Facial Plastic Surgery / Reconstructive Surgery

Facial Scars | Skin Cancer | Tissue Expansion

Facial Scars

Scarring occurs wherever multiple layers of the skin have been injured. As part of the bodies healing process, scarring can sometimes be the result of an accident, surgery, burn, or severe case of acne.

With many treatment options such as excisional surgery, punch grafting, soft tissue augmentation, laser skin resurfacing, chemical peels, microdermabrasion, and dermabrasion available, more people are seeking treatment to improve the appearance or texture of their facial scars.. Successful completion of facial scar revision could improve your appearance, self-confidence, and in some instances the level of facial functioning.

With any kind of scar revision, it's very important to follow your surgeon's instructions after surgery to ensure proper healing. Gradually resume normal activities as advised by your Doctor.

Keep in mind the degree of improvement depends on the size and direction of your scar, the nature and quality of your skin, and how well you care for the wound after the operation. If your scar looks worse, don't panic-the final results of your surgery may not be apparent for a year or more.

Skin Cancer

Skin cancer is the most common form of cancer in the United States. More than 500,000 new cases are reported each year—and the incidence is rising faster than any other type of cancer. While skin cancers can be found on any part of the body, about 80 percent appear on the face, head, or neck, where they can be disfiguring as well as dangerous.

Who gets skin cancer ...and why

The primary cause of skin cancer is ultraviolet radiation—most often from the sun, but also from artificial sources like sunlamps and tanning booths. In fact, researchers believe that our quest for the perfect tan, an increase in outdoor activities, and perhaps the thinning of the earth's protective ozone layer are behind the alarming rise we're now seeing in skin cancers.

Anyone can get skin cancer—no matter what your skin type, race or age, no matter where you live or what you do. But your risk is greater if...

Types of skin cancer

By far the most common type of skin cancer is basal cell carcinoma. Fortunately, it's also the least dangerous kind—it tends to grow slowly and rarely spreads beyond its original site. Though basal cell carcinoma is seldom life threatening, if left untreated it can grow deep beneath the skin and into the underlying tissue and bone, causing serious damage (particularly if it's located near the eye).

Squamous cell carcinoma is the next most common kind of skin cancer, frequently appearing on the lips, face, or ears. It sometimes spreads to distant sites, including lymph nodes and internal organs. Squamous cell carcinoma can become life threatening if it's not treated.

A third form of skin cancer, malignant melanoma, is the least common, but its incidence is increasing rapidly, especially in the Sunbelt states. Malignant melanoma is also the most dangerous type of skin cancer. If discovered early enough, it can be completely cured. If it's not treated quickly, however, malignant melanoma may spread throughout the body and is often deadly.

Other skin growths you should know about...

Two other common types of skin growths are moles and keratoses.

Moles are clusters of heavily pigmented skin cells, either flat or raised above the skin surface. While most pose no danger, some—particularly large moles present at birth—or those with mottled colors and poorly defined borders—may develop into malignant melanoma. Moles are frequently removed for cosmetic reasons, or because they're constantly irritated by clothing or jewelry (which can sometimes cause pre-cancerous changes).

Solar or actinic keratoses are rough, red or brown, scaly patches on the skin. They are usually found on areas exposed to the sun, and sometimes develop into squamous cell cancer.

Recognizing skin cancer

Basal and squamous cell carcinomas can vary widely in appearance. The cancer may begin as small, white or pink nodule or bumps; it can be smooth and shiny, waxy, or pitted on the surface. Or it might appear as a red spot that's rough, dry, or scaly; a firm, red lump that may form a crust; a crusted group of nodules; a sore that bleeds or doesn't heal after two to four weeks; or a white patch that looks like scar tissue.

Malignant melanoma is usually signaled by a change in the size, shape, or color of an existing mole, or as a new growth on normal skin. Watch for the "ABCD" warning signs of melanoma: Asymmetry—a growth with unmatched halves; Border irregularity—ragged or blurred edges; Color—a mottled appearance, with shades of tan, brown, and black, sometimes mixed with red, white, or blue; and Diameter—a growth more than 6 millimeters across (about the size of a pencil eraser), or any unusual increase in size.

