Q: My four year-old child had a surgery for repair of an elbow fracture. Screws were initially inserted to fix the upper arm bone where it attaches to the elbow. It went on to heal well and the screws were removed three months later through the same incision. Now he has an ugly wide scar which lies on the outside of his elbow and is very visible. It is about 3 cms wide. We need it to be removed as soon as a possible.
A: Scars from orthopedic surgery, particularly around a joint area, can often end up less than ideal. This has to do with a variety of factors including the intent of the surgery (fix the bone fracture, the appearance of the scar is largely irrelevant), the pulling on the skin edges from the equipment used in bone repair, repeat surgery through the same incision, age of the patient, and the continous stretching on the scar from the motion of the joint. By far, the latter plays the major role in such scar widening and hypertrophy. While a scar revision will make an immediate improvement the question of whether some scar widening may still occur is relevant given that the elbow joint will be moving after surgery. So pulling and tension on the scar will not be eliminated. What degree of scar widening will occur after revision can not be predicted, but hopefully it would be minimal.
One concept about the treatment of scars that must be tempered is the concept of removal. There is no such thing as scar elimination or removal. Scar revision is all about how much improvement can be obtained. A complete scar ‘cure‘ or total eradication is not possible for any scar.
Dr. Barry Eppley
Q: Dr Eppley, I was involved in a car accident several years ago which left me with a big ugly scar on my upper lip. The scar connects with a scar on my nose. It seems like I don’t have that line (margin) of the lip as it is flat. The scar has been revised several times but there has been no improvement. I was wondering if anything can be done to make that line/margin of the upper lip? I know the scar won’t disappear but at least just to have some improvement. Your help will be greatly appreciated.
A: While I would have to see pictures of the lip scar to be certain, it sounds like you are talking about loss of the philtral height or the philtral ridge. When a scar crosses it, it will likely lose its height or prominence. A skin scar revision alone will not restore the height of a philtral ridge. I have found that an allogeneic dermal graft placed under and along the philtral column underneath the scar area is necessary to resist scar contracture. Please send me some photographs of the scar for my assessment.
Dr. Barry Eppley
Q: Hi Dr. Eppley, I recently had a revison gynecomatia surgery to remove scar tissue about 3 months ago and now I have even more scar tissue buildup than I had before. I have a big lump under my left nipple and was wondering if I it was possible to get 5-FU injections to reduce the scar tissue because I heard that Kenalog can have significant side effects. My doctor does not offer 5-FU and I have heard that this needs to be injected within the first few months after surgery to have an effect so I would like to get this done if possible. I would appreciate hearing back from you and helping me out with this if possible. Thank you!
A: At this early point after your revisional surgery, it is reasonable to consider a non-surgical treatment for your recurrent scar tissue. If significant improvement was to occur, you should be seeing it by now. The standard injectable scar treatment is Kenalog. While there are potential side effects (fat and skin atrophy), these are very much dosage and location dependent. High and frequent injections of Kenalog in skin level scars can cause these problems. But low doses of Kenalog done judiciously for subcutaneous fibrosis is unlikely to create these potential problems.
5-FU scar injections are useful in scar issues that have proven resistant to Kenalog. While there is nothing wrong with using it as a first choice therapy, it may or may not be necessary. When administered it is mixed with either a small amount of Kenalog or local anesthetic since there is definite burning afterwards associated with 5-FU injections. You are correct in assuming that these injections should be done early as they work best when new scar tissue is forming as opposed to long-stand established scar tissue.
Dr. Barry Eppley
Q: I have 6 lines of self harm on my right wrist. They are white clear lines, which I would like them removed due to constantly being cautious to cover up when around people. I have recently found out that I am pregnant and would like them removed even more now, before the birth of my child. I’m so confused as to what I should do and which is the safest option. I’m so desperate to have them removed. I have had them for two years now and would like them removed by September of this year. What dio you recommend?
A: What you are referring to are many numerous fine white scar lines that often criss-cross each other on the volar aspect of the wrist. As self-mutilation/suicide attempt scars go, this pattern is fairly common and I have seen it numerous times in scar revision consultations. The reality is that there is no magic eraser and any technique for their removal. They are as narrow as scars can get due to their creation by a sharp instrument and their white color is unchangeable due to the scar in them. No form of laser resurfacing can ‘wipe them off’ or erase them, that simply is not going to work.
Since the stigmata of these scars are its classic pattern, an alternative approach is to create one larger scar which is more amorphous. A more confluent non-descript scar will at least not look like a pattern of knife cuts. In effect, this is creating a bigger burn scar which will look like a burn injury not a knife injury. Deep laser resurfacing can be done to create this effect. While this is not as desirous as erasing the scars, it is a more achievable goal.
Dr. Barry Eppley