A recent article by the surgical team of Jesse A. Taylor, chief of pediatric craniofacial surgery in Philadelphia, in the international journal Plastic and reconstructive surgery, reports a very interesting study on how we perceive facial scars. The question is : ” Is seeing a scar, even misdirected on an unknown face, really conflicting with a still admiring perception of a certain residual beauty, or is it, on the contrary, always repulsive? ».
The sensations felt by a large panel of independent observers have been analyzed and compared in a serious and statistically based study. The answer is ambivalent: some scars do not alter the perception of beauty for those who observe, which is obviously not the case with the patient’s feelings or his complexes about facing the gaze of another. It seemed to me interesting in these conditions to redo an overview of the current therapeutic possibilities to improve facial scars. To better evoke the problems it seems more logical to study the scars in the four important moments of the life of a human being: childhood, adolescence, in the young adult and finally the age of maturity.
Facial scars in young children
The main causes are either traumatic (road accident, dog bite, unfortunate wound), or congenital (operated malformation of the face such as cleft lip and palate, scarring after craniofacial surgery or facial malformation ). In the young child who perceives his own image in a conscious and critical way only from the age of 5 or 6 years, there is only little documentation to evaluate intimate suffering. At this age, it is especially the parents who suffer because they cannot bear that their child has a scar which they fear will ruin the whole life of their beloved offspring.
At this age, immediate repair of unsightly scars is almost never practiced, yet the possibilities of healing are excellent because all the tissues of the child are in full growth and have exceptionally effective healing factors. However, in young children the risk of hypertrophic scarring remains more frequent than in adults.
During adolescence
The presence of scars represents a real suffering that can lead to withdrawal and even a refusal of sociability. The causes of these scars are multiple:
- accident on public roads (fortunately the wounds on the windshield have practically disappeared thanks to the seat belt, the airbags, and the laminated structure of the windows);
- sequelae of a fight, glass wound, sequelae of burns;
- persistence of an unsightly scar due to acne or chickenpox having caused scratching lesions.
The adolescent is very keen on repairing scars, the parents are aware of this and do not hesitate to take their child to a surgeon who is competent in reconstructive and aesthetic plastic surgery. Many restorative possibilities exist with recent progress thanks to the development of technology but also thanks to the application of therapeutic principles specific to the plastic surgeon, such as Z-plasty to break an retractile scar, the repair of scars in several planes for make thinner, the dermal cigarette method to fill in the hollows.
Modern technological means include the use of CO type lasers2 which make it possible to flatten an irregular surface, to also use dermabrasion to smooth a scar without burning it, or microneedling the purpose of which is by very numerous multi-punctures to relaunch the healing process which has not gone to the end.
After a precise analysis of what makes the scar unsightly, the surgeon will decide on a therapeutic protocol intended to correct in one or more stages this lesion which is the witness of the accidents of the past that the young patient and his parents would like to erase or forget.
Plastic surgeons usually say that scars on the face must be oriented along particular lines called Langer’s lines. A scar that is along this line will show very little, while a scar that is perpendicular to this line will be very visible. In fact, Taylor’s study contradicts this assertion somewhat by showing that this misdirected scar often remains acceptable if the rest of the face is pretty.
In adults
The persistence of a scar is less important because of the contingent elements of an adult’s life: integrating into professional life, founding a family, being accepted by the other despite the scars which then take less time. ‘importance.
The causes of scars in adults are almost the same as in adolescents, sometimes adding traumatic causes during sporting activities or the aftermath of a state of war or urban violence.
The demand for repair of these scars is more or less important depending on the moments of life, and the vagaries of daily life. But this demand practically never goes out. It is not rare that at a moment of separation from a couple, or of a hiatus in professional life, the patient concerned suddenly feels the desire, somewhat suppressed until then, for a consultation to knowing what can be done to improve the scar that comes to the fore.
Each type of defective, keloid, misdirected or widened scar corresponds to a repair technique, the most effective modality of which must be chosen according to the experience of the practitioner..
In middle age after fifty
The existence of an unsightly scar on the face has been put into perspective by the usual course of life and its worries. But the obsession with a repair does not completely disappear, especially with treatments by aesthetic medicine which makes it possible to fill in hollow scars, by the use of laser resurfacing and sometimes by lipofilling which brings cells young strains under an adherent and retracted scar (such as radiodermatitis after burns by X-rays intended to treat progressive breast cancer).
At this age, all plastic surgery or orthopedic surgery or digestive surgery involves the need for a scar to penetrate deeply. Finally, the patient thinks less of the work accomplished in the depth of his flesh than of the scar, for which he demands from the operating surgeon an invisible aspect and sutures worthy of a real plastic surgeon!
It is moreover this requirement coming from the patients, eager to reduce as much as possible the scars of the interventions, which led to the development of digestive and gynecological endoscopic surgery.
What are the therapeutic principles currently used to reduce scars?
- The repair of the scar plan by plan consists of removing the old scar, taking off the edges to be able to bring the tissues closer together and stitching back the dermis and the epidermis step by step, with absorbable sutures using the principle of intradermal overcasting, in order to that we do not see the scar scales of the past on either side of the main scar.
- Z-plasties, or by flaps, consist in moving the tissues to reorient them along the lines of Langer, and to avoid retractile scars.
- The dermal cigarette consists of taking advantage of the scar itself when it is hollow: the surface epidermis is removed, the fibrous bottom of the scar is kept, and the detached edges are brought over to create a new scar at the above the first.
- Lipofilling consists of removing very small fat cells which will be implanted under the unsightly scar.
- The use of physical means (laser, plasma, chemical peeling) makes it possible to resurface a scarred area by calcining in a controlled manner all that exceeds it.
- Keloid scars are best treated by deep infiltrations of a powerful and long-acting “cortisone” product. Several sessions are generally necessary, spaced a month or two apart.
- dermabrasion and microneedling are methods of scar recovery and flattening irregular scars.
This brief description is not exhaustive of all the possibilities because for each situation it is necessary to analyze what is disturbing and to find the most suitable therapeutic option.
In the end, all the scars are not necessarily to be operated on, this is what the American study shows. There are patients who accept their scars very well, while others are devastated by them, the scar has a part of symbolic language. There are even patients who take advantage of their scars to camouflage them under an artistic tattoo. It is therefore the feeling of each patient that must be evaluated in order to act in the most effective, simplest and most aesthetic way possible according to the evolving data of surgical science.
