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About Face

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

Minimizing Scarring

Before deciding on the cosmetic repair procedures, we’ll make an assessment of the kind of wounding we are looking at. Some wounds are jagged tears called lacerations. Some are scrapes, or abrasions. Often, wounding by accident is a combination of lacerations and abrasions. There might also be puncture wounds or avulsions, where a part of the face has been torn away. Accidental wounding usually results in a number of contusions as well, otherwise known as bruises.

With each kind of wounding, it is important to measure the length and depth of the wound, and its location within or crossing regional aesthetic units. I’ve mentioned before that the eight regional aesthetic units of the face are the scalp, forehead, eyes, cheeks, lips (combined with the area surrounding the mouth), nose, chin, and neck. We look to see the direction a wound takes through a regional aesthetic unit and whether a tear in the skin is within what we call a “relaxed skin tension line”.

Each of the regional aesthetic units has its own set of relaxed skin tension lines - more commonly referred to as wrinkles. Sometimes we call these particular wrinkles “facial dynamic lines” because they correspond to underlying muscles that create movement in the face. In each region, the relaxed skin tension lines, or wrinkles, run perpendicular to the direction of muscle pull. The forehead muscle, for example, pulls vertically hence, the forehead wrinkles are horizontal. The wrinkle at the outside juncture of the cheek and lip regions is vertically curved. This is because the smiling muscles pull upward and outward.

There are a couple of reasons for checking to see if a laceration lies within one of these relaxed skin tension lines. For one, if it does, the laceration will generally heal in a more cosmetically pleasing way than it might otherwise. For another, wounding hidden within these lines is likely to heal in a barely noticeable scar, so it might not need much cosmetic surgery.

If the wound extends across two or more regional aesthetic units, it will create the kind of facial scarring that may be psychologically upsetting. First impressions make lasting impressions, and our society reserves harsh judgment for people afflicted with noticeable facial scars. Often, we impute an unsavory character to someone known as “scarface”. The magic of the cosmetic surgeon is to be able to camouflage a scar so that it folds naturally into the hiding places of the face: the relaxed skin tension lines.

Generally speaking, the face is an ideal place to perform cosmetic surgery because most of its skin can be manipulated easily; facial skin is mobile. This is true of all but the skin at the base of the nose and the corners of each eye, which is why, for example, a patient might end up with a scar that “pulls” on the eye if it extends into one of the more mobile regions.

If we are involved during the stages immediately after an accident, before we can start to fine-tune the transition from wounding to camouflaged scarring, we have to deal with closing up the torn skin. The idea is to re-create the basic subdermal support for the skin, if it has been damaged by accident. The two layers of the skin are the epidermis on the surface and the dermis below (see diagram on page 60). The dermis gives the skin its substance and support. Tore-create this support, we take a “deep dermal stitch”, a suture deep inside the wound, through the dermis, to prevent the wound from widening. This reduces the pulling-apart tension on the skin so that the process of growing new skin can begin.

Great advances have been make in the kind of sutures we are able to apply to the deep dermal stitch. We now have suture materials that allow the stitch to retain its tensile strength for a good sixty days, then slowly mix with the water in the body to dissolve out, or disappear within about 180 days.

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