Direct closure of round skin defects: a four-step technique with multiple subcutaneous and cutaneous "figure-of-8" sutures alleviating dog-ears

Excisional biopsies of rounded lesions are performed daily by surgeons. The objective of this article is to establish a surgical technique for direct closure of circular and elliptical defects without the need for additional excision of dog-ears. A four-step technique based on multiple cutaneous and subcutaneous "figure-of-8" sutures is presented. When correctly placed, these sutures can equally distribute the excess tissue along the scar and alleviate dog-ears. The results of the 65 presented cases show that this technique yields short scars and saves healthy skin. A significant reduction of the length-to-width ratio and the arc-to-scar length ratio is obtained. Direct closure of a circular or elliptical defect without stipulating a 3:1 length-to-width ratio is feasible. Among the advantages of the technique are that no excessive healthy tissue is removed and that the scar length is reduced. The long-term outcome is a scar that is thin, linear, flat, and concealed in the body structure.     

Absorbable versus nonabsorbable sutures to prevent postoperative stretching of wound area

In surgery it is not uncommon to demand considerable tensile strength of sutures, at least for the time it takes the scar to gain sufficient strength to resist wound-shearing forces without the help of sutures. There is controversial thinking as to whether absorbable or nonabsorbable sutures should be used in this situation. By tattooing two pairs of marks on each side of the wound after a midline sagittal excision of the scalp for correction of androgenetic alopecia and suturing 13 patients with Dexon (polyglycolic acid) and 8 with Prolene (polypropylene), the authors were able to measure a 48 to 59 percent larger postoperative stretching of the wound area in the Dexon group 2 months postoperatively. In addition, the scar width was 60 to 76 percent larger in the Dexon group 3 months postoperatively. These differences were highly significant. Differences in scar depression also supported the idea of more stretching in the Dexon group. This indicates the importance of careful choice of suture material in situations where problems are to be expected, such as in wide scars or wound failure.     

A comparison of intramarginal and extramarginal excision of hypertrophic burn scars

Hypertrophic scarring is common in burn patients. The treatment of such scarring is difficult, and recurrence of the hypertrophic changes after scar revision is not uncommon. It has been suggested that intramarginal excision diminishes the chances of recurrent hypertrophic scarring, but we could not find any papers in the literature actually comparing intramarginal and extramarginal excisions. We therefore reviewed our experience with intramarginal and extramarginal excision of hypertrophic scars. Between October 30, 1979, and March 26, 1986, we excised 50 hypertrophic scars in 23 burn patients. Thirty-one (62 percent) of the excisions were intramarginal and 19 (38 percent) were extramarginal. We compared the results and observed that the intramarginal excisions yielded better results than the extramarginal excisions.     

Skin waste, vertex angle, and scar length in excisional biopsies: comparing five excision patterns--fusiform ellipse, fusiform circle, rhomboid, mosque, and S-shaped

The common excision skin pattern is either a fusiform ellipse or another pattern with dissimilar length and width. The purpose of this study was to define the most advantageous skin pattern regarding skin waste, vertex angle, and scar length. Five skin excision patterns used traditionally for closure of round lesions were analyzed: fusiform ellipse, fusiform circle, rhomboid, mosque, and S-shaped. In the analysis, the pattern characteristics were formulated by geometric principles, from which the results were compared. The smallest skin waste was found in rhomboid and mosque patterns, whereas the largest skin waste was found in the fusiform circle and ellipse. The vertex angle was found to decrease monotonously with the excision length-to-width ratio for all patterns except the mosque shape, which is zero per definition. The paradigm stating that a vertex angle of 30 degrees or less is maintained for length-to-width ratios below 4 in the surgical ellipse was found incorrect. It holds only for rhomboid and S-shaped excisions. The scar length was found almost independent of the pattern, with a variance of 3 percent. The authors conclude that the most advantageous surgical skin patterns are the rhomboid and mosque excisions.     

Patients' perceptions of the cosmetic impact of melanoma resection

This study investigated the relationship between primary versus grafted closure for melanoma and the cosmetic impact on the patient of the resulting scar. A total of 176 patients with melanoma completed a multiple-choice questionnaire designed for this study. Two factors were significantly related to negative cosmetic impact: severity of scar indentation (but not scar length) and the extent to which patients were unprepared for the actual size of their scars. Patients whose scars were deeply indented as well as those whose scars were larger than anticipated displayed greatest distress about their appearance. Cosmetic impact was greater for women than for men. These observations suggest that primary closures, rather than closures requiring skin grafts, have important psychological benefits for patients and that physicians can assist postoperative adjustment by giving patients accurate information about the expected appearance of their scars.     

