Your Questions
Your Questions
Q: Dr. Eppley, I am interested in forehead scar revision. I was on Dr Eppley’s website and noticed a few pictures of a scar revisions he had performed with great results. Seeing that he has successfully treated similar scars in the forehead region I would like to see if Dr Eppley can help me with my indented forehead scar. My scar is a result of a scar revision done one year ago for an indented chicken pox scar. The scar is approx 1/2″ in length and it sits directly on my natural wrinkle line in the center of my forehead. Unfortunately the incision line is indented which results in an aweful shadow effect. Also at the one end of the incision there is small indented hole possibly caused by the corner of the incision opening up a bit early on.The plastic surgeon who did the revision used 3 buried dermal sutures and 6 exterior sutures however he said he did not evert the wound edges as he felt it was not necessary. No eversion plus possibly too much forehead movement during the healing phase resulted in what my scar looks like today. I have also had 1 dermabrasion procedure done to grind down the indentation appearance with very minimal results. If Dr Eppley can help minimize my scar it would be greatly appreciated. Thanks very much for your time.
A: In looking at your pictures I do believe your forehead scar could be improved by forehead scar revision. But I don’t think it is as simple as just cutting out the scar and closing it in a linear fashion…with or without wound edge eversion. While the scar needs to be re-excised and closed, the key element for sustained improvement is providing some structural support underneath the wound edges to prevent a recurrent indentation. This can be a small piece of fat, dermal graft from an old scar or even a piece of allogeneic dermis. (e.g., alloderm) This will create a mild temporary elevation of the scar which will settle into a flatter profile. But without adding anything to it the wound edges are likely develop recurrent indentation given the high muscle activity in the area.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have this terrible vertical line in the middle of my forehead and I really want it gone. Can you help me?
A: Vertical wrinkles in the forehead are a result of overactivity of the corrugator supercilii muscles. These are small muscles that run obliquely from the inner aspect of the eyebrow under the more superficial frontalis muscle and pass inward towards the central area between the eyebrows to insert to the underside of the skin. When these muscle contract they pull the inner half of the eyebrow inward. With both sides pulling inward together this creates the vertical lines between the eyebrows that many people have. This is why the name corrugator supercilii, which comes from Latin, means the ‘wrinkler of the eyebrows’.
The corrugator muscles are known as the frowning muscles and they produce a variety of vertical line patterns between the eyebrows. The most common are a pair of vertical lines, known as the 11s, and is the basis for the use of Botox injections to reduce their prominence. In some people a single deep vertical line appears, just like the one you have. They are often very deep and are the hardest of all vertical forehead lines to treat.
This is definitely not scleroderma which appears more liken shallow groove and does not appear in the midline. This is a deep expressive wrinkle (deep vertical line) which shows deep inversion. I would not think some much of fixing it as it is not that simple…but treating it to make it less noticeable. This is caused by excessive muscle action but not has become a deep etched vertical line which will not be resolved by simply weakening the muscle. (e.g., Botox injections) The hardest part of its treatment is to get the deep indentation back up and level with the surrounding skin. The simplest and most effective approach, but the least appealing, is to cut out the indentation and put it back together in a geometric closure pattern. (small running w-plasty like forehead scar revision) There is no more effective long-term skin leveling strategy than this approach but it is like trading one scar pattern (indented and vertical) for another pattern. (smooth and small irregular line) One could certainly argue that this is probably a much better ‘scar pattern’ than what you have now. The alternative non-excisional treatment would be to place something under the indented scar such as fat injections, a small dermal-fat graft or temporalis fascia. This would create less of an indentation that would not be quite as deep.
