Your Questions
Your Questions
Q: Dr. Eppley, it is hard to find a good scar revision specialist who can answer some basic questions without a formal consultation. As you have already answered my initial questions in regards to my scar, I would like to ask you my most important last question that is still on my mind.I still have not decided what to do about my scar. The best treatment would be excision as most of the doctors have recommended. But the reason why i still have not gone for excision is that I do not like the fact that my scar will be much longer. My chin scar is 0.3 cm wide and 0.5 cm long now. I had a prior consultation with scar revision specialist and he said that scar will be about 1.2 cm long after the revision which I do not like. He would place it in a curved or oblique line that parallels the curve of my chin pad – this is called a resting skin tension line (RSTL). I saw many scars after excision so why some of them are not so long even though they are as wide as mine. I would appreciate your answer.
A: The best treatment for your scar is a two-stage excision scar revision approach that does not make the scar any longer. The problem with your scar is that it is wide over a tight chin area. While it can be removed as a single stage procedure, the scar length would nearly double in size. Because of its width it is best served by doing a subtotal excision, let it heal for three months, and then doing a second stage completion scar revision. This is the only way to improve your scar without making it any longer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scar therapy to reduce the raised scar on the bridge of my nose caused by a racket strike during a game of racketball two months ago. Interested in the recommended procedure and number of treatments/visits, etc.
A: Thank your for your inquiry and sharing a picture of your nasal scar. It is important to realize that it is early after the injury and the scar healing process is active and ongoing. If you want to do everything you can do to ensure optimal scare outcome, I would recommend a single fractional laser treatment followed by the daily application of a scar gel and the night time application of occlusive taping. This sequence of scar therapy You can be pleasantly surprised how much better it can look in 3 to 6 months. It is also important to realize that these recommendations are based on a single picture assessment taken from a side view picture only.
When it comes to topical gels a wide variety of options exists and none has been clearly proven to be better than another. The same applies to the number of occlusive tapes and sheets which exist.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I got a scar on my wrist due to a traumatic injury. It has left a mark in the direction of the injury where the surrounding area seems to be darker than the other parts of the skin, upon bending my wrist, a white sheen is observed with mild indentation observable. The darker surrounding I mentioned seem to be coming from the missing skin and dent in rather than hyper-pigmentation? Is there any treatment available for this? The scar is still quite visible right now at the 10th week. I have been hearing that one should wait for 3 to 6 months before undergoing any treatment so as to see how the scar heals up first? Is that true? What is the downtime involved per treatment and how many treatments would be required for my case based on your experience? I am a little skeptical as to how the outcome would be like since the laser results I see are usually from tattoo removals and trauma scars on the face.
A: When it comes to scar revision, regardless of whatever the treatment may be, it is important to identify what are the physical aspects that make the scar noticeable. And then based on those physical characteristics answer the question of whether more time (scar maturation) will be helpful to improve its appearance. The issues of hyperpigmentation and wound contracture at less than three months after the injury are issues in which time may well improve them. Whether they will improve to the point to your satisfaction remains to be seen. The other compelling reason to allow for further wound maturation is that there are no good treatments for these types of scar problems. Much ‘magic’ is ascribed to the use of lasers in scars but much of that for common type scars is over rated in terms of effectiveness.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scar revision of my wide midline abdominal scar from a prior surgery. One surgeon I saw recommended a geometric broken line closure (GBLC) type of scar revision. You have recommended a more simpler vertical excision and straight line closure. My question is why would you choose that particular procedure over the GBLC if the broken line procedure yields better results?
