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About Face

Chapter Five Accidents Emergency Care Minimizing Scarring Scar Repair Excision Scar Transformation Dermabrasion

Excision

Simple excision is used mostly on scars that are too wide. We cut out the existing scar and then sew up the resulting wound, using the three-level approach that I described above of a deep dermal stitch, superficial stitch and taping. The original wound might have resulted in a wide scar because the skin was ruptured or lacerated by a blow or a jagged instrument in an accident. When we excise the scar and re-create the wound, the conditions are much more controlled as we use a scalpel to do the cutting. The cleaner edges of the wound will heal in a more level fashion.

Years ago, the technique of “serial excisions” was popular for large areas of scarring. This kind of scarring might result from a bad bout with skin cancer, for example. The idea was to cut out the scarring, apply a large skin graft, then every six months or so, in a series of operations, cut out a bit of the graft and sew up the resulting wound. The intervals between operations allowed new skin to stretch and grown into place. This way, the edges of the normal surrounding skin were gradually brought together and the graft was eventually made inconspicuous.

Today, faced with a large area of scarring, we use “tissue expanders” instead. these are silicone bags gradually filled with normal saline (saltwater) that are inserted under the skin. They stay in place just long enough for the ermis to regenerate and stretch over the bags so that there is enough local new skin to cover the defect or widened scar. It’s an unsightly process - patients can be grossly malformed by the very large bags - but well worth the temporary discomfort of six weeks or so. When we remove the bags, there is an entire new flap of the patient’s own skin that we can use to cover the area that was scarred.

The second technique to camouflage a scar is to excise the old scar and then move a new, surgically created scar closer to the nearest relaxed skin tension line. Let’s say, for example, that a patient had suffered a cancerous tumor on the nose that had had to be removed and patched up with skin grafts, creating a very noticeable scar. What I might do in this instance is cut out the graft scarring in the middle of the nose, then rotate adjacent skin to cover the exposed area. This would create thin linear scars where they are more easily camouflaged at the junction of nearby regional aesthetic units, like the nose-cheek grooves.

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