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Background:  Scars are a common patient concern, whether they be slight or significantly disfiguring. While scar treatments and therapies abound, significant scarring requires some form of surgical scar revision. Lacerations and traumatic wounds are particularly prone to hypertrophic scar formation, the most common type of raised and disfiguring scars. While less commonly seen on the face, hypertrophic scars can develop under two healing situations. One is when a laceration crosses a facial transition zone, such as the jaw line. The other is when an open facial wound is allowed to or can only heal by secondary intention. Abrasions, burns and other partial thickness wounds are particularly prone to abnormal scar formation

This is a 22 year-old female who was originally involved in a motor vehicle accident in which she was thrown from the car. She sustained multiple long facial lacerations including a deep abrasion from the left side of her face down into the neck. Her original care was unclear although she may have received suturing of some of her facial wounds. She went on to heal and came in for scar revision 18 months after the accident. Besides the numerous persistent red and prominent scars, she had a large scar contracture across the left jaw line. It was painful and tight and limited her from turning her head to the right.

She underwent revision of all of her scars in a single operation. Some basic plastic surgery scar principles were used. Scar revision of most facial scars is best done by changing the line or orientation of the scars. While you can’t change the direction of scars, you can make them more narrow and not a perfectly straight line. This is the principle of the running w-plasty, it changes a straight line into more of a pinking shears pattern. This is useful if the scar runs obliquely or perpendicular to the natural lines of skin tension. This is known as geometric scar rearrangement. Z-plasties are done when the scar is contracted and needs lengthening. This is of particular need in many scars that cross the jaw line, a transition zone between the face and the neck which differs in both skin thickness and exposure to stretching.

Over 500 skin sutures were placed in doing these comprehensive facial scar revisions. They were removed one week later and replaced with topical glue to allow further healing. She was lost to follow-up  but reappeared nearly two years later. Her scars had adequately faded and the final results of the initial scar efforts could be seen. While I thought some further scar improvements could be obtained, she declined any further scar work.

Case Highlights:

1)      Traumatic facial lacerations and wounds are prone to develop hypertrophic scars. Such scars can only be improved by surgical treatment.

 2)      The use of a combination of straight line closure and geometric rearrangement for facial scar revision is used based on scar orientation to the relaxed skin tension lines.

3)      Most facial scar revisions will require some form of touch-up which can include laser resurfacing and/or treatment of persistent redness. Such considerations should wait at least six months after the initial scar revision.

Dr. Barry Eppley

Indianapolis, Indiana

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