Considering a DIEP or SIEA flap for your breast reconstruction after mastectomy? You probably already know that to do so, you need to have enough tummy fat to construct your new breast. But did you also know that in some cases, previous abdominal surgeries may preclude you from having a DIEP or SEIA flap? The following guest blog by Dr. Minas Chrysopoulo
sheds light on who is and who is not a good candidate for a DIEP/SIEA procedure.
With more women becoming aware of DIEP flap breast reconstruction as an option, the question of who is and who isn't a good DIEP flap candidate is coming up more often.
As a general rule, women that have had extensive abdominal surgery like a previous TRAM flap, tummy tuck or a complex hernia repair cannot have a DIEP or SIEA flap breast reconstruction. This is because the lower tummy tissue that is needed has usually been removed or moved around, and the necessary blood supply has been disrupted.
Having said that, most of the time previous abdominal surgery isn't an issue in experienced hands.
Many women these days have had at least one previous c-section or another gynecologic procedure like a hysterectomy. It is possible for these procedures to cause damage to the blood vessels needed for DIEP flap surgery, but fortunately this is unusual. A previous C-section, hysterectomy, or tubal ligation is not a contraindication to having a DIEP or SIEA flap. Previous liposuction is not usually a problem either unless this was extensive.
If your surgeon is worried about potential damage from previous surgery, then certain tests can be performed to evaluate your anatomy more closely. This can include a simple Doppler ultrasound exam in the office or a more involved test like a CT angiogram. Unfortunately, the CT scan does involve radiation.
While previous abdominal surgeries may not prevent you from having DIEP flap reconstruction, women that have had multiple previous abdominal procedures are at increased risk of abdominal complications like bulging and hernia after DIEP flap surgery when compared to women that have never had prior abdominal surgery, even though the abdominal muscles are preserved. This is because the fascia (the strong layer of tissue over the muscles) has already been weakened by the previous surgeries.
Some medical issues can make any form of microsurgical breast reconstruction (like the DIEP flap) more difficult and they can also increase the risk of complications like flap loss. These include disorders that make the blood clot more easily (eg Factor V Leiden).
MInas Chrysopoulo, M.D. of The Center for Advanced Breast Reconstruction
provides breast reconstruction, including DIEP flaps, in San Antonio, TX.
Many women consider grenade-shaped surgical drains to be one of the most annoying aspects of recovery, but drains perform a necessary function. In the following guest blog, Dr. Aldona Spiegel
explains why drains are necessary after any type of breast reconstruction.
Questions about surgery drains are some of the most frequently asked topics about recovery from reconstructive surgery after breast cancer. Patients usually don’t like these pesky appendages which can be cumbersome but ultimately are your friend (hopefully not for too long).
The reason why drains are necessary in some surgical procedures is that the body has a tendency to release lymphatic fluid and a small amount of blood in areas that have been recently operated on during the process of inflammation and healing. When this is a small amount of fluid the body can reabsorb it without any problems, but if this volume of fluid is more than about 25 ml per day the fluid can accumulate and form a seroma. This is why it is important to measure the total amount of fluid that is generated through each drain every day so that we can tell whether the drain is ready to be removed. Remember that the more activity you are doing the more your drains will typically drain as movement increases the amount of fluid that is released.
The drain tube is made of a smooth silicone material that is easily removed in the office. It is sutured in place with a small black stitch and there is a black dot on the drain indicating where it should be in relation to the skin. The dot is generally at the position of the stitch, if the black dot on the drain is more than 2 inches away from the skin that means the drain has been pulled out and needs to be removed.
The color of the liquid collected in the drain bulbs can range between a clear liquid to a pink or a blood tinged one. The drain needs to be stripped approximately 3 to 4 times a day to prevent it from getting clogged. The nurses will have shown you how to do this before you leave the hospital. The fluid is emptied from the drain bulb into a measuring cup and the volume recorded in the drain output sheet. Typically two drains are used per area in order to make sure that if one drain gets clogged the other one is functional.
The drain bulb has a loop which can be used to put on a loose belt or secure with a safety pin to clothing. We have seen several very inventive ways of securing drains! It is important to be mindful as not to snag the drains because they can be accidentally pulled out, paying specific attention to them when showering to make sure they are secure.
Aldona Spiegel, M.D. of The Center for Breast Restoration
provides breast reconstruction, including perforator flaps, in Houston, TX.