A: There is no guarantee that a broken line closure will produce a better result on a midline abdominal scar and there is no medical evidence to support that it will. And if the scar should widen to any degree, you will have more scar length than what you started with. Whomever advised you that a GBLC for your midline abdominal scar (that has never had a revision before) was the right choice for scar revision is simply wrong. That is simply not done on many body scars. It is most commonly done on facial scars which are a completely different in how they heal than any scar below the neck. You should initially do the simplest and least risky scar revision technique first and then proceed to more complex forms should that not produce a substantial improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scalp scar revision. I had hair transplantation done twenty years ago. However I now shave my head but the recipient area at the front is knobbly and raised where the last line of plugs were placed which is my main concern. There is also a scar running along the top middle of my head an initial scalp reduction which is my second concern and lastly scars on the back of head (donor site) which is much more of a minor concern. So my first priority is to flatten and smooth the recipient area at the front then depending on costs try to break up the linear scar that runs up the middle of my scalp. The donor scars at the back aren’t too much of an issue to me at moment. Do I have to have the old plugs removed (don’t really want to go thru another round of surgery again if it’s at all avoidable) or could I fix this up with dermabrasion/laser/kenalog injection s etc. I would appreciate some advice.
A: When it comes to scar revision of previous hair transplantation recipient sites, there are really fairly limited options. The knobbly appearance is certainly not going to be improved by excising the plugs, that will likely make it worse. There is a substantial surface contour difference between the implanted sites and the native scalp that is not likely to be ever improved by any type of skin resurfacing. Like the face with deep acne scars, laser resurfacing would be a disappointing experience. Dermabrasion may be more effective but at the risk of inducing pigmentation changes. The only procedure that I would remotely consider would be fractional laser resurfacing, as it would be safe, but I doubt particularly effective. The linear scalp reduction may be capable of being improved in appearance by replacing it with a running w-plasty type of scar revision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a geometric broken line closure scar revision but I have a few questions.
1) Would you do multiple layer closure underneath the skin to ensure that there is proper wound undermining. If so many layers?
2) Since I’d be an out of town patient could you use dissolvable sutures on the outside?
3) Would dissolvable sutures affect the outcome negatively or it shouldn’t?
4) Is there anything you can do to help prevent the scar incision becoming indented and the outside edges looking raised?
5) Do you normally have to perform dermabrasion after the GBLR and if so when would this be performed? Would it cost more if I had to do dermabrasion later.
6) Given the size and location of my scar right in the middle of my cheek in your professional opinion do you think that GBLR is my best option? I just worry having different zig zaggy shapes might be more noticeable than a straight line but the problem I have with the straight line is how the edges are raised.
7) I had scar revision done 7 months ago do you think that it is ok to do another revision now since I know the raised edges won’t get better or do you think it’s too early?
A: In answer to your questions about an irregular or geometric broken line scar revision:
1) Every plastic surgery wound closure uses multiple layers.
2) Yes
3) No
4) That happens when there is scar widening. Interdigitating the scar limbs, like in a GBLC, helps prevent that.
5) Whether dermabrasion is needed later depends on how it heals. I would say the risk of that is way less than 50%. It is something that I find uncommon to need to do. Maybe a light laser resurfacing but not dermabrasion in your type of facial scar.
6) Your results with straight line closure have proven that approach is not adequate. It is either GBLC or leave it alone and accept its current appearance.
7) You do a revision when one is certain that no further improvements are going to happen with further healing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a non-straight line scar revision. Attached are some pictures of my facial scar.. I marked up some pictures with a horizontal line showing how it is raised on the side of the scar nearer my nose. Do you think that it would be possible to remove the raised skin on the inside of the scar near my nose or do you not think that would be necessary. My goal would be to smooth it out as much as possible where we could get rid of raised part as well as indented part on the incision line if possible. Note I am happy with how narrow the incision line is, I’m just not happy with how raised it is around the incision and I’m wondering if you think that a GBLR might break up the line to make it less obvious or if you think I should just try dermabrasion first to smooth it out. Also do you think a GBLR would be best or a straight line closure in the area of the cheek? I think the scar size is around 2 and a half cm in length.
A: Your prior straight line scar revision demonstrates the drawback of this approach in a facial area that does not parallel the relaxed skin tension lines. The scar line may be narrow but the edges around it are raised and visually obvious. With geometric broken line closure, the scar is also narrow but the edges do not usually get raised as the scar line is interdigitated and the contractile forces on it are better dissipated.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an indented scar on my cheek that needs some type of scar revision. It started out getting an injectable filler treatment (Restylane) that got infected. After antibiotics cleared the infection a few months later the area appeared indented and became a samll atrophic scar. It then had V-beam treatment for the indentation several months later but only became more indented. It lost whatever fat it had. It is an area under the eye where the cheek fat pad starts where there is a circle that is indented. One surgeon said there is no fat there and that is why it is sunken. I want to know if there a full thickness fat graft or some type of soft tissue implant that can be used to fill it?
