Your Questions
Your Questions
Q: Dr. Eppley, I am interested in tracheostomy scar revision. I have already consulted some local plastic surgeons, but they are not expert with this kind of procedure. One of them told me I would have to go there twice or three times to have a reasonable repair conclusion. Actually, I am kind of afraid of it. I would like to receive an advice from you. Please, show me if it is possible to be removed! Would you perform a lipofilling procedure? Thank you!
A: Thank you for your inquiry and sending your pictures. You have a very deep tracheostomy scar deformity that goes well into the sternal notch area. This represents a severe loss of fat between the skin and trachea. I imagine that there is also a skin retraction deformity which occurs when you swallow. In my hands, I believe you can get a very good result in a single procedure using a dermal fat graft to fill the defect and excising and closing the horizontal skin scar over it. Dermal-fat grafts survive very well in small defects like a depressed tracheostomy scar.This is a very straightforward and uncomplicated procedure that has a very minimal recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was born pre mature and have a bad tracheostomy scar that I really want improved. After reading your website I can see that you are a extremely talented surgeon with lost of practice in this area. I have attached two pictures, one where the neck is stretched and one where Im looking straight forward. Can you please tell me what is possible to do here, and what results I can expect?
A: What you have is a vertically oriented tracheostomy scar with a central depression. The best way to treat that type of trach scar would be total excision and contracture release, interpositional dermal-fat graft and linear or partial broken line skin closure. You most certainly should be able to substantially narrow the scar line and even out its contour with the surrounding unscarred skin. In short, there is a lot of room for improvement in your tracheostomy scar. The one negative to your trach scar is that it is vertically oriented, completely perpendicular to the natural horizontal relaxed skin tension lines of the neck. This natural anatomic violation will make any neck scar revision more prone to secondary widening than if the initial scar was horizontal in orientation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was in a bad car accident over 15 years ago. I had a tracheostomy to enable me to breathe. But it has left a terrible scar. Growing up through high school, college, and even some times today; people tease me about having a “hickey.” Also even children who I do not even know will point to me to their mothers after they see me because they notice the scar on my neck. I am tired of being teased by people I know and even young children who do not even know me at all. Would I be able to have tracheostomy scar revision to remove the scar. (The doctor “fashioned” the scar to look like a cross but since it’s over 10 years old, the scar does not resemble a scar.
A: I think there is no doubt that your tracheostomy scar had a lot of room for improvement. I would not use the term tracheostomy scar ‘removal’ as that would be impossible to never have any scar on your neck. But minimizing it is the realistic goal so the proper term would be tracheostomy scar revision or tracheostomy scar reduction. This would require complete horizontal scar excision, surrounding skin underming, possible dermal-graft placed underneath and then a linear layered closure done. While initially his would be just a fine line scar, it would take a few months to see if any scar widening developed. (although never to the degree that you have now) One should even think about a second stage revision or laser resurfacing for optimal improvement should the scar become a little wide although I would hope this would be unnecessary. This is a procedure that could be done general or IV sedation an an outpatient procedure. There essentially is no recovery from it other than scar healing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, after enduring over twenty years of having an indented tracheostomy scar, I am finally getting it revised. I understand that up to 50% of the fat tissue that is used as a filler gets dissolved by the body while it is healing. Is it possible that one would need multiple visits over the years to keep adding filler injections or something of that nature? Also, if one were to avoid that route in favor of something “off the counter” which product would you recommend? Thanks in advance.
A:Most tracheostomy scars can be revised and the neck skin leveled by simply closing the deeper layers of the excised scar as it is closed. This brings in tissue from the side and fills the defect or area of missing tissue underneath the skin. Larger or more indented tracheostomy scars, however, do have a real subcutaneous tissue deficiency as a result of fat loss due to pressure atrophy caused by the indwelling tratcheostomy tube. When these are merely excised and closed, they will revert to some degree of inversion as the skin is essentially closed over an ‘open space’. This is why the placement of fat grafts can be so helpful in tracheostomy scar revisions. However, the choice of fat grafts is critical and should be a dermal-fat graft and not fat injections. These are small composite grafts that can be taken from many locations with a small resultant scar. There are no ‘off the shelf’ products, such as allogeneic dermal grafts, that are a good substitute for a supple dermal-fat graft.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis, Indiana
Q: I was just wondering if I am a good candidate for a tracheostomy scar revision. I had a tracheostomy back in 2005 and never knew that a revision surgery was possible until recently. I am really self-conscious of this hole in my neck. Plus it constantly reminds of why it is there in the first place. (a car accident)
A: Tracheostomies that remain in for any extended period of time (weeks to months) will often leave a depressed scar once they are removed and heal. This is the result of a phenomenon known as pressure atrophy of the subcutaneous fat. The pressure of the tube and the subsequent scar that it creates results in fat loss and tethered or scarring down of the skin edges. Tracheostomies wounds are now closed after tube removal and are allowed to heal in on their own.
Some initial tracheostomy scars may look depressed or indented but may ‘fill out’ as healing progresses to an acceptable level. This is why I don’t do tracheosotomy scar revision in the first six months after tube removal unless the wound has real trouble healing. Conversely, it is never too late to revise the depressed neck scar.
Many tracheostomy scars can be improved by simple scar revision. Others may require some fat volume restoration with scar revision. I prefer a small dermal-fat graft to replace the lost tissues between the scar overlying the trachea and the underside of the skin. Even a small graft, 2.5 cm x 1 cm, can be really helpful. There is no substitute for your own natural fat for small areas of tissue filling. The graft can be easily harvested from old scars almost anywhere on the body.
Dr. Barry Eppley