Angular dermoid cysts in the endoscopic era: retrospective analysis of aesthetic results using the direct, classic method

The concept of the endoscopic approach was recently introduced for the removal of angular dermoid cysts. Therefore, it was considered necessary to evaluate the conventional direct incisional approach for angular dermoid cyst excision, with respect to long-term aesthetic results and complications. The need to change from the direct excisional technique to the endoscopic approach in hair-bearing areas was investigated. During a 25-year period, 95 children were surgically treated by a single surgeon (H.G.T.) for removal of angular dermoid cysts. Only 22 patients (23 percent) were available for reassessment. The follow-up periods after the excisional procedure were 1 to 12 years. Assessments were performed by a 15-member team of assessors, who scored the aesthetic results of the scars with comparative slides. In addition, a questionnaire was mailed to each family, to document the family members' perceptions of the aesthetic appearance of the scar. Twenty-eight families (29 percent) responded. The complications were determined through the medical records department. For 19 of 22 patients (86 percent), the scar was scored by 85 percent of the assessors as excellent or good. No assessor stated that a scar was unacceptable. In the family questionnaires, 26 of 28 families (93 percent) reported an excellent scar and two (7 percent) reported a fair scar. No family stated that the scar was unacceptable. The operative notes for the 95 patients revealed that only two cysts had ruptured during the surgical procedure (2 percent) and only one infection had occurred (1 percent). No other major complications were reported. It is concluded that the direct method for dermoid cyst excision is an excellent approach, with a low complication rate and a very high aesthetic success rate, when performed through a supra-eyebrow or infra-eyebrow incision.     

"Zigzag" wavy-line periareolar incision

There is almost no mention of improvement in the aesthetics of areolar incisions in the plastic and reconstructive surgery literature. The most visible area of the breast is the central mound; therefore, it behooves surgeons to make an areolar incision as inconspicuous as possible. Minimal incision breast operations and short-scar operations, such as mastopexy and vertical reduction mammaplasty, use a circumareolar incision. This circumareolar technique, which specifically avoids a purse-string support suture, is useful in all periareolar incisions. This method creates a scar that mimics the elusive, natural irregularity between the areola and periareolar skin. The goal is to have an irregular, random, wavy line that appears more natural. Between August of 1998 and August of 1999, 104 "zigzag" wavy-line procedures were performed. The complications seen in this series included delayed healing in four patients and hypertrophic scar in two patients. No scars were surgically revised. The results demonstrated a definite difference compared to a circular scar. The zigzag wavy-line technique complements the innovative methods that shorten scars while they create a more natural, lasting breast mound. For areolar incisions, good results are deceptively subtle, but unnatural results can be painfully obvious. The zigzag wavy-line incision subtly eludes the eye in diminishing the signs the patient has undergone an operation.     

Adjunctive treatment of congenital pigmented nevi with phenol chemical peel

The purpose of this study was a retrospective evaluation of the treatment of congenital pigmented nevi using the phenol chemical peel technique. Patients were treated with standard Baker formula in the operating room under general anesthesia or intravenous sedation with continuous electrocardiogram monitoring. A total of 20 patients were reviewed (13 girls and 7 boys, mean age 3.8 years). Eight patients had nevi located on the face, five patients had trunk lesions, and three patients had lesions on the thighs. Two patients had nevi located on both the face and the trunk, and two patients had involvement of the face, trunk, and thigh. Three of the above patients had the classic "bathing trunk" distribution of the nevi. A test area was peeled in four patients, and in five patients preoperative biopsies were performed to rule out malignancy before initiation of therapy. An average of 2.6 treatments were performed per patient. Two patients had adjunctive dermabrasion to increase the depth of peel and to contour surface irregularities. The length of follow-up ranged from 6 to 84 months with a mean of 28 months. Healing of the wounds occurred within 2 to 3 weeks postoperatively. Seventy-five percent of patients had satisfactory cosmetic improvement in the appearance of the lesions following treatment. Four patients had recurrence of the pigmentation after an initial lightening response, three of whom had their nevi subsequently excised. There was no incidence of hypertrophic scarring or cardiac and/or renal complications. There was one death from complications of leptomeningeal melanocytosis. Chemical peeling of congenital pigmented nevi is an acceptable alternative method of therapy for those lesions that are too large for excision and primary closure or for lesions in which excision would result in unacceptable scars in areas such as the face.     