A: The scar revision to which you refer is really the need for fat volume restoration. It sounds like you have a distinct area of fat atrophy with scar contracture on your cheek. While this is water over the dam so to speak, the use of a V-beam treatments was ill-advised for that type of depressed scar and did exactly what could have been predicted. That issue aside, options include fat injection or the placement of a small dermal-fat graft that treats exactly what the problem is…lost fat volume. Fat injections involve no incision or harvest site but are somewhat unpredictable in terms of volume retention and do not do a good job of releasing and scar contracture. A small dermal-fat graft would be more effective but it has to be placed somehow through a small incision and requires a harvest site which could be behind your ear.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scar revision. I am a black 26 year old female. I got to know about your practice online. I had a vertical scar on my face as a result of a bottle injury from three years ago. The scar is on the right side of my face just below my right eye on the cheek. So last year I had a scar revision where the Doctor surgically cut out the scar and stitched it up linearly. it looked good after that but some months later it started widening with some areas being indented and other side raised. I want to visit your practice for a scar revision. My mother also has keloids on her body, about two on her stomach, one on her breast, another at the pubic area. It itches her a lot and she wants to have them removed. She has had it removed it before but it grew back so it is a keloid. I have attached a picture of my facial scar and pictures of my mother’s keloid.
A: Your previous failed scar revision by a simple linear technique indicates that an exact repeat of that type of scar revision will result in the same outcome. Your next scar revision should be more of a geometric broken line closure pattern so that it is less likely to widen again. With your mother’s obvious keloids and their history or recurrence, their excision should be accompanied by either steroid of 5FU injections to try and lessen their likelihood of recurrence.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scar revision surgery. Actually I would like it completely gone. I have a 2 1/2 inch hypertrophic horizontal scar on my upper chest that is raised and tender. I would love to have it removed if possible. Here are the some photos of it. The scar is not a result of an injury or laceration. Suspected to be result of an ingrown hair follicle.
A: What you have is a hypertrophic scar and may be on the borderline of an actual keloid type scar. Its appearance and history suggests, in my experience, that may be ‘resistant’ to scar revision surgery. While it can surgically be excised into a fine line (there is no such thing as complete scar removal), its location on the chest gives it a high probability of recurrence, particularly with your darkly pigmented skin. That is the risk in doing it. When such a scar results from an otherwise innocuous event and remains painful for a long time and maybe even growing, this indicates that is exactly what will likely recur when it is surgically removed. The chest is a notorious place for poor scar formation. The best you can hope for is that the scar does not come back as wide as it once was. There will be some recurrent scar widening, it is just a question of how much.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in scar revision surgery. I have a transverse abdominal scar from surgery I had as an infant. It is “socked in” . My skin is adhered to my muscle and there is an overhanging lip above the scar. I am 27 years old. I also have a vertical 4.5 inch scar below the belly button I would like to have lightened. It is two years old.
A: It is very common to see scars from abdominal surgery done as an infant to be completely adhered to the muscles. This is because at such a young age there is little to no subcutaneous fat between the skin and the muscle. The incision line scars down to the muscle (as there is little to no fat interface) and appears as an indented fixed line as fat tissue develops between the skin and muscle around it as the patient gets older. This can be dramatically improved by scar revision surgery by cutting out the scar, releasing the surrounding tissues from the muscle and advancing and closing the skin edges together. While a scar line will still be present, it will be leveled and a much narrower scar. Such scar revisions can often make for a dramatic change in the appearance of such scars.
When it comes to scar lightening that is a different matter. There are not many effective therapies for scar discolorations other than to cut (excise) out the scar.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just got stitches above my top lip. The stitches go across the ridges under my nose. I’m so worried it’s going to leave a ugly scar. My dog jumped on the couch and his hind foot landed on my face. He felt like he was losing his balance and used his claws and that is how I got the cut in my face. The ER doctor did a good job on stitching up the cut. The cut goes from my lip to my nose. What can be done to keep the scarring down?
