An inevitable part of any surgical discussion is one about facial scars.
- Will I have a scar?
- How big?
- Now noticeable?
- Where is the scar?
- Will it heal better than my scar when I fell on a shovel?
- I don’t want a “botched” scar.
- I heard there’s a new scar gel that can make all scars disappear.
Though the list above is not exactly how the “scar talk” goes, these are all things that I have heard asked, and not just once. Some of us have scars that people can see, and sometimes these scars are the physical representations of past traumas. I don’t want to minimize the impact that scars have on my patients or people in general. However, not all scars are the same.
Traumatic scars are not planned and can happen in any part of the body. They are often made by objects that are less sharp than a surgical scalpel, and at skew angles and in prominent places on the face. Some traumatic wounds involve a loss of tissue or an infection that leads to a widened scar. Burn injuries sometimes heal by the skin growing from the periphery of an injury inwards, leaving a star-shaped, or “stellate” scar. Often times, the visible scar is accompanied by an emotional scar, invisible to the observer, sometimes dwarfing the visible scar.
Surgical scars are a totally separate entity. Surgical scars, made with scalpels or other cutting surgical instruments, in a sterile environment and with a planned purpose, heal much better. There is an element of control involved, even when there are unplanned diseases such as skin cancers. Though we cannot control the size and location of the skin cancer, we can control the subsequent scars to reconstruct the defect that cancer left. This control enables us to hide the facial scars in places and orientations that are the least conspicuous.
When the skin is incised or cut, perpendicular to the skin surface, the closure can gently evert the skin edges. As the scar matures and thins, it heals at the level of the skin rather than as a depressed scar. In traumatic wounds, the angle of the cut is determined by the trauma, and the closure is limited by what nature has given the patient (and the surgeon).
Facial Scar Placement
Scar placement is sometimes a luxury, but when it comes to cosmetic surgery of the face and neck, it is the norm rather than the exception. We can plan incisions to be as inconspicuous as possible, placed at natural transitions of the face and neck so as to not draw attention. They can be hidden behind shadows and given an irregular shape, as the eye is drawn to straight lines. We make them parallel the natural creases of the face and neck, called the “relaxed skin tension lines”. This not only hides the scar in a parallel direction to the natural facial aesthetic lines but also makes them heal thinner and less noticeable.
My Experience With Facial Scars
I am not saying that my patients do not have visible scars after surgery. After having a week of blue stitches, most patients will always remember their scars from surgery. However, the rest of the world is not inspecting your face for scars. When I ask my patients about comments about returning to work after surgery, I got the following responses:
- “I was asked if I got new glasses.”
- “I got comments about how good my hair looks.”
- “My co-worker said that I must have had a relaxing vacation (I told her we were going to the beach before I took time off).”
Nobody so far has mentioned the facial scars. This may be because people are too polite to point such things out, or it may be because they are too busy reacting to the new contours of the face to look for them. You can see some examples of surgical patients and may be able to find their scars on my Before and After Gallery. Practicing facial plastic surgery has taught me that the anxiety about scars is not to be minimized, as they are one of the noticeable changes after the bandages are taken down. However, in comparison to the “across the room” impression, or even the “across the table” impression, people are almost always more distracted by the new look to notice scars.