After breast reconstruction, some women opt to forego nipple reconstruction, although many others consider it to be the final step in the process. It’s an optional procedure that can be performed once the new breast has settled in place, or anytime—weeks or months—thereafter.
An older way of creating the nipple and areola involved transferring a small skin graft from the labia or upper thigh, since tissue from these areas is naturally darker than breast skin and doesn’t require tattooing. But the process can be uncomfortable (particularly involving a labial graft), it creates another incision that must heal, and it leaves a scar at the donor site. Labial tissue also tends to grow hair, so new nipples created in this way do as well.
Considering the disadvantages of nipples made with skin grafts, you can see why most surgeons think this procedure is outdated, preferring instead to make the new nipple with a small flap of breast skin. There are many different ways to do this (see illustration), and surgeons typically use the technique they most prefer. Tattooing then darkens the new nipple and simulates the areola around it. Some surgeons like to create the nipple, use a graft of darkened skin for the areola, and then tattoo the nipple to match the natural pigment.
One advantage of nipples/areolas created with skin grafts is that the pigment is permanent, while nipple/areola tattoos tend to fade considerably after a few years.
Done well, tattooed nipples and areolas look quite natural. The trick is to get someone who really knows what they're doing and takes the time to choose a pigment that matches your skin tone and that you’re happy with. Nipple tattooing takes just a few minutes. Tattoos are often applied in-office by the plastic surgeon or a member of the office staff (usually an RN). More surgeons now have tattoo artists provide the service or refer patients to them. This is actually better, because professionals tend to tattoo deeper into the skin, so that fading is less likely.
Many tattoo artists now specialize in reconstructive nipple tattoos, and some offer their services to breast cancer survivors at no charge. (Federal law requires health insurance companies that cover the cost of mastectomy also pay for breast reconstruction, including nipples and tattoos. If your plastic surgeon refers you to a professional tattooist, however, be sure to check with your insurance company to ensure preauthorization and subsequent payment.)
If you want to forego having nipples reconstructed, you might want to consider having just a tattoo—many professional tattoo artists can create beautifully simulated nipples with a 3-D look. Several companies also make adhesive nipples in varying pigments and sizes, which can be worn temporarily.
All surgical procedures, regardless of their purpose, carry risk to some degree, and breast reconstruction is no exception. Even though most women do not encounter serious problems from surgery, complications can occur, including the following:
- Infection. Any opening in the skin presents an opportunity for infection to sneak in. Precautionary measures—maintaining sterile operating environments and cleansing the skin with antibacterial wash before incisions are made—are effective. If you are diabetic, obese or you’ve previously had radiation therapy to the breast or you’re currently taking chemotherapy, you’re more susceptible to infection. Infection is particularly worrisome if you have tissue expanders or breast implants, which can be contaminated by bacteria in the bloodstream or infection in the body. Depending on the degree of infection, antibiotics are usually prescribed; debriding (removing unhealthy tissue) may be necessary if large portions of tissue are involved.
- Seroma. Sometimes clear fluid from blood vessels accumulates in the tissue, despite the use of surgical drains and compression garments. Small pockets of fluid are usually resorbed into the body. Larger seromas may need to be drained with a needle and subjected to several more days with a surgical drain. Treatment is important, because seromas that harden can become infected and require antibiotics or require another trip to the operating room to repair the problem.
- Bleeding. Most women don’t experience bleeding after their reconstructive surgery, but sometimes a hematoma (a pocket of blood) forms when a blood vessel leaks into the surrounding tissue. As a precaution, for a period before and after your reconstruction, you should stop taking any vitamins, herbs and medications that thin the blood—your plastic surgeon will discuss this with you before your surgery. Like seromas, many hematomas are resorbed by the body. Hematomas need to be monitored closely; any that are persistent may require additional surgery to reopen the incision and drain the collection of blood.
- Stubborn wounds. Some people, especially older patients and those who are obese, experience delayed wound healing after surgery. Other factors can also influence how quickly a wound heals. Patients who develop infections, are diabetic or who have other chronic health problems tend to heal more slowly and should be monitored carefully during and after surgery.