A: What you want to do to get the best lip scar result is the following. First, get the lip sutures removed in no more than 5 to 7 days after surgery. I don’t know if the doctor used a layered closure or what size the skin sutures are. If there is no dermal buried sutures below the skin sutures, then have a glue dressing (e.g., Dermabond, Indermil) applied once the sutures are removed. Second, beginning three weeks after surgery begin to apply a topical scar treatment twice a day. There are many type of scar gels and strips but on the lip a scar gel is far more practical. Continue twice a day scar gel application until three months after the injury. At three months after injury it is time to evaluate the scar. If it is quite narrow and flat and the redness is fading fast then I would only consider scar gel for another month. If the scar is fairly narrow and flat but still very red, then I would do BBL (broad band light) therapy to work out some of the redness sooner. If the scar is irregular in contour or slightly wide then I would have some fractional laser resurfacing done to even it out. Only if the scar edges are widely separated and irregular would actual surgical scar revision be necessary. Expect the final scar result to take a full 9 to 12 months until the final and best scar outcome is seen.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I got the scar 10 years ago from a car accident my air bag deployed and broke my radius and ulnar. I had staples in place the first time and during the revision done in August of 2012 the doctor sutured it from the inside and glue it but it still widened. I’m not sure what to do next or if i should or could do anything else. Currently I get acupuncture and massage on it every week and I am using essential oils. I don’t really understand what re-excision means so could you please explain. Does it mean you have to go in it again with surgery? I really appreciate and thank you for getting back to me. I’m going to see the doctor who performed the surgery on Friday for a check up and I want to tell him I’m unhappy with the results but I don’t really think that will change anything. I feel hopeless, disappointed and embarrassed. If there really isn’t anything I can do then I won’t and live with the scar. I just want an honest opinion.
A: Given your recurrent hypertrophic scar, the only way to have any chance of improvement is to recuit out the scar and reclose it. (re-excision) I was interested in knowing how it was closed to try and figure out why you developed this scar widening. Sometimes the scar revision technique can influence the result. If a repeat scar revision is considered youw ant to make sure that the exact prior technique is not repeated. For these type of scar revisions, I use a subcuticular skin closure using barbed sutures to try and prevent scar hypertrophy and widening which you are prone to develop given your skin type, ethnicity and the location of the scar. While it remains to be proven if re-excision would offer great improvement, it is hard to believe that what you have now is the best scar revision result that is possible.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, have a little crater on the outsite skin on the top of my nose. I tried filler, excision, laser and dermabrasion. Nothing helps. The crater is 2/3 millimeter deep. Now a doctor in Switzerland want to put a little piece of cartilage under the skin to lift the crater. But I have no confidence because they all have no experience in this case. Can you help me? It’s no problem for me to visit you because I love your country….
A: It is hard to comment on such a nasal defect without seeing a picture of it and knowing where in the nose it is located. The key question is whether this defect is located to just within the skin (dermal indentation) or whether it is located in the subcutaneous tissues between the skin and the underlying bone/cartilage. Only a subcutaneous defect will be positively affected by any implant placed
underneath the skin as this will push out the overly skin indentation. If, however, the indentation is a result of dermal thinning (which I suspect may be the case) then no implant under the skin will help as it will just make a bump appear with the skin indentation merely pushed outward….actually making it look worse. Dermal skin indentations, which are common in the nose, are virtually impossible to improve as you can’t smooth down the surrounding skin and there is no way to make the dermis thicker. In rare cases, it may be possible to place an allogeneic dermal graft directly on the underside of the dermis but even this approach does not assure elimination of the skin crater. This type of nasal scar is very difficult to improve regardless of the method of scar revision that is tried.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I have got a knife scar on my face since I was 5 years old. It is about one and half inch long, is not very deep by any means. I can really see it from 3 feet away. However, it still bothers me sometimes. Is there a way to make it disappear? Thanks a lot.
