When do you see Facial Scarring?
When the integrity of the facial skin is endangered, the chances of facial scarring are nearly 100 percent. It is up to the skills of the surgeon or other type of doctor, to return skin to its normal integrity with a scar that is the least noticeable. Facial scarring can happen under certain circumstances. These include:
• Severe lacerations from a motor vehicle accident, altercation, fall, or sporting accident. Some lacerations are more difficult to repair than others and special care must be taken to avoid severe scarring.
• Thermal burn to the face can yield extensive scarring. Thermal burns can come from home fires, car fires, occupational injuries, and even from barbecue grills. Second and third degree burns have the potential for scarring. First degree burns generally heal without scarring.
• Chemical burns, such as with acids and bases, can cause severe second and third degree burns to the face. With full thickness burns, skin grafting can be done to heal the burn faster and to minimize scarring.
• Acne can scar the face severely with pock marks that are indented into the skin from deep abscesses caused by severe acne conditions.
Types of Facial Scarring
Scars can look different depending on a person’s genetic makeup, the size of the scar and the location of the scar. The following are several different kinds of scars that can present on the face:
• Keloid Scars. These scars tend to be hereditary in nature and are the result of a healing process becoming overly aggressive. The scars are bumpy and extend past the boundaries of the original laceration or burn. If they get big enough, they can negatively affect a person’s facial mobility. Doctors can try to remove the keloid scar surgically, can use steroid injections, or apply silicone sheets to the keloid in order to flatten it. If the keloid is small, it can be treated with cryotherapy or laser therapy. If you are prone to keloid scars, you can use silicone gel pads to keep the keloid from forming. Keloids are more prominent and prevalent in people of African-American origin or other people with dark pigmentation.
• Contracture Scars. These occur when the skin has been burned in a sheet-like fashion. As the skin heals, it contracts the surface so that the skin becomes tight and is unable to facilitate movement. The contracture can affect muscles and nerves as well.
• Hypertrophic scars. These scars are similar to keloid scars with the exception that they do not go beyond the borders of the original wound. The scar is raised above the level of the skin. It can be treated by injecting the scar with corticosteroids or by using silicone sheets to make the scar flatter.
• Acne scars. There are several kinds of acne scars. The worst are those that pit the skin as they are very obvious and difficult to treat. Some acne scars can look like waves or can be more angular in appearance. The best treatment of acne scars is prevention of acne in the first place.
Symptoms of Facial Scarring
Severe facial scarring can include the muscle and nerves beneath the skin, resulting in pain or numbness and a limitation in the mobility of the affected part of the face.
Facial scars are also disfiguring in appearance and can lead the victim to avoidant behavior, depression and suicidal tendencies. No one wants to look disfigured and it is easy to hide from others so as to avoid the stigma of having a large facial scar. The same is true of acne scars, which unfortunately often affect fragile teens who are prone to avoidance, depression and suicidal ideation over their appearance.
Risks for Facial Scarring
As mentioned, those with a lot of pigment in their skin have a higher incidence of keloid scar and for scars that are a different color than their normal skin. People with acne are at higher risk of scars, particularly those who suffer from cystic acne.
People who have lacerations that are not surgically corrected properly can have a bad scar. This is especially true of burst lacerations, in which multiple lacerations come out of a central point, or irregular lacerations. Lacerations that go against the grain of the skin can contract and form a puckered facial scar.
People most likely to get a facial scar are those who play rough sports, those who box for sport or for a living, and those who participate in high risk behaviors such as driving too fast or getting into fist fights with others.
Diagnosing Facial Scars
Facial scars are easy to diagnose because they are easy to see. What isn’t easy to see is the extent of the scar. Does the scar involve skin and soft tissue only or has the scar extended into the underlying muscle and nerves?
In order to determine the extent of the scar, the doctor needs to evaluate the muscles of facial expression and the sensation of the face to see if they might be involved in the scar. For example, if the scar moves greatly along with a muscle contraction, then the scar might be attached to some degree to the muscle beneath it. If there is pain or numbness in an area near but not directly on the scar, a nerve may be entrapped within the scar.
• In diagnosing a facial scar, the doctor pays close attention to the natural lines of the skin. In the face, the lines go in different directions but can be determined using gentle traction on the skin. If the traction is along the lines of the skin, it will not separate as much as it will between lines of the skin.
Prevention of Facial Scars
There are ways to minimize the appearance of scars following an injury or following surgery to the face. Talk to your doctor about what you can do to improve the appearance of scars or try the following techniques to help your scar heal better and with a better cosmetic appearance. These techniques will heal the wound deeply so as to minimize any complications.
• First, massage cocoa butter or cocoa butter lotion into the scar on a daily basis. Cocoa butter is also used in the treatment of stretch marks. It has the ability to cause scars to fade by promoting cell regeneration.
• Put vitamin E oil or cream on the scar every day. Vitamin E has antioxidant properties and is antibacterial. It helps your wound heal and takes care of any inflammation within the scar tissue. You should also consider taking a vitamin E supplement orally to get an internal antioxidant effect.
