Unintended Consequences: Face Masks and Cosmetic Healing

Although mask-wearing is a normal part of life for many medical personnel, it was a unique and unwelcome experience for most of the lay public when mask mandates were issued in April 2020 due to COVID-19.

Acne and other inflammatory skin conditions caused by mask-wearing have been affectionately referred to as “maskne” (mask acne), but maskne was not the only unintended consequence of mask-wearing.

Most cosmetic surgery providers can probably provide examples of how increased wearing of facemasks complicated the process of surgery and recovery. I primarily noticed this in my laser and facelift patients.

Laser resurfacing patients (and especially deep treatments) present a healing challenge under optimum conditions with compliant patients. I have commonly dealt with health care providers who required facemasks as part of their profession, and masks made healing challenging, but that was a small percentage of patients. The necessity to wear masks by patients during the COVID-19 pandemic amplified this situation to levels not seen in the past.

The effects of mask-wearing are numerous and include increased condensation, moisture, temperature, and the introduction of microbes to the covered areas. One of the most protective masks (Envo Mask) is notorious for inhibiting moisture exchange (Figure 1).

Figure 1. Moisture, temperature, exhaled flora, and compression are some of the problems associated with protective masks.

Early on in the pandemic, I saw multiple cases of extended or atypical healing, which was confusing. Since my patients would remove their masks when seated in the exam room. It took me a while to correlate the healing events with mask-wearing. In addition, some patients wore custom masks, which further clouded the clinical picture. Figure 2 shows a patient with friction inflammation and delayed healing on the lateral facial region. The inflammatory areas correspond with the type of mask she was wearing.

Figure 2. Regions of inflammation and delayed healing from a patient wearing a homemade mask made from heavy cloth.

Many of my facelift patients undergo blepharoplasty with simultaneous periorbital CO₂ laser skin resurfacing, and conventional mask-wearing delayed healing and caused inflammation in multiple patients (Figure 3).

Figure 3. The metal band of conventional facemasks can increase pressure and friction to post-laser healing skin in the infraorbital region.

Wearing a facemask with ear loops can also be a physical irritant to posterior auricular incisions with facelift and otoplasty procedures. I perform more than 100 facelifts a year, and we distributed masks without ear loops that tied around the top of the head and around the neck to avoid pressure, inflammation, and infection in the posterior auricular sulcus region (Figure 4).

Figure 4. The left image shows a patient with pressure necrosis from wearing a mask with a bulky band and an adjustment ring, as shown on the right on a model.

Masks can also cause problems in non-surgical patients. The patient shown in Figure 5 has increased festoons that are due, in part, to mask compression.

Figure 5: Increased festoons due, in part, to mask compression.

It is known that masks can contribute to skin and healing problems, and as obvious as it seems, sometimes the direct correlation is not realized until the patient presents with a specific mask. Dirty masks, tight masks, masks that are made with thicker materials, and custom masks with retaining hardware can complicate the healing of various procedures. This must be taken into consideration when contemplating procedures whose healing may be affected by extended mask-wearing. I have stopped performing laser resurfacing for the time being due to this problem.

Postponement May Be Prudent

For most patients and practitioners, extended mask-wearing has been novel and hopefully won’t reoccur, but the unpredictability of COVID-19 mutations and future infectious diseases may require extended mask wear. Practitioners should postpone procedures where continual mask wear may be detrimental.