Aesth Plast Surg (2015) 39:318–324 DOI 10.1007/s00266-015-0466-z
ORIGINAL ARTICLE
BREAST
Effect of Dermal Thickness on Scars in Women with Type III–IV Fitzpatrick Skin Bilsev Ince1 • Mehmet Dadaci1 • Pembe Oltulu2 • Zeynep Altuntas1 Fatma Bilgen3
•
Received: 29 August 2014 / Accepted: 27 February 2015 / Published online: 19 March 2015 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2015
Abstract Background Both patients and physicians desire minimal scarring after surgical procedures. The removal of foreign bodies from around the wound, prevention of infection, and wound closure without tension is recommended for reducing scarring. The reasons underlying the differing appearance of scars between different anatomical regions of the same individual are not fully understood. Moreover, to our knowledge, the relationship between incision width and dermal thickness in different anatomical regions has yet to be investigated. Hence, in the present study, we aimed to determine the effect of dermal thickness on scar formation. Methods Fifty patients who were treated and followed up for breast hypertrophy between 2010 and 2013 were retrospectively investigated. In all patients, a 2 9 2-cm skin biopsy specimen was obtained from the medial right breast at the horizontal line of the T scar. A routine superomedial pedicle breast reduction was subsequently performed. The extracted excision materials and skin biopsy specimens were examined pathologically. Dermal thickness was measured from the starting point of the
& Bilsev Ince [email protected] 1
Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Meram Medicine, Necmettin Erbakan University, 42080 Meram, Konya, Turkey
2
Department of Pathology, Faculty of Meram Medicine, Necmettin Erbakan University, Konya, Turkey
3
Plastic, Reconstructive and Aesthetic Surgery Clinic, Elbistan State Hospital, Kahramanmaras, Turkey
123
subcutaneous tissue to the end point of the epidermis, at four different sites. The average dermal thickness was then calculated for each patient. The skin color of all patients was determined according to the Fitzpatrick classification. Scar width was measured in three different regions, including a combination of the vertical and horizontal portions of the T scar and the flap confluence. After the measurements, the scars were evaluated for vascularity, pigmentation, elasticity, thickness, and height by two plastic surgeons and a clinical nurse, who were blinded to patient data. Results The mean age of the 50 female patients was 40.8 years (range 18–65 years). The average follow-up period was 16 months (range 12–18 months). An average of 987.5 g (range 505–1621 g) of breast and fatty tissue was removed. The average dermal thickness was 4.99 mm (range 3.5–6.8 mm). The most common skin type was Fitzpatrick type IV (33 patients). The average total scar score was 14 (range 8–25). The total scar score was not significantly associated with dermal thickness. The scar width in patients with a dermal thickness of \0.5 cm was narrower than that in patients with a dermal thickness of C0.5 cm. Scar vascularity and noticeability were observed less often in patients with Fitzpatrick skin type III, regardless of scar width. Conclusion The study findings show that increased dermal thickness is a risk factor for wide scar formation. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Dermis thickness Scar Fitzpatrick skin phototype classification
Aesth Plast Surg (2015) 39:318–324
Introduction Both patients and physicians desire minimal scarring after surgical procedures. Various methods have been used during and after surgery to reduce scar formation. However, there is no currently available agent that can predictably eliminate the formation of esthetically unfavorable scars [1]. The removal of foreign bodies from around the wound, prevention of infection, and wound closure without tension is recommended for reducing scarring [1]. Although the exact causes of hypertrophic scars remain unknown, a delayed epithelialization over more than 10–14 days is known to markedly increase the incidence of hypertrophic scarring [2]. Wounds that are subjected to tension due to motion, location in the body, or tissue loss are associated with an increased risk of scar hypertrophy and spreading, and hence, patients should be informed of these risks prior to any surgery [3]. For preventing scar formation in the postoperative period, the proper care of wounds is recommended, including careful suture removal at the appropriate time and shielding the wound from sunlight. In addition, the most important factors determining scar formation include the genetic characteristics of the patients. Hypertrophic scars, which are noted in 6 % of the American population, are more common in dark-skinned individuals of Asian or African descent [1]. The location of the surgical incision also affects scar appearance. The sternum, shoulders, upper arms, earlobes, and cheeks are the areas most susceptible to keloid and hypertrophic scar formation [4]. In contrast, hypertrophic scars very rarely develop on the scalp, eyelids, and anterior lower leg [5]. The reasons underlying the differing appearance of scars between different anatomical regions of the same individual are not fully understood. Moreover, to our knowledge, the relationship between incision width and dermal thickness in different anatomical regions has yet to be reported. The appearance of scars is presumed to vary because of the differing dermal thicknesses between different areas of
Fig. 1 Scar width was measured in three different regions, including a combination of the vertical (a) and horizontal (b) portions of the T scar and the flap confluence (c)
319
the same person’s body, despite the similar genetic structure and skin color across those areas. In the present study, we aimed to determine the effect of dermal thickness on scar formation.