• Find a skin moisturizer that contains alpha hydroxy acids and apply it to the area of the scar on a daily basis. Alpha hydroxy acids promote scar fading and are healthy for your skin. It can speed up the process of healing your wound by helping collagen production go faster. You need collagen for the formation of strong scar tissue.
Treatment of Facial Scars
You can always use over the counter creams, gels or ointments and there are some of these by prescription. The creams contain antihistamines to reduce inflammation and corticosteroid creams that are known to flatten thick scars. Antihistamines also reduce the nasty itching of scars so you don’t damage the skin on and around the scar. Doctors can also use silicone gel sheets that treat thick scars or prevent thick scars.
It is possible to use skin grafts to narrow the appearance of the scar. Skin is used from a little seen part of your body to treat the scar. It is best to wait at least a year before having your scar treated this way as the scar can change over time and it might not be necessary to do a skin graft procedure.
Corticosteroid injections are especially good for keloid or hypertrophic scars. They thin the skin in the area of the injection so the scar shrinks down to a more normal size and shape.
Collagen injections or injections with another type of filler can be used for pitted or sunken scars. Unfortunately, depending on the filler used, they last only several months to a few years before the area has to be reinjected.
Sometimes there is no improvement with creams and injectables. The scar will need to be revised, usually by a plastic surgeon. A scar revision can be done in many ways.
The amount of scarring seen after a wound or injury depends on the size of the wound, how deep the wound is, the location of the wound and the amount of tension put upon the wound at the time of healing. The person’s genetic makeup, skin pigmentation and age will also determine the need for a scar revision. Scar revisions can be done under local anesthesia or general anesthesia.
You should consider waiting for your scar revision—at least 60-90 days after the initial injury. This is because scars lighten and shrink over time. In fact, some specialists believe you should wait at least a year for a scar revision because the scar changes a great deal during that time. Talk to the plastic surgeon about what would be the best waiting time before undergoing a revision.
One option for scar revision is to have the entire scar removed and a new incision created. Not always will the new, revised scar be linear. The doctor uses the lines of the face to determine what the new scar will look like.
Dermabrasion can be used particularly for scars that are raised. The upper layers of the skin are abraded with a wire burr or fraise. This is a special wire brush that allows new skin to grow over the abraded area in order to soften the surface of the skin. It can also be used to get rid of irregularities of the scar.
Some people can have large burned areas that yield a sheet-like scar that is hypertrophic and that involves muscles, tendons and joints. Surgery to improve the appearance and function of this type of scar is called a Z-plasty. The scar becomes thinner and follows the natural curves of the skin lines so it is less noticeable.
Skin grafting, as mentioned, takes a thin piece of skin from another body area and covers the scarred area, especially when the wound will not close or when it forms thin skin that will not heal properly. The appearance is not always perfect but the area is definitely more functional.
Tissue expansion can be used when you need more skin to fully close the wound in an optimal fashion. The procedure uses a silicone balloon that is inserted beneath the tissue and is gradually expanded to the size necessary to get enough skin to close the wound properly.
Scar revision is especially done in the following types of scars:
• You have a keloid scar
• You have a hypertrophic scar
• There has been a wound dehiscence—a splitting apart of the incision
• The scar is at a bad angle when compared to the tension lines of the face.
• The scar distorts the features of the face or interferes with movement.
There are risks for scar revision that include:
• Anesthesia risks
• Bleeding complications
• Infection of the wound
• Recurrence of the scar
• Recurrent keloid formation
• Wound dehiscence
Complications of a Facial Scar
One of the big problems of scars like keloid scars is that, once you remove them, they tend to grow back. The same thing can be said about hypertrophic scars. The tendency to form these kinds of scars is inborn so it may not be possible to simply remove and revise the scar.
There can also be a wound dehiscence. This is a separation of the wound before it has had a chance to heal and can occur if there is a great deal of tension on the wound or the wound is scratched too much. A wound dehiscence can result in an unsightly, wide and ugly wound.
Facial scars also have severe emotional consequences. They aren't wounds that can be hidden by clothing and so a person can become extremely self-conscious about their facial scar—sometimes to the point of severe depression and suicidality.
1. What are some of the methods to improve facial scarring?
There are many modalities that can improve facial scarring. Some of them are chemical peels, microdermabrasion, laser treatment and plastic surgery. Sometimes many of these modalities are used over time. Skin can time time to optimally heal. Try not to be discouraged, if the initial procedure does not produce the result you expected. Subsequent procedures can help a lot.
2. What is the best way to handle severe facial scarring psychologically? Should I encourage my friend to look at herself in the mirror.This is a very difficult issue . Generally speaking, it’s best to allow people to look in the mirror in their own timetable. Severe facial injuries are a difficult blow to anyone’s self-esteem. They should have someone they feel comfortable with when first looking at the scarring. Do not be hurt if it is not you. Some people feel more comfortable to be with a nurse or someone else who doesn’t know them when first viewing the scarring.