- Necrosis. Tissue that doesn’t receive enough blood dies from lack of oxygen. This necrosis can occur in the breast skin, which tends to be fragile after mastectomy, or in a flap of fat, skin and/or muscle that is used to reconstruct the new breast. If an area of necrosis is large or doesn’t shrink without further attention, it may need to be surgically removed. If an entire flap dies, it must be removed (rebuilding the breast then involves a different type of flap or breast implants). This rarely happens, but it is more likely to occur in patients who smoke, have circulatory problems, or who have had radiation to the breast (radiation compromise blood flow).
Most women have no problem healing after reconstructive surgery, but it is a good idea to be aware of the inherent risks of any surgical procedure before you enter the operating room.
One topic that has attracted growing attention in the field of Advanced Breast Reconstruction is autologous fat grafting
for total breast reconstruction. (“Autologous” means that the tissue is derived from the patient.) To understand what this procedure is, and how it compares to other procedures that are currently used for breast reconstruction, plastic surgeon Dr. Ergun Kocak
explains the important differences between a “graft” and a “flap.” -------------------------
- A flap is a piece of tissue that is transplanted or moved from one part of the body to another, based on a specific blood supply. The flap tissue, therefore, can survive on its own because it has its own, dedicated blood flow, from which it receives oxygen and nutrients.
- A graft is still a piece of tissue that is transplanted or moved from one part of the body to another, but it does not have its own blood supply. Instead, it relies on the nearby tissues to derive its oxygen and nutrients. Over time, most grafted tissues will develop their own blood flow as small arteries and veins grow in and out of the tissue. But until this happens, grafts rely completely on their surroundings to survive.
Presently, most of the autologous, or natural tissue options available for breast reconstruction utilize flaps. Examples include DIEP and SIEA flaps from the lower abdomen, GAP flaps from the buttock region, and TUG and PAP flaps from the thighs. All of these techniques are technically demanding and involve specialized training and environments to optimize outcomes. For this reason, there has been ongoing interest to develop methods that utilize natural tissue, without the need for such demanding operative techniques, such as autologous fat grafting.
So where does the fat come from? In most cases, liposuction is performed on parts of the body where fat tends to accumulate, such as the abdomen, flanks, and thighs. The suctioned fat is processed to purify the fat cells while excluding the body’s fluids and oils. The purified fat is then loaded into syringes and it is injected into the desired area. Small and large volume fat grafting
Fat grafting can be divided into two main categories: (1) small volume and (2) large volume fat grafting. Smaller volume fat grafting has been used for many years to correct small contour deformities after breast reconstruction using other techniques such as implant or flap reconstruction. For example, it is common to have a small area of volume deficiency at the inner, top part of the breast after implant reconstruction. Fat grafting small volumes (50-100 cc) into this area adds fullness and improves the contour, making many patients much happier with the appearance of their reconstructed breasts.
Smaller volume fat grafts can also be used to improve or correct deformities of the breast which occur after lumpectomy with or without radiation. While the overall goal of lumpectomy is to conserve the breast shape and size, deformities can occur, especially if radiation therapy is added to the treatment regimen. These deformities can be very difficult to repair as there are not many flaps which are small and versatile enough to be custom-tailored to replace the tissue that was taken out with the original lumpectomy. Furthermore, using implants to increase the size might seem like an easy fix, but this approach is generally unsuccessful due to the high rate of complications associated with implants in irradiated tissues. Fortunately, small volume fat grafts can sometimes be used to fill these areas. While it is very difficult to completely correct breast volume or shape, fat grafting can improve symmetry between the two breasts. Megavolume fat grafting for full breast reconstruction?
Can fat grafting be used to reconstruct an entire breast? Recently, there has been growing interest in this question and methods for transferring large volumes, sometimes called megavolumes, of fat have been described. At the surface, this method has a great deal of appeal. It makes reconstructing the breast with natural tissues possible without the need for highly complex flap operations, such as the DIEP and GAP flaps, which transplant large pieces of intact tissue from other parts of the body.
A closer look at the details, however, reveals several intricacies associated with high volume fat grafting procedures. For example, many of the reports using these methods utilize machines to apply suction to the outside of the breast skin (external expansion). These devices have to be used for extended periods of time and can be quite laborious.
Furthermore, liposuction of very large volumes of fat tissue is needed to harvest the fat that is used for the breast reconstruction. Liposuction has its own associated potential complications which should be carefully considered when exploring reconstructive options:
- Contour deformities. If an area is aggressively over-suctioned, it can lead to divots in the skin. These can be very difficult to correct.
