Importance of scar management
According to Dr Chernoff, patients are often more concerned with scars on the skin than the underlying tissue or organ injury, emphasizing the need for meticulous attention to wound healing and scar management. For optimal scar management, proactive wound care needs to be planned even before surgery. For example, assessing the best location for incision placement before surgery by following relaxed skin tension lines (RSTLs) is essential because these are parallel to dermal collagen bundles and offer the best cosmetic results. Incisions should also blend with body contours, as there are very few “straight lines” in the body. Poor scar outcomes often result when surgeons do not follow RSTLs due to time constraints. Thus, quality of results should never be compromised for speed of procedure.
Due to lack of proactive wound care, Dr Chernoff noted that there is often a discrepancy between patient- and physician-perceived qualities of wound closure. One study surveyed 20 surgeons from different specialties (ie, plastic, dermatologic, obstetrics-gynecology, oculoplastic) who have practiced for 10 to 30 years, and compared patient- and physician-perceived wound closure quality. Incision placements, proper use of RSTLs and the type of closure used were noted. instance, at the Midwest Stem Cell Treatment Center, Dr Chernoff offers adult stem cells for scar treatment, which uses a fat transfer surgical technology to isolate and implant the patient’s own adipose stem cells from a small quantity of fat harvested by liposuction on the same day. These stem cells are harvested under local anesthesia. On average, about 500,000 stem cells are found in 1 cm3 of fat. Generally, 25 cm3 of concentrated fat is harvested, which yields 10 to 20 million stem cells per harvest.1 Once transplanted, the adipose stem cells differentiate to mature adipose cells, develop their own blood supply and remain in their new location. According to Dr Chernoff, this is an excellent method to plump or increase the volume of the skin and other areas of the body with depressed or atrophic state due to disease, trauma, surgery or aging. Injections to the head and neck region are alternatives to major invasive surgical procedures for both aesthetic and functional purposes. Since it fills soft tissue from the regenerative effect of adiposederived mesenchymal stem cells, autologous fat injections often yield favorable outcomes and their have been widely used in head and neck surgeries.1
For wrinkles around the nose and mouth, the US Food and Drug Administration (FDA) has recently approved azficel-T (LAVIV®), an autologous cellular product currently indicated to improve the appearance of as one of the first-line treatments for keloids and hypertrophic scars.5 As a silicone gel, Dermatix® has an advantage over silicone gel sheeting due to its ease of application and around-the-clock coverage.4 Dermatix® Ultra is an improved version of the original Dermatix®, and contains vitamin C and cyclopentasiloxane (CPX). CPX gives Dermatix® Ultra the ability to dry quicker, leaving a matte, smooth silky surface that is acceptable to most patients, especially for those with affected areas involving the face.
Effectiveness of Dermatix®
In 2002, the international guidelines on scar management recommended silicone gel sheeting as the first-line therapy for linear hypertrophic scars, widespread burn hypertrophic scars and minor keloids.6 However, compared to silicone gel sheeting, Dermatix® has demonstrated better resolution of hypertrophic scars and excised keloids.4 In a 90-day prospective study led by Dr Chernoff, 30 patients with hypertrophic scars, keloid scars and post-laser exfoliation erythema were given Dermatix®, silicone gel sheeting or both.4 Each patient had a bilateral scar that served as untreated control, and outcome measures included profilometry and compared patient- and physician-perceived wound closure quality. Incision placements, proper use of RSTLs and the type of closure used were noted.
Using surface profilometry, scars were assessed 1 year after surgery. The study found that 55% of the surgeons surveyed did not follow the RSTLs in their incisions. Up to 40% of abdominal incisions were also closed under tension. Moreover, almost half of the surgeons performed improper suture removal. While 85% of physicians were satisfied with their work, 64% of patients reported dissatisfaction from the resulting scars. Thus, discrepancies in expectations in wound outcomes emphasize the need for proper preoperative planning for scars.