If all these variables sound confusing, the most important thing to remember is this: Get to know your skin and examine it regularly, from the top of your head to the soles of your feet. (Don't forget your back.) If you notice any unusual changes on any part of your body, have a doctor check it out.

Diagnosis and treatment

Skin cancer is diagnosed by removing all or part of the growth and examining its cells under a microscope. It can be treated by a number of methods, depending on the type of cancer, its stage of growth, and its location on your body. Small skin cancers can often be excised quickly and easily in our office.

Most skin cancers are removed surgically, by a plastic surgeon or a dermatologist. If the cancer is small, the procedure can be done quickly and easily, in an outpatient facility or the physician's office, using local anesthesia. The procedure may be a simple excision, which usually leaves a thin, barely visible scar. Or curettage and desiccation may be performed. In this procedure the cancer is scraped out with an electric current to control bleeding and kill any remaining cancer cells. This leaves a slightly larger, white scar. In either case, the risks accompanying surgery are low.

If the cancer is large, however, or if it has spread to the lymph glands or elsewhere in the body, major surgery may be required. Other possible treatments for skin cancer include cryosurgery (freezing the cancer cells), radiation therapy (using x-rays), topical chemotherapy (anti-cancer drugs applied to the skin), and Mohs surgery, a special procedure in which the cancer is shaved off one layer at a time. (Mohs surgery is performed only by specially trained physicians and often requires a reconstructive procedure as follow-up.)

Discussing your options and concerns

All of the treatments mentioned above, when chosen carefully and appropriately, have good cure rates for most basal cell and squamous cell cancers—and even for malignant melanoma, if it's caught very early, before it's had a chance to spread.

You should discuss these choices thoroughly with your doctor before beginning treatment. Find out which options are available to you

A word about reconstruction

The different techniques used in treating skin cancers can be life saving, but they may leave a patient with less than pleasing cosmetic or functional results. Depending on the location and severity of the cancer, the consequences may range from a small but unsightly scar to permanent changes in facial structures such as your nose, ear, or lip.

In such cases, no matter who performs the initial treatment, the plastic surgeon can be an important part of the treatment team. Reconstructive techniques—ranging from a simple scar revision to a complex transfer of tissue flaps from elsewhere on the body—can often repair damaged tissue, rebuild body parts, and restore most patients to acceptable appearance and function.

Preventing a recurrence

After you've been treated for skin cancer, your doctor should schedule regular follow-up visits to make sure the cancer hasn't recurred.

Your physician, however, can't prevent a recurrence. It's up to you to reduce your risks by changing old habits and developing new ones. (These preventive measures apply to people who have not had skin cancer as well.)

• Avoid prolonged exposure to the sun, especially between 10 a.m. And 2 p.m. and during the summer months. Remember that ultraviolet rays pass right through water and clouds, and reflect off sand and snow.
• When you do go out for an extended period of time, wear protective clothing such as wide brimmed hats and long sleeves.
• On any exposed skin, use a sunscreen with SPF (sun protection factor) of at least 15. Reapply it frequently, especially after you've been swimming or sweating.
• Finally, examine your skin regularly. If you find anything suspicious, consult a plastic surgeon or a dermatologist as soon as possible.

Tissue Expansion

Tissue expansion enables the body to "grow" extra skin for use in reconstructing almost any part of the body. A silicone balloon expander is inserted under the skin near the area to be repaired and then gradually filled with salt water over time, causing the skin to stretch and grow. It is most commonly used for breast reconstruction following breast removal—but it's also used to repair skin damaged by birth defects, accidents or surgery, and in certain cosmetic procedures.

The best candidates for tissue expansion

Almost anyone in need of additional skin can benefit from tissue expansion.