A: Scar ‘disappearing’ is not likely in any scar. Its further reduction in appearance may be possible, but there is no such thing as scar elimination. The involved skin can never be made completely normal. Scars can be made more narrow, more smooth and have a more normal color, but they can never be completely eliminated or made to completely disappear. Whether any of these techniques or changes will be beneficial to your scar, I would have to see pictures of the scar to provide a more specific scar revision recommendation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a scar from an accident that runs vertically on the middle of my forehead. The accident happened approximately one month ago. I am interested in hearing your thoughts about whether scar revision will significantly help as I am very self concious about it now.
A: As a general rule, one month after an injury would be way too early for scar revision for the vast majority of facial scars. The wound has barely healed and the scar is undoubtably very red due to the influx of blood vessels needed to help it heal. While being impatient is very understandable as it sits on a prominent facial area, patient is going to be urged in most circumstances.
That being said, there are two indications for early scar intervention. If the wound edges are horribly mismatched and it is apparent that no amount of healing time will improve its contour, then excising the scar and aligning the skin edges may be advantageous. The more common indications for early scar intervention is either fractional laser resurfacing and/or BBL. (broad band light therapy) These non-surgical approaches are done to help the redness of the scar fade sooner or to smooth out some fine edges early. Good wound approximation has to be present so there is no reason to suspect that scar excision would be needed later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a depressed scar across almost the whole of my forehead, cheeks and chin. I have tried chemical peel and microdermabrasion, but all seem to burn that arena alone precisely. I think the tissue or skin in that area is pretty damaged and I would like to have it excised.
A: Based on our description of a long depressed facial scar, I am not surprised that microdermabrasion or chemical peels were ineffective for its improvement. Neither of these are appropriate treatment strategies for scar reduction. I am glad that you went through those though so you could prove to yourself that scar excision, radical as it may seemed initially, is usually the only effective treatment for a depressed scar. A depressed scar by definition has a thinner and more atrophic skin composition and a surface contour discrepancy to that of the adjacent normal skin. No treatments are really going to lower the shoulders of the edges of the normal skin to match the depressed scar and that would not be appropriate even it could. Removing the abnormal scar tissue and leveling the skin edges by bringing normal tissue together (surgical scar revision) is almost always a better approach…even if it is surgery and does take time to heal and for scar maturation to occur.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a neck scar that is hypertrophic. My dermatologist just finished 3 steriods injections spaced 2 weeks apart per session. He told me that if I want to do a scar revison I must let the doc know about the steriod injection as steriods will cause delay in tissue healing.What do you think? I also have some other questions about the scar revision.
1) What kind of excision pattern will you use to resect my scar?
2) Are the stitches used in the layers are dissolvable or permanent?
3) Also, what are the chances of hypertrophic scar recurring after removal? Mine is definitely not a keloid, but several doctors tell me that scar revision is not ideal as removal of hypertrophic scar will lead to hypertrophic scarring again. Is this true?
Please kindly advise.
A: In answer to your questions:
The doctor who performs the scar revision should know about the steroids but they will not have a major effect on wound healing, particularly if there is some delay in moving forward with the scar revision.
1) Based on your scar shape, I would do a simple elliptical excisional pattern scar revision.
2) Sutures under the skin are always dissolveable. It is up to the doctor’s discretion and how easy it is for the patient to come back for follow-up as to whether sutures that are used on the outside will need to be removed or not.
3) There is always a chance of recurrent hypertrophic scarring. But the use of pre-revisional steriods before re-excision is a proven approach to lessen that risk.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just had a old tragus piercing split. Is this something that can be stitched back together or will the skin grow back? Or does it require plastic surgery? If the latter, will it look normal after plastic surgery? Thanks.
A: While piercings are common on both the earlobe and the tragus of the ear, there is one anatomic difference between them. The earlobe is completely comprised of soft tissue, skin and fat only, and this is what holds the piercing in place. The tragus, however, has a central core of cartilage with skin on top. It is the cartilage which holds piercing in place and it is usually much more secure and resistant to stretching unlike the earlobe. When a tragal piercing splits, presumably by it being pulled on, the underlying cartilage may have split as well.