Unlike surgical scars that can be managed early and preoperatively, disfiguring keloids and hypertrophic scars often result from traumatic causes, and can have a significant psychosocial burden on patients. However, these scars can still be improved immensely with appropriate treatment. In aiding patients recovering from trauma, the first thing to emphasize to them is to remove a sense of urgency because scar treatment is a prolonged process that can take up to 3 years. Only then will it be reasonable to expect scars to appear barely recognizable from a conversational distance. Nevertheless, with the currently available treatment modalities such as silicone gels, lasers and autologous cell injections, Dr Chernoff noted that nowadays, there are very few scars which cannot achieve excellent aesthetic results.
New modalities in scar treatment
Dr Chernoff currently uses a variety of modern treatment modalities in the treatment of scars. For For wrinkles around the nose and mouth, the US Food and Drug Administration (FDA) has recently approved azficel-T (LAVIV®), an autologous cellular product currently indicated to improve the appearance of moderate to severe nasolabial fold (NLF) wrinkles in adults.2 To harvest fibroblasts, a 3-mm biopsy of skin is taken from the back of the ear. The tissue is sent to Fibrocell Science, Inc. in Pennsylvania, USA to undergo tissue culture. It takes about 3 months for the cells to multiply for administration. Fibroblasts are then placed in syringes and sent out to the surgeon. With a shelf life of only 24 hours, it requires patients not to miss their appointments. In a multicenter, double-blind, placebo-controlled trial of adults with moderate to very severe NLF wrinkles, azficel-T was assessed to be safe and effective in improving the appearance of NLF wrinkles using a validated wrinkle assessment scale.2 Aside from wrinkles, autologous fibroblasts have also been used in acne scars and produced excellent results (Figure).3
Dermatix® is an FDA-registered substantial equivalent of silicone gel sheeting for the prevention and management of hypertrophic scars and keloids.4 Silicone gel sheeting is currently recommended Dermatix, silicone gel sheeting or both. Each patient had a bilateral scar that served as untreated control, and outcome measures included profilometry analysis of scar topography before and after punch biopsies of the control and treated scars, symptoms associated with the scars, and patient evaluations of the ease of treatment. Study results showed better resolution and improvement of scars with Dermatix® treatment alone or in combination with silicone gel sheeting versus silicone gel sheeting alone. Moreover, skin breakdown, maceration and itching were less in patients who used Dermatix®. Patients also rated Dermatix® as easier to use than silicone gel sheeting.
Summary and recommendations
Based on Dr Chernoff’s experience, multiple modalities in scar management, including Dermatix® silicone gel, help achieve optimal outcomes from both the patient’s and physician’s perspectives. Dermatix® is currently recommended to improve scar height, decrease erythema and improve skin texture and elasticity. Dermatix® is also more convenient to use for patients than silicone gel sheeting, and it offers the advantage of reducing skin breakdown, maceration and itching.
Figure. Combination of Dermatix®, fibroblast therapy and lasers resulted in marked improvement of acne scars. Left: Before treatment; Right: After treatment. Photo courtesy of Dr Chernoff.
1. Mazzola RF, Cantarella G, Torretta S, et al. Autologous fat injection to face and neck: from soft tissue augmentation to regenerative medicine. Acta Otorhinolaryngol Ital 2011;31:59-69.
2. Smith SR, Munavalli G, Weiss R, et al. A multicentre, double-blind, placebocontrolled trial of autologous fibroblast therapy for the treatment of nasolabial fold wrinkles. Dermatol Surg 2012;38:1234-43.
3. Boss WK Jr, Usal H, Chernoff G, et al. Autologous cultured fibroblasts as cellular therapy in plastic surgery. Clin Plast Surg 2000;27:613-26.
4. Chernoff WG, Cramer H, Su-Huang S. The efficacy of topical silicone gel elastomers in the treatment of hypertrophic scars, keloid scars, and post-laser exfoliation erythema. Aesthetic Plast Surg 2007;31:495-500.
5. Juckett G, Hartman-Adams H. Management of keloids and hypertrophic scars. Am Fam Physician 2009;80:253-60.
6. Mustoe TA, Cooter RD, Gold MH, et al. International clinical recommendations on scar management. Plast