Scar Revision

Tom D. Wang, MD,  by Shae Waddell and Jeffrey Frentzen

As with everything done in cosmetic and reconstructive surgery, a satisfactory outcome with scar revision begins with a detailed analysis and correct diagnosis of the problem. Only then can you develop a successful treatment strategy.

Scar revision involves much more than simply excising a scar and doing a better closure of the wound. Successful scar revision is really all about disguising the fact that a scar is present and will always be present. It is a matter of tricking the observer’s eye into overlooking or ignoring the scar’s presence.

To get an update on the state-of-the-art in scar revision and scar-revision procedures, PSP spoke with Tom D. Wang, MD, current president of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS).

Wang is also a facial plastic and reconstructive surgeon in both private practice and with the Oregon Health and Science University (OHSU) in Portland, as well as a teacher who has been invited to speak both nationally and internationally about cosmetic and reconstructive surgery. In addition, he has been published in medical journals and textbooks.

Wang is certified by the American Board of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology, and he earned his medical degree from Northwestern University Medical School in Chicago. He also completed his Otolaryngology/Head and Neck Surgery residency at Northwestern. He followed this up with a fellowship in facial plastic and reconstructive surgery at OHSU.

PSP: What are the recent developments in the use of scar revision or scar removal?

Tom D. Wang, MD: I think there has been greater understanding in aftercare of the wound following surgical intervention. This understanding will allow a more optimized healing, including the use of long-term occlusal modalities—like scar gels or sheets, which can help decrease the redness and the thickening we see in scar tissue.

Relatively recent, within the last 5 years or so, these types of products and treatments have become more popular as far as helping the patients with their scars heal more quickly than usual.

PSP: Are there any sheets, gels, or artificial types of tissues you use?

Wang: Over-the-counter products—scar gels, creams. There are a number of products. They are all pretty similar. They all are basically designed to provide occlusions over the wound, which then traps moisture and makes the immediate scar environment more humid. This seems to decrease inflammation and accelerate scar restoration. I do not have any specific brand preference or any specific manufacturers that I feel do a better job than another. I think they all are very similar.

It’s not really complex technology. It’s pretty simple, but it is something that as physicians we are just beginning to recognize to be more and more useful for our patients.

PSP: Are you using tissue sheets or organic tissue in scar healing?

Wang: Not as much at this point. The new thing is laser technology. It helps to decrease inflammation and redness in fractionated fashion. It seems to be really effective for treating scar-protected inflammation. That is something that is really quite new and something we are excited about.

PSP: Describe how it works.

Wang: In general, the placement of a laser beam helps deal with the blood vessels around the scar area tissue. In that manner it tends to break down the excess in collagen deposition and decrease scar recognition, which is the exact mechanism.

PSP: Does dermabrasion fall under the same category?

Wang: Dermabrasion is a well-utilized procedure modality for scar revision, and it is typically done probably 3 months or so after the surgical intervention for best results. It helps to smooth the surrounding tissue, therefore camouflaging it better. It is an old technique that is very useful and one that I employ routinely.

PSP: What about scars that have matured and are treated years later? What approach can be taken?

Wang: Scars that no longer actively remodel can be treated years later if they are objectionable, or if they are causing ecstatic or friction impairment. Treatment options include that of the traditional scar-revision surgery—excising the scar either on its own or in a pattern, which may help decrease some contraction issues. Then, following up once the surgical part has been done and we have converted the whole mature scar into a fresh one. We returned the hand of the clock back to zero, and it starts ticking from that point forward.

Months later, we could consider dermabrasion if the scar is in the part of the face that is immutable to that. Also, there is the use of scar gels or scar sheets on a long-term basis, usually about 6 months, to help minimize inflammation.

The use of the laser beam treatment in a fractionated pattern is still being established. But the preliminary studies are encouraging.

PSP: Would you say swelling is a major complication after scar removal or scar revision?

Wang: Yes. Certainly, it can be. Edema and swelling can occur after scar revision. We do everything we can to minimize that by the use of the ecstatic agronomic surgical technique, as well as the suture materials to keep edema and swelling to a minimum.

PSP: Looking ahead, where do you see the techniques and technology heading? What would you like to see happen in the more distant future?

Wang: I think it would be wonderful to accelerate the wound-healing process. We have some regenerative enzymes and tissue-growth factors which show promise, but really it’s far too early to have a predictable, reliable clinical application.