As you can see, the ‘fixing it’ strategy is not what can be achieved. It can only be improved and it is just a question of how one feels about either the options of a smoother fine line scar or simply less of a vertical indentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I came across your web site while googling for plastic surgeons. Six months ago I got hit in the forehead with a beer bottle (blunt trauma). The plastic surgeon only looked at the injury two days later and applied micropore tape rather than stitches. Around a month ago, I started going to to a few local plastic surgeons to see what could be done about the car. All the surgeons having different ideas on what to do. I really don’t want to have to travel overseas for treatment, but I do want the very best results (as I’m stuck with my face the rest of my life).
It seems like the local surgeons have the following two schools of thought:
1) To wait until a year has passed, and re-evaluate. I do not like this option, as it seems to be getting worse as time goes on, not better
2) To cut out the scar and re-stitch it. Within this there are 3 opinions:
a) Cut out the scar, and remain with a horizontal line which conforms to my face’s natural lines.
b) Cut out the scar in it’s current orientation (around 45 degrees), because it can not be adjusted to a horizontal orientation without doing a z-plasty
c) Make a horizontal cut through the middle of the scar, leaving a small vertical mark on the top and the bottom (which the plastic surgeon claims will disappear)
Within the opinions above:
1) No surgeon was exactly sure what is causing the scar to bulge. Some claim it is excess scar tissue from not being stitched initially after the injury. Others claims it is a cyst that has formed. Another claims it is some kind of “fluid” under the scar. Keep in mind that the bulge currently feels more like a hardish jelly that a hard bump.
2) I have asked each one regarding geometric broken line scar revision. Some just refer to the Z-plasty or W-plasty when I mention that word. They claim that W-plasty is not necessary as the scar is small and with a straight cut, it will eventually result in a smooth white line. Some even suggest that making any jagged patterns will make it more noticeable.
3) I have also asked regarding dermabrasion and/or laser. All of them have said that as long as the surgery is ok, and healing goes normally, they do not see any reason for dermabrasion or laser. Only if the scar looks like it is becoming hypertrophic will they apply some extra treatment.
4) I have also asked all of them about botox before surgery. They all claim it is unnecessary.
5) Regarding final outcome, some surgeons claim the scar will be a fine white line, others claim it will almost disappear, and others say “we can assume it will be better than it is now, but no guarantees”. From one end of the spectrum to the other?!
So my question is:
1) Is there any way to get it horizontal without Z-plasty?
2) Would a straight cut be better than GBLR?
3) Is demabrasion/laser really necessary?
4) What is your personal recommendation at this point? Am I taking a risk doing it locally, and if not, which school of thought should I trust?
Sorry for the long winded message. Just spent hundreds of dollars and hours
trying to find someone who is confident and know what they are doing,
but it seems hard to find someone who can suggest the best and most
optimum treatment locally.
Thanks in advance for your help/advice.
A: I will take your very detailed description and various opinions and summarize your forehead scar revision issues/recommendations succinctly.
This is a hypertrophic scar and would be expected given the original unrepaired wound. There is no mystery as to why it is there.
Totally removing the scar (excision) is the most expeditious and effective method to getting to an eventual better scar. Everything else is just wasting time and effort.
The excision should be based on a stair step pattern closure to at least get 50% of the scar horizontal.
Botox injections should be done at the time of scar revision. (not before so the wrinkles lines are well demarcated) This will provide several months of tension free healing in the critical few months after the procedure
Microdermabrasion or light laser resurfacing may or may not be needed afterwards based on how it heals.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am wondering if scar revision can help? I have had this one inch long scar in my eyebrow frown line since I was a toddler. Because of its location it is starting to become more noticeable as I approach 30. I have tried Botox, SmartXide laser, TCA Chemical Peels, and Sciton LaserPeel and not been that satisfied with the results. I was wondering if you thought it could be improved with a revision or dermal filler or if you think it should just be left alone. The indentation is my primary concern vs. the white line color. Looking forward to hearing from you!