Patients and Methods Fifty patients who were treated and followed up for breast hypertrophy between 2010 and 2013 were retrospectively investigated. Patients who had Fitzpatrick skin types III–IV were included in the study. Moreover, those who had known hypertrophic scars, were using drugs and/or smoking, or had wound infections or delayed wound healing were excluded. The same surgeon performed all operations and data collection. Patients were operated on under general anesthesia. Preoperative markings were made with the patients in the standing position. The breast meridian was marked from the midclavicular point to the new nipple position at the level of the submammary fold. Markings were subsequently made according to the inverted T scar pattern; the vertical length of the T scar was set to 5.5 cm in all patients. The superomedial pedicle, which was based on the medial limb of the vertical scar, was designed with the patient in the standing position. In all patients, a 2 9 2-cm skin biopsy specimen was obtained from the right breast at the middle part of the horizontal line of the T incision. The pedicle [with a 42-mm nipple areolar complex (NAC)] was deepithelized and beveled toward its base because the thinnest portion was under the NAC (2–2.5 cm thickness). The resection was performed in the clockwise direction in the right breast and in the counterclockwise direction in the left breast. Tissue was removed en bloc. The upper pole was then prepared, and the NAC was rotated to the proper position without tension on the pedicle. No pectoral fascia suspension sutures were used. The breast was shaped by using superior and inferior sutures, by bringing the medial and the lateral pillars together. After the placement of the NAC and pillar stitches, the arms of the T pattern were closed. A routine superomedial pedicle breast reduction was then performed. The subcutaneous tissue was closed with 2/0–3/0 polyglactin stitches, and the skin was closed with 3/0 and 4/0 poliglecaprone stitches. Patients were discharged after removing the drains, when no exudates from the wound were observed. In all patients, the dressing was changed daily with the application of antibiotic skin ointment. The stitches were absorbable and therefore did not require removal. No treatment for scar reduction was administered. The patients were photographed at 3 and 12 months postoperatively. The extracted excision materials and skin biopsy specimens were examined histologically. The skin and
123
320
Aesth Plast Surg (2015) 39:318–324
Table 1 Observer Scar Assessment Scale
Fig. 2 Microscopic appearance of the dermis in patients with a dermal thickness of 4 mm
subcutaneous tissues were stained with hematoxylin and eosin, and the dermal thickness was measured under a light microscope at 409 magnification. Dermal thickness was measured from the starting point of subcutaneous tissue to the end point of the epidermis, at four different sites. The average dermal thickness was then calculated for each patient. The skin color of all patients was determined according to the Fitzpatrick classification. At the 1-year postoperative follow-up, the scar width was measured in three different regions, including a combination of the vertical and horizontal portions of the T scar and the
123
Fig. 3 Microscopic appearance of the dermis in patients with a dermal thickness of 6 mm
flap confluence. The vertical scar width was measured from the middle of the areola’s lower end and the middle portion of the flap. The horizontal scar width was measured from the middle of the most medial region of the scar to the point of the junction medium (Fig. 1). After the measurements, the scars were evaluated for vascularity, pigmentation, elasticity, thickness, and height by two plastic surgeons and a
Aesth Plast Surg (2015) 39:318–324
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Dermal thickness was not significantly associated with the total scar score and Fitzpatrick skin type. The scar width in patients with a dermal thickness of \0.5 cm was narrower than that in patients with a dermal thickness of C0.5 cm (P \ 0.05) (Figs. 5, 6). Scar vascularity and noticeability were observed less often in patients with Fitzpatrick skin type III, regardless of the scar width (P \ 0.05) (Fig. 7). However, no significant association was observed between scar width and skin type. Furthermore, no significant association was found between scar width, patient age, or weight of the removed material.
Discussion
Fig. 4 Microscopic appearance of the dermis in patients with a dermal thickness of 7 mm
clinical nurse, who were blinded to patient data. In this evaluation, the Observer Scar Assessment Scale defined by Lieneke et al. [6] was used (Table 1). All items of the scale are scored numerically (from 1 to 10, with a score of 10 corresponding to the worst possible scar appearance). Statistical Analysis The statistical significance of the differences between the mean values was analyzed using SPSS 18.0 (USA) statistical software. The relationships between scar width and dermal thickness, skin type, scar location, and total scar score were analyzed using the Mann–Whitney U test. The relationship between the total scar score and skin type was analyzed using the v2 test. Values of P \ 0.05 were considered statistically significant.
Results The mean age of the 50 female patients was 40.8 years (range 18–65 years). The average follow-up period was 16 months (range 12–18 months). An average of 987.5 g (range 505–1621 g) of breast and fatty tissue was removed. The average dermal thickness was 4.99 mm (range 3.5–6.8 mm) (Figs. 2, 3, 4). The most common skin type was Fitzpatrick type IV (33 patients). The average total scar score was 14 (range 8–25) (Table 2).
