Facial scar revision — Techniques, dermabrasion and lasers
When and how to revise a facial scar: analysis, timing, excisional and irregularisation techniques, step-by-step dermabrasion — including use of the dental motor and bur selection — and which laser is indicated for each scar type.
Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.
Key points
- The goal is camouflage, not erasure. A scar cannot be completely removed, and the patient must know this before consenting.
- The first question is not which technique but when: most scars improve on their own over the first year of maturation.
- What does not improve with time — landmark malalignment and orientation perpendicular to the tension lines — justifies earlier intervention.
- Dermabrasion gives the best return for its simplicity: it levels, changes texture and blends the scar into surrounding skin. It can be done with a dental motor and diamond burs.
- There is no single laser: each target demands a different wavelength. Erythema and bulk respond to pulsed dye; texture to ablative fractional; pigment to Q-switched devices.
What depends on us and what does not
The final appearance of a scar depends on its orientation, the amount of tissue lost, its location on the face, the patient’s age, underlying health, genetic predisposition to poor healing, the closure technique and the occurrence of healing complications. It helps to split them into two columns: position, tissue loss, age, genetics and health are beyond the surgeon’s control; closure technique and complication prevention are not. That is where much of the result is decided, which is why the best scar revision is the one that never becomes necessary.
What to do at the first repair to avoid revising later
- Clean wound: remove foreign bodies and irrigate with sterile saline, which demonstrably lowers bacterial counts.
- Conservative debridement: only what is clearly devitalised. In burns it is hard to know early which tissue is viable, and what is removed does not come back.
- Do not reorient the wound at the outset. Irregularities help camouflage, and neighbouring tissue is worth preserving in case a second stage is needed.
- Layered closure if the injury goes beyond subcutaneous tissue, with gentle undermining if needed to appose without tension: tension is what widens and hypertrophies.
- Moist environment: antibiotic ointment or occlusive dressing over the wound surface.
The ideal scar and those that ask for revision
The ideal scar is narrow, flat, level with the surrounding skin and colour-matched. It sits within or parallel to the relaxed skin tension lines and, when possible, at a junction between aesthetic subunits. It neither tents nor bunches the adjacent skin. From there the indication for revision follows by exclusion: hypertrophic, widened, depressed, perpendicular to the tension lines, webbed, trap-door, malaligning a landmark — brow, vermilion, alar rim — or interfering with function. One case deserves separate mention: a narrow, well-oriented but hypertrophic scar may respond to intralesional triamcinolone alone, without surgery.
An examination step that gets forgotten
Before planning anything, look at all the patient’s old scars, not only the one they came about. A tendency to hypertrophy or keloid is usually written on previous wounds — a caesarean, an appendicectomy, a piercing — and detecting it changes the plan: the timing, whether steroid or pressure is added from the start, and sometimes the answer itself, which may be not to operate.
Timing: wait the year, with exceptions
All scars tend to improve spontaneously after a maturation period of about a year. The patient almost always wants it sooner, so the criterion comes from the scar’s features, not from impatience. If it is recent, narrow, flat, within the tension lines and merely erythematous, it is better reassessed once mature: the erythema fades by itself. If it has clearly unfavourable features — above all landmark malalignment, which does not correct with time — early revision does pay off. And there is a third group: minor revisions, dermabrasion and laser, which can be done as early as 8 weeks after the initial repair.
Why early dermabrasion makes sense
There are two arguments and they deserve separating. The first is theoretical: at 8 weeks fibroblast activity is still high and remodelling might exploit it. The second is practical and more solid: at that point the scar is still erythematous, and dermabrasion itself produces significant transient erythema. Doing it early overlaps the two red periods instead of chaining them, so the patient spends less total time with a red face.
Decision algorithm for a scar
Is it hypertrophic or a keloid?
Is it depressed or contracted?
Is it malpositioned, or does it malalign a landmark?
How long and how wide is it?
Excisional techniques: reposition, excise, excise in stages
Repositioning takes advantage of the fact that many scars lie close to a place where they would show less. The classic example is the visible preauricular scar after a facelift or parotidectomy, which can often be brought next to the tragus and disappears. Simple fusiform excision is ideal for short or small-diameter scars; the angles should be between 30 and 60 degrees, since above 60 a standing cone appears that requires an M-plasty or extension of the wound. And if the end of the spindle threatens to invade another aesthetic unit, an M-plasty shortens the ellipse without sacrificing the closure.
