Defects and deformities of the skin of the face and neck: causes, symptoms, diagnosis, treatment

Defects and deformations of the skin of the face and neck can be congenital and acquired (as a result of injuries, operations and various diseases : leishmaniasis, lupus erythematosus, syphilis, etc.).

Post-traumatic (including post-burn) and postoperative scars on the face are divided into atrophic, hypertrophic and keloid.

Atrophic scars

Atrophic scars are flat, the skin in their area is thinned, collected in thin folds, not welded to the underlying fiber. Usually the skin in the area of the scars is strongly pigmented, which attracts the attention of others and is therefore especially troubling and depressing patients.

Sometimes the atrophic scar in its central part and in some areas on the periphery is devoid of pigment and even more noticeable.

Hypertrophic scars

Hypertrophic scars are divided into hypertrophic and keloid proper. Actually, hypertrophic scars usually have the appearance of strands protruding above the surface of the skin.

These strands are thin rollers, covered with folded skin, under which a relatively soft, painless connective tissue scar is palpable. There are such strands after burns, operations, transferred smallpox. They are localized in the region of cheeks, naso-labial folds, around the mouth. Essential deformities of the face, observed with a keloid, they do not cause.

Keloid scars

Keloid scars are a kind of hypertrophic scars. Some authors quite rightly (from the oncological point of view) consider a keloid as a form of dermatofibroma, because they differ with a particularly pronounced hypertrophy of long subcutaneous strands of connective tissue that are parallel or perpendicular to the surface of the skin, which determines the cellular structure of the scar.

The epidermis in the scar zone has a normal appearance, the papillae of the skin are flattened or absent.

The podsosochkovy layer consists of a network of connective tissue fibers, having a normal appearance, but tightly pressed against each other.

Young keloids are formed from dense collagen fibers, growing into normal tissue, a large number of mast cells and fibroblasts against the background of the basic substance.

Old keloids contain less basic substance and cells, but more collagen fibers.

Keloid scars (especially burns) that occur on a large area of the face and neck cause physical and mental suffering to the patients: they deform the wings of the nose, twist the lips and eyelids, cause atresia of the nasal passages, and condition the neck's contracture. Patients often feel itching and pain in the area of scars, which can ulcerate.

Between the individual Cicatricial strands, sometimes funnel-shaped indentations are formed, lined with unaltered skin. Here (in men) grow hair that is difficult to cut or shave; they traumatize and irritate the epidermis over scarring, sometimes malignant.

Postleishmaniasis scars

Postleishmaniasis scars on the face are divided into flat, deforming, retracted, deforming, tuberous and mixed.

[1], [2]

Classification of cicatricial deformities of the neck

Undoubtedly of practical interest is the topographic and functional classification of the Rubtsovi neck strains according to AGMamonov (1967), which gives a clear idea of the area of skin loss on the anterior and lateral surfaces of the neck, as well as the degree of disruption of neck mobility. This classification takes into account the lack of skin in two directions: vertical (from the chin to the sternum) and horizontal (along the collar line of the neck).

In the vertical direction:

• I degree. In the normal position of the head, there is no skin tension; with the removal of the head to the back, separate strands and tension of the tissues of the lower part of the face appear. Head movements are limited only slightly.
• II degree. In the normal position, the head is slightly tilted anteriorly; the chin angle is smoothed. It is possible to remove the head to a normal position, but the soft tissues of the lower part of the face are considerably stretched.
• III degree. The chin is brought to the chest; the removal of the head is insignificant or completely impossible. Soft tissues of the lower part of the face are shifted and scarred.

In children with long-existing contractures, deformity of the lower jaw, prognathia, open bite, divergence of the lower frontal teeth, as well as changes in the cervical spine (flattening of the vertebral bodies) can occur.

In the horizontal direction:

• I degree. One or more vertically arranged strands border on the sides with healthy skin. Taking a scar in a crease, without the forced tension it is possible to bring together edges of a healthy skin. The width of the scar on the middle collar line does not exceed 5 cm.
• II degree. The width of the scar on the middle collar line is up to 10 cm. It is impossible to bring the edges of the skin from the side sections bordering the scar.
• III degree. Skin on the anterior and lateral surfaces of the neck is scarly changed. The width of the scar is from 10 to 20 cm and more. The displacement of healthy skin from the posterior-lateral sections of the neck anteriorly in the horizontal direction is negligible. This also includes a rarely occurring circular lesion of the skin of the neck.