Although various methods for reducing scar formation have been suggested, the reasons underlying scar formation remain to be elucidated. Offering one possible explanation, Ogawa [7] proposed that fibroproliferative diseases of the skin, including keloids and hypertrophic scars, resulted from an excessive responsiveness or functional failure of dermal cell mechanoreceptors or mechanosensitive nociceptors of the sensory fibers in the skin. That is, fibroproliferative diseases of the skin are mechanoreceptor/ mechanosensor or mechanosensitive nociceptor disorders. The present study revealed that scar width significantly increased with an increase in dermal thickness. This finding partially clarifies the reason for the differing appearance of scars between different anatomical regions of the same person. To our knowledge, breast dermal thickness has not been previously investigated, and in the present study, it was found to vary from 3.5 to 6.8 mm. In the literature, the maximum dermal thickness in the human body has been reported to be 4 mm [8]. Accordingly, it can be asserted that the dermal tissue of the breast is among the thickest in the body. In a study in which dermal thickness was measured on the nasal tip by using ultrasonography, the skin type and dermal thickness were found to have no influence on hypertrophic scarring [9]. However, in that study, the dermal thickness was measured only by ultrasonography, which provides more general information than microscopy; moreover, the scarring was observed only in a very short columnar incision. In the present study, the dermal thickness was observed microscopically, which enabled obtaining more objective information than that possible by ultrasonography. Furthermore, the measurement of the scars at three different areas increased the accuracy of the data. Hypertrophic scars are more common in weight-bearing or mobility-related areas such as the shoulders, sternum, and neck because of the increased tension in these areas.
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Table 2 Patient data Patient No
Age
Skin type
Dermis thickness (mm)
Total scar width (mm)
1
38
3
510
2
43
4
1045
5 4.2
25
9
9
12
3
44
4
976
4
38
4
535
4.5
10
10
5.5
52
5
27
4
25
645
5
34
6
28
24
3
505
4
9
7
10
37
4
530
4.6
7
11
8
48
3
673
5
31
12
9
44
4
911
6
23
24
10
58
4
976
5
15
16
11
57
4
1210
4
11
12
12
33
3
681
4.3
14
11
13
34
4
580
5
25
18
14
40
4
560
5
19
9
15
38
3
849
6
36
14
16
30
4
535
6.5
27
20
17
48
3
1120
6
23
13
18
34
4
543
5.2
18
19
19
24
3
969
4.6
11
10
20
50
4
1616
4.1
15
13
21
44
4
1063
4.5
17
17
22
45
3
1525
5
18
15
23
38
4
1011
5.5
26
21
24
33
4
641
4.8
10
11
25
54
3
1240
4
9
10
26
49
4
1576
5.3
11
10
27
47
4
1600
5
19
15
28
46
4
1283
4.8
14
16
29
57
3
1361
4
14
14
30
37
4
1150
5.3
23
9
31
18
3
690
5.2
30
11
32
18
4
505
5.5
25
22
33
49
4
1595
5.8
17
11
34
48
4
932
4
14
17
35
45
4
833
3.5
13
14
36
23
3
1530
6
22
10
37
48
4
1300
5
21
9
38
46
3
581
6.8
19
15
39
39
4
625
5
18
10
40
43
4
981
6.5
33
20
41
40
4
1621
4
10
17
42
29
4
1093
4.5
9
16
43
50
3
1209
5
20
8
44
35
3
830
6
29
15
45
44
3
1032
6
26
13
46
43
4
1615
5.5
17
10
47
65
4
955
3.5
8
9
48
52
4
870
3.8
12
9
49
43
3
1023
5.2
22
10
50
45
4
1136
5
18
11
123
Removed tissue (gr)
Total scar score
Aesth Plast Surg (2015) 39:318–324
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Fig. 5 Scar width in patients with a dermal thickness of \0.5 cm Fig. 7 Scar vascularity and noticeability were observed less often in patients with Fitzpatrick skin type III, irrespective of scar width
Fig. 6 Scar width in patients with a dermal thickness of C0.5 cm
Meanwhile, scarring seems to be relatively less severe for incisions made on the eyelid, cesarean line, and fold locations. These findings illustrate the role of tension on hypertrophic scar formation. However, when wounds are closed without tension in regions such as the shoulders, the scarring is wider than in other regions, revealing that tension is not the only determining factor in hypertrophic scar formation. In our study, scar width was measured in three different regions, including a combination of the vertical and horizontal portions of the T scar and the flap