A: Given the effort that you have made to improve your forehead scar, it is reasonable to consider surgical scar revision at this point.That scar is perfectly oriented in exactly where vertical glabellar wrinkles develop. That is why it has been getting more noticeable as you age because it probably is deepening slightly with repeated expressive motions. I am not surprised that none of the treatments you have had were successful as the depth of the ‘crease’ is beyond what they can level out. You are correct in assuming that scar revision would be the only successful approach. An injectable filler will lift up the depression as the skin edges are tethered down. A small geometric broken line closure scar revision would both release the scar contracture, elevate the scar and rearrange the skin edges by interdigitation to prevent recurrence.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is there a wait time needed for healing after the original scar has developed? I had an accident this past February where I injured my forehead. The ER doctor said that it was hard to pull the wound together because I had skin lost and the wound might need to be reopened and restitched. Well I had the stitches removed and it left a scar that is about 2.5cm long and at its widest less than .5 cm wide. Please let me know if there needs to be a certain amount of time before scheduling an appointment. I look forward to your response.
A: My approach to scar revision may differ from the historic approach of waiting one year or more before having a revisional procedure. Waiting on scar maturation is advised when the problem that is making the scar visible will improve with time. If the scar is narrow, has a relatively even surface contour and is red in color, then time will help the scar’s color to fade. (although even that problem is treated earlier today with BBL therapy) But if the scar is wide, indented or raised (color aside), time will not improve those scar characteristics. This scar revision may be undertaken as early as 3 months after the injury when much the inflammation from primary healing has subsided.
Please send me a picture of your forehead scar for my assessment.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, can you tell is there a way of reducing the excess skin between the eyes (glabella area) and what is the procedure for that? Only the skin, not the bone or fat. Will there be a big scar after the surgery? Thank you!
A: Some people will develop deep vertical furrows between the eyebrows, also known as the glabellar area. These are the result of extreme muscle action of the glabellar musculature. These furrows can become so deep and excessive that in some people they will appear as actual rolls or vertical folds of skin. While Botox is the standard treatment for glabellar furrows, it will have little effect in reducing these glabellar skin rolls. I have actually done excisions of select vertical glabellar skin rolls. While this does create a dramatic flattening of the glabellar area, and one can also perform muscle excision at the inner eyebrows to create a more permanent Botox-like effect, it does result in a prominent scar if one has thicker type skin. (which is almost always in whom these skin rolls exist) In each and every case, I have needed to do subsequent scar revisions for an improvement in their appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have been looking at your web site for over a week now and I believe I have finally found a perfect plastic surgeon for my problem with my forehead. I’m 58 years old in fairly good health. I’ve had car accident long time ago when I was about 20 years old, which left a scar running vertically in the middle of my forehead. It looks like a thick vein coming down in the middle of my forehead. Also due to scarring (swelling like) there are 2 shallow bulging just above both of my eye brows. What do you think needs to be done to make for a smoother and level forehead?
A: It certainly sounds like you have a depressed scar that runs down the middle of the forehead, which is not surprising with long scars that run perpendicular to the relaxed skin tension lines in the forehead. The smaller two bulges to which you refer could be either your native brow ridges (which have become more prominent due to the depressed scar/bone) or they may be extra bone formations. (periosteal reactions to the original injury) I would have to see photographs to answer that part of your forehead issue better. But let us assume this is what the forehead issues are. In this case, a scar revision of the entire forehead length can be done and the bony prominences reduced through this open exposure. It may also be necessary to do a little buildup of the bone underneath the scar will a little bone cement to help make the bony part of the forehead smooth across the original injury area. (forehead contouring) But this would await what is found during surgery.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, Hello! I have a scar on my forehead indented with a small amount of tissue over and it is same color as skin. Any options for improvement? Here is a picture of what it looks like. I am just particular about it and cover it with makeup daily:) My brother thought Juvederm would work, but I am looking for something a little more long term. Thank you so much.