In order to represent the form of cicatricial deformity of the neck, the degree of functional restriction and anatomical disorders, it is necessary to take the most suitable for this classification indicators of skin loss in the vertical and horizontal directions and denote them in the form of fractions (in the numerator - the degree of reduction of the chin to the sternum, and in the denominator - width of the scar along the line surrounding the neck).

[3], [4]

Treatment of scars

Treat atrophic scars in the following ways:

1. Excision of the scar, mobilization of the edges of the wound by cutting, bringing them closer to the blind seams. As a result of this operation, the amorphous atrophic scar turns into a neat postoperative linear scar. This method is indicated for small scars in the area, when after cutting them, the edges of the wound can be brought together, without causing a turn of the eyelid or lip, without deforming the wing of the nose or the corner of the mouth.
2. Free skin transplantation on the part of the wound formed after excision of the scar, which can not be closed by mobilizing and sewing its edges.
3. Deepithelization of pigmented layers of the rumen with the help of a milling cutter or coarse-grained carborundum stone. The operation is suitable for large flat scars, which can not be removed with subsequent replacement with healthy skin for any reason. In some cases, pigmented sections of the scar can be de-epithelialized with erythemal doses of quartz.

If the scar has a whitish color, it can be "colored" by 10% r-rum silver nitrate (or 3-5% potassium permanganate) or subjected to ultraviolet radiation. After that, the scar turns dark and becomes less noticeable. Treatment of common hypertrophic scars and keloids on the face and neck can be conservative, surgical or combined. In the scars formed on the wound healing site by the primary tension, the elastic fibers appear earlier and in a larger quantity than in the scars at the wound healing site by secondary tension. In keloid scars, elastic fibers do not appear even 3-5 years after injury.

As shown by the research data, the process of scarring on the face is accompanied by significant disturbances of the histochemical structure of the scars: in young scars (2-4 months) a high content of acidic mucopolysaccharides is noted, then their content progressively decreases, and the number of neutral mucopolis harids increases.

Acid mucopolysaccharides play an important role in the barrier function of connective tissue, since they have the ability to neutralize toxins and prevent the spread of microorganisms. Reducing them may, apparently, reduce the resistance of scar tissue to infection. Therefore, the expediency of early plastic operations on scars is understandable.

On the other hand, the decrease in the amount of acidic mucopolysaccharides in old scars explains the low effectiveness of enzyme preparations (lidases, ronidases) used in such cases for therapeutic purposes, which are known to have a direct effect on acid mucopolysaccharides, causing profound changes mainly in hyaluronic acid.

Therefore, it is advisable to use enzymatic preparations such as hyaluronidase to treat only traumatic scars that exist no more than 6-8 months. The same applies to X-ray therapy of keloid scars, to which only fresh keloids are most sensitive (no more than 6-9 months).

The use of ultrasound therapy (UZT) for the treatment of young scars reduces the possibility of deformation of the lips, cheeks, eyelids, and neck contractions. Ultrasound absorbs ruby tissue by splitting the bundles of collagen fibers into separate fibrils and separating them from the amorphous cementitious substance of the connective tissue. For ultrasound treatment, the cicatrized skin of the face and neck is divided into several fields - each with an area of 150-180 cm ²; simultaneously act on 2 fields within 4 minutes.

To improve the effectiveness of treatment for UZT, scars are lubricated with hydrocortisone ointment (consisting of 5.0 g of hydrocortisone emulsion, 25.0 g of Vaseline and 25.0 g of lanolin).

It is possible to combine UZT with heat and mud therapy. In the treatment of cicatricial processes after cheiloplasty in children, it is recommended that the area of scars be treated with an ultrasound intensity of 0.2 W / cm ² for 2-3 minutes; course - 12 procedures (every other day) (RI Mikhailova, SI Zheltova, 1976).