confluence. In most patients, the widest scar was found at the flap confluence, which was the incision area with the greatest tension. This finding shows that thin scars may widen to a greater extent than scars with good dermal layer approximation. Age is an another factor that affects scar appearance. Although scar maturation occurs more slowly in older persons than in young patients, scar appearance can be better in an older individual [1] because of the decrease in dermal thickness with age. In the present study, no significant association was observed between scar width and patient age, possibly because of the narrow patient age range. Determination of skin phototypes allows physicians to assess a person’s risk of developing sunburn and, by extension, the need for sun protection to prevent the development of skin cancer. Hence, the Fitzpatrick skin phototype classification was developed [10]. The current Fitzpatrick skin-type classification denotes six different skin types, colors, and reactions to sun exposure that range from very fair (skin type I) to very dark (skin type VI) depending on whether the patient’s skin burns or tans at the
Table 3 Fitzpatrick skin phototype classification Immediate pigment darkening
Delayed tanning
Constitutitve color (unexposed buttock skin)
UV-A MED (mJ/cm2)
UV-B MED (mJ/cm2)
Phototype
Sunburn and tanning history
I
Burns easily, never tans
None (–)
None (–)
Ivory white
20–35
15–30
II
Burns easily, tans minimally with difficulty
Weak
Minimal to weak
White
30–45
25–40
III
Burns moderately, tans moderately and uniformly
Definite
Low
White
40–55
30–50
IV
Burns minimally, tans moderately and easily
Moderate
Moderate
Beige-olive, lightly tanned
50–80
40–60
V
Rarely burns, tans profusely
Intense (brown)
Strong, intense brown
Moderate brown or tanned
70–100
60–90
VI
Never burns, tans profusely
Intense (dark brown)
Strong, intense brown
Dark brown or black
100
90–150
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324
first average sun exposure (Table 3) [11]. Of relevance to the present study, hypertrophic scarring is frequently seen in persons with dark skin. Moreover, hyperpigmentation commonly occurs in Fitzpatrick skin types III to VI, and can have a considerable impact on the quality of life [12]. Therefore, patients with Fitzpatrick skin types III and IV were included in the present study. Although scar width was not significantly associated with skin type in the present study, scar vascularity and noticeability were observed more frequently in patients with Fitzpatrick skin type IV. Furthermore, although a thicker dermis at the incision area affected the scar width, no effect on scar noticeability was evident. Black, Hispanic, and Asian individuals are much more likely to develop keloids than Caucasians [13, 14]. In addition, Omo-Dare [15] recognized familial predisposition as a factor in scar formation, and observed both autosomal dominant and recessive genetic variants for hypertrophic scarring and keloid formation. However, the genes that contribute to hypertrophic scarring have not been identified. Hence, in our study, the possible genetic differences could not be determined because of an inability to perform a genetic analysis. This study had several strengths. First, all of the patients were of the same ethnicity and skin type. Second, biopsy specimens were taken from the medial right breast of all patients to minimize the effects of anatomical differences. Third, patients were operated on by the same surgeon using the same technique to maintain a consistent amount of tension. Wound care and patient follow-up were also performed by the same surgeon. Finally, we attempted to control for all factors that could play a role in scar formation to examine more effectively the effect of dermal thickness on scar formation. In conclusion, the study findings show that increased dermal thickness is a risk factor for wide scar formation. Acknowledgments This research received no specific Grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors thank Mehmet Uyar, MD, for his statistical analysis support.
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Aesth Plast Surg (2015) 39:318–324 Ethical Standard This Declaration.
study
conformed
to
the
Helsinki
Conflict of interest All named authors hereby declare that they have no conflicts of interest to disclose.
