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Address reprint requests and correspondence: Travis T. Tollefson, MD, FACS, Facial Plastic and Reconstructive Surgery, University of California, Davis Medical Center, Department of Otolaryngology Head and Neck Surgery, 2521 Stockton Blvd, Suite 7200, Sacramento, CA 95817
Tracheostomy tube placement is a common procedure performed in patients with severe maxillofacial trauma. Many patients that do not require emergent intubation will require an elective tracheostomy at the time of maxillomandibular fixation and fracture repair due to oropharyngeal edema. After recovery and decanulation, these patients often have a resulting tracheostomy scar that is hypertrophy and discolored. The scar may be adherent (or tethered) to the underlying trachea which can be uncomfortable during swallowing. The objectives of surgical revision of a tracheostomy scar are to improve the appearance and symptoms of tracheocutaneous tethering. A variety of standard scar revision techniques are employed to fill the depressed scar and to separate the skin from the tracheal scar with mobilized strap muscles or grafting material, such as cadaveric acellular dermis.
Tracheostomy tube placement is a common procedure for patients with severe maxillofacial trauma, airway compromise, or head and neck cancer. After decanulation, the resulting tracheotomy scar is commonly unsightly both at rest and during swallowing. Typically, the vertical movement of the scar with the trachea is termed tracheocutaneous tethering (or tug). The scar develops during secondary intention wound healing after the tracheostomy tube is removed. The tracheocutaneous fistula is filled in with granulation tissue and subsequent wound contraction leads to scar depression. The patient may complain of dysphagia and discomfort with neck movement due to the adherence of the subcutaneous tissue to the trachea.
Tracheostomy scar revision is a commonly performed procedure to improve both the appearance and symptoms of tracheocutaneous tethering. A variety of tracheostomy scar revision techniques have been described and will be reviewed in the context of the authors' preferred method. The objectives are to minimize the visibility of the external scar both at rest and during swallowing by (1) filling the depressed scar and (2) allowing the skin to glide over the underlying scar. A graft may be placed between the scar and the trachea to augment the scar revision.
Surgical technique
A modification of the surgical technique described by Lewin and Keunen may be used.
The tracheostomy scar is incised in an ellipse, and then, de-epithelialized (Figure 1). The surrounding skin is circumferentially undermined for 2 to 3 cm. Bilateral sternohyoid and sternothyroid muscles are mobilized both superior and inferior to the scar. The de-epithelialized scars are then imbricated to fill in the depression. The strap muscles are approximated in the midline with three interrupted, absorbable sutures (Figure 2). In severely depressed scars or recalcitrant tracheocutaneous tethering cases, acellular human dermis may be used. A sheet of 0.045- to 0.070-inch thick Alloderm® (Lifecell Corp, Branchburg, NJ) is soaked in saline, cut to fit the exposed area, and secured over the midline strap muscles (Figure 3). The skin is then closed in 2 layers with 5-0 polydiaxone for the dermal closure and 6-0 nylon suture or topical skin glue.
Figure 1An illustration of the tracheostomy scar revision technique described by Lewen and Keunen is shown. (A) The scar is incised with an ellipse. (B) The scar is de-epithelialized. (C) Imbrication of the scar edges with suture adds tissue volume to the scar depression.
The strap muscles are mobilized and suspended in the midline with three interrupted 3-0 absorbable sutures. (Color version of figure is available online.)
Figure 3Intraoperative photograph of human acellular dermis (Alloderm, LifeCell Corp, Branchberg, NJ) sutured to the surface of the medialized strap muscles with 4-0 Vicryl sutures. (Color version of figure is available online.)
Using these local tissue transfer techniques, successful resolution of tracheocutaneous tethering and improved scar appearance can be seen (Figure 4). The authors' have not seen complications such as infection, seroma, or acellular dermis extrusion. Although standard postoperative scar management using scar massage and silicone gel or sheeting is encouraged, occasionally triamcinolone 10 mg/mL is injected into the scar to treat hypertrophic scarring. Superficial injection of steroids is contraindicated as dermal atrophy and hypopigmentation may occur.
Figure 4(A) Preoperative photograph of tracheostomy scar illustrating the characteristic features, including (1) widened and erythematous; (2) retracted and depressed; and (3) tracheocutaneous tethering. (B) Postoperative photograph of the same patient 6 months after scar revision using acellular dermis. (Color version of figure is available online.)
The authors' preferred tracheostomy scar revision techniques are a combination of several traditional techniques. The first description of the correction of depressed scars was in 1918 by Poulard, who described the de-epithelization of the cicatricial island after incision around the scar, mobilization of surrounding skin flaps, and skin closure.
Lewin and Keunen modified Poulard's procedure by suggesting a de-epithelialization of the scar with dermabrasion and rolling the deep scar into a tube with sutures to compensate for scar depression (see Figure 1).
In 1972, Kulber and Passy suggested medializing the strap muscles and emphasized that the intact muscle fascia would help prevent tracheocutaneous adhesions (see Figure 2). This technique not only added fullness to the depressed scar, but also separated the tracheal from the more superficial scar.
Since the introduction as a grafting material, the safety and applicability of acellular human dermis has been examined in a variety of surgical areas. In 1999, reports of the successful use of lyophilized dura in tracheostomy scar revision stimulated our consideration of using acellular human dermis as an alternative interpositional material.
Acellular human dermis (Alloderm, Lifecell Corp, Branchburg, NJ) was originally introduced as a cadaveric skin graft substitute for the treatment of burns.
The authors' have placed acellular human dermis as an interpositional graft during tracheostomy scar revision under the hypothesis that the formation of adhesions between the trachea and skin can be prevented; but is it necessary? Some disadvantages of using acellular human dermis in tracheostomy scar revision could include the additional cost for the material, risk of viral transmission from the donor, and the potential for seroma in the dead space that is created between the graft and the soft tissues.
The techniques chosen by the authors' during tracheostomy scar revision are based on the characteristics of the scar. In severely depressed scars, soft tissue augmentation with surrounding muscle is necessary to fill the concavity. In tracheocutaneous tethering, the skin can be separated from the trachea using strap muscles and/or an interpositional graft. Presently, the authors' preferred technique does not routinely include using acellular human dermis.
Conclusions
Patients with disfiguring tracheostomy scars can be treated with traditional scar revision techniques. The surgeon must not only be attentive to improving the scar appearance but also to treatment of the tracheocutaneous tethering by separating the skin from the tracheal scar with strap muscle or grafting material. The criteria for grafting material have not been established and will require further comparative studies.
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