Posttraumatic soft-tissue injuries of the face are often the most lasting sequelae of facial trauma. The disfigurement of posttraumatic scarring lies in both their physical deformity and psychosocial ramifications. This review outlines a variety of techniques to improve facial scars and limit their lasting effects.
Key points
- •
Traumatic scars can aesthetically, functionally, and psychologically impair patients. Through comprehensive evaluation and thorough planning, patients should be counseled on realistic expectations.
- •
Fortunately, there are many surgical and nonsurgical techniques to greatly improve scars at several time points along the scarring process.
- •
Meticulous execution and postoperative care are necessary to achieve the best results.
Introduction
Posttraumatic facial scarring can be limiting from both physiologic and psychological standpoints. Some scars result in physical limitations to basic functions such as vision or eating. Others are simply an unpleasant reminder of a traumatic event of the past. Improving both function and aesthetics related to posttraumatic scarring are important goals in their treatment.
In the preoperative setting it is important to delineate the goals and expectations of scar revision. Patients often present with considerable misperceptions about what is feasible in scar revision. While decreasing the visibility of scarring is a reasonable objective, patients should be reminded that total elimination of a scar is not feasible. Moreover, recurrence of the same scarring pattern after repair can be an unfortunate possibility.
Introduction
Posttraumatic facial scarring can be limiting from both physiologic and psychological standpoints. Some scars result in physical limitations to basic functions such as vision or eating. Others are simply an unpleasant reminder of a traumatic event of the past. Improving both function and aesthetics related to posttraumatic scarring are important goals in their treatment.
In the preoperative setting it is important to delineate the goals and expectations of scar revision. Patients often present with considerable misperceptions about what is feasible in scar revision. While decreasing the visibility of scarring is a reasonable objective, patients should be reminded that total elimination of a scar is not feasible. Moreover, recurrence of the same scarring pattern after repair can be an unfortunate possibility.
Prevention
The appropriate management of facial soft-tissue injuries begins in the acute setting. Foreign debris should be removed and wounds should be thoroughly irrigated to reduce bacterial counts. Conservative debridement can decrease the degree of persistent scarring and traumatic tattooing. The undermining of adjacent tissue may assist in the closure; however, elaborate flaps at the time of initial repair are usually inappropriate. Meticulous, tension-free closure in layers should be performed to minimize scar formation. Avoidance of infection through wound care and use of ointment or occlusive dressing optimizes healing. Posttraumatic infections are rare in the well-vascularized head and neck region. The literature shows that prophylactic antibiotics do not reduce infection rates but instead promote bacterial resistance. Prophylactic antibiotics have both increased cost and undesirable side effects (ie, diarrhea). Antibiotics should be reserved for patients with risk factors (ie, immunosuppression, diabetes), or wound risks (ie, animal bites, heavily contaminated wounds). As in many surgical challenges, prevention is an important part of the overall treatment plan.
Wound Healing
The phases of wound healing must be considered to better understand the formation of facial scars. Would healing progresses through 3 phases: inflammatory, proliferative, and scar maturation/remodeling. Youthful turgor can widen scars; the lack of facial rhytids also makes scars more apparent for a longer period. Conservative measures such as sun protection, intralesional steroid treatment for hypertrophic scars, and topical bleaching agents can all be essential parts of scar management. Discussing these issues with the patient at the initial consultation is an important part of the treatment plan.
Scar Physiology
Ideal scars are hidden, narrow, and flush with the adjacent skin. Prominent scars tend to have color mismatch, persistent erythema, and pigmentary irregularities (both hyperpigmentation and hypopigmentation). People with skin types higher on the Fitzpatrick Scale are more likely to have hyperpigmented scars. Those with lower Fitzpatrick skin types are more likely to experience persisting erythema and eventual hypopigmented scar. Contour irregularities can make scars more noticeable, particularly in direct overhead lighting. Textural abnormalities can also bring unwanted attention to a scar. Normal skin has a matte finish attributable to microsurface irregularities that scatter light. Scarring can lead to surface changes that alter these characteristics, resulting in a smooth surface and a shiny appearance.
