The effect of facial scarring is more than skin deep. Often it is very difficult to evaluate the emotional impact of such injuries. This is especially true with children who are unable to verbalize their feelings about the scars, or in males who are taught to minimize their concern about their appearance. It is apparent that many people undergo unnecessary deformity because either they or their families have failed to deal with their concern over the effects of facial scarring or have failed to seek advice on what can be done to improve the appearance of facial scars.
The treatment of facial scarring can be one of the most gratifying surgical procedures that a plastic surgeon does. On the other hand, it would be unfair if we did not point out that it is also one of the most difficult and challenging aspects of surgery. Unlike most cosmetic procedures, incisions usually cannot be hidden. The area of incision has already been predetermined by the injury. Often it is in the worst possible place, such as on the cheeks or on the jaw line.
TIMING SCAR REVISION
Patients tend to be impatient about the results of scar revision surgery. They are often already upset by the injury itself and find it difficult to understand that adequate and complete treatment may take many months or even several years.
Children and young adults are the most common victims of injury. Unfortunately, their skin tends to heal with more scarring. Although these scars tend to fade with time, it still makes the treatment program more difficult. Furthermore, it makes it much more important to wait before initiating treatment since a scar that looks poor a month or so after injury may continue to greatly improve in appearance for many months. Ultimately, it may be so unnoticeable as to not require treatment.
Although the repair carried out at the time of injury does influence the amount of scarring that exists after healing, even the most careful repair may not provide a totally acceptable result. When treating the initial injury, one is never sure how tissues will heal. Lost tissue may have to be replaced with grafts. Wounds may have to be closed under tension. These are only some of the factors that tend to promote increased scarring.
TYPES OF TREATMENT AVAILABLE FOR SCARS
Before instituting any form of treatment, we should watch the scar for a period of time. As long as there is significant improvement, then no surgical treatment should be instituted. Of course, proper treatment at the time of and following the injury will help to minimize scarring. Usually, within six-twelve months, the scar will have matured to near its optimum. If it is obviously unsatisfactory at that time, then scar revision should be considered.
IPL (Intense Pulsed Light), also known as BBL (Broad Band Laser): IPL treatments are a minimally invasive procedure that can help reduce the redness surrounding scar tissue. Typically multiple treatments are required at monthly intervals, during which time the scar will fade and gradually become less prominent.
Pressure and Massage: It is important to remember that sometimes conservative treatment is the best form of therapy. Repeated massage using vitamin E can greatly improve the appearance of scars. In some cases, special pressure dressing may also be of use.
Cortisone Drugs: Various types of cortisone drugs may be used either as injections, topical preparations, or in the form of special tapes. These may well improve the scar to a point where surgery is not required.
Re-excision: In many cases, simple excision and re-closure of the wound will greatly improve the result. We may be able to close the wound without the tension that was present at the time of the initial repair. Furthermore, what was originally a jagged cut may now be changed into a clean surgical incision.
Zig-Zag-Plasty: The Zig-Zag-Plasty is a technique of excising a scar and replacing the line with a geometric broken line. This type of wound tends to heal with less tension, and replaces a straight-line scar with a broken line scar that tends to be less apparent to the eye. This is one of the most common and successful techniques of dealing with facial scars.
Dermabrasion or Laser Resurfacing: Dermabrasion is a surgical planing technique that can be used to smooth down raised or uneven scars. Most commonly used for acne scarring, it is frequently helpful in the treatment of other injury scars.
Collagen Implantation: Collagen implantation involves the injection of a collagen material into the scar. It can be helpful in the treatment of depressed scars. In some cases, it can flatten the scars and make them almost imperceptible. Collagen does not result in permanent correction and treatment must be repeated after several months.
Silicone Pressure Therapy: In many cases, a silicone dressing can be applied to a raised scar and helps to soften or thin out the scar. The mechanism of this effect is unknown at the present time, but it has proven useful in many cases. It is very safe and simple to use. The special silicone sheet is cut to size and applied to the scar. It should be kept in place for 12 to 24 hours a day, depending on tolerance. Effects are not immediate, but results are usually seen within several weeks to months.
Serial Excision: In many cases, wide or extensive scarring cannot be adequately treated with one operation. A planned, staged approach may be required in which several operations are utilized to lead to the best possible result. In some situations, a device called a tissue expander can be used to hasten this type of reconstruction.
RISKS of SCAR REVISION
As mentioned, when dealing with scars, we must operate in the area predetermined by the accident. Most cosmetic procedures involve the placement of scars in inconspicuous areas or areas that are known to heal with minimal scarring. Any time an incision is made, a scar will result. Unfortunately, the thickness and the texture of the scar is only partially related to the skill of the surgeon and the procedure itself. In no case will scar revision surgery eliminate a scar completely. In nearly all cases, it will minimize the scar. In very rare cases, the scar could be made worse. Although very uncommon, it is a risk that must be accepted by the patient.
Postoperative healing requires some mandatory down time as part of the surgical recovery process. Post surgical healing requires the body to repair the surgical wound (whether in the skin, fat, muscle or bone) with scar tissue. The bruise and tissue fluid in the wound are gradually replaced by stronger scar or fibrous tissue over a period of 6-8 weeks. Until the time that the healing area is strong enough to maintain tissue integrity, the wound is held together by the sutures (stitches) placed at the time of surgery. Too much wound tension (stress) before the strength of the healing tissue is satisfactory, can cause disruption of the incision. I place sutures very precisely to account for these healing characteristics to maximize your postoperative activity, comfort, and safety. However, your inherent healing characteristics significantly dictate these parameters. Stretching, movement, massage, and return to normal activities of daily living in the early postoperative recovery allow for the optimal return to your full normal life style.
After the initial burst of high energy healing and the ‘bulking up’ of scar tissue, the wound enters a maturation phase, and the scar tissue becomes thinner, less red, and stronger. The maturing and stabilization of scar tissue occurs over a period of 6-12 months. Long-term changes tend to be more subtle, slower, and less evident than short-term changes that occur in the first 6-8 weeks.