Modified Cicatrectomy with Part of the Cicatricial Dermis Retained

Sir:FigureScars usually cause significant cosmetic problems, especially those that occur on the face and other exposed parts. Although there are many methods of treating scars, cicatrectomy is still the most common and optimal one for small and narrow scars.1 Unfortunately, increased width of the scar and even renewed hypertrophy after cicatrectomy can often be observed over time, although the scar is not obvious in the early stages after cicatrectomy. There are many reasons for this phenomenon, among which the incision tension is the most common.2,3 To reduce the incision tension, subcutaneous tension-relaxing sutures were usually performed during cicatrectomy.4 Subcutaneous tissue under scar is loose connective tissue consisting mainly of fat. In traditional cicatrectomy, subcutaneous tissue could not withstand the tension of subcutaneous tension-relaxing sutures, so the tension of sutures is focused mainly on the incision line instead of subcutaneous suture, and although the scar is not obvious early postoperatively, there would be various degrees of hypertrophy and increasing width over time. To tackle this issue, we have modified the subcutaneous tension-relaxing suture in recent years. In this modified method, part of the cicatricial dermis was retained during cicatrectomy. Cicatricial tissue is dense and has high resistance to stretching. Our suturing technique, in which the deep layer of the dermis adjacent to the wound is anchored to the cicatricial dermis strip, thereby relieving tension on the wound edges, achieves wound edge approximation with minimal tension. Surgical procedures are as follows: (1) remove scars but with the central part of the cicatricial dermis strip retained (the wider the scar resected, the wider the cicatricial dermis retained); (2) fully dissociate subcutaneous tissue on both sides of the incision; (3) suture both sides of the cicatricial dermis strip with the deep layer of dermis on each side of the incision (Fig. 1) to reduce the tension of wound closing as much as possible; and (4) perform routine intradermic suture and skin closure. It is important to retain proper quantities of cicatricial dermis strip. It could not withstand subcutaneous suture tension if too little of the cicatricial dermis is retained, whereas retention of too much could result in a lack of smoothness and prominence.Fig. 1: Retained cicatricial dermis strip sutured to both sides, with the deep layer of dermis on each side of the incision.A total of 11 patients with scars underwent this modified cicatrectomy. The follow-up period was 3 to 12 months, and the results were satisfactory. This method could effectively reduce skin suture tension after scar resection and thus could lighten the hypertrophy and broaden postoperative scars (Fig. 2, above). Furthermore, it is generally acknowledged that direct cicatrectomy is not suitable for facial scars wider than 1 cm5; however, with this modified cicatrectomy, facial scars with a width of 3 cm or even more could be treated (Fig. 2, below). This modified method could expand the indication for direct cicatrectomy, making some staged resection and local flap repair surgery unnecessary. Consequently, it not only simplifies the operative procedure and avoids additional incision but also shortens the course of treatment.Fig. 2: Modified cicatrectomy with part of the cicatricial dermis retained. (Above, left) Frontal scar, before surgery; (above, right) 1 year after surgery; (below, left) left facial scar, wound after scar resection; (below, right) after wound closing.Dongyun Yang Ruiheng Wang Ling Tao Liang Wang Shirong Li Southwest Hospital, Third Military Medical University, Chongqing, People's Republic of China DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.