Serial excision: how it is chained
- WhenWhen the scar or lesion is too large to close in one stage: graft-covered scars and burn sequelae
- First stageIncision within the scar, at one margin. Undermine the edges, excise a portion after advancement and close
- Interval8 to 12 weeks, the time the skin needs to stretch. Repeat with the incision again inside the scar border
- Final stageExcise the remaining scar and appose normal skin to normal skin: in a straight line, W-plasty or broken line
- How far it goesThe skin’s ability to stretch is enormous: defects covering up to half the forehead have been serially excised
The three ways to irregularise a scar
| Technique | What it does | When to choose it |
|---|---|---|
| Z-plasty | Irregularises and lengthens. Transposes two triangles around the scar, which acts as the central member; the new orientation is perpendicular to the original | Contracted scar, web, trap-door. It is the only one that adds length |
| W-plasty | Irregularises without lengthening. Excises successive triangles on both sides and advances each into its opposing defect; there is no transposition | Scar perpendicular to the tension lines, of moderate length. In long scars it is inferior to broken line closure |
| Geometric broken line closure | A series of randomly alternating triangles, rectangles, trapezoids, semicircles and squares on one edge, and their mirror image on the other | Long scar crossing an aesthetic unit, such as the cheek. The eye cannot follow a pattern that does not repeat |
Numbers worth memorising
- Z-plasty: 30° angles lengthen by 25 %, 45° by 50 % and 60° by 75 %. These are theoretical figures, but they order the choice.
- The Z limbs should be under 1 cm so that the Z itself is camouflaged.
- In broken line closure, the limbs should be under 6 mm: above that the eye follows them.
- Unequal-angle Z-plasty: the smaller-angle flap rotates more, and serves to bring tissue into a deficient area.
- Z-plasty lengthens: anticipate in which direction. A Z on a vertical forehead scar near the brow can end up displacing the brow.
Dermabrasion: what it actually does
Dermabrasion removes the epidermis and part of the papillary dermis, and the surface re-epithelialises from the surrounding epithelium and from the adnexa — follicles and sebaceous glands — remaining in the dermis. That is why one cannot go down indefinitely: destroy the adnexa and there is nothing left to re-epithelialise from. The effect on the scar is threefold: it levels relief, changes texture and blends the edge into adjacent skin. And there is an added biological effect: controlled injury to the papillary dermis induces neocollagen and reorientation of the fibres.
How to tell what depth I am at
| Plane | What is seen | What it means |
|---|---|---|
| Epidermis | Whitish surface, no bleeding | Still not enough. Continue |
| Papillary dermis | Pinpoint bleeding, in fine even dots | The classic landmark and the minimum target |
| Superficial reticular dermis | More confluent bleeding and parallel chamois-coloured collagen fibres | The ideal depth for a scar. Stop here |
| Deep reticular dermis | Frayed white fibres | Too far. Beyond this point it scars and depigments |
Dermabrasion step by step
- BeforeLocal anaesthetic or block; for a full face, tumescent, sedation or general. Ophthalmologically safe antiseptic. Mask and face shield for the whole team: the aerosol is blood
- Mark and stretchMark the area. The skin must be held taut and firm by an assistant: on lax skin the bur skips and depth control is lost
- DirectionMove the handpiece perpendicular to the direction of bur rotation: that gives the most control. Over the scar, apply it perpendicular and oblique to its axis
- StrokeDiamond bur: back and forth. Wire brush: one direction only. Treat one subunit at a time and feather the edges
- StopWhen confluent pinpoint bleeding and chamois-coloured fibres appear. Never down to frayed white fibres
- AfterSaline gauze, occlusive ointment and daily dressing. Re-epithelialisation takes 1 to 2 weeks; erythema, up to two months
Which tip to use and at what speed
| Tip | How it injures | Speed and use |
|---|---|---|
| Fine diamond fraise | Friction from diamond microparticles. Very controllable | Small areas, delicate skin and superficial scars. The tip to start with |
| Coarse diamond fraise | Same, with larger grit: removes more per pass | Deep scars and full face. Avoid on the eyelid and nasal ala |
| Wire brush | Microlacerations, not friction. 2-3 mm wires that penetrate with minimal pressure | More aggressive and less forgiving. Do not exceed 25,000 rpm. Not the tip to begin with |
| Sterile sandpaper or abrasive mesh | Manual abrasion, wrapped around a finger or a syringe | No motor. For spot touch-ups and to feather the border between treated and untreated skin |
The dental motor as a dermabrader
The dental surgical micromotor works, and in maxillofacial surgery it is already in theatre. Three points. First: diamond burs, not tungsten carbide. Carbide burs cut, diamond burs abrade; using a cutting bur on skin is precisely the mistake to avoid. Second: the speed is far lower than on a classic dermabrader — fine abrasion with a diamond bur has been described at 2,000-3,000 rpm, against the usual 12,000-15,000 rpm of a dedicated dermabrader — and with less speed more pressure is needed, which is where control is lost if one rushes. Third: choose the shape to suit the lesion — cone, cylinder, bullet, pear, wheel — because that is exactly the advantage: more shapes and sizes are available, they are cheap and autoclavable, allowing small or awkwardly contoured areas to be treated without invading surrounding healthy skin.
