Dr. Sam Lam Plastic Surgery Forum

I had a MOHS procedure 4 yrs ago to remove basal cell carcinoma just above my upper lip, resulting in a linear incision scar that angles upward from my mouth toward the cheek & is about 3/4 of an inch long. My dermatologist suggested dermbrasion, but I've had dermabrasion before & it left hypopigmentation on my very light olive (caucasian) skin. Is there a lasting filler that would help fill in this linear groove?

Additionally, 3 decades ago I had dermabrasion on acne scars & was left with a hypopigmented, quarter-sized, very slightly depressed area on my cheekbone. This rounded area is shiny white & even under heavy makeup, the edges show through as a circle of different texture & color. Can the edges of this scar be sanded down to blend in a little better w/the surrounding cheek? Or is there some other procedure (a filler?) that might help?

A thousand blessings on you for operating this forum - it's so generous of you to take time from your busy schedule to answer questions from an anxious public!

hi doodlebug,
i'm glad you are getting some useful info out of this forum. as far as the linear scar is concerned, dermabrasion is the best way to improve it in most cases. obviously, i would have to see it.

PCIT (percutaneous collagen induction therapy) is an alternative but so far in my hands disappointing. this is a procedure in which little needles run over a scar to generate collagen. it has almost no recovery but probably will not do enough to make an impact. however, you asked if there is an alternative.

it is really hard to fill a linear scar. it is better to sand it down. i know that hypopigmentation is always a risk. however, a really gentle dermabrasion with controlled hands hopefully should limit that risk. i rarely see that despite the fact that i use a more aggressive wire brush technique. in my hands, a wire brush is very safe. in someone else's it can be a WMD.

if you have a depression in the cheek, i prefer micro silicone to fill it in because it is permanent. you can also use restylane or radiesse as a long-acting, temporary filler. remember that these products last a lot longer than in the area around the mouth since there is less motion here. i would advise either restylane (because it is reversible) or silicone (which is not reversible, but since it is built up using micro droplets and a little at a time it can be as safe in experienced hands).

to manage the hypopigmentation standing out, a few things to consider that you can do:

1) bleach the surrounding skin with 4% hydroquinone, a prescription-strength bleaching product. i assume you know that you cannot go out in the sun with this product otherwise you will have no result plus it will possibly create a sun burn as it is photosensitizing.
2) that leads me to point#2, stay out of the sun. if an area of the face is not pigmenting well, it will stand out more with any sun exposure especially if you are olive skin, i.e., tan easily. also, you have heard me rant about how bad sun is for your skin as far as aging and you already have a skin cancer history!!!
3) you can also repigment areas that are hypopigmented using PUVA therapy, a type of ultraviolet light. however, the melanocytes (cells that create pigment in your skin) can refade after the series. i think this can be a bit dangerous because you may overpigment the area, then make it more noticeable in the other direction.

here is perhaps the best advise. as you heard, a lot of people who have had a procedure of any kind start to obsess with the treated area making them think that everyone and his brother notice the problem when actually only the individual himself/herself sees it. the problem is compounded in women because as makeup is applied women look way too closely to fix something that does not need fixing. plus, at the end of the day, it is very hard to make an improvement to the satisfy someone looking that closely to the problem, that is 3 inches away with magnification under hot lights.

okay, i know most of my forum readers know my beef. just trying to save people money that they don't need to spend and to minimize risk profiles by not doing excessive things to micromanage the face. that being said, i have not seen you in person so i have no idea whether these problems stand out to the casual bystander (not the overzealous overstudious friend of yours) but to me: a trained but neutral observer. also, you probably will have someone else notice your problem oftentimes ONLY AFTER you pointed it out to your friend/spouse/S.O. "Honey, don't you see this problem?" Now, he does! Anyways, my work is as much about psychology of perception as it is about quality PS work.
best,
sml

Dr. Lam, You are a credit to your profession, to take the time to give me & so many others such informative, detailed, kind responses - sure makes this TX-born exile wish I were back in Big D, so I could see you in your office on a regular basis. Please do NOT bother to reply to this msg, just wanted to say thanks again for this outstanding forum!

no problem. one more thing: the best way to fix a linear scar is a geometric broken line repair. however, a gblr is really bad in the upper lip because it will cause distortion to the surrounding lip area from taking too much tissue away. anyway, just forgot to put that in my response in case you were wondering. ditto for a z-plasty that can lengthen a lip, which is a bad trade-off unless it is contracted upward. then it is a great option. if you do not understand all of this, just read my scar revision faqs section which is in my faqs section. however, as stated, this does not pertain to you. again, thanks for the warm sentiments.