Facial Scar Revision Techniques

While he has made his living performing facelifts and rhinoplasty, Regan Thomas, MD, professor of facial plastic surgery, Northwestern University of Medicine, Chicago, Ill., says his favorite procedure is facial scar revision.

“When you are able to help those patients, it makes such a dramatic change in their self-image and their confidence level,” says Dr. Thomas. “You don't want to scar anywhere, but if the scar’s on your back or your shoulder, you can probably tolerate it. If you have a significant scar on your face, and it's really a major issue for you, I'm pleased that in our specialty, we are able to make a difference for most people to make those scars better.”

He tells his patients that he can’t make a scar go away once it’s there, but with the tools he has acquired over the years, he can change and camouflage the scar to be less notable.

In his presentation, “Optimizing Results in Facial Scar Revision” at the recent American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) virtual meeting, he discussed the key techniques he implements, both surgical and nonsurgical, to transform a once-prominent scar into one that can be barely seen by the naked eye.

Scar Strategy

After traumatic injury to the skin, the formation of scar tissue can result in very obvious, wide, sunken, red, raised, or pale scars along with causing facial disfigurement or distortion, according to AAFPRS.

Surgically, Dr. Thomas uses a variety of techniques to improve the appearance of facial scars.

“If the scar is too wide or it's depressed, we can make that scar edge to edge and narrow,” he says.

The skin on the face is mobile and movable, Dr. Thomas says, and because of this, he can surgically remove an existing scar, move it to another area and hide it within natural facial landmarks like the nasolabial creases, the hairline, or in front of the ear.

When moving a scar, he aligns it to fall within resting skin tension lines.

“These are lines that you're used to seeing with animation on the face,” says Dr. Thomas. “If a scar is perpendicular, those are more noticeable, but if it runs into those lines, it's easier to camouflage and it makes the scar better. As we shift the scar in our techniques, it is less tension on the scar and it tends to heal better and [with] less widening.”

When changing the outline of prominent scars, he uses a running W-plasty.

The accordion effect of this technique makes the resulting scar less noticeable by reducing skin tension during healing and scar maturation.

“I tell the patients, it's like military camouflage,” says Dr. Thomas. “If you have a big truck or a tank and you paint it with all those globs of green and brown and tan paint, you think that would make it more [noticeable], but what happens is those blobs break up the lines… and it blends into the background. These little W's tend to break up the scar line, so your eye doesn't see it.”

As a variation of a running W-plasty, he sometimes also uses a geometric broken line closure.

“In addition to the little W's, we make little squares and rectangles and that further breaks up that line so your eye doesn't follow [it] as well,” he says.

While he always strives for the best scar possible through his facial scar revision techniques, Dr. Thomas says that hypertrophic, and keloid scars are more difficult.

“There are treatments that we can do for those that help with those scars and perhaps improve them, but unfortunately for that group of individuals, we can never make the scars as good as normal skin healing and normal scarring effect,” he says.

Once the scar has been revised surgically, he adds a dermabrasion treatment, typically six to eight weeks post-procedure, to further even out any uneven areas.

Notably, when the original scar is minimal, or less prominent, Dr. Thomas uses dermabrasion alone to improve the appearance.

While laser modalities are also available, he says the combination of his surgical techniques and dermabrasion result in the best possible outcomes for his patients.

“There are laser modalities that are useful that we use sometimes,” he says. “But more often than not, the dermabrasion seems to fulfill our goals in terms of getting the best ultimate score that we can.”