The overall length of the scar is an important consideration. Scars up to 6 mm in length are often imperceptible, even if they do not follow the relaxed skin-tension lines. A long scar with a predictable direction is more noticeable, particularly those that do not follow the relaxed skin-tension lines. At a subconscious level, the eye is less drawn to scars that follow relaxed skin-tension lines. Facial motion increases the perceptibility of scars that run contrary to the relaxed skin-tension lines. Scars that lie along aesthetic subunit borders (ie, melolabial crease) or hide in natural shadows (ie, beneath the brow) are often less perceptible. By contrast, scars that are located over a prominence (ie, malar mound), particularly on a smooth, youthful face, are far more noticeable.
Hypertrophic scars and keloids
Unlike light microscopy, scanning electron microscopy is able to show the difference between normal skin, hypertrophic scars, and keloids. Normal skin consists of distinct collagen bundles that run parallel to the epithelial surface. In comparison with normal skin, the collagen within hypertrophic scars are flat, wavy, less demarcated, and fragmented; however, collagen fibers of hypertrophic scars still run parallel to the surface. The hypertrophic scar is confined within the borders of the wound, often occur in the early phases of injury, and may be erythematous, pruritic, and have telangiectasias. Hypertrophic scars are more likely to develop in areas of tension and are common with through-and-through injuries of the lip, particularly those that have some element of crush injury.
Keloids extend outside of wound borders and contain disorganized collagen fibers with random orientation to the surface. Keloids are more common in people with higher Fitzpatrick skin types and often occur in zones of increased tension, such as the clavicle, sternum, and upper back. Keloids in the face are a rare occurrence with the exception of the ear and neck.
Treatment of hypertrophic scars and keloids can include careful observation, camouflage, and revision surgery. For extensive facial scarring, custom-made pressure devices, as are often seen in burn units, may be considered. Laser technologies can also be used in the acute phases of scar hypertrophy to decrease vascularity and scar prominence. The most common and predictable treatment of scar hypertrophy is intralesional steroids. Dermal injections with triamcinolone acetonide (Kenalog; Bristol-Myers Squibb, New York, NY) at an initial concentration of 10 mg/mL can be used every 2 to 3 months as needed. Occasionally the concentration can be increased for recalcitrant lesions. Topical steroid application with flurandrenolide tape (Cordran Tape; Watson Pharmaceuticals, Corona, CA) or Silastic gel sheeting (Dow Corning Corp, Midland, MI) may also improve or prevent scars. Aldara or 5% Imiquimod cream (3M Pharmaceuticals, St Paul, MN) is a topical immune-response modifier that stimulates an increase in collagen breakdown. The use of Imiquimod cream has prevented the recurrence of keloids after surgical excision in some studies, but further evaluation is needed. Challenging scars are often treated with combination therapy, which can decrease the wound erythema and hypertrophy of dermal tissues.
Radiotherapy is typically reserved for scars that have failed other treatment modalities, but has been successful when combined with surgery. It has been postulated that radiotherapy limits collagen synthesis by altering fibroblast proliferation and inducing apoptosis. Many dosages and regimens have been described, but good results have been achieved with 15 to 20 Gy over 5 to 6 sessions in the acute postoperative period. Side effects include hyperpigmentation, erythema, and the rare but potential risk of radiation-induced malignancy.
Physiologic Considerations
Structural distortion caused by a scar can alter physiology. For example, a scar that traverses the alar rim with subsequent scar contracture can result in nasal obstruction. Similarly, injuries near the eyelid or lip can cause retraction with ectropion formation or oral incompetence, respectively. Trauma to the scalp may cause telogen effluvium, and severe injuries may lead to permanent hair loss.
