Transforming Facial Scars

The success of facial scar revision depends on many factors: the scar's size, shape, and location, as well as the patient's age, heredity, and general skin condition. Depending on the above factors and Dr. Maas's recommendations, different procedures like acne scar laser treatment or scar surgery may be used.

Scar Treatments

Dr. Maas takes an individual approach to the treatment and revision of scars and applies the principles of scar revision to each unique case. This personalized approach to facial scar revision considers the patient's age, their Fitzpatrick skin type (I-VII), the scar's location, and the age of the scar. Remember that most patients have more than one of the reasons for their particular scars to be unacceptably visible.

Another basic premise in scar revision is remembering that scar formation is the normal process for the body to heal. Any approach to making scars less visible relies on this principle of wound healing. There are many false claims that various treatments, creams, or scar surgery can make scars disappear, which is not true.

What is true is that we can make scars almost invisible with one or more combinations of scar treatments. There are excellent options to improve their appearance or significantly eliminate scar visibility. Below, the approach to treatment for each of the above-listed reasons is explained.

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Location or Direction of the Scar

Scars that go across the natural lines of relaxed skin tension (RSTL) are invariably more visible than those that follow these lines. If one gently pinches the skin in any area of the body, the RSTL is visible.

There are several effective techniques employed to change the direction of a scar so that the scar follows these lines of relaxed skin tension. By doing this, we can blend the line of the scar with the lines (fine or other) we see naturally in our skin. As all the procedures described, this is done with techniques to limit the scar's width. Ideally, we like to see a scar no wider than one millimeter (0.04 inches) Scars that cross natural facial boundaries like the nasolabial fold, the lip border, the jawline, the navel, or the nipple are also much more visible as they distort these natural boundaries.

Dr. Maas employs several techniques to change the direction of scars that cross these anatomic boundaries. Among them are Z-plasty and multiple Z-plasty techniques. These and others can align most of the scar into a small line within the boundary, making it very difficult to see.

Scars in central areas of the face, like the cheek, forehead, or nose, are particularly visible. These areas require several techniques to make them indistinguishable. Geometric broken line closure and multiple W-plastys are among the better methods for primary therapy in these areas. They allow the scar to be "broken up" into tiny irregular segments that the eye has difficulty identifying. This technique is invariably followed by blending using one or more of the resurfacing techniques with which we have extensive experience: dermabrasion, chemical peels, and most often now fractionated laser resurfacing using the optimally powered CO2 lasers (Active FX), which are described in more detail below.

Dr. Maas often sees patients referred to him after having poorly designed or executed cosmetic surgery. Facelift, brow lift, and eyelid scars (blepharoplasty scars) are often direction and location-related scars. These can be successfully treated using the same techniques used for trauma-related scarring and, in many cases, can be combined to restore better contour and further lifting or restoration.

Width of the Scar

The scar's width is among the most reliably treatable scarring conditions, and Dr. Maas considers two distinct categories. The first are areas of lower skin tension. Depending on the patient's age, low skin tension areas include the face, neck, and abdomen. Scars in children represent a unique challenge as the skin is highly taut, and special techniques are used as described below, even in the face, to avoid late-term scar "stretch-back." As we discussed above, facial scars can be reliably revised to achieve a width of 1 mm or less.

Scar width in high-tension areas like the back, abdomen, breasts, and extremities (arms and legs) require special attention intraoperatively and post-operatively to reduce the tension or pull across the scar to prevent late-term scar "stretch-back," which many patients experience even if the initially the scar looks quite acceptable. Special subcutaneous sutures, which continue to hold the skin edges together for months to years, are used in these cases. These highly biocompatible sutures do not need to be removed and are not visible after the wound is healed. In time, the stretch-back risk is substantially reduced, and the body safely reabsorbed or broken down these sutures. The color of scars can be particularly distressing as even fine-line scars, when red, hyperpigmented (brown), or hypopigmented (white), can stand out and be quite noticeable. The treatment of scar color problems involves techniques that either improve the color of the scar or blend the color of the surrounding skin to make the scar less visible.