Like the earlobe, a tragal split will heal on its own due to the excellent blood supply. Whether it will heal with a notch or cleft in it is impossible to say. I would allow it to heal on its own and see what it looks like later. Scar revision can always be performed of the contour of the tragus is not perfectly smooth.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have several keloid scars that need to be treated. I had a submental tuckup procedure done and at the same time had a mole on my chest removed. My submental tuckup procedure was done in an unconventional fashion as it included removing neck skin vertically and not just horizontally under the chin. I now have a wide and raised keloid scar on the vertical scar in the neck as well as the one on my chest. I have done some research and have read about the use of steroids with scar revision. Do you think this combined approach will work for me? I have attached some pictures of the scars in question.
A: In looking at your pictures what you have on your chest and neck are not keloids. Those are known as hypertrophic scars which are quite different biologically from a keloid which is a true pathologic derangement of scar formation. Hypertrophic scars often result in very predictable areas, such as the chest and vertically in the neck, due to the tension that is placed on the scar line. Treatment of hypertrophic scars is excision and reclosure, not steroids. Steroids will likely result in a recurrently wide but depressed scar as it interferes with collagen formation and wound healing. Steroids should only be used in true keloids that are recurrent and not hypertrophic scars. The location of your two scars in question places them in jeopardy for hypertrophic scar formation, even with scar revision consisting of repeat excision and closure. But this is still a worthwhile effort to do and improvement in the appearance of the scars is likely.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a scar question.What about when a dog ear scar is right in the middle of your cheek. I hate it and I have had it for almost 7years. I am scared to undergo a scar revision as the excision will make the scar longer. Are there any alternatives?
A: Dog ears are excess tissue at the ends of scars or healed incisions. They are usually composed of skin and fat. To get rid of many dogears, it does require a scar revision by excision which will result in a lengthening of the scar. But some dogears can be flattened by defatting alone without skin removal. Through the end of the scar, fat can be excised without extending the scar. This technique relies on the overlying skin to flatten as the fat underneath it is removed. The fat can be removed through either direct excision or sometimes microcannula liposuction. Short of this approach, there are no other alternatives to the dog ear scar problem.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have heard alot about you and even read alot about the scar revisions you do on the internet. I found your website very helpful. I had a car accident in January, 2010. I had an injury under my chin. I was taken to the hospital and the doctor just cleaned the wound and put a band-aid on it. After a month when i shaved i had two scars under my chin. one in oval shape and one in small line red-pinkish in color. I showed it to a plastic surgeon and he told me to use Kelo-cote gel for two months. i used it for 2 months and the scar was a little bit soft but not much result was seen. Then n November, 2010 i had a revision surgery on both the scars. One remained the same and the other was reduced to 60% of the original since doctor had told me she will reduce the whole scar in two surgeries. I am not satisfied with the results from the first surgery. The scar is very visible and is pinkish in color and is even more visible now. I am attaching a picture of my scar before surgery and after revision. I would welcome your recommendations.
A: In looking at your submental or neck scars, I can see that both scars are fairly wide and in need of further scar revision. The biggest scar from the beginning was a tough assigment given its very large width. I have no idea as to the type of scar revision that was performed but I suspect it was a simple linear excision. Both scars would fare better with geometric approach to scar revision to distribute the tension on the closure better to decrease the amount of postoperatve widening. This is particularly needed when the excisions are wide and in an area prone to scar stretching influences.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, This is a micropigmentation inquiry. I have a rather pronounced scar of 3 to 4mm width above the left eye, in the middle of my forehead, from a car accident many years ago. Will micropigmentation be effective in hiding the scar? Will the sun still reveal it if the skin around it tans? Thanks.
A: As a general rule, tattooing a scar is almost never a good technique for scar camouflage. It is very difficult, if not close to impossible, to match the surrounding skin color with any implantable pigments. It would always appear different in color to that of the skin and risks actually making the scar more noticeable. Tattoo pigments are also not very stable and are probe to fading and needing re-treatment. Lastly, as you have pointed out, the skin around the scar will tan and the tattooed scar will not creating a noticeable color mismatch. For these reasons, you need to think more about excisional scar revision as it will narrow the scar and bring naturally-colored skin that will tan closer together.
