Dr. Sam Lam Plastic Surgery Forum

Dr Lam,

I currently have 3 hypertrophic scar/keloid on my jawline near me ear. Not sure which one they are. They are about the size of a large pimple. I got them from acne. I am considering coming to see you, but I live in California. My question is, how many sessions is typical for a patient who comes to see you for these raised scars. Assuming you will do 5FU and laser treatments. Cost is the main factor, as I cannot afford many trips to Texas.

this is always a hard thing to estimate whether i see photos or you in person because response and healing are unpredictable. it would probably take a couple of rounds to get things improved if it is just hypertrophic scarring but it could take many more sessions. you might try to find someone more local to help you to be more realistic about things. i wish i can help you in the future if need be.
best,
sml

What factors would you consider as to whether you choose excision as the first option? as opposed to injections?

if it looks angry, i typically control it with laser and injections first. that is a qualitative feature, obviously. if it is hypertrophic, in general, it is usually better to get some front end control of it before excision. if it is a keloid, almost definitely unless you are considering radiation. if it is just a slightly thicker scar that is unattractive, i usually just go straight to excision. hope that helps.
best,
sml

Thanks for the quick response! I am considering doing a phone consultation with you, how far are you booked for those right now? Im really just at a loss and unsure as to what I want to do right now. I have an appt with a derm this week for kenalog injections, but don't even know if I wanna take that route. What is your opinion of kenalog?

1. as far as phone consults scheduling, you must call my office or email my office (info@lamfacialplastics.com). i have no idea. i know i am booking close to december but i think they make some accommodations for phone consults and can get you in earlier.
2. i personally HATE kenalog for hypertrophic scars. there is simply too much of a risk that can lead to dermal atrophy. i use 5-FU injections that truly are much safer. for keloids, i will blend in kenalog into the dilute 5-FU.
hope that helps.
best,
sml

Dr. Lam,

Continuing on this thread about hypertrophic scar revision... I remember in your earlier posts, you mentioned that during scar excision, you would consider using intraoperative injections (Kenalog + 5FU) with serious scars like keloids.

My question is, are these intraoperative injections injected after the wound has been sutured (sticking needle through closed skin), or right after the scar excision but before suturing the skin back together (when it's still open wound)? I'm asking because if the injection needle has to puncture through the skin to get the drug inside the wound, I'm worried this may cause dermal atrophy / needle holes on the skin's surface. Is this a valid concern?

first, if i am considering radiation, i don't even bother. the radiation will manage the keloid. if i am not planning on supportive radiation, then i inject the steroid after the wound is closed. if you do it before, the substance is dripping all over the place and will leak out. third, your understanding of dermal atrophy is flawed. it has nothing to do with a needle stick. it is just an unfavorable reaction when steroid is placed anytime in skin. that is why i almost never take the steroid risk except with monsters like keloids that do not respond well to 5-FU alone. i almost wish for dermal atrophy over a keloid recurrence. it is almost the lesser of two evils. when i deal with hypertrophic scars, i rarely inject steroids due to the risk. with that condition the risk far outweighs the benefits in my opinion even though 98% of surgeons out there liberally use steroid. mostly because they don't know about 5-FU or how to use it.
best,
sml

Thanks for the detailed response.

Besides dermal atrophy, what other significant risks are involved in using kenalog?

that's about it. but that is a big one.