About Face

Procedures Menu

About Face

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

Scar Repair

So far, I’ve talked about the immediate reaction to wounding of facial soft tissue. As you can see, our motivation is to minimize the scarring that will form as the body heals. But, as I said, skilled cosmetic surgeons are not always on the front line in the emergency room. Scar camouflage surgery is not performed at the time of initial repair. For most faila lacerations, the emergency doctor is well trained to sew up the patient and recommend follow-up visits to a cosmetic surgeon for possible scar revision. Scar revision, or linear scar revision as it is called, is one of the major areas of study in our field.

Before we can work to camouflage unacceptable scarring on the face, the original scars must mature. This involves the “six and six” rule that I have mentioned previously: at six weeks, a scar will look its worst (very red); at six months, the scar starts to mature. A mature scar is white and sometimes barely noticeable. Obviously, it is in everyone’s best interest to wait and see how the original scarring matures. It might fade to the point that no cosmetic revision is necessary.

We have a set of general guidelines as to what makes a “good” scar, whether it be formed by accident or through surgery. A good scar must be level with its surrounding skin; it should not be higher than adjacent areas, nor in a depression deeper than half a millimeter. A good scar is no wider than two millimeters, but its length can vary depending on where it appears on the face.

If the scar is at the junction of two regional aesthetic units, say the cheek and the nose, and it happens to lie exactly within the junction line, a good scar can be very long and still be inconspicuous. When a car forms within a single aesthetic unit, length can be more of a problem. Within the region of the forehead, a good scar could be long and barely noticeable: if it were horizontal, tucked into one of the relaxed skin tension lines and level with the surround skin, the length really wouldn’t matter. But in the region of the cheek, a good scar can’t be longer than one-and-a-half centimeters, or it is too easily identifiable to the eye.
A good scar should heal without contracting, or else it will “pull” at the borders of regional aesthetic units, as I mentioned above. Mature scars are without pigment, which makes them easy to see in darker-skinned people if the scars are too wide or too long. A good scar should allow normal facial movement, which again might be a problem if the scar transverses two regional aesthetic units, or if a laceration to the lip has been improperly repaired.

There are many types of problem scars, or “bad” scars, including scars that lack the desirable characteristics I’ve talked about. Other problem scars include the traumatic scar shaped like a C or a half-circle - often on the forehead - that heals by raising the surface inside the circle. This is what we call the “trapdoor” phenomenon. Scarring in the inner canthal area, the inside corner of the eye where the upper and lower lids meet, sometimes results in a “web” scar that creates an Oriental type of appearance with an epicanthal fold. And a scar that transverses the mandibular line of the lower jaw often will form a deep depression.

Our purpose, when we approach a patient with matured problem scarring, is to revise the scars, or transform them into “good” scars. Keep in mid, the cosmetic surgeon’s skill is to be able to deceive the eye; the scars are not removed, they are camouflaged.

There are four basic techniques that can be used to camouflage scars: simple excision; excision and moving the scar to the relaxed skin tension lines; breaking up the scar; and skin leveling, or dermabrasion.

[previous page] [next page]