Tracheostomies often result in unsightly neck scars. Its prominent location on the neck and permanent breathing tube often leaves a sunken scar on the neck after removal. It is often seen as a belly button with the skin turned inward. This is known as a tracheal pull, although it is the lack of underlying soft tissue that makes it look this way.
An unwanted-looking scar from a tracheostomy can be corrected months after a breathing tube has been removed, if desired. Historically, tracheostomy revisions have been performed when the scar is more mature. (more than six months after catheter removal) However, it is not necessary to wait that long. The plastic surgery techniques used are not really affected by the maturity of the tracheostomy scar. And, for many patients, they would like to remove 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 result from a tracheostomy scar revision, there are three basic concepts that must be achieved surgically. First, the bent skin edges must be freed from the deeper tissues and completely released. Second, this release creates a true tissue volume defect between the skin and the trachea that must be filled. Finally, closing the skin should create a fine-line scar that runs in a horizontal direction along a natural skin fold on the neck. By far filling in lost tissue is the most difficult to accomplish, but absolutely necessary if one does not want the end result to have an indentation. The filling of the missing fabric can be done in a number of ways. If the tracheostomy scar is not that deep and fairly shallow, the edges of the surrounding skin can be utilized using a technique known as edge de-epithelialization. The edges of the thinned skin are turned down for some tissue filling and the edges of the full thickness skin are closed over them. However, for tracheostomy scars that have significant bleeding, more volume is required. I prefer to use dermal fat grafts which can be quite thick if desired, up to 1cm. A donor site is needed to harvest it and this will leave a scar on other parts of the body. However, if one has a scar from a previous surgery elsewhere that comes from a favorable area that has a certain thickness of fat, then this should be seriously considered. Otherwise, allogeneic dermal (cadaver skin) grafts can be used, which is a standard product.
Tracheostomy scar revision is a fairly simple outpatient procedure. All sutures are placed under the skin so there is nothing to remove. A fine line red scar will exist for a while afterwards (months) but this will eventually fade into an almost imperceptible pencil line thin scar. Again, the key to a successful tracheostomy scar revision is to completely resolve the attachment of the skin to the trachea and replace any missing tissue.