight on TGF-B and could lead to future discoveries by otherresearch groups.
2.2. Surgical Treatment. Despite meticulous technique, sur-gical scars can still distort mobile anatomic regions suchas the nasal ala, the lip, and the eyelid. The conventionalmethod to lengthen a scar and change its orientation is bytransposing its limbs. In Z-plasty Made Simple, Aasi demon-strates her technique for demystifying Z plasties which canbe conceptually complex particularly for trainees. She offersfoolproof methods with excellent results to optimize scarsthat need revision after Mohs Micrographic Surgery. Thistechnique needs to be in the armamentarium of everysurgeon performing skin and soft tissue surgery.
2.2.1. Surgical Treatment: Special Considerations. The reduc-tion of scarring and skin coverage in burn patients is one ofthe most difficult challenges facing reconstructive surgeons.Prompt replacement of the charred skin with a functionalalternative is fundamental in minimizing contractures as wellas eventual cosmesis. In Long-Term Followup of Dermal Sub-stitution with Acellular Dermal Implant in Burns and PostburnScar Corrections, Juhasz et al. describe their experience inusing Alloderm in 18 patients as well as reviewing the variouscoverage options. In their study, they used the VancouverScar Scale with a 50-month followup. They demonstratedvery favorable results when combined with a split thicknessskin graft compared to more complicated flaps.
Finally, Fabbrocini et al. provide a comprehensive reviewof acne scars in their paper entitled Acne Scars: Pathogenesis,Classification and Treatment. In a very straightforwardapproach, the authors explain the current theory on whyacne scars occur, how to classify them into atrophic,boxcar or icepick, and then how to choose the appropriate
treatment(s). The authors nicely summarize the varioustherapeutic options including the increasingly popular tech-nique of needling using a roller device. They tackle thistopic well and astutely point out that there are no universalguidelines for treating acne scars and that randomizedcontrolled studies are needed as well as evaluating the all-important psychological impact of this scarring on thispatient population.
As editors, we can only hope that these articles stimulatefurther discussion and spur new research to minimizescarring and allow these patients to live healthy and activelives without disfigurement.
Hayes B. GladstoneDaniel Berg
Michel McDonald
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