Various options available for treating cancer surgery scars

New York - Most patients heal well from Mohs micrographic or other surgeries to remove skin cancers. For those whose scarring from surgery is anatomically or cosmetically unacceptable, there is good news.

Primary goal

Dr. Carucci is a dermatologic surgeon practicing in New York City and chief of Mohs micrographic surgery, department of dermatology, Weill Medical College of Cornell at New York Presbyterian Hospital.

According to Dr. Carucci, when possible, dermatologic surgeons minimize incision visibility by hiding incisions in some concavity - the ear or mouth. Or they place incisions behind the hairline, keeping in mind that hairlines change.

"From a practical point of view, one of the best places to hide an incision is along the boundary of a cosmetic unit. If you are able to plan reconstruction such that you are utilizing the borders between those units, you will get a very natural result in terms of healing," he says.

Greatest risk

Those at greatest risk of an unfavorable result are patients with thick, sebaceous skin.

"In these patients, you might be thinking in terms of minimizing length and number of incisions," Dr. Carucci says.

The first step in treating an unfavorable scar after skin cancer removal is to determine what it is that makes the scar or imperfection stand out, Dr. Carucci explains. He suggests determining whether the cause is contour irregularity, an indentation or raised area, pigment or color differentiation from surrounding skin.

"If a wound is raised after an incision or repair, you want to first ask how long ago was the procedure performed and realize that, in general, even though the healing on the surface of the skin takes about a week, it is not healed beneath the skin. Healing beneath the skin can take up to a year," Dr. Carucci says. "Contour irregularities can pop up during the collagen remodeling process, so it is important not to jump the gun and try to do something before the right time."

Dermabrasion

Dermabrasion is an effective treatment for a scar's raised, rough or noticeable edge.

The conventional wisdom, Dr. Carucci says, is that dermabrasion can be performed as early as six to eight weeks after surgery. Dermatologists can also easily treat redness or vascularity at the incision site early on with the pulsed dye laser. Recent studies suggest a benefit from pulsed dye laser treatment at the time of suture removal, he says.

There are a number of treatments for raised keloidal or hypertrophic scars. One proven method is corticosteroid injection, which helps to break up scar tissue. But dermatologists should under-treat rather than over-treat in order to avoid atrophy, he says.

Dermatologists also have used the pulsed dye laser to treat hypertrophic scars, especially if the scar is red.

Dr. Carucci treats hyperpigmentation around incision sites with bleaching agents or combination treatments of hydroquinone, topical steroids and topical retinoids. Hypopigmentation, however, is more of a challenge to treat. It occurs rarely from cancer surgery reconstruction, but can occur, for example, on later follow-up of skin grafts.

"That is one reason that I tend to favor skin flaps over skin grafts, because I think skin grafts result in hypopigmentation over time," Dr. Carucci says.

Scalpel revision

In scalpel scar revision, Dr. Carucci tends to use Z-plasty or geometric broken line closure. These are ways of breaking up and redirecting the scar.