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optimize scar outcomes. Further, for patients at higher risk of
hypertrophic scarring or keloids, perioperative protocols can be
enacted to minimize the chance of excessive scarring and
associated scar-related symptoms. If patients do develop
hypertrophic scarring or keloids, multimodality therapy potentially
involving a combination of noninvasive and invasive therapies can
allow for successful treatment and significantly lower the chance of
recurrence.
QUESTIONS
1. Which of the following treatments is most likely to be effective
in treating and reducing the risk of recurrence in a keloid that
has been unresponsive to several intralesional steroid
injections?
a. Additional steroid injections
b. Laser therapy
c. Surgical excision alone
d. Surgical excision plus radiotherapy
2. The risk of hypertrophic scarring in a postsurgical scar has
been described as high as which of the following rates?
a. 10%
b. 25%
c. 50%
d. 70%
3. What is the best option for treatment of hypertrophic scars
over joints leading to significant contracture?
a. Scar massage
b. Scar release with Z-plasty
c. Silicone gel
d. Radiation therapy
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ANSWERS AND EXPLANATIONS
1. Answer: d. Surgical excision is recommended for keloids
that are unresponsive to conservative therapies. The most
effective way to reduce recurrence following excision is to follow
excision with postoperative radiation therapy, typically initiated
within 24 hours of surgery.
2. Answer: d. Studies have reported rates as high as 70% of
patients experiencing hypertrophic scarring after surgery.
3. Answer: b. For significant contracture across joints,
conservative therapies will likely be insufficient to provide
effective treatment. Scar release through Z-plasties, potentially
combined with local flap or skin graft reconstruction, can
improve functional outcomes and allow for long-lasting reduction
in symptoms.
REFERENCES
1. Gurtner GC, Werner S, Barrandon Y, Longaker MT. Wound repair
and regeneration. Nature. 2008;453(7193):314-321.
2. Limandjaja GC, Niessen FB, Scheper RJ, Gibbs S. Hypertrophic
scars and keloids: overview of the evidence and practical guide for
differentiating between these abnormal scars. Exp Dermatol.
2021;30(1):146-161.
3. Gaugli GG, Korting HC, Pavicic T, Ruzicka T, Jeschke MG.
Hypertrophic scarring and keloids: pathomechanisms and current
and emerging treatment strategies. Mol Med. 2011;17(1-2):113-125.
4. Arno AI, Gaugli GG, Barret JP, Jeschke MG. Up-to-date
approach to manage keloids and hypertrophic scars: a useful
guide. Burns. 2014;40(7):1255-1266.
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5. Buelaar L, Soykan EA, Galindo Garre F , et al. Going into
surgery: risk factors for hypertrophic scarring. Wound Repair
Regen. 2015;23(4):531-537.
6. Thompson C, Hocking AM, Honari S, Muffley LA, Ga M, Gibran
NS. Genetic risk factors for hypertrophic scar development. J Burn
Care Res. 2013;34(5):477-482.
7. Wilhelmi BJ, Blackwell SJ, Phillips LG. Langer’s lines: to use or not
to use. Plast Reconstr Surg. 1999;104(1):208-214.
8. Lubczynska A, Garncarczyk A, Wcislo-Dziadecka D. Effectiveness
of various methods of manual scar therapy. Skin Res Technol.
2023;29(3):e13272.
9. Sco HC, Stockdale C, Robinson A, Robinson LS, Brown T. Is
massage an effective intervention in the management of postoperative scarring? A scoping review. J Hand Ther. 2022;35:186-
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Taeymans J. Physical management of scar tissue: a systematic
review and meta-analysis. J Altern Complement Med.
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of scarring: evidence for mechanism of action for silicone gel. J
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hypertrophic scars and keloids. J Cutan Aesthet Surg. 2009;2:104-
106.
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controlled trial of the embrace advanced scar therapy device to
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treating hypertrophic and keloid scars. Cochrane Database Syst
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of hypertrophic scars and keloids by the prophylactic use of topical
silicone gel sheets following a surgical procedure in an office
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a silicone sheet in postoperative scar management. Adv Skin
Wound Care. 2016;29(9):414-420.
