US Pharm. 2006;4:54-62.   

With the rise in popularity and success of radical weight-loss surgery among obese persons, a new postoperative cosmetic challenge has emerged. Following massive weight loss achieved by diet, exercise, gastric bypass, or gastric banding, the patient typically has significant areas of excess skin, commonly including on the abdomen, breasts, arms, and thighs. Skin will progressively sag in characteristic as well as idiosyncratic patterns like melting wax from a burning candle. No amount of exercise or special diets will tighten it. Total body lift surgery addresses the entire skin laxity problem of the trunk and thighs. The transverse removal of unwanted skin and fat is followed by tight closure, which in effect lifts the lower adjoining region. While the improvements are dramatic, this is major surgery that comes with serious risks and impressive scars.



Wound Healing
The wound healing process (TABLE 1) is a complex series of events that begin at the moment of injury and continue for months to years. A thin coagulum of fibrin (from the tissues and serum) and red blood cells forms a clot that unites the edges of the wound. Eventually the clot is replaced by granulation tissue, a connective tissue with a rich blood supply. Scars are red because of increased small vessels, and the color gradually fades to white as the vascularization decreases and the collagen matrix matures. Remodeling of the collagen matrix may continue for years depending on individual genetics and age. In general, a thin pale long scar remains when the scars are mature.




Many variables can affect the severity of scarring, including the size and depth of the wound, the blood supply to the area, the thickness and color of the skin, and the direction of the scar. How much the appearance of the scar bothers a patient is, of course, a personal matter. While no scar can be removed entirely, its appearance can be improved. The de­ gree of improvement depends on the size and direction of the scar, the nature and quality of the person's skin, and how well the person cares for the wound after the operation.

Two Types of Scars
Keloids are thick, puckered, itchy clusters of scar tissue that grow beyond the edges of the wound or incision. They are often red or darker in color than the surrounding skin. Keloids occur when the body continues to produce the tough, fibrous protein known as collagen, after a wound has healed. Keloids can appear anywhere on the body, but they are most common over the breastbone, on the earlobes, and on the shoulders. They occur more often in dark-skinned people than in those who are fair-skinned. The tendency to develop keloids lessens with age. Hypertrophic scars are often confused with keloids, since both tend to be thick, red, and raised. Hypertrophic scars, however, remain within the boundaries of the original incision or wound.

 

Treatment Methods

Keloids can be treated aggressively and early by injecting a steroid medication directly into the scar tissue to reduce redness, itching, and burning. In some cases, this will also shrink the scar. If steroid treatment is inadequate, the scar tissue can be cut out and the wound closed with one or more layers of stitches. This is generally performed under local anesthesia as an outpatient procedure, and stitches are removed in a few days. Unfortunately, keloids tend to recur, sometimes larger than before. In some cases, application of a pressure garment over the area is recommended for as long as a year. Keloids may return at any time, requiring repeated procedures, but this is not common.




Hypertrophic scars often improve on their own--though it may take a year or more with the help of steroid applications or injections. If a conservative approach does not appear to be effective, hypertrophic scars can often be improved surgically. The plastic surgeon will remove excess scar tissue and may reposition the incision so that it heals in a less visible pattern. The surgery may be done under local or general anesthesia, depending on the scar's location and what the patient and surgeon decide. The patient may receive steroid injections during surgery and at intervals for up to two years afterward to prevent the thick scar from forming again.




Differentiating hypertrophic scars from keloids can be challenging. Scars can range between those that become hypertrophic in the first few months and then completely resolve with no treatment, to the keloids that become disfiguring and permanent. Table 2 shows methods used to treat scars.




Silicone gel sheeting has been a widely used option for hypertrophic scars and keloids since the 1980s. The mechanism of action of topical silicone is unknown but there are temperature differences as small as 1°C under silicone gel sheeting. This could have a profound effect on collagen kinetics and may reduce scarring. Silicone itself has never been found in significant amounts in scars treated with sheeting, so a direct chemical effect is unlikely. It has also been theorized that static electricity generated by silicone gel sheeting induces a polarization of scar tissue that results in involution. Occlusion of scars by silicone gel sheeting might alter cytokine levels, which in turn would have an effect on scar remodeling (Figure 1).




Table 3 lists additional treatments that can be used to improve the appearance of scars. If the scar requires more intensive treatment, additional options include dermabrasion, scar revision surgery, cortisone injections, cryosurgery, and laser resurfacing. A useful graded protocol to manage postoperative scarring starts with patients using silicone gel sheeting at three to four weeks. The application of adhesive microporous hypoallergenic paper tape after surgery is frequently successful. The mechanism of benefit is unknown, but it may in part be mechanical (pressure) and/or occlusive.




Adapted from Total Body Lift by Dennis J. Hurwitz, MD, FACS, Director, Hurwitz Center for Plastic Surgery, Pittsburgh, Pennsylvania.

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