References 1. Thorne CH (2007) Techniques and principles in plastic surgery. In: Thorne CH (ed) Grabb & Smith’s Plastic Surgery, vol 6th ed. Lippincolt Williams & Wilkins, Philadelphia, pp 3–22 2. Mustoe TA, Cooter RD, Gold MH, Hobbs FD, Ramelet AA, Shakespeare PG et al (2002) International clinical recommendations on scar management. Plast Reconstr Surg 110:560–571 3. Mutalik S (2005) Treatment of keloids and hypertrophic scars. Indian J Dermatol Venereol Leprol 71:3–8 4. Juckett G, Hartman-Adams H (2009) Management of keloids and hypertrophic scars. Am Fam Physician 80:253–260 5. Murakami M, Ogawa R, Nishikawa M, Hyakusoku H (2006) A rare case of hypertrophic scar on the scalp. Plast Reconstr Surg 117:321–322 6. Lieneke JD, Tempelman FRH, Botman YAM, Tuinebreijer WE, Middelkoop E, Kreis RW et al (2004) The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. Plast Reconstr Surg 113:1960–1965 7. Ogawa R (2008) Keloid and hypertrophic scarring may result from a mechanoreceptor or mechanosensitive nociceptor disorder. Med Hypotheses 71:493–500 8. Saladin KS (2012) The integumentary system. In: Saladin KS (ed) Anatomy and Physiology, vol 6th ed. McGraw-Hill, New York, pp 180–206 9. Verim A, Duymus R, Calim OF, Karaca CT, Ozkul MH, Yasar H et al (2013) Effect of nose skin on the columellar incision scar in a Turkish population. Otolaryngol Head Neck Surg 149:438–444 10. Eilers S, Bach DQ, Gaber R, Blatt H, Guevara Y, Nitsche K et al (2013) Accuracy of self-report in assessing Fitzpatrick skin phototypes I through VI. JAMA Dermatol 149:1289–1294 11. Sachdeva S (2009) Fitzpatrick skin typing: applications in dermatology. Indian J Dermatol Venereol Leprol 75:93–96 12. Nieuweboer-Krobotova L (2013) Hyperpigmentation: types, diagnostics and targeted treatment options. J Eur Acad Dermatol Venereol 27:2–4 13. Brissett AE, Sherris DA (2001) Scar contractures, hypertrophic scars, and keloids. Facial Plast Surg 17:263–272 14. Butler PD, Longaker MT, Yang GP (2008) Current progress in keloid research and treatment. J Am Coll Surg 206:731–741 15. Omo-Dare P (1975) Genetic studies on keloid. J Natl Med Assoc 67:428–432
ORIGINAL ARTICLE
BREAST
Effect of Dermal Thickness on Scars in Women with Type III–IV Fitzpatrick Skin Bilsev Ince1 • Mehmet Dadaci1 • Pembe Oltulu2 • Zeynep Altuntas1 Fatma Bilgen3
•
Received: 29 August 2014 / Accepted: 27 February 2015 / Published online: 19 March 2015 Ó Springer Science+Business Media New York and International Society of Aesthetic Plastic Surgery 2015
Abstract Background Both patients and physicians desire minimal scarring after surgical procedures. The removal of foreign bodies from around the wound, prevention of infection, and wound closure without tension is recommended for reducing scarring. The reasons underlying the differing appearance of scars between different anatomical regions of the same individual are not fully understood. Moreover, to our knowledge, the relationship between incision width and dermal thickness in different anatomical regions has yet to be investigated. Hence, in the present study, we aimed to determine the effect of dermal thickness on scar formation. Methods Fifty patients who were treated and followed up for breast hypertrophy between 2010 and 2013 were retrospectively investigated. In all patients, a 2 9 2-cm skin biopsy specimen was obtained from the medial right breast at the horizontal line of the T scar. A routine superomedial pedicle breast reduction was subsequently performed. The extracted excision materials and skin biopsy specimens were examined pathologically. Dermal thickness was measured from the starting point of the
& Bilsev Ince [email protected] 1
Department of Plastic, Reconstructive and Aesthetic Surgery, Faculty of Meram Medicine, Necmettin Erbakan University, 42080 Meram, Konya, Turkey
2
Department of Pathology, Faculty of Meram Medicine, Necmettin Erbakan University, Konya, Turkey
3
Plastic, Reconstructive and Aesthetic Surgery Clinic, Elbistan State Hospital, Kahramanmaras, Turkey
123
subcutaneous tissue to the end point of the epidermis, at four different sites. The average dermal thickness was then calculated for each patient. The skin color of all patients was determined according to the Fitzpatrick classification. Scar width was measured in three different regions, including a combination of the vertical and horizontal portions of the T scar and the flap confluence. After the measurements, the scars were evaluated for vascularity, pigmentation, elasticity, thickness, and height by two plastic surgeons and a clinical nurse, who were blinded to patient data. Results The mean age of the 50 female patients was 40.8 years (range 18–65 years). The average follow-up period was 16 months (range 12–18 months). An average of 987.5 g (range 505–1621 g) of breast and fatty tissue was removed. The average dermal thickness was 4.99 mm (range 3.5–6.8 mm). The most common skin type was Fitzpatrick type IV (33 patients). The average total scar score was 14 (range 8–25). The total scar score was not significantly associated with dermal thickness. The scar width in patients with a dermal thickness of \0.5 cm was narrower than that in patients with a dermal thickness of C0.5 cm. Scar vascularity and noticeability were observed less often in patients with Fitzpatrick skin type III, regardless of scar width. Conclusion The study findings show that increased dermal thickness is a risk factor for wide scar formation. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. Keywords Dermis thickness Scar Fitzpatrick skin phototype classification
Aesth Plast Surg (2015) 39:318–324