A: When evaluating scars it is first important to evaluate its physical characteristics. That is the key to determining the best treatment for its potential improvement. Your vertical glabellar (between the eyebrows) scar has one feature that makes it the most visible…it is wide with a depressed gap between the skin edges. When you have a depressed scar the only chance for improvement is excision and reclosure to level out the skin edges and make the scar more narrow. In addition to prevent recurrent collapse of the scar line, the closure should not be a straight lone closure but that of a broken line or geometric closure like a w-plasty pattern. Your small forehead scar revision could be done in the office under local anesthesia.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am undergoing scar revision from a bad forehead injury and my plastic surgeon said he would use forehead skin mobilization? I looked it up and only one example came up. Will this technique move my current scar in a different direction? How big would my new scar be after the direct scar excision? When I think of the word total forehead mobilization I think of my forhead being lifted and moved around. What does this mean and how does it work to improve the appearance of the final scar? I was initially interested in tissue expansion help my forehead scar but my doctor said that was too extreme and didn’t need to be done for my smaller scar issue.
A: Tissue mobilization means the tissues around the scar are freed up so that the wound closure after scar excision is not tight. Tension is the biggest enemy for maintaining a narrow scar and is undoubtably why many initial excision ended up with scars the re-widen afterwards. This is particulalry true in the tight tissue of the forehead. Tissue mobilization is a technique to make more tissue around the excision site available for wound closure. It is in some ways a poor man's tissue expansion method. The location of the scar does not change nor will it be any longer when subperiosteal tissue mobilization is done in forehead scar revision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a depressed forehead scars right in the middle of my forehead, parts of which contain pigment from a previous birthmark removal. I am desperate and need a doctor to help me. I know you are one of the best and I trust your opinion. I was researching and thought that the use of tissue expansion may be hekpful in its removal. I figured you can make the insision through my eyebrow for the flap/scar for the tissue expander. I am also interested in hair line lowering but not sure you can combine both procedures. I am open minded to ideas .I just need this fixed.
A: Thank you for sending your pictures. Your forehead scar is more vertically-oriented than circular perhaps from a previous surgical excision of a congenital nevus, hence the residual pigment. Regardless of its origin, let me clarify for you some basic misconceptions that you have about its potential surgical improvement. First, tissue expansion is a reconstructive technique that is way beyond what is needed for your scar revision. While it is a wonderful reconstructive technique for creating more forehead skin, your scar problem does not merit such an aggressive approach. In other words, the magnitude of the solution (tissue expansion) does not match the smaller severity of the problem. (scar) When such mismatches occur, other aesthetic issues arise that are usually worse than the original problem. in the case of tissue expansion, this means a larger scalp incision is needed for its placement (and an additional scar elsewhere), it requires a two-stage surgery (cost) and the inconvenience of walking around with an obvious mass in the middle of your forehead between the first and second surgery for a few weeks. (plus you have to be able to do the daily or weekly tissue expansion by needle on your own) Secondly, no access to the forehead can be obtained through the eyelid or brow area. There is a large nerve there that would have to be cut to do it giving you permanent forehead and scalp numbess. Plus an eyelid incision is neither big enough to place a tissue expander nor is scarless in someone with substantial skin pigment. (postoperative scar hyperpigmetation)
On a more practical basis, what you need is a much simpler approach…direct scar excision with complete forehead skin mobilization (done through the scar) to alleviate tension of the forehead skin closure after the scar is revised. This could easily be combined with a hairline lowering/scalp advancement procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 22 year-old girl who has a dented scar in the middle of my forehead as big as a dime. It is circular so filler will not work. Can tissue expansion work to create a new forehead? Is it possible to combine it with forehead lowering surgery. I figured that the scar from the expansion will be in the scalp or new hairline. I can send you pictures of my scar if you’d like. I really need a doctor to help me as I am constantly hiding behind hair and hats.
