Scar Revision Techniques: Z-Plasty, W-Plasty, and Geometric Broken Line Closure

This article addresses the use of scar revision surgery as it relates to the use of Z-plasty, W-plasty, and geometric broken line closure. Each of these techniques is discussed in detail and the author provides perspectives regarding the indications, advantages, and limitations of each procedure. The surgeon should be experienced with each of these and apply these methods as appropriate. As with any technique, careful preoperative planning along with meticulous execution will lead to optimal results.

Most scars are traumatic in nature and their length and orientation result from the initial injury and repair. The scar reflects the degree and depth of the injury and whether or not the skin edges were torn, frayed, or beveled. The amount of skin loss affects not only the appearance of the scar but the degree of distortion involving adjacent structures. In addition to the extent of injury and soft-tissue loss, there are multiple other factors affecting the degree of the scar deformity. These factors include the orientation of the scar, the position of the scar with respect to facial landmarks, the age of patient, the genetic factors affecting healing and scar formation, and the techniques used in wound closure.

Scar revision procedures are designed to optimize the appearance of the scar. An ideal scar is one that is thin and flat, has a good color match with the surrounding skin, and is oriented along the relaxed skin tension lines (RSTLs). Scar revision procedures are designed to change the characteristics of the scar in such a way that it becomes a more ideal scar. There are limitations imposed by the shape and size of the scar, neighboring facial landmarks, and the variabilities of healing.

In counseling patients about scar revision, it is important to emphasize that the procedure is designed to trade a poor scar for a better scar. Misconceptions about creating an invisible scar must be corrected.

This article addresses the use of scar revision surgery as it relates to irregularization techniques. Each of these is discussed in detail and the author will provide his perspectives with respect to the indications, advantages, and limitations of each procedure.

Timing of scar revision

Scars tend to improve spontaneously as they mature. The timing of scar revision has traditionally been in the range of 6 to 12 months; however, for some scars there is enough deformity that consideration can be given for earlier scar revision. One rule of thumb is what the author and colleagues have termed the plateau phenomenon; that is, if patients and the physician observe the scar over a 2- to 3-month period and there is no significant improvement, a decision can be made as to whether scar revision is indicated. Typically, scar revision is not performed before 3 months following injury. It is important to note the resolution of the acute inflammatory changes in the tissues surrounding the scar. The adjacent skin should be soft, supple, and nontender. Ideally, there should be no significant residual erythema, edema, or induration.

The necessity and timing of scar revision is a joint decision made by the physician and the patient. The role of the physician is to inform and educate patients about what options exist and what degree of improvement can be expected. If there is a question about whether scar revision is indicated, it is always best to err on the side of waiting. In general, scars improve over time, and unless there are functional issues, there is usually no downside to further observation before surgical intervention is entertained.

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