Q: Dr. Eppley, I am looking for a surgeon who can help me to decide how to improve my scar. I know it is hard to evaluate a scar from just pictures. I have a small scar 0.5 cm on my chin resulted from squeezing and scratching the spot and I got it infected. It was 10 years ago.The scar was just a very little raised and became white. I had radio frequency treatment done 5 months ago. And after a month the scar became a little more raised. I attached the picture of the scar so you can have a look. It is a slightly hypertrophic scar.
I got a lot of different options from the doctors. Nothing has been done yet, I am very careful as the scar is on the face. A few doctors recommended to me that laser CO2 fractional would be the option for me and some of them said that excision of the scar will give me a more significant improvement and I should have a scar as fine line. Two doctors recommended steroid injection to flatten my scar but it will not reduce the white color.Another doctor said that it could make another complications like pigmentation surrounding skin. I do not want to try laser CO2 as I had radio frequency treatment done on my face and my scar became a little more raised and white.
I would go for excision but a few doctors said that my scar could look worse because of the location. One doctor explained to me why he would not do excision as the scar is on the chin and there is no loose skin so if he cuts it out it will have to be closed under tension which could make my scar worse.
Another surgeon told me something different please read below:
‘The existing scar is not big enough that there should be much tension on the surgical scar. With a good surgeon, and a good post-operative healing process, should leave you with a fine white line. I would place it in a curve or oblique line that parallels the curve of your chin pad – this is called a resting skin tension line (RSTL). The deeper layer of sutures should be dissolving, but the last layer at skin level should be non-dissolving for the best chances at a good result.’
Another surgeon told me this:
‘One of the surgeons you have seen is right to say that it does depend a little on how much loose skin there is but in general, there is ample laxity in facial skin to perform an excision of this kind without distortion. So long as the new scar is placed carefully in relation to the natural lines of relaxed skin tension the new scar should be favorable, but it will still be a scar.’
What do you think about it?
What would you recommend after excision, i need to know your opinion to get the best care after excision.
One of the surgeons wrote me this:
‘I ask my patients to cover their wound/scar with Micropore for the first 3-4 weeks as this provides some mechanical protection to the wound, and traps some sweat and waxes from the underlying skin, which is good for the scar.’
Silicone sheeting is applied after 3-4 weeks, as the scar undergoes a change in how it is behaving. For the first 3-4 weeks, a scar is depositing collagen bundles in a random manner to build up strength. After that 3-4 week,s it enters the remodelling phase, where the scar starts to pull down the random collagen bundles and arrange them in the best possible direction for the scar. At this stage, the body also send in new blood vessels to help that process. This is when scar management such as scar massage and silicone sheeting will help. Starting to do these things earlier than 3 weeks can weaken the scar and cause it to widen.
What do you think about it?
A: The short answer is…if you want to have any chance of a visible improvement in your scar, you have to excise it. There is not an issue of inadequate skin laxity ti close it. Scar revision has ittl chance to make it worse, it is only a question of how much improvement can be gained.
When it comes to scar therapy, I do not believe there is any magic. Given the very small size of the scar, I would recommend topical steroid gel applied at night only.
Dr. Barry Eppley
Q: Dr. Eppley, I have chin scar which is still new and is about 3 months old. I got it falling off a skateboard falling onto asphalt. It is in the central and lower area of my chin and is slightly indented I am uncertain as to exactly what to do. I hope it does not stay this way as it heals further. I have attached some pictures of it for your advice? Is there going to be a substantial improvement in the way it looks in the next few months? I am worried about the indentation and the whitish color of the scar line. I appreciate any advice you can give.
A: Thank you for sending your pictures which show the chin scar well. As scars heal there are certain features which will improve with time and others that won’t. Scar redness and a feeling of firmness are the main features that will improve with time. A raised scar is also a scar feature that can settle down and get flat as it matures. The two features that won’t improve significantly with time are scar width and depression or indentation. Scars over bony facial prominences, such as the chin and cheeks, often end up indented as fatty tissue is lost underneath it from the trauma of the injury. When combined with scar contracture/tightening as it heals, the scar can seem like it is being pulled inward.