A: A round scar in the forehead poses a challenge unless it is very small and can be elliptically excised with a very small scar. But a round scar the size of a dime just about anywhere on the forehead is not an easy problem to improve, particularly if it right in the middle of the forehead. While it can elliptically excised, the length of the scar in the middle of a young woman’s forehead would not be a good trade-off and may actually even be worse. It is true that the forehead skin could be expanded and then the scar excised but that is a lot of effort to still end up with a visible scar even if its length is a little smaller and not ending up quite as wide. I don’t view tissue expansion as a viable option either.
I would recommend one of two potential approaches. The first is staged serial excision. This is in effect a ‘poor man’s’ tissue expansion. Do an initial scar excision that stays inside the boundaries of the round scar. Let it heal for 6 months and then come back and do it again. It may even require a third time excision but the goal is to eventually have a linear scar that is not much bigger than the diameter of the initial scar and be a fine line that is not indented. The other option is to try and fill it with either a fat injection or a dermal-fat graft. In essence, try to improve the contour but do not make any more scar that what you already have. Whether either of these is reasonable would depend on what the scar looks like. For this reason seeing a picture of it would be very helpful.
There is also the possibility that no method is really worthwhile for this depressed circular forehead scar and it may be left alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a pretty big scar which runs down the middle of my forehead. It is from an accident I was in last October. It was cut down to the skull and they did plastic surgery but my doctor said its all healed now. I want it to blend in more and not look so scary. What type of scar revision would help me the most?
A: As your scar is now nine months old, it is likely close to maturity. This is confirmed by your doctor saying that it is ‘all healed now’. In looking at your pictures, your scar could be improved through further manipulations. It is not tremendously wide but it is visually obvious because it is a vertical scar in the forehead where the relaxed skin tension lines (RSTL) run horizontal, completely perpendicular to your scar’s orientation. I think you would benefit by a two-staged scar revision approach. A first-stage running w-plasty scar revision done under local anesthesia in the office. This would help change the straight line vertical scar appearance to a more of a broken line closure. That would achieve two things. First it will help redistribute the tension better by the interdigitation of the wound edges so it will likely end up as a more narrow scar. Secondly, an irregular line is a better camouflage when the scar runs adversely to the RSTL of the forehead. If needed, a second-stage fractional laser resurfacing of the scar several months later for optimal blending into the surrounding skin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, First of all I would like to appreciate your approach to educate general people like me about plastic, reconstructive and cosmetic procedures. I have a question regarding my scar revision. I have done scar revision yesterday. The revision was done to revise a pox scar on the lower middle forehead about 1 cm up of the starting of nose bridge. The scar was 5mm in wide and 6mm in length. Right now I am very much concerned about the post scar it will leave. I am hoping for a linear scar rather than the circular one. I would really appreciate your feedback regarding this.
A: Not having any knowledge of how your scar revision was performed, this is a question you should ask the doctor who performed it. By your description, I would assume that a simple horizontally-oriented elliptical excision of the forehead pox mark would be done with a resultant linear scar trade-off. This circular scar result is a bit confusing to me unless some form of subcision was done in an effort to raise up a depressed scar rather than excising it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, about three months ago my plastic surgeon cut out a chunk of skin out from the center of my forehead that had pock-like scarring and sutured it together. He told me that once the line heals, it would barely be noticeable and flow in into the creases of my forehead. He did a v-shaped straight line which looks anything at this point but a natural horizontal forehead crease. Is it normal right now for the closure line to appear indented and red and would you recommend Fraxel lasers and silicon strips at this point in time. Is all that i’m seeing pretty normal or did this doctor jack up my face?
