Nonsurgical Scar Management and Camouflage Techniques

Abstract

Scarring is an inevitable consequence of the natural healing process that occurs when the skin repairs itself following wounding. The scar initially appears red and raised but will usually fade over time. In many patients it will flatten, as it matures over a 12- to 24-month period. Patients therefore need to be advised of this long process and must maintain a high degree of patience and motivation. Unfortunately, in some patients, as the scar matures, it can become highly visible, especially if it is not managed appropriately. However, timely and appropriate care can minimise its appearance and the stigma that comes with scarring (especially when they occur on the face). The use of cosmetics has long been a useful adjunct to scar treatment. In recent years, technical advancements in the chemistry and composition of cosmetic products have provided patients with a broader range of products for concealing scars. It is our responsibility to help and advise patients, so they can cope with their concerns.

1 Introduction

Scarring is an inevitable consequence of the natural healing process that occurs when the skin repairs itself following wounding. The scar initially appears red and raised but will usually fade over time. In many patients it will flatten, as it matures over a 12- to 24-month period. Patients therefore need to be advised of this long process and must maintain a high degree of patience and motivation. Unfortunately, in some patients, as the scar matures, it can become highly visible, especially if it is not managed appropriately. However, timely and appropriate care can minimise its appearance and the stigma that comes with scarring (especially when they occur on the face). The use of cosmetics has long been a useful adjunct to scar treatment. In recent years, technical advancements in the chemistry and composition of cosmetic products have provided patients with a broader range of products for concealing scars. It is our responsibility to help and advise patients, so they can cope with their concerns.

Management of scars is usually a staged process that includes:

• Preparation of the skin (hygienic measures)

• Scar softening, sometimes with steroids

• Massage and pressure dressings

These processes may be required a 1- to 2-year period and need regular follow-up. Many factors affect the final result, but the two most important factors that the surgeon must endeavour to control are patient preparation (including skin health) and patient compliance throughout treatment. Keloids are particularly challenging to treat, and patients must understand that the final result will usually be a compromise. New grafting techniques, such as cultured autogenous dermal grafts, may offer improved results in the future.

2 Initial Scar Management

Scar management is often multidisciplinary, using integrated and innovative ways of caring for patients. There are now a number of management options available during the initial phase of wound healing, which can reduce the risks of developing unwanted or abnormal scarring and its subsequent visibility. When this management is commenced at an early stage, the risk of developing abnormal scarring or functional restriction is reduced. Ideally, patients should receive seamless, coordinated care and support following referral by the surgical team soon after wound repair.

2.1 Noninvasive Treatments

2.1.1 Massage and Moisturiser

These are used to help soften and reduce the stiffness and ‘leathery feel’ to a scar, which occurs when a wound starts to mature. This results in the scar flattening. Massaging the area affected also helps to desensitise the skin, which helps prevent discomfort. Areas of numbness may also improve (as a result of ‘collateral macrosprouting’). Depending on the technique used, massaging by rubbing is performed using a nonperfumed moisturiser (Fig. 49.1). The use of moisturiser in this technique not only helps to hydrate the scar but also helps prevent abrasion during the massage period. Massage is not needed in every patient. If a scar is already soft and flat, it should be kept to a minimum; otherwise the scar may stretch. Regular review is therefore advisable.

The ‘pull and roll’ massage technique is done without the use of a moisturiser to allow the patient to hold onto the scar firmly whilst rolling. It is recommended to start massaging the scar once the wound has healed, at least three to five times daily for 3 to 5 minutes each episode. Many patients initially complain of sensitivity to the scar. Hence it is advisable to start massaging the area gently to help desensitise the affected scar.

Fig. 49.1

Nonperfumed moisturisers come in many forms

2.1.2 Sunscreen

Use of sunscreen not only protects the skin but will help reduce and prevent the new scar from becoming darker in colour once it matures. The use of sunscreen SPF50 is often suggested. If used in conjunction with camouflage, then an oil-free-based sunscreen is recommended (Fig. 49.2).