For instance, if we were to have a scar that was revised after around the time of the closure, then we could sprinkle in the tissue growth factor, which would allow the wound edges to heal in an accelerated fashion. This will shorten the overall healing time and lead us to the final outcome more quickly.

It would make the recovery time more easy for the patient and, of course, give us the results sooner rather than having to wait 12 months. This would be something on the horizon, and there is promise in that area.

I think that scar revision is a powerful and useful tool to manage unfavorable scar tissue that patients and their providers may not be aware of. After a patient obtains lacerations or injury, he or she may just be happy to have the episode behind them. However, the scar that is left can be a sort of tail sign. By means of diminishing them, it helps the patient physiologically.

PSP: So one of the goals of this procedure is to bring the patient to a better self-image?

Wang: Yes it is, exactly.

A depressed scar of the right cheek with noticeable contracture on smiling view was treated with a geometric broken line closure followed by dermabrasion.

One year postop. PHOTOS COURTESY OF THOMAS D. WANG, MD

Breakthrough Surgical Adhesive Dramatically Reduces Fluid Accumulation After Plastic Surgery

Coeli Carr, Contributor

Knowing that a loved one has come through a plastic surgery procedure is a relief. Seeing them post-surgery sprouting drainage tubes from various parts of their body is another story entirely.

Drainage tubes have long been one of medicine’s necessary evils. After plastic surgeons complete their procedure and are about to close the incision, they’re looking at an open wound. Ideally these layers of tissue, which the surgery has disturbed, need to be securely – really securely – reattached to each other and to the inner portion of the dermis before the wound is stapled or sewn. Without this level of adhesion, fluid will accumulate in the wound space.

“Fluid build-up is enemy number one because, when the tissues gets separated by fluids, you don’t know how it will react,” says Dirk F. Richter, a plastic surgeon and chairman of the plastic surgery department at Dreifaltigkeits Hospital, in Wesseling, Germany. When strong tissue adhesion is missing – and fluids start accumulating – drainage tubes are the only recourse. The challenge is even greater with large-flap surgeries: think stomachs undergoing tummy tucks.

However, a new technology which became commercially available in Europe two months ago, may change all that.

Over the last two months, Richter has been using TissuGlu Surgical Adhesive, a product that may be the biggest breakthrough in plastic surgery in years. “It’s what we’ve been waiting for,” he says. “Surgery, which is always a trauma, produces swelling. And the swelling produces fluid in the tissue vacuum. Fluids are the best environment for germs to produce infection.”

TissuGlu holds the layers of tissue in place and prevents fluid accumulation, thereby reducing the need for drainage.

An adhesive developed for plastic surgery procedures, TissuGlu consists of biocompatible material – a lysine-derived urethane polymer adhesive that performs ideally in a moist environment – that can be broken down and assimilated back into the body. TissuGlu’s magic lies in the strength of its adhesive bond, which research has demonstrated to be five times stronger than any commercially available products used in soft-tissue surgical procedures.

“The faster an adhesive can seal the wound – so that tissues can’t be pulled apart – is what controls the accumulation of fluid,” says Richter. In surgeries where he used TissuGlu – the product is delivered in a grid pattern, three drops at a time onto the open wound, through a handheld applicator that automatically releases the product – “fluid accumulation was dramatically reduced.”

Up to this point, there has been no synthetic non-toxic adhesive on the market able to seal layers of internal tissue strongly enough to each other to keep fluid from accumulating, says Patrick Daly, 47, founder and CEO of medical product developer Cohera Medical Inc., which created TissuGlu.

For the past 100 years, Daly explained, the medical establishment has relied on rubber drainage tubes to remove accumulating post-operative fluids. “The tubes stayed in the patient for as long as fluid came out of them, which could be as long as 10 days,” he says. “Tending the tubes are inconvenient and painful to the patient.” Even worse, he adds, between fifteen and 52 percent of patients have medical complications – the drainage tubes may become infected, clogged or leak.

Even after physicians remove the drainage tubes and the patient is sent home, seroma – fluid build-up in dead space after the drain has been removed – may still occur, which results in the wound area “becoming as puffy as a water bed,” says Daly. Then, it’s back to the doctor’s office for fluid removal and perhaps a reinsertion of the drainage tubes.

The genesis of TissuGlu was technology created by Eric Beckman, a chemical engineer, and Michael Buckley, a maxillofacial surgeon. In 2004, the duo had filed paperwork to start a company based on their surgical adhesive technology. The following year, they met Daly, then regional director of Ethicon Endo-Surgery, a subsidiary of Johnson & Johnson. Seeing promise in Beckman’s and Buckley’s work, Daly quit his job and, in January 2006, officially launched Cohera Biomedical Adhesives.