- Seromas. These are collections of body fluid in the areas that are suctioned. They can persist as soft contour deformities in the suctioned areas.
- Fat embolism. During liposuction, small blood vessels can be ruptured or broken, making it possible for small pieces of fat to enter the blood stream and plug vessels in the lungs and/or brain.
Do transplanted stem cells in fat tissue stimulate cancer?
- Visceral perforation. Since liposuction is done through small puncture incisions, the surgeon cannot see the end of the liposuction cannula. This makes it possible for the tip of the cannula to travel deeper than desired, leading to puncture of the internal organs such as the intestines during abdominal liposuction.
Another potential concern that has been raised by some Medical Oncologists and Surgical Oncologists relates to the effects the grafted fat cells may have on the beds of tissue into which they are grafted. Fat tissue contains several different types of cells. Small parts of these cells are known as stem cells because they have the ability to turn into different types of tissue and to dictate the behavior of the cells nearby. For cases where the reconstruction is taking place after a mastectomy that is done for a breast cancer, this raises the theoretical concern that these stem cells, if grafted into the area where the cancer once was, could influence the behavior of the cells at the recipient site and promote cancer recurrences. Several scientific studies in laboratory and animal models have been carried out to evaluate this concern. Most show that the stem cells that are in fat grafts do not promote tumor growth, but some studies indicate otherwise and no human studies have been done at this time.
In summary, fat grafting is an important part of advanced breast reconstruction and can be used in several different ways to fine-tune other types of reconstruction and possibly even reconstruct entire breasts. While the technique has been around for years, there is a recent revival in interest around fat grafting and several centers are exploring the ways it can be safely used in breast reconstruction.
Dr. Kocak, MD, MS, of Midwest Breast and Aesthetic Surgery
provides breast reconstruction, including perforator flaps, in Columbus and Cleveland, OH.
A retrospective study conducted by Northern Westchester Hospital in Mt. Kisco, New York found that women who have breast reconstruction with implants and an acellular dermal matrix
(ADM) have better results than those who have implant reconstruction without an ADM. (The study did not study results of women who had other types of breast reconstruction.)
Researchers examined the results of 881 reconstructions with breast implants over a five-year period. Results were divided into two groups: those whose reconstruction included AlloDerm or FlexHD and those who did not. Study authors concluded that the use of either ADM product with breast implants resulted in several advantages:
· more natural-looking, symmetrical breasts
· superior contour
· better implant position
· fewer surgical complications
Other studies suggest that use of an ADM with breast implants lowers the risk of capsular contracture in women who have breast reconstruction.
AlloDerm or FlexHD are ADMs: sterile tissue substitutes made from donated human skin that has been stripped of its cellular materials, but retains collagen and other proteins. ADMs are often used in breast reconstruction with expanders or implants to provide additional support to the skin, cover otherwise exposed edges, and to maintain position. AlloDerm was initially developed to replace skin of burn victims, and is also used for hernia repair and facial reconstruction. FlexHD® Pliable™ was more recently developed in response to plastic surgeons who requested a more pliable ADM specifically for breast reconstruction. Source:
Michael H. Rosenberg, David A. Palaia, Anthony C. Cahan, et al. “Breast Reconstruction With or Without Human Acellular Dermal Matrices: A Single-Clinic, Review of Esthetic Outcomes and Risk Factors for Complications.” American Journal of Cosmetic Surgery
(2014) Vol. 31, No. 1, pp. 7-17.
For many women, potentially needing post-mastectomy radiation can affect the ability to have immediate breast reconstruction. Mastectomy patients who are diagnosed with invasive breast tumors often don’t know whether they need radiation until after their mastectomy; that’s because the extent of lymph node involvement and clear-cut staging of the tumor really can’t be done until the mastectomy is performed.
Breast cancer experts often advise women to delay having breast reconstruction if there is a possibility that adjuvant (after surgery) radiation will be needed. It can be a very disappointing turn of events for women who were hoping to have immediate breast reconstruction along with their mastectomy—they’ll not only wake up from mastectomy without breasts, but they miss out on the cosmetic benefits of having immediate breast reconstruction. They also have to endure additional surgery and recovery if they choose to have delayed breast reconstruction at some later time.