Mistakes that cost dearly
Keep sponges and gauze away from the running bur: if gauze catches, it winds onto the shaft and drags the skin with it. Thin skin, fine bur or nothing at all: in the periorbital region coarse or wire tips carry a real risk of deep or full-thickness abrasion. Take care in areas of lax skin: eyelid, lip and nasal ala, where it cannot be held taut. And skin refrigerants are no longer used in most practices since freon was banned, so firmness must come from traction, not from freezing.
Who not to abrade, and how to prepare the rest
- Active herpes simplex: contraindication. It must have been dormant 6-8 weeks. With a history, antiviral prophylaxis from 2 days before to 2 weeks after; some give it to every patient.
- Isotretinoin: classically a one-year interval was required before deep mechanical dermabrasion, because of pilosebaceous atrophy and risk of atypical scarring. The 2017 systematic review with consensus relaxed the criterion and accepts that manual abrasion or microdermabrasion may be safe; decide case by case.
- Phototype: safest in Fitzpatrick I and II. From III upwards the risk of hyper- and hypopigmentation rises, and must be weighed against expected benefit.
- Skin preparation: strict photoprotection for two months before, 4 % hydroquinone for 2-4 weeks to reduce dyschromia, and a topical retinoid from a month before to speed re-epithelialisation.
- Active acne: relative contraindication, because of postoperative infection risk.
Which laser for which problem
| Problem | Laser | Why |
|---|---|---|
| Red, hypertrophic, itching or burning scar | Pulsed dye (585-595 nm) | Vascular target: it reduces erythema and also thickness, and relieves itching and burning. It can be started early |
| Hyperpigmented or dark scar | Q-switched | Melanin target: it fragments pigment without ablating the surface |
| Irregular texture, relief, depressed scar | CO₂ or erbium, today mostly in fractional mode | Ablative resurfacing. It is credited with greater collagen reorganisation than mechanical abrasion; scanner patterns allow selective ablation around a depression to level it |
| Extensive hypertrophic burn scar | Combination of pulsed dye and ablative fractional | Recent systematic reviews find both work equivalently alone, and that the combination achieves the greatest effect size in fewer sessions |
Laser or dermabrasion: the deciding nuance
The argument for the laser is collagen reorganisation. The argument against is thermal damage: it adds a variable that makes depth of penetration less predictable than in mechanical abrasion, where depth is read directly from the colour of the bed. Scanner technology has made results considerably more consistent, but the nuance still holds, and explains why dermabrasion has not disappeared: in experienced hands, a bed you can read is more reliable than a parameter you program.
Fillers: what they add and what they do not
Dermal fillers — hyaluronic acid, collagen — elevate a depressed scar when injected beneath it. Their virtue is being immediate and reversible; their limit is being temporary: the effect lasts on the order of 2 to 6 months. They work well as a diagnostic test — showing the patient what the corrected defect would look like — and as maintenance, but they do not replace a dermal fat graft when stable volume is what is needed. The dermal fat graft, harvested from the abdomen or supraclavicular region, gives better longevity and predictability than free fat grafting alone, and can be placed with or without excising the overlying scar.
Postoperative care and surveillance
- First weekAntibiotic ointment on the suture line or abraded surface. After laser, an occlusive or semiocclusive dressing — the ointment or petrolatum itself will do
- Suture removalAt one week, unless healing is compromised
- 48-72 hoursWatch for infection: honey-coloured crust suggests staphylococcus; disproportionate pain, herpes
- Day 5-7Delayed healing with exudate, oedema or itching: think Candida
- Day 10Persistent granulation tissue = red flag. Look for infection, contact dermatitis or a systemic cause
- Following weeksIf signs of hypertrophy appear: intradermal triamcinolone 10 mg/mL, mechanical pressure or silicone gel sheeting. Early laser also helps
The sequence that pays best
Dermabrasion does not compete with surgery: it completes it. The highest-yield scheme is to perform the reorienting or irregularising revision first — Z-plasty, W-plasty, broken line closure — and add dermabrasion at 8 weeks as a second stage, to level residual relief and blend the edges. Planning it from the outset as part of the strategy, rather than as a rescue when the result disappoints, changes considerably what can be offered.
References
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- 3.Bedford L, Hemmerich C, Daveluy S. Skin resurfacing dermabrasion. StatPearls. Treasure Island: StatPearls Publishing; 2023.
- 4.Gupta S, Jangra RS, Gupta S, Mahendra A. Precision dermabrasion of small areas of vitiliginous skin using dental diamond burs. J Cutan Aesthet Surg. 2021;14(2):220-222.
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Related specialty: Complex Facial Reconstruction