In looking at your scar, although it is still early, the width of the scar and its indentation suggest that it may not improve greatly as it heals. I would give it the benefit of some more time. But if you see no substantial change in the next few months, then I would consider early scar revision. The good news is that the scar width and indentation can be significantly improved by scar revision techniques.
Dr. Barry Eppley
Q: I had an accident about a year ago in 2009 and got a stitch on my right chin to fix it. The scar is about 1 inch long. I got my real color and texture for the scar. But the skin above the scar had a slight swelling which is making the scar more evident. Is there any way to reduce this swelling? I would like to know the technique and cost of the treatment, which would help to improve the appearance of the scar.
A: The slight swelling to which you refer in your scar is no longer swelling. That would have resolved a long time ago given that this injury is more than a year old. What you undoubtably have is a residual mismatch in the skin edges with the upper edge being slightly higher than the lower one. This gives the illusion of swelling when it is really differences in tissue thickness between the two sides. This is a result of the original repair.
The best and only solution to improve this scar is excisional scar revision. The edges of the scar are opened up and the skin edges are realigned so they lay more flush and can heal back in a smoother fashion.
Dr. Barry Eppley
Q: Hi Dr. Eppley, I have a chin scar that I would like improved. I have lived with it for three years but it has not gotten any better. I fell over my bicycle handlebars and ran my chin into the ground. (ouch!) While it was stitched up in an emergency room, it did not turn out as well as I would have liked. It is on the left side of my lower chin and it turns inward. Do you think scar revision will help? I have attached some pictures for you to see what it looks like.
A: Thank you for sending your photos. The origin of your poor chin scar has to do with its geometry. It is essentially a Y-shaped scar pattern so that when it healed, scar contracture pulled downward towards the V portion of the scar. This is a classic scar healing process. Given that the Y is angulated in an unnatural position on the chin (there is no natural position for a Y-shaped scar on the chin), the resultant scar deformity that you have is fairly predictable.
Essentially you have an indented and downward pulling of the chin scar. This could definitely be improved by scar revision. In doing your scar revision, the scar lines would be opened up and a dermal or fat graft placed underneath to add volume. Then the Y pattern of the scar would be closed in a ‘shorter’ Y (V-Y advancement) so that the skin edges would be more level and the downward pull eliminated. While you would still end up with a scar, the goal is to have it smoother and not indented as it appears now.
Dr. Barry Eppley
Q: I had a chin surgery in the past with a silicone implant placed from inside my mouth. I didn’t like it so the doctor removed it two weeks later. Within a few days after its removal, I could feel fluid inside. The doctor removed it by a needle and it looked fine. But five days later I had a hard ball in my chin and the doctor told me that it was scar tissue. He assured me that I would return to the profile I had before my surgery. But it did not go back and I went to see another doctor who also told me it was scar tissue and injected me with steroids. The steroid helped a little but the labiomental sulcus is still much fuller than it was before the chin implant was placed. It now feels soft but is still fat. I think that the majority of the problem is in the upper part of the chin in the mentolabial sulcus. I don’t have the normal S curve that divides the chin and the lips. When you touch it you can feel something soft inside and the doctors here have told me it is scar tissue but they only want to fix the problem with more steroid injections. But I am afraid now because I have a dent from the steroids. Do you think it is possible to take out the scar tissue in the labiomental sulcus ?
A: You have experienced one of the problems from intraoral chin implant placement. When the implant is removed, the muscles remain expanded and an ‘open’ pocket exists where the implant once was. While the implant removal was undoubtably done quickly and easily in the office, no effort was made to put the mentalis muscle back in place and re-tighten it. A technique well known in plastic surgery as eliminating the dead space. Since the body abhors dead space, it will fill it with serous fluid…a perfect nidus for the development of scar tissue.
My recommended approach for this type of chin scar revision is excise scar tissue and reposition the muscle back down to the bone. This would be done from inside the mouth through your old incision. This is the most assured way to get back your chin profile and re-establish the depth of the labiomental sulcus.
Dr. Barry Eppley