Introduction Both patients and physicians desire minimal scarring after surgical procedures. Various methods have been used during and after surgery to reduce scar formation. However, there is no currently available agent that can predictably eliminate the formation of esthetically unfavorable scars [1]. The removal of foreign bodies from around the wound, prevention of infection, and wound closure without tension is recommended for reducing scarring [1]. Although the exact causes of hypertrophic scars remain unknown, a delayed epithelialization over more than 10–14 days is known to markedly increase the incidence of hypertrophic scarring [2]. Wounds that are subjected to tension due to motion, location in the body, or tissue loss are associated with an increased risk of scar hypertrophy and spreading, and hence, patients should be informed of these risks prior to any surgery [3]. For preventing scar formation in the postoperative period, the proper care of wounds is recommended, including careful suture removal at the appropriate time and shielding the wound from sunlight. In addition, the most important factors determining scar formation include the genetic characteristics of the patients. Hypertrophic scars, which are noted in 6 % of the American population, are more common in dark-skinned individuals of Asian or African descent [1]. The location of the surgical incision also affects scar appearance. The sternum, shoulders, upper arms, earlobes, and cheeks are the areas most susceptible to keloid and hypertrophic scar formation [4]. In contrast, hypertrophic scars very rarely develop on the scalp, eyelids, and anterior lower leg [5]. The reasons underlying the differing appearance of scars between different anatomical regions of the same individual are not fully understood. Moreover, to our knowledge, the relationship between incision width and dermal thickness in different anatomical regions has yet to be reported. The appearance of scars is presumed to vary because of the differing dermal thicknesses between different areas of
Fig. 1 Scar width was measured in three different regions, including a combination of the vertical (a) and horizontal (b) portions of the T scar and the flap confluence (c)
319
the same person’s body, despite the similar genetic structure and skin color across those areas. In the present study, we aimed to determine the effect of dermal thickness on scar formation.
Patients and Methods Fifty patients who were treated and followed up for breast hypertrophy between 2010 and 2013 were retrospectively investigated. Patients who had Fitzpatrick skin types III–IV were included in the study. Moreover, those who had known hypertrophic scars, were using drugs and/or smoking, or had wound infections or delayed wound healing were excluded. The same surgeon performed all operations and data collection. Patients were operated on under general anesthesia. Preoperative markings were made with the patients in the standing position. The breast meridian was marked from the midclavicular point to the new nipple position at the level of the submammary fold. Markings were subsequently made according to the inverted T scar pattern; the vertical length of the T scar was set to 5.5 cm in all patients. The superomedial pedicle, which was based on the medial limb of the vertical scar, was designed with the patient in the standing position. In all patients, a 2 9 2-cm skin biopsy specimen was obtained from the right breast at the middle part of the horizontal line of the T incision. The pedicle [with a 42-mm nipple areolar complex (NAC)] was deepithelized and beveled toward its base because the thinnest portion was under the NAC (2–2.5 cm thickness). The resection was performed in the clockwise direction in the right breast and in the counterclockwise direction in the left breast. Tissue was removed en bloc. The upper pole was then prepared, and the NAC was rotated to the proper position without tension on the pedicle. No pectoral fascia suspension sutures were used. The breast was shaped by using superior and inferior sutures, by bringing the medial and the lateral pillars together. After the placement of the NAC and pillar stitches, the arms of the T pattern were closed. A routine superomedial pedicle breast reduction was then performed. The subcutaneous tissue was closed with 2/0–3/0 polyglactin stitches, and the skin was closed with 3/0 and 4/0 poliglecaprone stitches. Patients were discharged after removing the drains, when no exudates from the wound were observed. In all patients, the dressing was changed daily with the application of antibiotic skin ointment. The stitches were absorbable and therefore did not require removal. No treatment for scar reduction was administered. The patients were photographed at 3 and 12 months postoperatively. The extracted excision materials and skin biopsy specimens were examined histologically. The skin and
123
320
Aesth Plast Surg (2015) 39:318–324
Table 1 Observer Scar Assessment Scale
Fig. 2 Microscopic appearance of the dermis in patients with a dermal thickness of 4 mm
subcutaneous tissues were stained with hematoxylin and eosin, and the dermal thickness was measured under a light microscope at 409 magnification. Dermal thickness was measured from the starting point of subcutaneous tissue to the end point of the epidermis, at four different sites. The average dermal thickness was then calculated for each patient. The skin color of all patients was determined according to the Fitzpatrick classification. At the 1-year postoperative follow-up, the scar width was measured in three different regions, including a combination of the vertical and horizontal portions of the T scar and the
123
Fig. 3 Microscopic appearance of the dermis in patients with a dermal thickness of 6 mm
flap confluence. The vertical scar width was measured from the middle of the areola’s lower end and the middle portion of the flap. The horizontal scar width was measured from the middle of the most medial region of the scar to the point of the junction medium (Fig. 1). After the measurements, the scars were evaluated for vascularity, pigmentation, elasticity, thickness, and height by two plastic surgeons and a
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321
Dermal thickness was not significantly associated with the total scar score and Fitzpatrick skin type. The scar width in patients with a dermal thickness of \0.5 cm was narrower than that in patients with a dermal thickness of C0.5 cm (P \ 0.05) (Figs. 5, 6). Scar vascularity and noticeability were observed less often in patients with Fitzpatrick skin type III, regardless of the scar width (P \ 0.05) (Fig. 7). However, no significant association was observed between scar width and skin type. Furthermore, no significant association was found between scar width, patient age, or weight of the removed material.