A: I do not know what you looked like before and was not involved in how the decision for that approach was decided. I can make no educated comment on the decision for that particular approach to your problem. This is not an approach that I have ever used for pock scarring issues in the forehead. Most certainly if I would have done that large forehead excision I would not have made it v-shaped. There is nothing natural about that scar orientation in the forehead. What I can say is that for three months out in thick pigmented skin, the scar is what I would antiipate…very red and noticeable. It is going to take considerable time for any amount of fading that may occur. Given the way it was done, your scar appearance does not surprise me at this point. I do envision the eventual need for some additional work, whether it is scar revision or fractional laser resurfacing remains to be seen with more time.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to ask about how to get rid of a facial scar. I want to fade or remove my scar in my face on my forehead. That scar was caused by a car accident in 1998. The characteristics of the forehead scar are flat, vertically-oriented above my right eye, its size is 33mm in length and 2.5mm in width. The color of the scar is darker (more red) than surrounding healthy skin. It tends to be flat and is slightly less irregular but, when my facial skin is flexed, the edges of the scar tissue can be unified. What is the best way to repair my scar? Thank you very much.
A: Your scar description describes perfectly that it is best treated by a formal scar revision. This scar revision would include total excision (cut out) of the scar and a geometric closure. (irregular or broken line closure) The appearance of a scar that is wide and flexible can only be narrowed by total excision of the scar. Because the scar has a vertical orientation in the forehead, it runs perpendicular to its relaxed skin tension lines. This means that if a straight line closure is done after the scar’s excision, there will be a tendency for it to widen again. (although it may end up as wide as it is now) Changing the closure pattern to an irregular or broken line closure will redistribute the tension on the scar so that it will be more likely to stay as narrow as possible (less than 1mm) Also an irregular non-straight line is better camouflaged as it is harder for the eye to follow a broken line as opposed to a straight one. This type of scar revision is the best approach based on your scar’s description.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr. Eppley, I wanted to send you my pictures to review. I had a childhood scar which I had revised in 1995 and the result was this elongated revision which I have not been too happy with. It has been about 16 years since then and I was hoping to find out if can have anything done to make it less visible. I am currently 30 years old and of Asian decent. If you have few minutes, I would appreciate your input on a few of the questions as it will help me be more knowledgeable.
1. I realize that the scar revision is replacing one scar with a less visible one. Would you consider the revision for this vertical midline scar to be GBLC, serial W-plasty or a simple vertical excision?
2. I know there may be a bandage or silicone gel sheet after the procedure. Any idea of how long I need to wear one and the down time in general?
3. Following the revision, would there be any additional resurfacing required? If so, would you recommend dermabrasion? And any idea of total number of follow-ups required?
A: Thank you for sending your pictures and reviwing your scar history. Your forehead is a relatively flat wide scar that runs vertically right down the middle of your forehead. In answer to your questions:
- As this scar runs completely perpendicular to the relaxed skin tension lines of the forehead, which run horizontal, any successful scar revision should nto be a straight line. Some form of irregular pattern needs to be used. Given that the scar is absolutely vertical, I would use a running or serial w-plasty type of scar revision.
- I would apply just some glued brown tapes for a week after the procedure over the sutures. Thereafter, one would apply a light antibiotic ointmnent for an additional week and then change to a topical scar gel. Scarguard is my preference.
- I suspect that some light laser resurfacing may be beneficial done once about 6 to 8 weeks after the procedure. That would depend on how the scar appears. Definitely not dermabrasion as that is too deep. With your Asian skin I would be very conservative with any type of scar treatments that use heat due to the risk of pigmentation changes.
Dr. Barry Eppley
Indianapolis Indiana
Q: I fell and now have a depressed scar on my forehead that I think (but what do I know) should probably be cut open and resutured so it results in just a fine line. It’s about 2″ long. I have attached a picture of it for you to see what it looks like. What do you think?
A: Scar revision is ideal for those scars that have healed with a contour depression or indentation. No other method, such as injectable fillers or lasr resurfacing, can change the level of the line of original injury as well as excision and reclosure. By cutting out the scar edges and recruiting normal unscarred skin and subcutaneous tissues, the lack of volume which represents the original scar indentation is replaced. You are correct in assuming that you are trading off an indentation for a smoother fine line scar. Your scar is small enough that it can be done in the office under local anesthesia, saving the expense of the operating room and other supplies. The new scar will be finer and mor even with the surrounding skin. It will take months for its redness to go away but, in the end, its appearance will be much improved.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a long and wide forehead scar that I would like to be made to look better. I have attached some pictures of it for you to review. I was wondering if you think that laser resurfacing will help. I have read that it can make scars go away. What is your opinion of it?
