Q: My son was born premature and needed a tracheostomy. He was unable to be decannulated and then had a tracheolaryngoplasty performed at three years of age. This has left a large ‘hole’ in his neck. He is now 11. We have seen a plastic surgeon who seemed to think that it couldn’t be made better and he should wait until he is fifteen years old. Do you have any experience with this type of neck scar problem? He is quite small for his age, has a very husky voice and the scar is not good for his self-esteem.
A: Having done numerous tracheostomy scar revisions over the years, I have observed that they come in numerous scar orientations (vertical vs horizontal) and depths. (smooth vs indented) The most difficult tracheostomy scars are those that are significantly indented such as the one your son appears to have. They are difficult because the problem is more than just a wide scar but that there is a significant soft tissue deficiency between the skin and the underlying trachea. The pressure of the tracheostomy tube has caused subcutaneous fat atrophy which is why it is indented. This tissue deficiency must be replaced to get a satisfactory outcome. In these cases, I usually use a dermal-fat graft to fill in the defect after the scar edges are released and undermined. Then the skin portion of the scar is closed over it. Because the skin closure is usually under considerable tension, a second scar revision on the skin may needed a year later if it widens to any degree.
Dr. Barry Eppley