A randomized, placebo-controlled, double-blind, prospective
clinical trial of silicone gel in prevention of hypertrophic scar
development in median sternotomy wound. Plast Reconstr Surg.
2005;116(4):1013-1020; discussion 1021-1022.
controlled, double blind study of silicone gel in prevention of
hypertrophic scar at donor site of skin grafting. J Cutan Aesthet
Surg. 2013;6(1):12-16.
scar management: a systematic review and meta-analysis of
randomised controlled trials. Int Wound J. 2020;17(3):765-773.
evidence statement for the use of pressure therapy for
management of hypertrophic scarring. J Burn Care Res.
2016;37(4):255-264.
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conservative strategies in scar management after burn injury. In:
Téot L, Mustoe TA, Middelkoop E, Gaugli GG , eds. Textbook on
Scar Management: State of the Art Management and Emerging
Technologies. Springer; 2020.
resulting from burns. Burns. 1980;6:244-250.
hypertrophic scars. Cochrane Database Syst Rev.
2021;9(9):CD013357.
hypertrophic sternotomy scars: comparison among intralesional
corticosteroid, 5-fluorouracil, and 585-nm flashlamp-pumped
pulsed-dye laser treatments. Arch Dermatol. 2002;138(9):1149-1155.
safety of 1064-nm Q-switched Nd:YAG laser with low fluence for
keloids and hypertrophic scars. J Eur Acad Dermatol Venereol.
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treatment of specific scar characteristics in hypertrophic scars and
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scar patients: a prospective cohort study. Burns Trauma.
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CHAPTER 4 Principles of Flap Design
and Application
Kevin Chen and Neil Tanna
KEY POINTS
Understanding the defect will guide flap design and
selection.
Flap design and selection should take into consideration
both donor and recipient needs.
Flap classification is imperfect but regardless can help
guide flap design.
New technological tools can assist with flap design.
What is plastic surgery? One hundred surgeons may give you one
hundred different answers. As a specialty without a specific organ
system, we rely instead on a set of principles to navigate the entire
body. Knowledge of flaps is important for knowledge of plastic
surgery. At their most basic essence, flaps are a body of tissue with
its own blood supply that can be raised and moved. Though simple
in description, flaps are the armamentarium that the plastic surgeon
brings to any complex problem, anywhere from mandible
reconstruction to facelifts.
HISTORY
Flaps have been inextricably linked to plastic surgery since around
800 bc, when Sushruta documented both the first plastic surgery and
the first flap in his seminal treatise on medicine, Sushruta Samhita.
1,2
With his description of what has become known as the “Indian
method” of nasal reconstruction through the use of a pedicled flap,
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Sushruta has become known as the “Father of Plastic Surgery.” Half
a millennium before Hippocrates was even born, Sushruta described
cutting a pattern to match the defect using a creeper leaf and using
the pattern to plan the size of the transferred tissue. Though
Sushruta’s initial description involved the use of a cheek flap, the
“Indian method” had morphed to the use of forehead skin by the
early ad and had made its way to Europe by the 18th century (Figure
4.1).
2
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FIGURE 4.1. A. Early example of design and
reconstruction of the nose using the Indian Method. B.
Inset of the flap from the forehead using the Indian
Method. (A. From Indian method of surgical restoration of
the nose B.L. to Mr Urban, concerning Cowasjee, a man
who had his nose reconstructed with the aid of plastic
surgery. 1764. Wellcome Collection. Public Domain.
https://wellcomecollection.org/works/rs4aekkb). B. (From
Carpue JC. An Account of Two Successful Operations for
Restoring a Lost Nose from the integuments of the
forehead in the cases of two officers of His Majesty’s
Army; to which are prefixed historical and physiological
remarks on the nasal operation; including descriptions of
the Indian and Italian methods. 1816. Wellcome
Collection. Public Domain.
https://wellcomecollection.org/works/bywk8uhq)
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