Q: Dr. Eppley, I had a Moh’s surgery on my right cheek Dec. 27th 2012. I am unhappy about the indentation on the mid to lower half of the scar especially when I speak. I have photos I can send. Would like to know if you think I would need a revision, subcision, or laser, or this will subside in the months. Also, if revised, do you agree with the theory of lasering 4 to 8wks after sutures are removed to reconfigure the modeling of the tissues resulting in superior results, rather than waiting the full year of the old theory. I am not interested in temporary fillers.
A: I am assuming that you had a primary closure of your original Moh’s defect. The reason you have an indentation is that there is tissue missing over a dynamic area. As such, no amount of release or scar revision is going to improve its appearance. This is a tissue loss problem and releasing underneath or cutting out the scar/indentation from above does not address the biology of why it is there. I would take a reverse approach to conventional wisdom by doing fat injections under the indented area. This will provide both a release and adds volume at the same time. While fat may be unpredictable in survival, this natural form of tissue volume expansion better addresses the cause of the problem. This would be more effective done early in the healing process (months) rather than later. (year or longer) The overlying scar in the face of underlying tissue expansion should wait for further healing.
Dr. Barry Eppley
Q: Dr. Eppley, Attached are the pictures of my scar on my cheek. What bothers me the most is the indentation. I would like to get surgical scar revision as I’ve tried lasers etc and nothing has worked. Do you think I’d be a candidate for scar revision? My scar is 6 years old or so. It looks red in some photos as I had a tca peel done a few months ago, which didn’t help with the indentation. I was interested in finding out what you would think would help? I read up about geometric line closure correction do you think this would be more favorable than a single line surgical scar? Let me know your thoughts, Thanks so much.
A: Thank you for sending your pictures. Given your scar’s appearance, I would think the only possible improvement for it would be geometric scar revision. Scar indentations can never be improved by very superficial skin treatments like chemical peels or even laser resurfacing. The entire scar must be excised and normal tissue brought together over the indented area. By the perimeter shape of the scar, it would be brought together in a geometric pattern, merely its irregular shape from the beginning. While one could make an argument to do a wider elliptical excision of it and close it in a linear or straight line fashion given is parallel orientation to the nasolabial fold, I would initially prefer a geometric approach which would also produce less total scar size.
Dr. Barry Eppley
Q: I am writing to you because I have a very troublesome scar on one of my cheeks. The scar has been there for a long time since I was 5 years old. At that time I had some type of cyst removed which left a bad scar. It has bothered me for over 20 years and has very negatively affected how I see myself. I have tried the best that laser resurfacing (Fraxel) has to offer as well as Botox and filler injections, all with no visible improvement. I have paid good money for these treatments and I was really disappointed to see that they did not make a difference. What do you recommend?
A: Your question has me at a disadvantage as I can not see your facial scar. Having seen and operated on children for facial nevi and other tumors, however, it is like that your scar is plagued by multiple adverse scar factors including being wide, is deeper or more depressed than the surrounding skin, and is positioned over a prominent facial area. I can say that with some confidence because you were still young when the scar occurred and your face has grown much since that time. Facial growth always causes scars to stretch and be thinner than the surrounding skin.
The only hope of any improvement is actual scar excision. Cutting all or part of the scar out and then re-closing it can narrow it. Often this takes two stages to get the scar narrowed as much as possible. Thereafter laser resurfacing may be beneficial but may not be needed at all. When one considers serial scar revision, including healing and scar fading time, this is a process that easily can take a year or longer to get to where you want to be. A patient must be prepared to make such a time commitment. You are still young so such lengthy efforts will still have a long lifetime of benefits.
Dr. Barry Eppley