Softening and reduction of keloid post-burn cicatrices of the face and neck are facilitated by irrigation with hydrogen sulfide water, which (depending on the patient's general condition, peculiarities of location and condition of the scars) can be carried out in one of three modes:

• regime of weak impact (t ° water 38-39 ° C, pressure of jet 1-1.5 atm, duration of procedure 8-10 min, course - 12-14 procedures);
• moderate mode (t ° - 38-39 ° С, pressure 1.5 atm, exposure - 10-12 min, course - 12-15 procedures);
• intensive regime (t ° - 39-40 ° C, jet pressure 1.5-2.0 atm, exposure 12-15 min, course 15-20 procedures).

Accordingly, the procedure is carried out using a multi-jet tip-irrigator or a soft brush-irrigator. Such procedures are carried out during the period of sanatorium treatment of patients.

When preparing for surgery for scarring, it is necessary to take into account the prescription of their existence, as well as the individual characteristics of the body and the nature of the fibrinoplasty process.

If an operation is to be performed for a relatively recent development of scar deformity of the face (no more than 6-8 months), it is advisable to conduct a course of treatment with lidase (hyaluronidase) to soften the scars. Especially effective is lidazoterapiya in the first 4-6 months of development of scars, when their tissue contains many acidic mucopolysaccharides.

Preparation of keloid scars for the operation of enzymatic preparations is carried out as follows:

• ronidase - daily gauze or cotton applications on the rumen area for 30 days;
• Lidazoy - 10 injections (under the scar) at 64 units with interruptions of 1-2 days or more (depending on the reaction to the administration of the drug).

Good results are provided by vacuum therapy of face and neck scars: after 2-3 procedures, discomfort disappears in the area of the scars (tenderness, tension), they become softer and their color approaches the surrounding skin more.

After the application of vacuum therapy of scars, the volume of surgical intervention is reduced, and postoperative healing occurs by primary tension, despite the fact that they operate in the area of scar-modified tissues. This is due to the fact that vacuum therapy improves trophism in the cicatrized area of the face or neck.

In the presence of "young" postoperative keloid or burn scars, a course of pyrogenal treatment can be conducted in the order of their preparation for surgery (old scars can not be cured).

Preoperative preparation of keloid scars should be carried out particularly vigorously and aggressively. If pyrogenal treatment does not lead to the desired results, X-ray therapy is used, with the total total dose not exceeding 10,000 P (X-ray) or 2600 tK / kg (milliculus per kilogram). If irradiation with a total dose of 8000 P (2064 tK / kg) did not produce a therapeutic effect, it should be discontinued.

It is important to observe a certain rhythm of exposure (depending on the dose). With the arrangement of scars in the upper part of the face, you can limit yourself to the smallest number of exposures (2-5) with a total dose of 4848 P (1250.7 tK / kg). If the scars are in the middle section, the total radiation dose should be increased from 2175 to 8490 Р (from 516 to 2190 mK / kg), and in the lower part and neck - from 3250 to 10 540 Р (from 839 to 2203 tК / kg ).

The nature of the operation depends on the type of scar (normal hypertrophic or keloid).

Actually, hypertrophic scars are eliminated in one of the following ways:

• excision of the scar and rapprochement of the edges of the wound (with narrow and easily movable scars);
• rassosredototenie rumen (by the method of cutting out one or several pairs of counter triangular flaps of skin according to A. A. Limberg); It is used in cases when the scar causes a displacement of the eyelid, the corner of the mouth, the wing of the nose or in the presence of a "hidden" scar, which is invisible at rest, and when smiling, laughing and eating, becomes visible, acquiring the appearance of vertical folded cords. Keloid scars are eliminated by excision within healthy tissues, cutting off the edges of the wound, applying catgut stitches to the subcutaneous tissue (to reduce tension, which may play a significant role in the development of keloid-relapse) and synthetic filaments on the skin. This operation is possible in the case when the scar is small and the wound that is formed after its excision can be easily eliminated by neighboring tissues. If this fails, the defect of the skin is replaced by a freely transplantable skin flap or Filatov's stalk (the latter is used for extensive scabbard scars that seize its entire front surface).

