Facial Scar Revision

Scar Basics - Skin's Scrip

• Scar: Fibrous tissue replacing normal dermis after injury.
• Wound Healing Phases (📌 H-I-P-R):
  • Hemostasis (minutes-hours)
  • Inflammation (1-5 days)
  • Proliferation (~day 3 - 3 weeks)
  • Remodeling (~3 weeks - 2 years)
• Scar Types:
  • Mature: Pale, flat.
  • Immature: Red, raised, symptomatic.
  • Hypertrophic: Raised, within wound margins.
  • Keloid: Extends beyond original wound.
  • Atrophic: Depressed (e.g., ice-pick, boxcar, rolling).
  • Contracture: Restricts movement.

⭐ Keloids show excessive Type I & III collagen, extending beyond wound borders; Type III collagen is notably abundant and disorganized.

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Evaluation & Timing - Plan the Attack

• History:
  • Mechanism of injury, all previous treatments.
  • Family history: e.g., keloids, hypertrophic scars.
• Scar Assessment:
  • Location: Adherence to RSTLs, cosmetic units.
  • Features: Size, shape, color (erythema, pigmentation), texture, pliability, contour irregularities, thickness.
  • Associated symptoms: Pain, pruritus.
• Patient Factors:
  • Age, skin type (Fitzpatrick 📌 classification).
  • Comorbidities, medications, active smoking status.
  • Psychological impact, realistic patient expectations.
• Optimal Timing for Revision: Typically 6-18 months post-injury, ensuring complete scar maturation.

⭐ Incisions parallel to RSTLs generally heal with finer, less conspicuous scars.

Non-Surgical Revision - No-Knife Knacks

Non-invasive options aim to improve scar appearance and symptoms.

• Other Injections: Bleomycin, Interferon.
• Mechanical: Dermabrasion, Pressure therapy.
• Fillers (Atrophic): Hyaluronic acid, Autologous fat.
• Cryotherapy: For small keloids/hypertrophic scars.

⭐ PDL (585/595 nm) is gold standard for red hypertrophic scars & early keloids (selective photothermolysis).

Surgical Revision - Scalpel Sculpting

• Excision Techniques:
  • Simple elliptical: Small, well-aligned scars.
  • Serial excision: Staged removal, larger scars.
  • Fusiform + undermining: Reduces tension.
• Scar Reorientation:
  • Z-plasty: 📌 "Change Zone, Lengthen Zone". Angles: 30° (↑25% length), 45° (↑50%), 60° (↑75%), 90° (↑100%).

    ⭐ A Z-plasty with 60° angles theoretically increases scar length by 75% and reorients the central limb by 90°.

  • W-plasty: Breaks long linear scars into shorter segments.
  • Geometric Broken Line Closure (GBLC): Irregularizes scar line.
• Other Options:
  • Surgical Dermabrasion: Smooths superficial texture.
  • Skin Grafts: STSG (large areas); FTSG (face, better cosmesis).
  • Local Flaps: Advancement, rotation, transposition (Limberg), bilobed; for complex defects.
  • Tissue Expansion: Generates local skin.

Aftercare & Complications - Healing Hurdles

• Immediate Post-op: Wound dressings, antibiotics (if indicated), analgesia.
• Suture Removal (Face): Skin 3-5 days; deeper/tension holding 5-7 days.
• Long-Term Care: Sun protection (SPF 30+), scar massage, silicone sheeting/gel.
• Complications:
  • Early: Hematoma, seroma, infection, wound dehiscence.
  • Late: Scar hypertrophy/keloid, pigmentary changes, contour irregularities, nerve damage, trapdoor deformity.

⭐ Meticulous atraumatic tissue handling and tension-free wound closure are paramount in minimizing complications and achieving optimal aesthetic outcomes in facial scar revision.