Fig. 49.2

Sunscreens

2.1.3 Pressure Dressings/Garments

The use of pressure garments also helps reduce hypertrophic scarring at the initial phase of wound healing. These should be applied until the scar matures.

2.1.4 Silicone Gel

Silicone gel is a medically graded gel or dressing, which helps hydrate the scar. This is only applied when the wound is closed. Patients are advised to apply at least twice daily for 3–6 months before they see any benefits.

2.2 Camouflage

Camouflage is the application of makeup creams and/or powders to conceal colour or contour irregularities or other abnormalities. It has wide usage both in trauma and other skin conditions (e.g. telangiectasia, vitiligo, acne, tattoos). Creams were first developed during World War II to cover the massive burns received by fighter pilots. Nowadays, they help with colour match in the management of scars. Camouflage is a noninvasive, easy and effective method of concealing depigmentation following surgery, burns or trauma. This specific treatment is a very useful tool in the patient’s road to recovery from the early stages of injury. Camouflage will not change the form or texture of the scar, but it will help to disguise pigmentation and make the scar less noticeable.

Water-resistant camouflage products come in the form of creams and a powder which are readily available privately or by prescription. They require careful skin matching by a trained camouflage practitioner. These products are designed to last longer than an ordinary concealer, provided they are used appropriately. They also contain sun protection and can be used in conjunction with other oil-free-based makeup or sunscreen products. In some countries they are also available in liquid spray form. It is important that camouflage practitioners are aware of what and what not to camouflage, especially in relation to skin lesions or poorly healing wounds. Diagnosis from the medical team should be sought prior to camouflaging the skin pigmentations (Box 49.1).

Box 49.1 Contraindications to Camouflage

Bacterial, fungal, viral infections

Infestations

Insect and animal bites

Skin cancers (including suspicious lesions and moles)

Occupational and contact dermatitis

Open wounds

Sutures

Undiagnosed rashes and skin conditions

Communicable diseases which present on the skin (such as chicken pox)

Camouflage treatment at an early stage is only possible once the skin is intact. Otherwise there is a risk of infection. Products used are formulated so that they will help to disguise any swelling, bruising, lesions and incision lines following trauma or surgery, until the scarring fades. Most of today’s products are water resistant due to their wax-oil ingredients. This means patients can continue with sporting activities such as swimming, whilst wearing the camouflage. With due care, camouflage can last 8–12 hours on the face before the need to reapply.

These cosmetics work in two ways:

• 1. By using ‘colour theory’ to reduce the appearance of a scar and

• 2. By concealing the scar using a layer of foundation or camouflage makeup.

2.3 Colour Theory

The principle behind colour theory is that it is possible to tone down a particular colour by covering it with its opposite shade. Cosmetics are thus available in shades that neutralise common undesirable colours. For example, if a scar has a reddish hue to it, this can be reduced by applying a green concealer. For blue or purple discolouration (seen in bruising), a yellow concealer will help. Brown tones can be lessened by white concealers and yellow tones with lavender-coloured concealers. Highlights and shadows can also be hidden using darker and lighter shades of concealer—a shade of makeup that is darker than the surrounding skin can appear to reduce the height of a raised scar. A shade that is lighter will make a depression look smaller. Some concealers now have added sunscreen and are hypoallergenic.

2.4 Foundation

The aim of foundation is to smooth and even out the skin’s texture and tone. Foundation should match the skin tone. Choosing a foundation depends on the patient’s skin type and the level of opacity needed. Four basic foundation types are available:

• 1. Oil-based foundations are better for dry skin.

• 2. Oil-free work is best for oily skin.

• 3. Water-based foundations suit all skin types.

• 4. Water-free is specially formulated to be very long-lasting and is used only when complete and total coverage is required.

Foundation is applied using a ‘dab and blend’ technique, rather than wiping it on with a sponge. If a good foundation is blended well, there should not be any visible lines of demarcation on the face. For minor imperfections, a regular foundation will usually do the job. But for greater coverage, anhydrous foundations, created with a waxy base, are available. Because they are waterproof, they will need a special cream to be removed.