Dr. Barry Eppley
Indianapolis, Indiana
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
Indianapolis Indiana
Q: My 13 year-old daughter was bitten by a bull mastiff just 4 days. She has a lot of jagged lacerations across the nose and just under the left eye. There were no lacerations on her left eyelid or any eyeball trauma. She was repaired in our hospital’s emergency room with a lot of stitches. It was not a fun experience for her to have it done that way with just local anesthesia. It will be time to get her stitches out shortly and I want to be on top of anything that can be done to minimize her scarring.
A: Like any patient that has gotten their face cut, but particularly for the parent of a child, there is always great concern about the eventual scarring that will occur. In the short-term, getting the stitches out and letting the initial healing take place for a few months is all one can do. There are no magical potions or lasers that can alter or make better the early phases of wound healing. Once the wounds have healed and scar tissue has formed (which is inevitable and absolutely necessary for healing) there are highly touted methods of scar treatment. These can include topical agents, such as silicone patches/tapes and paint-on products, as well as light and laser therapies. It is controversial as to how helpful these are as to the final scar appearance but they are not harmful and may have some benefit. Therefore, I would recommend any of them, or a combination, beginning several months after the injury up to six months after. Which one(s) to use will vary based on the opinion and expertise of your plastic surgeon as well as the scar’s appearance and location. After 6 months, actual surgical scar revision becomes more of a useful technique.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi Dr Eppley, I have been reading with interest on the extensive archive of questions that you have previously responded to pertaining to scar revision. In one of the replies posted, you wrote that the extremities presents the most difficult anatomical sites on which to perform surgical revision. I have a long fairly wide <1 cm in most places) surgical scar sustained from ankle fracture surgery. It is slightly raised in areas, and slightly depressed in certain areas. It has been 3 yrs so it is actually no longer red but pale, shiny and wrinkled in areas. The scar bothers me greatly so I’ll really wish for it to be aggressively treated. I understand that the skin is thicker and more prone to shear /mechanical forces as explained in your response. If I plan to stay at home over the course of the entire recovery period and restrict movement to an absolute minimum, will this help my recovery to a large degree? I will also want to do taping/apply pressure (perhaps in the form of a compression garment or silicone sheeting) to prevent any widening of the scar. As an adjunct, I could possibly have dermabrasion or laser early in my recovery to improve the aesthetic outcome. Do you believe this to be a reasonable approach/treatment plan for improvement of my scar? Apologies in advance for the numerous questions; I’ll be extremely grateful if you can spend a few minutes of your time addressing the points I have raised above. Many many thanks!
A: Scars over the ankle are particularly difficult to improve. Since it is a wide scar, the primary basis for its treatment would be surgical excision (scar revision by cutting it out and re-closing it) to make it a more narrow line. Since it is a mature scar and very pliable, the end result should certainly be better than the width of the scar that exists now. The best treatment to do after would be cross-taping to resist the shear and tensional forces across the healing incision. Avoiding strenuous activities, such as exercise on it, for the first 6 to 8 weeks after its revision would be helpful. I do not think that severe physical restriction, however, would make a big difference as stresses across it will continue for years. The use of dermabrasion or laser may be secondarily useful depending upon how the scar outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have had a couple of surgeries on my shoulder to revise an old scar I have. However, I am not quite satisfied with the results. In retrospect, while I believe my surgeon did a decent job and intended well, he did make some crucial mistakes. I fully understand that each scar is different, but do believe that my expectations are all-in-all reasonable, that is why I am looking for the right expert to perform a last try to improve the scar in a way that is satisfactory to me. I have been impressed with the scar revision results you have posted and would like to know if it would be a start to send you some pictures of the scar, maybe follow up with a call if that makes sense. It is not a problem for me come over to the states for the surgery in case we come to a consensus. Thanks.