A: The origin of your question is will any form of laser resurfacing make your forehead scar disappear. The simple answer to your question is no, no matter what type of laser resurfacing technique is used. And let me explain to you why. Your forehead scar is composed of abnormal tissue which is why it does not feel or look like normal skin. It is in fact abnormal tissue or scar but, most relevantly, that scar involves the entire thickness of your skin. In other words, the skin has been replaced by full-thickness scar. You can smooth of the surface of the scar out all you want with any form of laser resurfacing but it will always appear just as wide, just as discolored and just as obvious. Laser resurfacing only smooths out the surface of the scar, which is helpful if the scar’s main problem is surface irregularities, but it will get rid of the actual full-thickness of the scar. Only cutting it out (excision) can do that. When excision is combined with a geometric broken-line closure, the scar will become more narrow and less obvious. Secondary touch-up with laser resurfacing may be helpful but it is an ineffective treatment to do first. I realize that grasping out the hope of laser resurfacing seem appealing but it is but a treatment mirage. Formal surgical scar revision is what would benefit you the most.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have a wide circular scar in the middle of my lower forehead from removal of basal cell cancer in the fall of 2009. It measures 5 mm wide by 10mm long and is depressed. (atrophic) The dermotologist used the ‘scraping method’ the remove the skin cancer. As the scar is in a very prominent place, I am strongly considering scar revision to make the scar is long and narrow. What are your thoughts?
A: Whether scar revision will be helpful is determined by two primary features of the scar in question. First, what does the scar look like? Scars that have width and height issues (raised, depressed and/or wide) are prime candidates for a positive outcome from scar revision. Narrowing and leveling a scar is one of the main changes that scar revision does well. Second, what is the age of the scar? Most scars must be mature enough to allow for good tissue handling and manipulation. In general, scars should be at least 6 months old if not longer. But the most important feature, not just time, is how pliable or flexible the surrounding skin is. Soft flexible skin is important to make most scar revisions successful.
Because the scar is located on the forehead, it is also likely that simple straightforward excision and closure, while better than what currently exists, is not ideal. Most likely, some form of geometric scar line rearrangement is needed to optimize its ultimate visibility. Scar revision using non-linear closure is best for any forehead scar that is not parallel to one’s natural wrinkle lines.
Dr. Barry Eppley
Indianapolis Indiana
Q: I was wondering if a scar on my forehead can be improved by plastic surgery. Two years ago, I fell and had a deep cut into between my eyebrows. Even though it was stitched up in an emergency room, it has still left a very noticeable scar. Because of where it is located next to my eyebrow, it always looks like I am frowning even though I am not. I am only 29 and don’t want to look like I am scowling or have wrinkles at this age. Would scar revision be helpful?
A: Scars are particularly noticeable when they are in unnatural locations. Whle most people will eventually develop some vertical lines between their eyebrows due to excessive muscle activity (expression), that is not a ‘natural line’ for a younger person. Having seen such scars in this are before, they are noticeable because they are indented along the scar line. This creates a vertical groove which can certainly look like a deep glabellar furrow or wrinkle.
Unlike expression-induced glabellar furrows, Botox is not an answer because it is caused by injury and scar. The problem is in the skin and not the muscle. Most scars in this area can be significantly improved by surgical scar revision. By cutting out the old scar and closing the line in an irregular (running w-plasty) pattern, the scar will usually become much less noticeable. Not only in the scar line no longer completely straight but it will not indent and be smoother. This simple procedure can be done in the office under local anesthesia.
While scar revision is not a magic eraser, it can reduce its appearance to be much less noticeable.
Dr. Barry Eppley
Indianapolis, Indiana
