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 accept 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 the most gratifying thing that a cosmetic 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 this type of practice. 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 jawline.
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 as an accompaniment to their ability to heal more rapidly. 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
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 injury will help to minimize scarring. Instructions for wound care are available, on request, at the Center. Usually, within six months, the scar will have matured to near its optimum. If it is obviously unsatisfactory at that time, then scar revision should be considered.
Pressure and Massage: It is important to remember that conservative measures can be very important in the management of scars. Repeated massage using cocoa butter or 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 scar excision and 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.
Laser Resurfacing: The surgical laser has been found to be an effective resurfacing tool that can be helpful in the management of scars. Laser resurfacing is frequently used as a planned component of the initial repair. Approximately five weeks after the initial wound is sutured, the repaired area is treated. This often results in a scar less noticeable than it would have been without the combined treatment. Laser resurfacing can also be helpful in the management of severe acne scars.
Injectables: These can be helpful in the treatment of depressed scars. In some cases, it can flatten the scars and make them almost imperceptible. Choices include temporary fillers such as Restylane® or permanent fillers such as microdroplet silicone injection therapy.
Silicone Therapy: In many cases, a silicone dressing can be applied to a raised scar and help 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. Various liquid silicone preparations are also available which may be more convenient to use 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.
ScarGuard MD®: Recently, a commercial product has become available which combines vitamin E, cortisone and silicone in the form of a liquid which is painted on scars. The liquid dries quickly and offers the additional advantage of a protective covering over the incision. Many of our patients have found this product to be helpful in the management of incisions after surgery. There are numerous anecdotal reports of improved scaring, although there are no objective studies that substantiate these claims. We do have the product available at our Center for those that wish to use it and it has become a very popular product, if for no other reason than the fact that it combines a number of well established modalities and simplifies the management of incisions after surgery.
RISKS OF SCAR REVISION
As mentioned, when dealing with scars, we must operate in the area predetermined by the accident. Most other 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.