Treatment goals and planned outcomes
For certain scars, medical and topical therapy alone does not achieve the desired result. When considering scar revisions, there are several patient characteristics that can influence treatment choices and timing:
Age of the Scar
The age of the scar is an important consideration. Surgical intervention in the inflammatory and proliferative phases may actually increase the total amount of scar-tissue formation. Thus, deferring surgery until scars have matured is often a prudent choice. In fact, scar maturation may significantly improve some of the previously discussed scar characteristics and obviate surgical treatment completely.
Age of the Patient
Patient age is also an important consideration. Tissue in younger patients is under greater tension, and relaxation of this tension is an important consideration before planning surgery. The age of the patient also influences the setting for revision. What can be a simple office procedure in an adult may necessitate general anesthesia in a child. Furthermore, functional loss has a significant influence on the timing of surgery. A scar contracture in the eyelid that creates an ectropion and corneal exposure mandates more urgent surgical intervention.
Skin Pigmentation
Skin pigmentation as represented by the Fitzpatrick Scale is also a consideration in treatment choice. Patients with Fitzpatrick skin scores greater than III are far more likely to develop postinflammatory hyperpigmentation following resurfacing technologies. Similarly, erythema that is slow to resolve is seen in lower Fitzpatrick skin types and may improve with the passage of time. If the patient or family has a history of scar hypertrophy or keloid formation, this should be discussed with the patient and family before surgical treatment.
Multiple Scars
Unfortunately, many traumatic incidents create facial lacerations with multiple independent or interconnecting scars. In these circumstances, the entire scar-maturation process is protracted and adjacent scars influence excisional treatment options. For example, if there are several nearly parallel scars with contour irregularities, scar excision and reapproximation may be an appropriate treatment option. However, it may be most appropriate to treat the scars sequentially rather than simultaneously, as the excisional treatment of both scars may result in excessive wound tension.
Patient Education
Finally, it is important to have clear communication with the patient about expectations for scar camouflage that is feasible and the duration and number of planned treatments. A patient with unrealistic expectations requires education on these issues before any scar-revision surgery is entertained. Patient education is greatly aided by reviewing photographs of other patients in one’s practice and their outcome.
Preoperative planning and surgical techniques
Surgical intervention is often considered 6 to 12 months after the initial injury, before which concealment can be performed with the use of makeup and camouflaging. In the interim, the wound can be improved with treatment options such as silicone sheeting, gel, or bleaching agents for areas of posttraumatic hyperpigmentation. Depressed areas or irregular surfaces may benefit from injections of biological fillers for temporary improvement. Ideally, definitive soft-tissue augmentation during surgery avoids the ongoing need for fillers.
A variety of surgical techniques is available to improve scars. The simplest option available for scars within relaxed skin-tension lines is excision and meticulous repair. This technique is best used for scars that are wide, have significant surface irregularities or traumatic tattooing, and follow the relaxed skin-retention lines. Scar tissue should be excised with undermining and mobilization of adjacent tissue. The incisions should be closed in layers, and the superficial layer should be meticulously repaired with fine, monofilament, permanent, or 6-0 fast-absorbing gut sutures. A thin layer of antibiotic ointment is applied, followed by the use of antitension tape for 1 week up to 3 months, depending on the surgeon’s preference and the tension on the wound. Prolonged use of antitension tapes is often not feasible for patients after the first week.
Z-Plasty
A Z-plasty is a useful technique for scar lengthening and realignment. A Z-plasty is positioned such that the central limb lies over the contracted scar and the tangential limbs are positioned to rest as close as possible to the relaxed skin-tension lines. This technique is also useful for enlarging contracted orifices such as the mouth or nostril. Z-plasties are used to lengthen contracted tissues such as the eyelid with ectropion or lagophthalmos, or a cheek contraction that distorts the lips. A Z-plasty is also useful for making long, easily perceived scars less visible by establishing an irregular pattern that is more difficult for the eye to follow. The technique is also useful for reorienting scars that run perpendicular to the relaxed skin-tension lines ( Figs. 1 and 2 ).
