Plastic Surgery Revision of Tracheostomy Scars
Tracheostomies frequently result in unsightly neck scars. Their prominent neck location and the temporary indwelling breathing tube commonly leaves a depressed neck scar after its removal. It often looks like a belly button with the skin turned inward. This is known as a tracheal tug although it is the lack of underlying soft tissue that makes it look this way.
An undesired looking scar from a tracheostomy can undergo correction within months after a breathing tube has been removed if so desired. Historically, tracheostomy revisions have been done when the scar is more mature. (greater than six months after tube removal) It is not necessary to wait this long however. The plastic surgery techniques used are not really affected by how mature the tracheostomy scar is. And, for many patients, they would like to eliminate as soon as possible the physical and psychological marks of the experience of why the tracheostomy was there in the first place.
To get a good outcome from a tracheostomy scar revision, there are three basic concepts that must be achieved surgically. First, the turned in skin edges must be released from the deeper tissues and be completely freed up. Secondly, this release creates a real tissue volume defect between the skin and the trachea which must be filled in. Lastly, closing the skin must create a fine line scar that lies in a horizontal direction along a natural neck skin fold. By far, filling in the lost tissue is the hardest one to achieve but it absolutely necessary if one does not want the final result to have any indentation. Filling in the missing tissue can be done in a variety of ways. If the tracheostomy scar is not that deep and fairly shallow, the surrounding skin edges can be used through a technique known as edge de-epithelization. The thinned skin edges are then turned down for a little tissue fill and the full-thickness skin edges closed over it. For tracheostomy scars that are significantly indented, however, more volume is required. I prefer using dermal-fat grafts which can be quite thick if desired, up to 1 cm. A donor site is needed to harvest it and this will leave a scar elsewhere on the body. However, if one has a scar from a previous surgery elsewhere that is from a favorable area that has some fat thickness, then this should strongly considered. Otherwise, allogeneic dermal grafts (from cadaver skin) can be used which is an off-the-shelf product.
Tracheostomy scar revision is a fairly simple outpatient procedure. All sutures are placed under the skin so there is none to remove. A fine line red scar will exist for awhile afterwards (months) but this will eventually fade into a near imperceptible pencil line thin scar. Again the key to a successful tracheostomy scar revision is to completely resolve the skin tethering to the trachea and replace any missing tissue.