What Is The Best Way To Do My Forehead Scar Revision?

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