Self-mutilation behavior is defined as the deliberate, repetitive, and non-lethal harming of one’s self. This could include a variety of harmful skin injuries including cutting, scratching, and burning, all of which leaves visible. In my Indianapolis plastic surgery practice over the years, I have seen all of these types of injuries due to the scars that they create.
I don’t pretend as a plastic surgeon to understand the why of this behavior. But I have only seen it in children, teenagers, and young adults. I suspect that it is done as an effort to feel something or satisfy some deep-seated loneliness or isolation. In a world full of broken homes, declining morals, and near unlimited access to destructive past times, our youth are becoming desensitized. Perhaps this desensitization leaves a longing for some that needs to be filled.
Self-mutilation leaves scars most commonly on the arms. While the original behavior may or may not have been done to attract attention, patients that are recovering or have recovered do their best to disguise these scars. They do so by wearing clothes that conceal the scars or tell cover up stories that explain their injuries from a different cause. They seek plastic surgery consultation to see what can be done to remove or improve their scars to the point that they don’t look like obvious self-mutilation injuries.
Invariably, the scar pattern is a series of scattered linear scars in a random array on an arm location (usually) where repetitive cutting or scratching was done. These scars are often flat or only slightly raised because their original depth was not full-thickness. They are numerous and no single scar revision on any of them will change their obvious self-mutilation look.
One has to look at them as a unit area rather than as single scars. Two approaches that I have found helpful are laser resurfacing, either moderate or deep. The objective is different with the depth of laser skin injury. Moderate depth resurfacing (200 to 300 microns) is helpful if the scars are very superficial and the goal is to lessen their appearance without creating additional scars from a burn injury. Deep laser resurfacing (> 300 to 400 microns) is done to create a near full-thickness injury with the objective of having the involved area becoming a more confluent scar. That would create a scarred area that would be easier to explain as a burn injury.
There is always the option of excising the area and replacing it with a split-thickness or full-thickness skin graft. And this is certainly a ‘salvage’ position if the laser treatment did not create the result that the patient wanted. But I find creating a deeper burn with a resultant more confluent scar easier. Such laser treatments can be done in the office under local anesthesia unlike skin grafting.
Disguising self-mutilation scars is an uncommon plastic surgery problem.The goal is to either reduce their appearance by softening them or creating a more confluent scar that looks like it came from a more common and less embarrassing source of injury.
Dr. Barry Eppley
Indianapolis, Indiana