The effects of a single dose of 5-fluorouracil on keloid scars: a clinical trial of timed wound irrigation after extralesional excision

The possibility of altering the pathophysiology of keloid scars was investigated in 11 patients, using a single application of 5-fluorouracil solution for 5 minutes after extralesional excision was performed. Similar excisional wounds treated with phosphate-buffered saline for 5 minutes served as synchronous controls. An objective scoring system and subjective assessment were made to assay the change in the quality of the wound-healing and scar tissue produced by this treatment. A keloid scar score was used at regular time intervals after treatment to assess the quality of scar produced, thereby enabling the treated and control scars to be clinically compared.Biopsies were taken of the control and treated scars 1 month after treatment; the biopsy specimens were then subjected to immunohistochemical analysis as well as a functional assessment of cultured keloid fibroblasts. The immunohistochemical antigens assayed were Ki-67 (also called MIB-1; a marker of cell proliferation); vascular cell adhesion molecule-1 (a marker of inflammation); transforming growth factor beta-1 (a factor involved in scarring) and CD-68 (a macrophage-specific marker). Fibroblast-populated collagen lattices provided a functional assessment of fibroblast contraction.All treated and control wounds healed without any dehiscence or infection. The keloid scar score revealed that there was a perceived improvement in condition for those treated with 5-fluorouracil, compared with the control specimens, during the 6-month follow-up period in the five patients who attended all their clinic appointments; data on later recurrence are not complete as yet. The wounds treated with 5-fluorouracil produced scars that had a significant (p < 0.01) reduction in all the markers assayed, apart from CD-68. Functionally, the keloid fibroblasts from three of five of the treated patients showed reduced contractile capacity.This pilot study demonstrates that a "single-touch" technique with 5-fluorouracil can produce a change in the characteristics of the healing keloid wound after extralesional excision. Long-term studies are required to elucidate the correct dosage and time of exposure to improve the efficacy of this potential treatment.     

Management of parotid hemangioma in 100 children

Most problematic infantile hemangiomas are successfully treated with pharmacological therapy. However, there are reports that hemangioma of the parotid gland responds poorly to corticosteroid and interferon. To better clarify the management of parotid hemangioma, the authors retrospectively studied the records of 100 consecutive patients, seen between 1975 and 2002. The characteristics of the tumor, including sex ratio, presence at birth, size, side, complications, and involvement of adjacent structures, were recorded. The indications for and response to treatment and the need for surgical procedures were documented and statistically analyzed. The female-to-male ratio was 4.5:1. Forty percent of parotid hemangiomas were on the right side, 36 percent were on the left, and 24 percent were bilateral. Forty-five percent of patients had a premonitory cutaneous lesion at birth. Fifty-nine percent of parotid hemangiomas ulcerated during the early proliferative phase. Eighty-eight percent involved nearby structures (ear, 70 percent; lip, 34 percent; subglottic region, 21 percent; eye, 18 percent; and nose, 3 percent). Seven percent of patients required tracheostomy, and 3 percent had signs of congestive heart failure. Seventy infants received pharmacological treatment. Sixty-seven patients were initially managed with corticosteroids; regression or stabilization was noted in 83 percent of tumors (56 of 67 tumors). Twenty-one patients received interferon: 11 in whom corticosteroid therapy had failed, seven in whom the tumor stabilized with corticosteroid therapy but further regression was needed, and three who had interferon as primary therapy. Ninety-five percent of the lesions that were resistant to corticosteroid subsequently responded to interferon alfa-2a or -2b. The overall response rate to pharmacological therapy was 98 percent. A reconstructive procedure was necessary during the involuting or involuted phase in 66 percent of patients: 92 percent had preauricular excision of redundant skin and/or fibrofatty tissue and 37 percent of patients had auricular revision. In summary, drug therapy was effective in the majority of infants with parotid hemangioma, whether given because the tumor was large, deforming, ulcerated, or involved nearby structures with functional consequences. Infantile hemangioma in the parotid gland responded to pharmacological treatment in a similar manner as hemangioma in other locations.     