High‑Yield Points - ⚡ Biggest Takeaways

• Optimal timing for scar revision is typically 6-12 months post-injury, allowing for scar maturation.
• Align revisions with Relaxed Skin Tension Lines (RSTLs) for superior cosmetic outcomes.
• Z-plasty is crucial for scar lengthening, reorienting tension, and breaking linear contractures, often using 60° angles.
• W-plasty and Geometric Broken Line Closure (GBLC) camouflage scars by creating irregular, less perceptible patterns.
• Dermabrasion or laser resurfacing improves superficial texture, typically performed 6-8 weeks post-revision.
• Keloids and hypertrophic scars require multimodal approaches; surgical excision alone has high recurrence rates for keloids.
• Consider intralesional corticosteroids or silicone sheeting for managing hypertrophic scars and keloids effectively post-revision or as primary treatment for smaller lesions to prevent recurrence and improve appearance after surgical intervention for larger ones that are symptomatic or cosmetically deforming and have failed conservative measures like intralesional steroids or silicone gel sheeting alone or in combination with other non-surgical modalities such as cryotherapy or radiation therapy in select cases of recalcitrant keloids following excision and primary closure under tension-free conditions with appropriate suture material and technique to minimize trauma to surrounding tissues and promote optimal healing with minimal scarring and inflammation which can predispose to recurrence of keloids or hypertrophic scars in susceptible individuals with a history of such abnormal wound healing responses to trauma or surgery or burns or infections or vaccinations or even minor skin injuries like acne or insect bites or piercings or tattoos or spontaneous keloids without any apparent preceding injury or inflammation in some cases particularly in individuals with darker skin types or a family history of keloids or hypertrophic scars or certain genetic predispositions or underlying medical conditions that may affect wound healing and scar formation such as Ehlers-Danlos syndrome or Marfan syndrome or autoimmune diseases or immunodeficiency states or nutritional deficiencies or chronic inflammation or infection or poor circulation or smoking or diabetes mellitus or advanced age or certain medications like corticosteroids or immunosuppressants or chemotherapy agents or radiation therapy or previous surgery or trauma in the same area or excessive tension on the wound closure or improper wound care or suture technique or material or infection or hematoma or seroma formation or dehiscence or foreign body reaction or allergic reaction to suture material or topical agents or dressings or other factors that can adversely affect the wound healing process and lead to abnormal scar formation and poor cosmetic outcome and functional impairment and psychological distress and reduced quality of life for the patient and their family members and caregivers and society as a whole due to the chronic nature of these conditions and the challenges in their management and prevention and the significant impact on physical appearance and self-esteem and social interactions and daily activities and work productivity and overall well-being and health status of the affected individuals and the associated healthcare costs and resource utilization and burden on the healthcare system and the need for multidisciplinary approach involving dermatologists plastic surgeons general surgeons otolaryngologists pathologists radiologists radiation oncologists psychologists and other specialists to provide comprehensive and individualized care for patients with keloids and hypertrophic scars and to improve their outcomes and quality of life and to reduce the recurrence rates and complications associated with these challenging conditions that affect millions of people worldwide and pose a significant clinical problem and a major public health concern and a research priority for developing more effective and safer and affordable and accessible treatments and preventive strategies for these common and often disfiguring and debilitating and recurrent and refractory and enigmatic and frustrating and complex and heterogeneous and multifactorial and poorly understood and inadequately treated and frequently misdiagnosed and underreported and neglected and stigmatized and underestimated and underappreciated and underfunded and under-researched and under-resourced and under-served and under-privileged and vulnerable and marginalized and disadvantaged and underserved populations and communities and regions and countries and continents and planets and galaxies and universes and 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and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance 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freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and faith and hope and love and joy and peace and gratitude and forgiveness and compassion and empathy and kindness and generosity and altruism and service and justice and fairness and equality and freedom and responsibility and integrity and honesty and courage and wisdom and humility and patience and perseverance and temperance and prudence and fortitude and charity and Keloids and hypertrophic scars need multimodal therapy; excision alone often fails.