One approach to this issue is delayed-immediate breast reconstruction. It’s not exactly traditional immediate reconstruction or delayed reconstruction. Rather, it’s a hybrid of the two. During this procedure, after the breast tissue has been removed, a tissue expander is placed in a pocket under the pectoral muscle. The expander is then fully inflated; this preserves the remaining breast skin and breast shape for later reconstruction.
If it turns out that radiation isn’t needed after all, the expander can be swapped out for a full-size breast implant or a flap of the woman's own healthy tissue. If radiation is required, the expander can be deflated (so there is no chance that it might interfere with delivery of the radiation) but left in place. A few months after radiation treatments have been completed, the expander can be replaced with a natural tissue flap. (Breast implants aren't the best option for reconstruction after radiation, due to the significant potential for complications Radiated tissue is usually a poor combination with breast implants, and even though a natural tissue flap is a better option for most women, the radiated reconstructed breast may take on a different shape and feel than the opposite reconstructed breast.
The Mayo Clinic is using an innovative approach that emphasizes pain control with less use of intravenous opioids to facilitate easier, quicker recovery for women who have breast reconstruction after mastectomy.
Enhanced recovery pathway (ERP) is an evidence-based approach that was developed in Denmark more than 15 years ago. Patient feedback and studies show that ERP works, although many of the components contradict standard pre- and post-op practices. ERP patients are not required to fast prior to surgery (they may have a small meal the night before their operation and a protein beverage the morning of surgery), and contrary to standard post-surgery procedure, they are encouraged to rehydrate in the recovery room and to eat shortly thereafter.
Mayo Clinic plastic surgeon Michel Saint-Cyr worked with anesthesiologists, pharmacists and nursing staff to develop a unique ERP for breast reconstruction patients. The protocol has been so successful, it is now used for all plastic surgeries at the Mayo Clinic. Compared to traditional methods, the new approach includes preoperative analgesics to help prevent pain, nonsteroidal anti-inflammatories, preventive nausea treatment, and use of an inoperative nerve-numbing agent at the surgical site.
In a study of 48 women who had free flap breast reconstruction at the Mayo Clinic, 31 individuals who experienced ERP reported significant postoperative improvements compared to the 17 patients who did not receive ERP, including:
· Ambulatory within 24 hours of surgery.
· Reduced pain (ranging from 0 to 4 on a scale of 10, compared to 6 to 8).
· Reduced (by half) use of opioid painkillers.
· Less pain reported 24 hours after surgery.
· Shorter hospital stay (an average of 3 days compared to 4½).
· Acetaminophen rather than narcotics were sufficient for many upon leaving the hospital.
· Resumed driving and returned to work in 2–3 weeks, compared to 4 to 6
Although most women who consider breast reconstruction do so following mastectomy, many women who have a lumpectomy to treat breast cancer are candidates for reconstruction. In the following guest blog plastic surgeon Dr. Nirav Savalia
explains the philosophy behind oncoplastic breast reconstruction and its benefits. ---------------------------
What Is Oncoplastic Breast Reconstruction?
Following a breast cancer diagnosis, many women are often overwhelmed by their diagnosis and treatment plan. Then they have the added worry of how their breasts will look after a medically necessary lumpectomy or mastectomy. Thankfully, advancements in surgical techniques offer the right lumpectomy candidates a better breast reconstruction method known as oncoplastic reconstruction surgery
. Oncoplastic surgery successfully removes the cancer while saving as much natural breast tissue as possible and addressing cosmetic concerns at the same time.
Simply put, oncoplastic reconstruction is oncological (cancer) surgery combined with reconstructive breast surgery, all in one procedure. Oncoplastic reconstruction is ideal for women whose cancer necessitates a lumpectomy that would dramatically alter the appearance of the breast.
During the procedure, the removal of any unhealthy tissue by the cancer surgeon is the first and most important step. After this, I reshape the affected breast by repositioning the remaining tissue and redraping the skin for more natural-looking contours. Next, if needed, I can modify the opposite, healthy breast to improve symmetry, sometimes through tissue removal, a breast lift or a combination of the two. The ultimate goal is to effectively address both the health and aesthetic aspects of breast cancer surgery, while preserving as much natural tissue as possible. Oncoplastic Breast Reconstruction Benefits
Here are the major ways women can benefit from this reconstructive technique. Oncoplastic breast surgery:
Different Reconstruction Methods
- allows the cancer surgeon to make a wider excision around the tumor without compromising aesthetics.
