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 or acquired (as a result of injuries, operations and various diseases: leishmaniasis, lupus erythematosus, syphilis, etc.).

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

Atrophic scars

Atrophic scars are flat, the skin in their area is thinned, gathers into thin folds, not fused with the underlying tissue. Usually the skin in the area of scars is heavily pigmented, which attracts the attention of others and therefore especially worries and depresses patients.

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

Hypertrophic scars

Hypertrophic scars are divided into hypertrophic and keloid. Hypertrophic scars usually look like strands protruding above the skin surface.

These cords are thin rollers covered with folded skin, under which a relatively soft, painless connective tissue base of the scar is palpated. Such cords appear after burns, operations, and smallpox. They are localized in the cheeks, nasolabial folds, and around the mouth. They do not cause significant facial deformations observed with keloids.

Keloid scars

Keloid scars are a type of hypertrophic scars. Some authors quite rightly (from an oncological point of view) consider keloids to be a form of dermatofibroma, since they are distinguished by particularly pronounced hypertrophy of long subcutaneous connective tissue strands located parallel or perpendicular to the skin surface, which causes the cellular structure of the scar.

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

The subpapillary layer consists of a network of connective tissue fibers that have a normal appearance but are 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 main substance.

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

Keloid scars (especially burn scars) that develop over a large area of the face and neck cause physical and mental suffering to patients: they deform the wings of the nose, turn out the lips and eyelids, cause atresia of the nasal passages, and cause contracture of the neck. Patients often feel itching and pain in the area of the scars, which may ulcerate.

Between the individual scar strands, funnel-shaped depressions lined with unchanged skin sometimes form. Here (in men) hair grows, which is difficult to cut or shave; as it grows, it injures and irritates the epidermis above the scars, which sometimes undergoes malignancy.

Post-leishmanial scars

Postleishmanial scars on the face are divided into flat, deforming recessed, deforming tuberous and mixed.

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Classification of cicatricial deformities of the neck

Of undoubted practical interest is the topographic-functional classification of cicatricial deformities of the neck according to A. G. Mamonov (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 impairment 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. When the head is in a normal position, there is no tension on the skin; when the head is moved backward, individual strands and tension on the tissues of the lower part of the face occur. Head movements are slightly limited.
• II degree. In the normal position, the head is slightly tilted forward; the chin angle is smoothed out. It is possible to move the head back to a normal position, but this significantly stretches the soft tissues of the lower part of the face.
• Grade III. The chin is drawn to the chest; head abduction is slight or impossible. The soft tissues of the lower face are displaced by scars and are tense.

Children with long-term contractures may experience deformation of the lower jaw, prognathism, open bite, divergence of the lower frontal teeth, as well as changes in the cervical spine (flattening of the vertebral bodies).

In the horizontal direction:

• I degree. One or more vertically located strands border healthy skin on the sides. By taking the scar in a fold, without forced tension, it is possible to bring the edges of healthy skin together. The width of the scar along the middle collar line does not exceed 5 cm.
• II degree. The width of the scar along the middle collar line is up to 10 cm. It is impossible to bring the edges of the skin together from the lateral sections bordering the scar.
• III degree. The skin on the anterior and lateral surfaces of the neck is cicatricially altered. The width of the scar is from 10 to 20 cm or more. The displacement of healthy skin from the posterolateral parts of the neck forward in the horizontal direction is insignificant. This also includes a rare circular lesion of the skin of the neck.

In order to represent the form of cicatricial deformation of the neck, the degree of functional limitation and anatomical disorders, it is necessary to take the most suitable indicators of skin loss in the vertical and horizontal directions according to this classification and designate them as a fraction (in the numerator - the degree of bringing the chin to the sternum, and in the denominator - the width of the scar along the line encircling the neck).

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Scar treatment

Atrophic scars are treated in the following ways:

1. Excision of the scar, mobilization of the wound edges by separation, bringing them together with blind sutures. As a result of this operation, a shapeless atrophic scar is transformed into a neat postoperative linear scar. This method is indicated for small-area scars, when after their excision it is possible to bring the edges of the wound together without causing eversion of the eyelid or lip, without deforming the wing of the nose or the corner of the mouth.
2. Free skin grafting onto a portion of a wound formed after excision of a scar that cannot be closed by mobilizing and suturing its edges.
3. Deepithelialization of pigmented scar layers using a burr or coarse-grained carborundum stone. The operation is advisable for large flat scars, the removal of which with subsequent replacement with healthy skin is impossible for some reason. In some cases, pigmented areas of the scar can be de-epithelialized using erythemal doses of quartz.