The fate of sternotomy scars in children

The scars from sternal split incisions were examined and rated in 101 consecutive children attending a cardiology clinic at least 1 year after surgery. Each scar was rated as excellent, good, acceptable, or poor. Factors that may correlate with scar quality were analyzed. This analysis showed that poor scars were most likely to have been closed with intracuticular polyglycolic acid suture; males were more likely to have better scars than females; the younger the child at operation, the better was the scar result; and only 18 of the 69 scars that were hypertrophic 1 year postoperatively remained so after a mean of 5.5 years.     

X-irradiation reduces lesion scarring at the contusion site of adult rat spinal cord

Spinal cord injury (SCI) results in cell death and tissue destruction, and ultimately cavitation followed by the formation of lesion scars at the injury site. The lesion scars include an astrocytic component (glial scar) and a fibroblastic component (connective tissue scar). The purpose of the present study is to determine if X-irradiation could minimize the formation of lesion scars and reduce the levels of chondroitin sulfate proteoglycans (CSPGs) in the contusion SCI model of the adult rat. Two weeks after SCI, a connective tissue scar formed at the injury site consisting primarily of fibroblasts and exhibits strong CSPG immunoreactivity. The fibroblasts might originate from the connective tissue of pia mater or arachnoid mater. At the same time, reactive astrocytes in the spared tissue accumulate surrounding the lesion cavity to form a thick glial scar with significant enhancement of glial fibrillary acidic protein (GFAP) and CSPG immunoreactivity. After X-irradiation (40 Gy) of the injury site 2 days post-injury, that results in an attenuated dose to the lesion, the connective tissue scar was not observed, and accordingly, almost no CSPG immunoreactivity was detected at this area. Meanwhile, the glial scar and its CSPG immunoreactivity were prominently reduced. X-irradiation did not show significant improvement in locomotor recovery, but resulted in a slight delay of body weight recovery following injury. This preparative treatment could be used to reduce secondary scarring in the lesion resulting in an enriched site for further treatment such as growth related transplantation.     

Simultaneous reconstruction of the secondary bilateral cleft lip and nasal deformity: Abbé flap revisited

The purpose of this retrospective study was to review the method of using the Abbé flap for correction of secondary bilateral cleft lip deformity in selected patients with tight upper lip, short prolabium, lack of acceptable philtral column and Cupid's bow definition, central vermilion deficiency, irregular lip scars, and associated nasal deformity. A total of 39 patients with the bilateral cleft lip nasal deformity received Abbé flap and simultaneous nasal reconstruction during a period of 6 years. Mean patient age at the time of the operation was 19.1 years, and ranged from 6.6 to 38.5 years. The average follow-up period was 1.8 years. Fourteen patients had prior orthognathic operations. The Abbé flap was designed 13 to 14 mm in length and 8 to 9 mm in width and contained full-thickness tissue from the central lower lip, with a slightly narrow reverse-V caudal end. The prolabium, including the scars and central vermilion, was excised. Lengthening procedures of the upper lip segments were performed if vertical deficiency existed. Part of the prolabial skin was preserved and mobilized for columellar elongation, if indicated. Open rhinoplasty was carried out with or without cartilage graft for columella and nasal tip reconstruction. Reduction of the alar width and nostrils was achieved by a Z-plasty or excision of scar tissue at the nostril floor. The Abbé flap was then transposed cephalad, insetting into the median defect and sutured in layers. The results demonstrated no flap problems or perioperative complications. Seven patients needed further minor revisions on the nose and/or lip. Laser treatment was used to improve the lip scars in three patients. The patients were satisfied with the final outcome and found the lower lip scars acceptable. In conclusion, the described technique of Abbé flap and simultaneous rhinoplasty is an effective reconstructive method for select patients with bilateral cleft lip and nasal deformity.     

Treatment of keloids by surgical excision and immediate postoperative single-fraction radiotherapy

The authors report the outcomes of patients with keloid scars treated with a protocol of extralesional excision and immediate single-fraction adjuvant radiotherapy. The design of the study was a retrospective analysis with up to 5-year outcome data. The setting was a single treatment team, University Teaching Hospital in London, United Kingdom. Participants (n = 80) were treated for 80 keloid scars (59 percent female patients, 76 percent nonwhite), and 44 percent of keloids were located on earlobes. For all patients, prior treatment without radiotherapy had failed. The salvage treatment reported in this article is combined extralesional excision and immediate postoperative external-beam radiotherapy. A 10-Gy dose of superficial 60-kV or 100-kV photon irradiation was given within 24 hours of the operation. The main outcome measure was freedom from recurrence of keloid scars. Results were that all keloid scars were controlled at 4-week follow-up. Probability of relapse at 1 year was 9 percent; at 5 years, probability of relapse was 16 percent. The earlobe showed no greater chance of relapse than other sites on the body. The authors' report shows that extralesional excision of keloid followed by early, single-fraction, postoperative radiotherapy is both simple and effective in preventing recurrence at excision sites.     