- requires just one operation that combines cancer removal and reconstruction of the breast ("immediate" reconstruction).
- in many cases can be combined with intraoperative, single-dose radiation treatment, eliminating the need for 6 weeks of follow-up radiation appointments.
- can be performed for women with both noninvasive (DCIS) and invasive breast cancer.
- is covered by major insurance plans as any other reconstruction method.
- saves more natural breast tissue, helping me to create a more satisfying and natural-looking result compared to traditional reconstructive techniques.
As with every surgery, not every woman is a candidate for an oncoplastic procedure. While the simultaneous approach and tissue-saving aspects of the surgery may appeal to some women, delaying the reconstruction process may be more appropriate or preferable for others. Sometimes the thought of dealing with reconstruction while also participating in a treatment plan is simply too much, while in other cases, reconstruction may be better delayed until cancer treatment is complete. Consulting with an experienced breast reconstruction specialist can help you decide which options are best for you. Dr. Savalia has been performing oncoplastic breast reconstruction with a team of cancer specialists at Hoag Hospital in Newport Beach, California for many years
Visible scars on a reconstructed breast are an ever-present reminder of mastectomy and reconstruction. Surgery and scars go hand-in-hand; scars form as the body’s healing process floods the incision with collagen, the body’s version of spackle. The evolution of a scar
Reconstruction is performed through the mastectomy incision. If you have immediate reconstruction (at the same time as your mastectomy), your plastic surgeon will place a breast implant or tissue flap before the mastectomy incision is closed; your breast surgeon and plastic surgeon work together to decide on the location and length of the incision. (Many women, especially those who have larger breasts, require more than one incision to adequately allow for removal of the breast tissue.) If you have delayed reconstruction, your mastectomy incision will be reopened to facilitate your reconstruction.
Mastectomy incisions cut through the dermis
, the thick tissue beneath the skin; that initially produces red, prominent scars. They fade to pink after a few weeks, as collagen and new blood vessel facilitate healing. Mastectomy scars never disappear, but they can often be hidden under the new breast or by a tattooed areola. A year or two after mastectomy, most scars have faded to thin white lines.
Your genetics and age, the depth of the incision, and how the underlying tissues were sewn influence how your incision heals and how your scar will eventually appear. Smoking and poor circulation, which inhibit blood flow, may impede healing and contribute to larger, angrier-looking scars. Two women who have identical mastectomy and breast reconstruction procedures by the same surgeons may have scars that look very different. Your scars from previous surgeries will give you a good idea of how your mastectomy/reconstruction scars may appear. What you can do to improve the appearance of scars
Despite a booming market in “scar improvement” products, no well-documented studies have found any topical treatment that significantly improves the appearance of a surgical scar. But you can take steps to promote healing and make your scars look smoother and less noticeable.
- Let your incision heal. Don’t pick at the surgical glue or tape your surgeon places over your incisions; they help to hold the edges of wound tightly together.
- Moisture your scar. Applying lotion that does not contain alcohol or fragrance, such as coco butter, mineral oil or aloe vera, to your incision will keep it moist and encourage healing. Don’t apply anything to the incision until it is completely closed and your surgeon gives you the okay to do so.
- Massage your scar. Massage lotion or cream along the line of your scar with your fingertips to stretch the fibers under the skin
- Give your body the nutrition it needs. Maintain a balanced diet that provides your body with nutrients that aid healing.
- Protect your scar from the sun. Ultraviolet light may darken scars, especially in the first year after surgery. Once your incision heals, apply a sunblock of SPF20 or higher to protect against both UVA and UVB rays. Reapply frequently.
- Try a scar management product. Consistent use (repeated application daily for several months) of over-the-counter creams or silicone sheeting may help your scar to fade.
If you develop keloids,
thick scars that spread beyond the incision into the skin, or hypertropic
scars, scars that rise above the surrounding skin, apply silicone gel sheeting as soon as your incision heals. Ask your dermatologist or surgeon about cortisone or steroid injections, prescription topical treatments or application of a fractional carbon dioxide laser. Scars can also be surgically revised—this involves cutting away the hardened tissue and resuturing the scar into a tighter line. It doesn’t guarantee a better scar, but in some cases, it may help.