Investors were similarly enthused.

In July 2006 Cohera Medical (the company changed its name in spring of that year)  netted $7.86 million from private investors in its first round of financing. Its second round, in October 2008, drew $16.1 million. The third round closes next month and should generate more than $25 million. “Some individuals have invested in all three series,” says Daly, whose company now employs 27 people.

At end of December 2009, Cohera took its TissuGlu Surgical Adhesive – the final version of the product, after several years of research, development and addressing customer feedback –  to Germany, where it underwent successful human clinical trials. This July the technology received the European CE Mark, allowing the product to be sold in all member countries of the EU. Already sales have been “robust,” says Daly, who’ll be expanding his sales teams in England, France, Italy, Spain and the Netherlands, and projects sales revenues in the “lower seven figures” for 2012.

With the CE Mark in hand, Daly will pursue FDA approval for TissuGlu and projects the first clinical trials to begin in the U.S. in 2012. He anticipates selling the product in the U.S. by the third quarter of 2014.

In addition to TissuGlu’s cutting down on post-operative risks of infection caused by drainage tubes, the technology saves time. Richter notes that suturing wound tissue that measures between 12 to 16 inches (approximately 30 to 40 centimeters) might take at least a half hour, compared to between three and four minutes using TissuGlu. The product also provides a cost benefit by cutting down time spent in the operating room.

In addition to preparing for TissuGlu’s FDA clinical trials, Cohera is planning to bring its second product, a surgical bowel sealant, to market.

Bonding with end users – a goal for many companies – rings especially true for the company behind TissuGlu. Cohera has found that creating an exceptionally strong bond is incredibly good for business.

In the name of charity, Las Vegas plastic surgeon cares for the faces of fighters

By JESSICA FRYMAN

At one southwest Las Vegas plastic surgery office, VIP treatment isn’t reserved just for world champion fighters or notable socialites — although Dr. Jeffrey Roth has worked on them, too.

Despite Roth’s experience in freshening up the pretty faces in the city’s spotlight, he also specializes in treating the average locals who stand behind the tables.

To ease the aging look from a card dealer’s tired hands, Roth said a microdermabrasion and filler is a safe bet for $50. Other locals find affordable options in chemical peels and skin treatments, he said, noting that not everybody needs surgery to look a little younger.

“Most often, my clientele is just people who want to look and feel better for themselves,” he said. “Little things can make a difference. It doesn’t have to be surgery.”

Roth said he enjoys treating the locals in the valley he has called home most of his life. He moved here in 1977 and graduated from Chaparral High School in 1984. After extensive training at top schools across the country, Roth said he returned to the southwest to give back to the community that raised him. His practice often sponsors youth sports and contributes to about a dozen charities, from Keep Memory Alive and the Juvenile Diabetes Research Foundation to Nathan Adelson Hospice and the Nevada Cancer Institute.

Growing up in Las Vegas, Roth said he remembers legendary boxing matches at Caesars Palace in an era when “everybody was a fight fan.”

After watching the Manny Pacquiao-Juan Manuel Marquez II fight in 2008, someone recognized the doctor and asked him to jump in and save Pacquiao. Not in the ring, Roth added with a laugh , noting he wouldn’t last, but behind the scenes where two doctors from the Philippines were using what looked like World War II instruments to stitch the world champion’s face.

“Now, he expects me to be there,” Roth said of working dozens of fights in the past three years.

“The boxing stuff has been really neat,” he said, rattling off the big names he has sat next to ring side. “There’s really nothing like 18,000 people going bananas at a fight.”

As exciting as contributing to the sport might be, he says making an impact in someone’s life beats it.

Watching a young girl look in the mirror after you fix her deformed ears; witnessing a man move his arm after you reattached the limb that was hanging by a thread; removing extra skin from a 92-year-old woman’s eyelids so she could see again — “Those cases stand out, ” he said.

Now that his career has progressed, Roth said he focuses mostly on more aesthetic work, but that can be just as rewarding.

It means “taking the edge off” for a 50-year-old who wants to look how he feels because he’s still racing in triathalons or giving a mom her body back when the gym just won’t cut it.

“I think physical appearance is an important adjunct to people feeling good about themselves,” Roth said.

“You get to make a big impact in someone’s life.”

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