Hypertrophic sternal scars: silicone gel sheet versus Kenalog injection treatment.

A prospective, randomized trial was designed to compare the standard Kenalog injection of established hypertrophic sternal scars with topical silicone gel sheets (Spenco). Fourteen poststernotomy cardiac patients with symptomatic scars were randomized to treatment in one-half of the scar with Kenalog injection. Simultaneously, the other half of the scar received the silicone gel sheet. The standard Kenalog injection used was 40 mg/ml x 1 cc, mixed with 1 cc of 1% Xylocaine with epinephrine. The gel sheets were worn continuously for 12 hours for 12 weeks. Pretreatment and posttreatment photographs were compared for color and appearance by blindfolded observers. Scar measurements (length, width, and height) were taken weekly in each area, and the patients were asked to rank their symptoms within each half as worse, the same, or better. The primary outcome of patient preference was analyzed sequentially, and the recruitment was terminated after 11 patients had completed the study, 10 of whom favored the silicone gel treatment (p < 0.05). Three patients remained in the treatment phase at the time of termination and completed the study subsequently. For the total sample of 14 subjects, 11 preferred the silicone gel, 1 expressed no preference, and 2 preferred the injection. The average time to improvement was 3.9 +/- 0.62 days (gel) versus 6.8 +/- 1.86 days (Kenalog). This study demonstrates that silicone gel sheets provide earlier symptomatic relief and a more aesthetic scar and are the preferred treatment of patients with symptomatic hypertrophic sternal scars.     

Cosmetic and reconstructive breast surgery in blacks

Black women have not embraced cosmetic and reconstructive surgery of the breast with the same enthusiasm as their Caucasian counterparts because of fear of hypertrophic scars. The authors offer suggestions on how to minimize the scarring associated with breast surgery in black women. They feel that intraareolar incisions should be used whenever circumareolar incisions are indicated in augmentation mammaplasty, because the areola, being a favored area, is less likely to produce hypertrophic scars. The Marchac technique of reduction mammaplasty is recommended because it produces a short horizontal scar of 5 to 8 cm confined to the breast without medial and lateral extension, which may hypertrophy in black women. In the reduction of large breasts, secondary excision of dogears 6 or more weeks after mammaplasty reduces the medial and lateral extents of the scar. The use of liposuction as an adjunct to reduction mammaplasty may also accomplish the same thing. Amputation and free nipple-areola grafting should be used with caution in black patients because of the tendency of the grafted areola to hypopigment. In postmastectomy reconstruction, the authors suggest that the techniques described by Ryan and Radovan should be considered first before the techniques of reconstruction utilizing myocutaneous flaps. In these procedures, no new scars which may hypertrophy are created away from the site of reconstruction. Staples should not be used in skin closure in blacks because they cause cross-hatching of the wound even when removed early.     

Wound-induced assembly and closure of an actomyosin purse string in Xenopus oocytes.

BACKGROUND: Both single cells and multicellular systems rapidly heal physical insults but are thought to do so by distinctly different mechanisms. Wounds in single cells heal by calcium-dependent membrane fusion, whereas multicellular wounds heal by a variety of different mechanisms, including circumferential contraction of an actomyosin 'purse string' that assembles around wound borders and is dependent upon the small GTPase Rho. RESULTS: We investigated healing of puncture wounds made in Xenopus oocytes, a single-cell system. Oocyte wounds rapidly assumed a circular morphology and constricted circumferentially, coincident with the recruitment of filamentous actin (F-actin) and myosin-II to the wound borders. Surprisingly, recruitment of myosin-II to wound borders occurred before that of F-actin. Further, experimental disruption of F-actin prevented healing but did not prevent myosin-II recruitment. Actomyosin purse-string assembly and closure was dependent on Rho GTPases and extracellular calcium. Wounding resulted in reorganization of microtubules into an array similar to that which forms during cytokinesis in Xenopus embryos. Experimental perturbation of oocyte microtubules before wounding inhibited actomyosin recruitment and wound closure, whereas depolymerization of microtubules after wounding accelerated wound closure. CONCLUSIONS: We conclude the following: actomyosin purse strings can close single-cell wounds; myosin-II is recruited to wound borders independently of F-actin; purse-string assembly is dependent on a Rho GTPase; and purse-string assembly and closure are controlled by microtubules. More generally, the results indicate that actomyosin purse strings have been co-opted through evolution to dispatch a broad variety of single-cell and multicellular processes, including wound healing, cytokinesis and morphogenesis.     