Discussion
Fig. 4 Microscopic appearance of the dermis in patients with a dermal thickness of 7 mm
clinical nurse, who were blinded to patient data. In this evaluation, the Observer Scar Assessment Scale defined by Lieneke et al. [6] was used (Table 1). All items of the scale are scored numerically (from 1 to 10, with a score of 10 corresponding to the worst possible scar appearance). Statistical Analysis The statistical significance of the differences between the mean values was analyzed using SPSS 18.0 (USA) statistical software. The relationships between scar width and dermal thickness, skin type, scar location, and total scar score were analyzed using the Mann–Whitney U test. The relationship between the total scar score and skin type was analyzed using the v2 test. Values of P \ 0.05 were considered statistically significant.
Results The mean age of the 50 female patients was 40.8 years (range 18–65 years). The average follow-up period was 16 months (range 12–18 months). An average of 987.5 g (range 505–1621 g) of breast and fatty tissue was removed. The average dermal thickness was 4.99 mm (range 3.5–6.8 mm) (Figs. 2, 3, 4). The most common skin type was Fitzpatrick type IV (33 patients). The average total scar score was 14 (range 8–25) (Table 2).
Although various methods for reducing scar formation have been suggested, the reasons underlying scar formation remain to be elucidated. Offering one possible explanation, Ogawa [7] proposed that fibroproliferative diseases of the skin, including keloids and hypertrophic scars, resulted from an excessive responsiveness or functional failure of dermal cell mechanoreceptors or mechanosensitive nociceptors of the sensory fibers in the skin. That is, fibroproliferative diseases of the skin are mechanoreceptor/ mechanosensor or mechanosensitive nociceptor disorders. The present study revealed that scar width significantly increased with an increase in dermal thickness. This finding partially clarifies the reason for the differing appearance of scars between different anatomical regions of the same person. To our knowledge, breast dermal thickness has not been previously investigated, and in the present study, it was found to vary from 3.5 to 6.8 mm. In the literature, the maximum dermal thickness in the human body has been reported to be 4 mm [8]. Accordingly, it can be asserted that the dermal tissue of the breast is among the thickest in the body. In a study in which dermal thickness was measured on the nasal tip by using ultrasonography, the skin type and dermal thickness were found to have no influence on hypertrophic scarring [9]. However, in that study, the dermal thickness was measured only by ultrasonography, which provides more general information than microscopy; moreover, the scarring was observed only in a very short columnar incision. In the present study, the dermal thickness was observed microscopically, which enabled obtaining more objective information than that possible by ultrasonography. Furthermore, the measurement of the scars at three different areas increased the accuracy of the data. Hypertrophic scars are more common in weight-bearing or mobility-related areas such as the shoulders, sternum, and neck because of the increased tension in these areas.
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Table 2 Patient data Patient No
Age
Skin type
Dermis thickness (mm)
Total scar width (mm)
1
38
3
510
2
43
4
1045
5 4.2
25
9
9
12
3
44
4
976
4
38
4
535
4.5
10
10
5.5
52
5
27
4
25
645
5
34
6
28
24
3
505
4
9
7
10
37
4
530
4.6
7
11
8
48
3
673
5
31
12
9
44
4
911
6
23
24
10
58
4
976
5
15
16
11
57
4
1210
4
11
12
12
33
3
681
4.3
14
11
13
34
4
580
5
25
18
14
40
4
560
5
19
9
15
38
3
849
6
36
14
16
30
4
535
6.5
27
20
17
48
3
1120
6
23
13
18
34
4
543
5.2
18
19
19
24
3
969
4.6
11
10
20
50
4
1616
4.1
15
13
21
44
4
1063
4.5
17
17
22
45
3
1525
5
18
15
23
38
4
1011
5.5
26
21
24
33
4
641
4.8
10
11
25
54
3
1240
4
9
10
26
49
4
1576
5.3
11
10
27
47
4
1600
5
19
15
28
46
4
1283
4.8
14
16
29
57
3
1361
4
14
14
30
37
4
1150
5.3
23
9
31
18
3
690
5.2
30
11
32
18
4
505
5.5
25
22
33
49
4
1595
5.8
17
11
34
48
4
932
4
14
17
35
45
4
833
3.5
13
14
36
23
3
1530
6
22
10
37
48
4
1300
5
21
9
38
46
3
581
6.8
19
15
39
39
4
625
5
18
10
40
43
4
981
6.5
33
20
41
40
4
1621
4
10
17
42
29
4
1093
4.5
9
16
43
50
3
1209
5
20
8
44
35
3
830
6
29
15
45
44
3
1032
6
26
13
46
43
4
1615
5.5
17
10
47
65
4
955
3.5
8
9
48
52
4
870
3.8
12
9
49
43
3
1023
5.2
22
10
50
45
4
1136
5
18
11
123
Removed tissue (gr)
Total scar score
Aesth Plast Surg (2015) 39:318–324
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Fig. 5 Scar width in patients with a dermal thickness of \0.5 cm Fig. 7 Scar vascularity and noticeability were observed less often in patients with Fitzpatrick skin type III, irrespective of scar width
Fig. 6 Scar width in patients with a dermal thickness of C0.5 cm