A: Scars on the shoulders are a particularly difficult problem. Between very thick skin and relatively constant motion, scars across the shoulders will often end up fairly wide and hypertrophic. This can occur even in well done scar revisions. I would be hesitant to state that your prior surgeon made ‘some crucial mistakes’ merely because the scar did not end up significantly improved. In considering any further efforts at shoulder scar revision, it would be extremely helpful to know what was done (surgically) to determine if a different surgical technique for scar revision can be used that might have a different outcome.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have several questions in regards to scar revision. When you perform a geometric broken pattern scar revision, then will you be cutting out more skin beside the original scar? What is the role of injecting Botox in the scar revision surgery?
A: Your assumption in how geometric scar revision works is correct. To make the various limbs and angles, some normal tissue in addition to the scar must be removed. This does not lengthen the scar in total visual length as the small tissue areas are taken from the sides of the scar not from the ends. If you straightened out the scar ins a single straight line, it would in fact be longer than the original scar by actual length measurement. But this increase in scar length is ‘internal’, staying within the original length of the scar.
The use of Botox in scar revision remains, at this point, entirely theoretical. Its use in scars is more hope than proven science. While Botox does seem to be good for a lot of problems, it is not good for everything. Botox works by decreasing nerve output, usually to muscle. Scar and any resultant hypertrophy or widening is not usually a muscle or nerve problem in most cases. Poor scarring is more related to tension on the wound edges and the type of skin and mechanism of injury. It is not clear why Botox would work for most scars unless it is weakening any pull on the scar edges from the underlying muscles in the critical scar phase of the first six months after its creation.
Dr. Barry Eppley
Indianapolis Indiana
Q: Sir, I have a couple two to four inch long hypertrophic scar on my inner forearm and it looks HORRIBLE. I have been using silicone sheets and scarguard with little help. I heard that steroid injections canhelp unbulk the scar and was wondering what your recommendations were?
A: Based on your pictures, you have a common scar condition known as hypertrophic scars. While often confused with keloids, they are not. They are still a normal scar process in which the scar tissue raises above the level of the surrounding skin bit still stays within the original boundaries of the scar. They also reach a certain point of hypertrophy and then get no higher. In the early phases of scar healing, a hypertrophic scar has the potential to be improved by numerous topical therapies including silicone sheeting and topical products. When collagen is being laid down, ti can be suppressed and even flattened by these type of scar approaches. This is also the period when steroid injections may also be useful. Once the scar is mature, however, these non-surgical therapies are unlikely to work. A mature scar is when collagen formation is no longer active and this is why the cross-linking of the collagen molecules is unlikely to be reversed.
At this point, scar excision and re-closure is the most assured method for improvement. The scars will get much narrower this way from the beginning. When the scar is removed in this controlled fashion, hypertrophy is less likely to occur. After scar revision, it is still appropriate and helpful to do topical scar therapies from the very beginning of new scar healing.
Dr. Barry Eppley
Q : My son is 5 years old and he has three scars on his face that we would like to have improved. The first scar is a laceration scar that is located above his eyebrow that happened about 2 years ago. The other two scars are minor scars that just never went away. We are just looking to see what options we have for scar revision and if he is even old enough to receive surgical treatment for his scars.
A: Age of the patient is rarely a reason that scar revision can not be done. The most important issue regarding age is how old is the scar? Scars that are immature, usually less than 6 months old, are often too ‘young’ for treatment as their appearance is still evolving. Scars that are raised, red or have initially appearing uneven skin edges will usually have improvement in these features as healing progresses.
Time is a scar’s best friend unless the scar has physical characteristics that time does not improve. One of the time-resistant features of a scar is width. As scars heal they will not get more narrow. Often the opposite will occur, they will get wider due to the effects of skin tension on them. For this reason, I may do scar revision early in very wide scars as waiting further only loses time in getting to a point of a better appearing scar.
On a different scar note, one of the most frequent misconceptions about what makes scars look better is that of laser resurfacing. It is commonly believed that the laser is the primary tool used in scar revision. This is completely false. It rarely can make a significant difference in how a scar looks. It’s role is often as an adjunctive tool after surgical scar revision is done.
Dr. Barry Eppley
Indianapolis, Indiana