Effect of Mederma on hypertrophic scarring in the rabbit ear model

Currently accepted conservative treatments of hypertrophic scars are limited to steroid injections, radiation therapy, and silicone occlusive therapy. However, the use of Mederma for these problematic lesions has become quite prevalent in the clinical setting. Little scientific evidence exists to support the efficacy of this product in reducing hypertrophic scars. The aim of this study was to study the effects of Mederma on hypertrophic scars in the rabbit hypertrophic scar model, allowing the histologic quantification of scar elevation, dermal collagen organization, vascularity, and inflammation and the gross examination of scar erythema. Full-thickness wounds down to cartilage, four per ear, were created in four New Zealand White rabbits, for a total of 32 scars. Twenty-eight days after the initial wounding, the hypertrophic scars were photographed, and treatment of half of the scars on each ear was begun with Mederma three times per day for a total of 4 weeks. The untreated scars served as control scars and were left exposed to air. After 4 weeks of treatment, the scars were once again photographed. The rabbits were then killed, and the scars were analyzed histologically. The pretreatment and posttreatment photographs were compared by using computer quantification of magenta, yellow, and cyan expression within the scars.Histologic analysis demonstrated no significant reduction in scar hypertrophy or scar elevation index. However, a significant improvement in dermal collagen organization was noted on comparing Mederma-treated scars with untreated control scars (p < 0.05). No significant difference in dermal vascularity or inflammation was noted. Computer analysis of the scar photographs demonstrated no significant reduction in scar erythema with Mederma treatment. The active product in Mederma, allium cepa, has as its derivative quercetin, a bioflavonoid noted for its antiproliferative effects on both normal and malignant cells, and its antihistamine release effects. These properties could theoretically prove beneficial in reversing the inflammatory and proliferative responses noted in hypertrophic scars. Despite the authors' inability to demonstrate a reduction in scar hypertrophy, the improvement in collagen organization noted in the Mederma-treated scars suggests it may have an effect on the pathophysiology of hypertrophic scar formation.     

Reduction mammaplasty with a circular folded pedicle technique.

A personal technique for breast reduction utilizing a circular dermal-breast pedicle is presented. After a cutaneous glandular excision in the inferior pole and glandular excision in a discoid shape under the central area, the pedicle is folded on itself to produce a direct elevation of the nipple-areola complex into its new position, to enhance projection, and to act as a central support. A rational economy of scars is obtained by a central convergence of the breast tissue that stretches the breast periphery and by sutures finishing in the inferoareolar area. There the skin excess is removed to avoid scar lengthening in both the caudal and cranial directions. Evaluation of long-term results reveals maintenance of breast projection, preservation of the inframammary fold to inferior areola distance, and minimal residual scarring.     

Widening of scars: foe coaxed into a friend? The Millard technique revisited

Widening of scars is a frustrating event that most if not all plastic surgeons have encountered. Several therapeutic modalities have been proposed, but frequently the result is disappointing. During revision surgery, it is advocated that the dermal scar be used in providing support to the tissues instead of being discarded. The author proposes a technique by which tension on the wound is carried by tough scar tissue instead of the suture line, thereby reducing the incidence of postoperative widening. This technique was used to treat 35 nonburn scars that had widened: 31 scars were facial (24 patients) and 4 were inframammary (2 male patients). All scars were at least 4 months old. The operations were performed between February of 1996 and December of 1998; follow-up was 9 to 14 months. Only one scar widened during the follow-up period. Overall, 71 percent of patients rated the improvement as marked. This is a revisiting of the original Millard's technique, which seems to have fallen into oblivion. The author recommends this technique in dealing with widened scars during revision surgery.