The procedure is used widely in breast reconstruction when there is not enough skin to accommodate a permanent implant to restore a woman's natural appearance. It is also an option for repairing or replacing areas of the scalp, where hair growth makes it difficult to replace lost tissue with skin from other areas of the body. Tissue expansion generally produces excellent results when reconstructing some areas of the face and neck, the hands, arms, and legs.

Tissue expansion is ideal for scalp repair because the stretched skin on the scalp retains normal hair growth. Most other body tissue does not grow hair to the same degree.

Following tissue expansion, the repaired scalp looks very natural. Expansion may be more difficult on the back, torso, or other areas where skin is thick. If the affected area is severely damaged or scarred, expansion is probably not an option, since healthy skin is the first requirement.

Advantages and disadvantages

Until recently, surgeons were limited to skin flaps and skin grafts to reconstruct damaged tissue. Tissue expansion, however, provides an added technique with several advantages.

First, expansion offers a near-perfect match of color, texture, and hair-bearing qualities. Second, because the skin remains connected to the donor area's blood and nerve supply, there is a smaller risk that it will die. In addition, because the skin doesn't have to be moved from one area to another, scars are often less apparent.

On the other hand, skin expansion has one significant drawback—the length of time required to grow additional skin. The process usually takes 3-4 months total, in which time there may be an visible bulge. Also, the procedure requires repeated visits to the surgeon for injection of the salt water that inflates the balloon.

Despite the drawbacks, tissue expansion can produce very pleasing results, and is a superior technique for its reconstructive purpose.

Possible Complications

Although expanders are thoroughly tested and carefully inserted, leaks can occur. If the expander leaks, the saline solution will be harmlessly absorbed by your body. Minor surgery is required to replace the expander.

Rarely, an infection may develop around the expander. In some cases, the expander may need to be removed for several months until the infection clears. A new expander can then be inserted.

You may have concerns about the use of a silicone tissue expander in this procedure because of the Food & Drug Administration's (FDA) limitations on silicone breast implants. At this time, the FDA ruling does not affect tissue expanders because they are filled with salt water, not silicone gel, and not permanent placements.

Before Surgery

During your initial consultation, your surgeon will evaluate your condition. Your age, skin condition, medical history and other factors will help your surgeon determine if you will benefit from tissue expansion. Your flexibility and tolerance for the inconvenience associated with this procedure will help you decide whether it is right for you.

Your surgeon will give you specific instructions on how to prepare for surgery, including guidelines on eating and drinking, smoking, and medications. If you smoke, your surgeon will probably ask you to quit for at least two weeks before and after your surgery, since smoking may have an effect on how well you heal.

Whether your surgery is done on an outpatient or inpatient basis, you should arrange for someone to drive you home after your surgery, and to help you out for a day or two, if needed.

Tissue expansion is now often performed on an outpatient basis under local anesthesia. Your individual circumstances will determine where the surgery is performed and what type of anesthesia will be used.

The Surgery

The initial operation will most likely take 1-2 hours, depending on the size and area of skin being expanded. A small incision, discreet incision is made next to the area of skin.

A silicone balloon expander is inserted in a pocket created beneath the skin. The expander includes a tiny tube and a self-sealing valve that allows the surgeon to gradually fill the expander with saline solution. The valve is usually left just beneath the surface of the skin. Once in place, the expander is gradually filled with salt water through a tiny valve.

When the incision heals, we will need to inject the expander with additional saline. This will require some follow up office visits. As the expander enlarges, your skin will stretch. This may cause minor discomfort for a couple of hours. Any discomfort you experience may be controlled with pain medication.

The expander is removed when the skin is sufficiently stretched. In breast reconstruction, a permanent implant is then inserted. When the skin has stretched enough to cover the affected area, you'll have a second operation to remove the expander and reposition the new tissue.

After the Surgery

The speed of your recovery depends on the extent of the surgery. For breast reconstruction patients, normal activity can usually resume in 2-4 days. Most patients can resume normal activity within a week following the second surgery.

As with any cosmetic surgery, realistic expectations are important. Patients in good physical and psychological health will benefit from this procedure the most.