Table of calculation of tissue growth in relation to the dimensions of the angles of opposing triangular flaps (according to A. A. Limberg)

Angle dimensions	Thirty	45 °	60 °	75 °	90 °
Thirty	1.24	1.34	1.45	1.47	1.50
45 °	1.34	1.47	1.59	1.67	1.73
60 °	1.42	1.59	1.73	1.85	1.93
75 °	1.47	1.67	1.87	1.99	2.10
90 °	1.50	1.73	1.93	2.10	2.24

Since the transplanted skin graft is subjected to dystrophic and necrobiotic changes, and in the Filatov stem as a result of its movement blood and lymphatic circulation is disturbed, it is recommended to saturate the graft and the zone of its transplantation with oxygen in order to create a favorable microclimate for engrafting the graft (oxygen leads to an intensification of oxidative processes in tissues).

Complications of scar treatment

In the days following the operation, suppuration and rejection of the transplant or its necrosis without signs of suppuration are possible . The cause of suppuration may be non-compliance with the requirements of asepsis and antiseptics during surgery, an outbreak of dormant infection nesting in the scars. Therefore, the prevention of suppuration should include careful local and general (increasing resistance) training the patient for surgery.

Necrosis of a transplant can be caused by the following reasons.

• unjustified use of local plastic for very extensive and deep scars (excision of which leads to the formation of a significant defect to be closed by a freely transplanted flap);
• injury to the flap during transplantation, improper preparation of the receiving bed and other technical errors.

Sometimes the old (more than a year) keloid is excised, turning into a young scar, and irradiated with Bucca rays (having a bionegative effect on the uniform elements of the young tissue). Irradiation is performed from 1 to 8 times with an interval of 1.5-2 months (10-15 Gy (gray) per session). First time irradiate on the day of removal of stitches. This method is effective for small keloid scars, but its use does not always prevent the recurrence of keloids.

The choice of the method for the removal of scar tissue and conglomerates in the neck depends on the extent and depth of the skin and the underlying tissue, muscles, and the degree of limitation of mobility of the neck.

When planning operations on the neck with the use of counter triangular flaps of the skin, first of all, determine the amount of shortening along the direction of the rumen, which is equal to the difference between the distance from the chin to the sternum in a healthy and sick person of the same age; on this value it is necessary to obtain elongation along the direction of the rumen. Based on these data and using Table. 9, it is necessary to choose such a form of opposing triangular flaps, the length of the cuts and the angles that will provide the desired elongation.

If there are no vertical shortening of the neck, narrow scars located horizontally should be excised and the wound formed closed by closing its edges. In the case of extensive wounds resulting from excision of wide scars, the stock of transportable skin can be increased by additional incisions in the region of the wound edges. This movement reduces the need for skin transplanted from distant parts of the body.

In some patients with long-lasting extensive burn scars on the face and neck, passing to the front surface of the chest (with sharp deformation of the jaw and other changes), existing and widely used local-plastic methods of treatment on soft tissues can not always be successfully applied. In such cases, it is possible to use skin-muscle grafts on the stalk. Thus, A. A. Kolmakova, S. A. Nersesyants, G.S. Skult (1988), having experience in the use of musculocutaneous flaps with inclusions of the latissimus muscle of the back during reconstruction operations of the maxillofacial area, described the application of this method with positive outcome in a patient with extensive long-term post-burn keloid scars of the face, neck and anterior surface of the chest, combined with a sharp deformation of the jaws and bringing the chin to the chest.

In addition, it is now possible and free transplantation of large musculocutaneous flaps (with the use of microsurgical methods of sewing the ends of the crossed blood supply sources to the vessels of the transplant).

[5], [6], [7], [8], [9], [10], [11], [12]

Outcomes of scar treatment

Provided that all the rules of transplantation and postoperative care are followed, the treatment gives good results in a cosmetic and functional sense.

In concluding this chapter, it should be noted that the problem of the wider use of the fila-stov stalk, its modifications, as well as free skin transplantation with extensive facial defects is described in detail in the works of FM Khitrov (1984) and NM Aleksandrov (1985) .