Dark or hyperpigmented scars are treated using a combination of special creams prescribed by a compounding pharmacy. While many over-the-counter scar fade creams are marketed, few (if any) have a real effect compared to a placebo. In addition, most scars in this category will quickly respond to Intense Pulsed Light (IPL) phototherapy and fractionated laser resurfacing (ActiveFX). Compounded combinations of medications placed into creams take longer. Still, they are often more effective in scars in Asian patients, scars in Latin or Hispanic patients, and scars in other ethnic patients with darker skin types.

Scars generally have minimal pigment, and while some laser therapies have been tried unsuccessfully to stimulate pigment production in scars, few options are available to stimulate pigment production in white or hypopigmented scars. Certain formulations of creams, including retinoids and antioxidants, have shown limited success and are certainly worth trying. Still, the best therapies for hyperpigmented scars are to use a combination of techniques we have discussed to minimize the scar's width and disguise the scar in facial lines and boundaries. Proactive measures, which are quite effective, blend the surrounding skin texture and color using a combination of IPL and fractionated laser resurfacing or dermabrasion. Tanning or surrounding sun damage makes this type of scar particularly noticeable, and phototherapy (IPL) and compulsive sun protection can dramatically reduce their visibility.

Red scars showcase visible signs of ongoing inflammation. There are many reasons for chronic or ongoing inflammation of scars, but it is important to understand that inflammation is part of the wound healing and scarring process. There are ways to accelerate the resolution of redness in scars depending on its cause. Redness is resolved quickly in normal scars within 6-8 weeks. This resolution can be hastened by phototherapy (IPL) and, in some instances, corticosteroids either topically or by injection. In hypertrophic and keloid scars, the redness and mass of the scar can be improved with intralesional corticosteroid injection (injected directly into the scar) and some combination of phototherapy and fractionated resurfacing.

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Depressed or Elevated Scars

Depressed scars, lower than the skin's surface, are among the more common of the five treatable characteristics of unfavorable scars. It is also one of the most reliably treated characteristics. Depressed scars can be elevated using a variety of dermal fillers. Treating depressed scars, like ice-pick acne scars, with Juvederm, Restylane, or Cosmoderm is common, and we have had great success in using these products for that purpose. The longevity of improvement is variable with filler treatments. While many patients benefit long-term from this simple office treatment, Dr. Maas encourages a more comprehensive approach with fillers and other therapy combinations, such as fractionated laser resurfacing (Active/DeepFX). Elevated scars are usually the result of poor wound closure (poor alignment of the skin edges when suturing, resulting in uneven edges or ridges around the scar) or chronic inflammation of the scar, resulting in hypertrophic or keloid scars. Uneven edges or ridges in or around the scar are treated in the office with scar revision – excision of the bad scar, undermining, and careful approximation of the wound edges with eversion.

This method ensures a small scar that is level with the surrounding skin. A fractionated laser skin resurfacing (Active FX) is often performed 6-8 weeks after the revision to ensure a superior blending of the scar with the surrounding skin. Hypertrophic and Keloid scars represent special circumstances in the elevated category. These scars result from exaggerating the normal wound healing process that does not properly "shut off." It is NOT necessarily the best option to use surgical excision as the primary therapy for these types of scars, as excision stimulates more inflammation and may result in the recurrence of the thickened scar. Expertise is required in treating Keloid scars, which occur more commonly in darker skin types. Many patients benefit from early therapy with intralesional corticosteroid or immunomodulator injections followed by surgery, or in some cases, the order is reversed. In contrast to popular belief, keloid scars can be successfully treated in African American, Asian, and Hispanic patients.

Dr. Maas working on patient

Scar Length

Scars can be shortened by breaking them into tiny nonlinear scars that are difficult for the human eye to identify. If one were to take a tiny ruler and measure these little segments, the scar would increase in length. However, the human eye does not perceive this, and the result of a geometric broken line or multiple M- or W-plasty is a net reduction in the visibility of a scar. Using subsequent blending procedures such as fractional laser resurfacing and IPL almost always supports these techniques.

Corey S. Maas, MD, and the staff at The Maas Clinic™ in San Francisco look forward to answering any questions you may have about facial scar revision. To schedule an appointment, please contact us today.

Corey S. Maas, MD, reviewed this information about facial scar revision. If you have any questions, please don't hesitate to contact us using our contact form below.

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