Once these have been applied, colour can then be added via blushers, lipsticks and eyeshadows (Box 49.2) (Figs. 49.3 and 49.4).

Fig. 49.3

Some of the products available

Fig. 49.4

Some of the products available

Box 49.2 Application of Camouflage

Skin Preparation:

• (a) The skin should be clean and dry.

• (b) Apply oil-free moisturiser, sun block or rose water if required to affected area.

Application of Camouflage:

• (a) Take a small amount of camouflage cream from the pot to your clean hand to soften the cream.

• (b) Apply camouflage cream as demonstrated with fingers (press and roll technique), sponge or brush if necessary. Wait for few minutes to settle.

• (c) Buff with fixing powder and wait to set for at least 5 minutes.

• (d) Remove chalky residue or excess powder with brush, and then blot over with a damp sponge flannel to set and waterproof the application.

• (e) Repeat procedure a–d if necessary.

• (f) It is recommended that you apply fixing spray onto large areas camouflaged.

Removal of Camouflage:

• (a) Use cleansing cream, unscented baby wipes or baby lotion by gently massaging the area with fingers in circular motion. This will help loosen the camouflage cream.

• (b) Gently wipe off with damp flannel or cotton wool pads until the area is clean.

• (c) Do not use tissue paper to the face as this can be coarse and can affect the skin.

• (d) Make sure to dry the area by patting with dry soft cloth after a bath, shower or swimming.

Note:

• Oil-free sun protector or oil-free makeup can be applied over the already camouflaged area.

• Precaution must be observed during application of sun protector or makeup so that camouflage is not disturbed.

2.5 Case Examples

The following cases demonstrate the scope and the efficacy of scar camouflage—contour defects are important however—and may prove difficult to conceal (Figs. 49.5, 49.6, 49.7, 49.8, 49.9, 49.10, 49.11, 49.12, 49.13).

Fig. 49.5

(a, b) Scarring and bruising 2 days post-manipulation under anaesthesia (MUA) of fractured nose

Fig. 49.6

(a–c) Traumatic scars followed by surgery then camouflage treatment—note that the contour defects are difficult to conceal

Fig. 49.7

(a, b) Scar after glass injury and then followed by camouflage treatment

Fig. 49.8

(a, b) Atrophic scar—these are possible to conceal well

Fig. 49.9

(a, b) Hyperpigmentation. These are surprisingly easy to conceal

Fig. 49.10

(a, b) Eyebrow scarring with skin graft before and after. Different parts of the scarred area may need to be managed by different camouflage techniques

Fig. 49.11

(a, b) Hypopigmentation. In contrast, hypopigmentation is more straightforward to manage

Fig. 49.12

(a–c) A small injury that developed into a keloid scar. These photos show pre- and post-triamcinolone injection followed by camouflage therapy

Fig. 49.13

(a, b) The difference between a keloid and hypertrophic scar can be difficult to quantify on occasion, particularly with large injuries. This lesion responded well to steroid injections—note the telangiectasias

3 Invasive Treatment

A scar that has matured and continues to show signs and symptoms of growth can be treated with triamcinolone. This may need to be injected regularly every 6 to 8 weeks. A course of treatment is equivalent to six episodes of injection; regular assessment by the doctors is required prior to further treatment.

3.1 Dermabrasion and Laser

These are invasive treatments, where the top layer of skin is removed, along with any pigmentation, tattooing or superficial scarring. A new layer of healthy dermis is then allowed to cover the defect. This is sometimes performed 6 to 9 weeks following injury or months to years later when other treatments have failed. Case selection is important. Laser resurfacing is now a popular alternative to dermabrasion but requires expensive equipment and specialist training. However, it provides more control over the depth of tissue destruction and is quicker to do. Infection risk is lower, as dermabrasion can produce an aerosol of the patient’s blood/fluids.