If the scar has a whitish color, it can be "colored" by smearing it with a 10% solution of silver nitrate (or 3-5% solution of potassium permanganate) or by exposing it to ultraviolet radiation. After this, the scar darkens and becomes less noticeable. Treatment of common hypertrophic scars and keloids on the face and neck can be conservative, surgical, or combined. In scars formed at the site of wound healing by primary intention, elastic fibers appear earlier and in greater quantities than in scars at the site of wound healing by secondary intention. In keloid scars, elastic fibers do not appear even 3-5 years after the injury.

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

Acid mucopolysaccharides play an important role in the barrier function of connective tissue, as they have the ability to neutralize toxins and prevent the spread of microorganisms. Their reduction can obviously cause a decrease in the resistance of scar tissue to infection. Therefore, the expediency of early plastic surgery on scars is understandable.

On the other hand, the decrease in the amount of acidic mucopolysaccharides in old scars explains the low efficiency of using enzyme preparations (lidase, ronidase) for therapeutic purposes in such cases, which, as is known, specifically affect acidic mucopolysaccharides, causing profound changes mainly in hyaluronic acid.

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

The use of ultrasound therapy (UZT) for the treatment of young scars reduces the possibility of developing deformation of the lips, cheeks, eyelids, and neck contracture. Ultrasound dissolves scar tissue by splitting bundles of collagen fibers into individual fibrils and separating them from the amorphous cementing substance of connective tissue. For ultrasound treatment, the scarred skin of the face and neck is divided into several fields - each with an area of 150-180 cm ²; 2 fields are simultaneously affected for 4 minutes.

To increase the effectiveness of treatment, before ultrasound therapy, scars are lubricated with hydrocortisone ointment (consisting of 5.0 g of hydrocortisone emulsion, 25.0 g of petroleum jelly and 25.0 g of lanolin).

It is possible to combine ultrasound therapy with heat and mud therapy. When treating cicatricial adhesive processes after cheiloplasty in children, it is recommended to treat the scar area with ultrasound of 0.2 W/cm2 intensity ^for 2-3 minutes; a course of 12 procedures (every other day) (R. I. Mikhailova, S. I. Zheltova, 1976).

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

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

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

When preparing for surgery on scars, it is necessary to take into account how long they have existed, as well as the individual characteristics of the body and the nature of the fibrinoplastic process.

If surgery is planned for a relatively recently developed cicatricial deformation of the face (no more than 6-8 months), it is advisable to undergo a course of treatment with lidase (hyaluronidase) to soften the scars. Lidazotherapy is especially effective in the first 4-6 months of scar development, when their tissue contains a lot of acidic mucopolysaccharides.

Preparation of keloid scars for surgery with enzyme preparations is carried out as follows:

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

Vacuum therapy of scars on the face and neck gives good results: after just 2-3 procedures, patients experience no more unpleasant sensations in the scar area (pain, feeling of tension), they become softer and their color approaches that of the surrounding skin.

After the use of vacuum therapy of scars, the scope of surgical intervention is reduced, and postoperative healing occurs by primary intention, despite the fact that the operation is performed in the area of scar tissue. This is explained by the fact that vacuum therapy improves trophism in the scar area of the face or neck.

In the presence of “young” postoperative keloid or burn scars, a course of treatment with pyrogenal can be carried out in preparation for surgery (old scars are not amenable to this treatment).

Preoperative preparation of keloid scars should be carried out especially vigorously and persistently. If treatment with pyrogenal does not lead to the desired results, X-ray therapy is used, and the total dose should not exceed 10,000 R (roentgen) or 2,600 tC/kg (millicoulomb per kilogram). If irradiation with a total dose of 8,000 R (2,064 tC/kg) does not produce a therapeutic effect, it should be stopped.

