Dr. Sam Lam Plastic Surgery Forum

So let's say the scar is deemed appropriate for excision. After the operation, how soon will the 5-fu/laser combination treatment begin? Right after the sutures come out and the wound is closed which is, if I am not mistaken, roughly 2 weeks post-op usually if there are no complications?
IN BAD CASES, I DO IT INTRAOPERATIVELY, I.E., AT THE TIME OF THE PROCEDURE. I JUST TOOK OUT THIS MOUND OF SCAR ON FRIDAY IN THE LOWER WHITE LIP FOR A LADY WHO HAD A BURN INJURY THERE AND INJECTED 5-FU AND STEROID INTO IT RIGHT AT THE END OF THE PROCEDURE. SUTURES ARE REMOVED ON THE FACE AT 1 WEEK (7 DAYS) AND IN THE NECK/SCALP/EARS AT 10 DAYS.

Also, knowing a patient is prone to hypertrophic scarring, is it beneficial to inject some 5-fu DURING the excision operation, in order to start the hypertrophy-prevention process as soon as possible? Will this intervene and delay the normal wound healing?
SEE THE ANSWER ABOVE. USUALLY NO SIGNIFICANT DELAY. THE FACE HEALS WELL.

You mentioned that the 5-fu/laser treatment is not always successful. I understand that it adds little value to give a success percentage, but would you say there is at least a 50-50 chance of it being effective in preventing hypertrophy? I just want to know my chances before making a decision.
I WOULD SAY THE SUCCESS RATE IN MY HANDS IS VERY HIGH (I DON'T LIKE PERCENTAGES BECAUSE EVERYONE'S PERCEPTION IS DIFFERENT). HOWEVER, WHEN I MEAN VERY HIGH IT MEANS SEVERAL THINGS:
1. NOT A PERFECT RESULT IN THAT THERE COULD BE SOME RESIDUAL MILD HYPERTROPHY. HOPEFULLY ALL GONE BUT CANNOT ABSOLUTELY PROMISE.
2. IF I AM NOT DEALING WITH A KELOID, IN WHICH ALL BETS ARE OFF.

Dear Dr. Lam,

I heard that sometimes excessive strength from the vascular laser would discolour the skin and cause prolonged swelling.

While applying KTP / PDL lasers on a hypertrophic scar, what is the range of spot sizes (mm), pulse width (ms), and fluence (J/cm^2) that you have found to be the most effective? My scar is about 6-8mm wide, red, and slightly raised.

of course, overdoing any laser intensity can create swelling and longer recovery. i don't like to comment on fluences here because i think it is dangerous to recommend treatment protocols and be responsible for those recommendations on the Net. sorry.
sml

Dear Dr. Lam,

I have read that 5% Imiquidmod cream (Aldara) has been successful in some cases to prevent hypertrophic scarring / keloids. A study claimed that application of Aldara on keloid excision sites prevented keloid recurrence at 24 weeks post-op, and the full link can be found here --> http://www.emedicine.com/derm/TOPIC205.HTM

"The authors have studied the effects of topically applied imiquimod 5% cream (Aldara) on the postexcision recurrence rates of 13 keloids excised surgically from 12 patients.

Starting the night of surgery, imiquimod 5% cream was applied for 8 weeks. Patients were examined at weeks 4, 8, 16, and 24 for local erythema, edema, erosions, pigment alteration, and/or recurrence of the keloid. Of the 11 keloids evaluated at 24 weeks, none (0%) recurred. The rate of hyperpigmentation was 63.6%. Two cases of mild irritation and superficial erosion cleared with temporary discontinuation of imiquimod. Both patients completed the 8 weeks of topical therapy and the final 24-week assessment."
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Since sometimes the efficacy of treatments is quite different in clinical practice than on paper, I would like ask if you have used or considered Aldara while treating hypertrophic scarring? If yes, how were the results?

Another question: you mentioned before that you much preferred 5-FU over Kenalog when dealing with hypertrophic scars... why is that? What are the most common risks of Kenalog?

Thanks again for taking the time to answer my questions.

1. Yes, I use Aldara for keloids only. I think I can usually manage hypertrophic scars without the need for Aldara but would use it if I needed to. I have only been using Aldara for the past 6 months so I don't have enough clinical experience to speak authoritatively on the subject.
2. I do use kenalog for keloids but routinely not that often for first-time hypertrophic scars. The real risk of kenalog is "dermal atrophy" that can lead to a glistening white skin devoid of the pores and also can be sunken in like a hole. Usually this complication is temporary but I would rather never see it if possible.
best,
sml

During your 6-month experience with Aldara, what were the adverse effects (temporary or prolonged), if any? Some praise it as a miracle drug, while others complain about fatigue, muscle ache, and burning feeling.

I understand that you do not yet have enough clinical experience with the imiquimod, but could you tell me the keloid recurrence rate among your patients so far, after the application of Aldara on a newly excised site?

Also, for keloids do you use Aldara as a complement to 5-FU/steroid injections?

aldara is only a complement to my other treatments. when i deal with a keloid, i throw the kitchen sink at it. so far, i have not had a complaint of any side effects. bottom line is that if you are really interested in Aldara, I am not the one to comment appropriately on it.
sml

Dr. Lam,

What do you think about the application of topical 5-FU cream, instead of injections, on hypertrophic scars? It would certainly be less painful. Would its efficacy be similar to injections?

Also, some claim that IPL (intense pulse laser) is as effective on hypertrophic scars as KTP or PDL laser. Do you think this is accurate?

Honestly, I have no experience with topical 5-FU or IPL compared with KTP. You expect honest responses from me, and that is what you are getting.
Best,
SML

Hi doc,

this has been an interesting thread, as i myself am planning to come in for a consultation for hypertrophic scar revision.

after a hypertrophic scar is excised, how soon will you start using the ktp laser and 5-fu injections on the incision? within 1 or 2 weeks post-excision?

yes, sometimes, i even put it in earlier like at the time of the procedure. if i get it all out and it looks better, sometimes i wait a month or so. i need to see you to decide that.
best,
sml

how about the ktp laser? how many weeks post-op would you wait to start that?

no perfect answer. in general 3 to 4 weeks after but occasionally a week after.

hi dr.lam

i have 2 hypertrophic scars which resulted from an op i had back in 2004. they are located ard the collarbone area. slightly below the neck.

for the 1st scar, i had 3-4 steroid injection and half of it has shrunk till its a thin line although its raised and red and the other half has shrunk as well, just not as much as the previous half.

my 2nd scar is located right below my 1st scar and altho i had steroid jabs for it as well, there were no improvement at all. the scar is smaller and i think it somehow merged with my 1st scar (the half that did not shrink as much) or at least it looked like it did.

my doc stopped injection because she commented that my surrounding skin is thinning.this was back in 2007, now im keen to laser it off so do you recommend PDL + 5fu injection for my case? if not, what do you recommend? thanks!

P.S my scar has remain the same (since it shrank) even after these past 4 yrs.

as i explained in my email to you , i think your scars look like burn injuries and should probably be treated as such. since i don't specialize in that, i would have to refer you out to someone else who does. i would say that 5FU and KTP laser would provide little improvement in your situation. i personally hate long-term steroids in areas because i think ultimately the tissues atrophy and things look worse instead of better.
s.