Meanwhile, scarring seems to be relatively less severe for incisions made on the eyelid, cesarean line, and fold locations. These findings illustrate the role of tension on hypertrophic scar formation. However, when wounds are closed without tension in regions such as the shoulders, the scarring is wider than in other regions, revealing that tension is not the only determining factor in hypertrophic scar formation. In our study, scar width was measured in three different regions, including a combination of the vertical and horizontal portions of the T scar and the flap
confluence. In most patients, the widest scar was found at the flap confluence, which was the incision area with the greatest tension. This finding shows that thin scars may widen to a greater extent than scars with good dermal layer approximation. Age is an another factor that affects scar appearance. Although scar maturation occurs more slowly in older persons than in young patients, scar appearance can be better in an older individual [1] because of the decrease in dermal thickness with age. In the present study, no significant association was observed between scar width and patient age, possibly because of the narrow patient age range. Determination of skin phototypes allows physicians to assess a person’s risk of developing sunburn and, by extension, the need for sun protection to prevent the development of skin cancer. Hence, the Fitzpatrick skin phototype classification was developed [10]. The current Fitzpatrick skin-type classification denotes six different skin types, colors, and reactions to sun exposure that range from very fair (skin type I) to very dark (skin type VI) depending on whether the patient’s skin burns or tans at the
Table 3 Fitzpatrick skin phototype classification Immediate pigment darkening
Delayed tanning
Constitutitve color (unexposed buttock skin)
UV-A MED (mJ/cm2)
UV-B MED (mJ/cm2)
Phototype
Sunburn and tanning history
I
Burns easily, never tans
None (–)
None (–)
Ivory white
20–35
15–30
II
Burns easily, tans minimally with difficulty
Weak
Minimal to weak
White
30–45
25–40
III
Burns moderately, tans moderately and uniformly
Definite
Low
White
40–55
30–50
IV
Burns minimally, tans moderately and easily
Moderate
Moderate
Beige-olive, lightly tanned
50–80
40–60
V
Rarely burns, tans profusely
Intense (brown)
Strong, intense brown
Moderate brown or tanned
70–100
60–90
VI
Never burns, tans profusely
Intense (dark brown)
Strong, intense brown
Dark brown or black
100
90–150
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first average sun exposure (Table 3) [11]. Of relevance to the present study, hypertrophic scarring is frequently seen in persons with dark skin. Moreover, hyperpigmentation commonly occurs in Fitzpatrick skin types III to VI, and can have a considerable impact on the quality of life [12]. Therefore, patients with Fitzpatrick skin types III and IV were included in the present study. Although scar width was not significantly associated with skin type in the present study, scar vascularity and noticeability were observed more frequently in patients with Fitzpatrick skin type IV. Furthermore, although a thicker dermis at the incision area affected the scar width, no effect on scar noticeability was evident. Black, Hispanic, and Asian individuals are much more likely to develop keloids than Caucasians [13, 14]. In addition, Omo-Dare [15] recognized familial predisposition as a factor in scar formation, and observed both autosomal dominant and recessive genetic variants for hypertrophic scarring and keloid formation. However, the genes that contribute to hypertrophic scarring have not been identified. Hence, in our study, the possible genetic differences could not be determined because of an inability to perform a genetic analysis. This study had several strengths. First, all of the patients were of the same ethnicity and skin type. Second, biopsy specimens were taken from the medial right breast of all patients to minimize the effects of anatomical differences. Third, patients were operated on by the same surgeon using the same technique to maintain a consistent amount of tension. Wound care and patient follow-up were also performed by the same surgeon. Finally, we attempted to control for all factors that could play a role in scar formation to examine more effectively the effect of dermal thickness on scar formation. In conclusion, the study findings show that increased dermal thickness is a risk factor for wide scar formation. Acknowledgments This research received no specific Grant from any funding agency in the public, commercial, or not-for-profit sectors. The authors thank Mehmet Uyar, MD, for his statistical analysis support.
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Aesth Plast Surg (2015) 39:318–324 Ethical Standard This Declaration.
study
conformed
to
the
Helsinki
Conflict of interest All named authors hereby declare that they have no conflicts of interest to disclose.
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