It is important to follow a certain irradiation rhythm (depending on the dose). If the scars are located in the upper part of the face, the smallest number of irradiations (2-5) with a total dose of 4848 R (1250.7 mK/kg) can be used. If the scars are in the middle part, the total irradiation dose should be increased from 2175 to 8490 R (from 516 to 2190 mK/kg), and in the lower part and on the neck - from 3250 to 10,540 R (from 839 to 2203 mK/kg).

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

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

• excision of the scar and bringing the edges of the wound closer together (for narrow and easily movable scars);
• scar dispersal (by cutting out one or more pairs of opposing triangular flaps of skin according to A. A. Limberg); used in cases where a scar causes a displacement of the eyelid, corner of the mouth, wing of the nose, or in the presence of a "hidden" scar, which is not noticeable at rest, but becomes noticeable when smiling, laughing, or eating, taking on the appearance of vertical folded strands. Keloid scars are removed by excision within healthy tissue, separation of the wound edges, application of catgut sutures to the subcutaneous tissue (to reduce tension, which may play a significant role in the development of a recurrent keloid), and sutures of synthetic threads to the skin. Such an operation is possible in cases where the scar is small and the wound formed after its excision can be easily eliminated at the expense of adjacent tissues. If this fails, the skin defect is replaced with a freely transplanted skin flap or a Filatov stem (the latter is used for extensive scars that cover the entire anterior surface).

Table for calculating tissue growth depending on the sizes of the angles of the opposing triangular flaps (according to A. A. Limberg)

Angle dimensions	30°	45°	60°	75°	90°
30°	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 a freely transplanted skin graft is subject to dystrophic and necrobiotic changes, and in the Filatov stem, as a result of its movement, blood and lymph circulation is disrupted, it is recommended to saturate the graft and the area of its transplantation with oxygen in order to create a favorable microclimate for the engraftment of the graft (oxygen leads to increased 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 antisepsis during the operation, an outbreak of a dormant infection nesting in the scars. Therefore, prevention of suppuration should include careful local and general (increasing resistance) preparation of the patient for the operation.

Graft necrosis may be caused by the following reasons.

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

Sometimes an old (more than a year old) keloid is excised, turning it into a young scar, and irradiated with Bucky rays (which have a bio-negative effect on the formed elements of young tissue). Irradiation is performed from 1 to 8 times with an interval of 1.5-2 months (10-15 Gy (gray) per session). The first time is irradiated on the day of removing the stitches. This method is effective for small keloid scars, but its use does not always prevent keloid recurrence.

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

When planning operations on the neck using counter triangular flaps of skin, it is necessary first of all to determine the amount of shortening in the direction of the scar, which is equal to the difference in the distance from the chin to the sternum in a healthy and sick person of the same age; it is necessary to obtain an elongation in the direction of the scar by this amount. Based on these data and using Table 9, it is necessary to select the form of counter triangular flaps, the length of the incisions and the size of the angles that will provide the necessary elongation.

If there is no vertical shortening of the neck, then narrow horizontal scars should be excised, and the resulting wound should be closed by bringing its edges together. In the case of extensive wounds that form after excision of wide scars, the supply of relocatable skin can be increased by making additional incisions in the area of the wound edges. Such relocation reduces the need for skin transplanted from distant areas of the body.

In some patients with long-standing extensive burn scars on the face and neck, extending to the anterior surface of the chest (with sharp deformation of the jaws and other changes), existing and widely used local plastic methods of treatment on soft tissues cannot always be applied successfully. In such cases, it is possible to use skin-muscle flaps on a pedicle. Thus, A. A. Kolmakova, S. A. Nersesyants, G. S. Skult (1988), having experience in using skin-muscle flaps with inclusions of the latissimus dorsi muscle in reconstructive surgeries of the maxillofacial region, described the use of such a method with a positive outcome in a patient with extensive long-standing post-burn keloid scars of the face, neck and anterior surface of the chest, combined with sharp deformation of the jaws and bringing the chin to the chest.

In addition, free transplantation of large skin-muscle flaps is now possible (using microsurgical methods of suturing the ends of the intersected blood supply sources with the transplant vessels).

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Scar treatment outcomes

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

In conclusion of this chapter, it should be noted that the problem of wider use of the Filatov stem, its modifications, as well as free skin grafting for extensive facial defects is covered in detail in the works of F. M. Khitrov (1984) and N. M. Aleksandrov (1985).