Scars on the face can be difficult for patients. It can be difficult for patients if the scars are noticeable or if the scars draw unnecessary attention to the face.
Scars can result from a variety of causes including chicken pox, acne scarring, trauma or accidents. The key with a scar for patients is to understand that once they have a scar, there is no way to remove a scar. Scar can be improved and blended to make them look less conscpious. In addition, after scar revision surgery, the patients may need additional follow ups and procedures depending on how their individual healing characteristics.
Technical aspects of scar revision face:
The principles of successful scar closure are based on closing the skin without tension. In some patients, scars heal raised up while in other patients scars can separate leaving a visible trough. The surgeon can get a sense of how scars will heal based on the location of other scars on the body and face, but each area can heal independent of others.
Keys to successful scar closure:
1. Loss of tension on incision (surgeon will undermine skin to release it and ideally allow form more of a tension free closure)
2. Location of scar (scars in certain areas are more difficult than others. The corner of the eye and the sternum are examples of areas which are notoriously difficult to heal well with standard suture closure techniques)
3. Technique of closure (ideally scars are undermined first and then closed with slight eversion. Eversion means that the scars are actually brought together and raised when closed, almost like a mini pleat. The reason for this is that the skin is biologic and as it heals will typically flatten with time.)
4. Type of sutures (there is not a “best” type of suture for scars. some sutures are less reactive, but there is some individual differences. typically deep tissue closure is performed with absorbable sutures and superficial skin closure can be performed with either absorbable, non-absorbable, or even tissue glues
5. Proper soft tissue handling (skin is delicate and a gentle touch using hooks rather than instruments which put undue pressure on the skin are better).
Scars – What are ways to improve a scar other than technical aspects:
Orientation- Ideally scars are located within the RSTLs (Relaxed Skin Tension Lines). To determine a person’s RSTL’s, have a person smile, animate, frown and the lines of animation will be present. These lines can be marked and used as a guide to orient the scar within the framework of the RSTL
Improve location of scar- Sometimes moving a scar from a visible location to a less visible location can help conceal a scar. An example of this may be seen after a facelift. If the facelift scar is located too far anteriorly on the cheek, the skin can be undermined to reposition the scar closer to the hairline
Design of scar- Sometimes a straight line is not the best line for a scar. Particularly long scars or scars that cross anatomic borders (neck, jawline, face) do better with a subtle pattern in the scar. If tension is found on the scar a term called z-plasty can be used to help lengthen the scar and prevent its contracture. Examples of scar designs include geometric broken line, z-plasty, running z-plasty, w plasty
Types of scars -There are a variety of scar types seen in the face:
Examples include the following:
Result of trauma, can be a dogbite, abrasion, car accident
Tagged with a bad memory
Acne scars
Keloid
Hypertrophic scar
Phases of healing for a scar
All wounds undergo three phases of healing. The first phase is termed inflammation. During this phase, local cells are recruited to the wound. The proliferation phase happens and next and happens in part in concert with the inflammation phase. Skin begins to close and wounds begin to heal. The final phase takes the longest and is called the maturation phase or remodeling phase. It is during this phase that collagen is synthesized to help heal the wound. In patients who make keloids, this phase can create an abnormal healing response and create raised scars. The incision has about 80% of the strength of the original skin at 60 days after injury. Remodeling begins 21 days after the procedure.
Important things to remember about a scar and a scar revision:
- scars cannot disappear with surgery
- lasers do not make scars disappear
- scar gels do not fade all scars
- all scars are not treated the same
Locations of scars:
- Forehead scars
- Eyelid scars
- Lip Scars
- Neck scars
- Cheek scars
- Nose scars
- Chin scars
Timing of scar revision
A common dilemma for both surgeon and patient alike is when to revise a scar. If a scar is recent and looks appropriately closed, the surgeon should consider observation of the scar prior to revison. Scars take time to heal and may improve with time and may not a formal excision and revision. If the scar looks poorly reconstructed and aligned, the surgeon should consider earlier revision of the scar.
Scar Revision Questions:
How long does it take for a scar to finalize healing?
Scars take about a year to mature in most patients. Scars go through various forms of healing
Do lasers fade scars?
Lasers can help improve the appearance of some scars but not all scars. Lasers cannot remove scars completely.
Do scar gels work?
There is not enough evidence to support the use of scar gels at this time
Do scars fade over time?
Some scars will fade with time. Other scars will have hyperpigmentation or hypopigmentation as a result of the scar.
What do i do about scars which are raised?
Raised scars can be treated with a variety of techniques including formal scar revision and injectables to the scar region
Do scars affect people of different ethnciites differently?
Scars can actually affect people of the same family or same person differently. In some patients they may have piercings along their entire body. However one site on the body may create a keloid.
Can scars be changed?
Scars can be changed but patients must have a realistic expectation of the risks and degree of scar improvement which can be made.