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  • It is currently Sat May 25, 2013 3:05 am

Mohs nose woes advice please!

This section of the forum is dedicated to discussions addressing linear scars, depressed scars, keloid scars, hypertrophic scars, and other facial reconstructive topics. (Of note, Dr. Lam no longer accepts medical insurance so he rarely manages cancer reconstruction or trauma anymore.)
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Mohs nose woes advice please!

Postby jimboh » Sun Jun 07, 2009 2:18 pm

Dear Dr. Lam,
I greatly appeciate the understanding and compassion you show by taking the time to share your tremendous wealth of knowledge and expertise! I'm a middle age white male and my biggest concern about my atrophic "1/2 wide by "3/4 high U shaped scar from a skin flap, following Mohs for BCC, that is centered on the bridge of my nose is the soft, shallow and gradual horizontal half moon shaped depression at the bottom. It looks bad outdoors and in the shadows casted by certain lighting. Presumably, the mild vertical line incision scars, which are more sharply but less depressed, could be fine tuned and plumped up with a fractional laser in skilled hands, or would you say that this collagen stimulating laser can't be pinpointed precisely enough? Additionally, I've been told that this treatment wouldn't stimulate enough collagen to fill in the horizontal contour deformity that is not much deeper than "1/16. Do you agree or do you think it really depends on the skill of the doctor?
Of course, I would prefer to avoid another surgery. However, is another shorter flap pulled up from below a good option despite virtually no horizontal scar texture issues and the long healing process that would follow? I also have a "1/2 long moderately deep atrophic childhood scar between my eyes that I would like to have surgically revised. Perhaps some fat could be harvested from there and injected into the depression below or would you recommend another filler instead and if so which one(s) would work best? I live in another state so for this and other reasons I would really prefer a permanent correction but the best possible result is my first priority.
Another factor to consider is that this U shaped "trapdoor" scar is apparently adhereing to the underlying tissue. So can and should these adhesions be broken up with saline injections or something else first perhaps? Or would self massage be effective on this 2 plus year old scar?
Of course, I understand that your answers are sight unseen and based on my subjective description. Regardless, I greatly value your opinion as the foremost authority on this subject. Please reply. Thank you very much!
jimboh
 
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Joined: Sun Jun 07, 2009 12:33 pm
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Re: Mohs nose woes advice please!

Postby dr. lam » Sun Jun 07, 2009 9:59 pm

thanks for the comments:
1. a trapdoor deformity usually needs to be surgically revised. anything short of that will probably lead to failure. part of the trick with doing a nose is undermining in a different plane than where most docs go that is not below the skin but just above bone lining called periosteum (the plane is called sub-SMAS). i would say that is the #1 reason for bad healing is very superficial depth of dissection. you should have that done most likely if i see you in person to alleviate the trapdoor followed by dermabrasion to clean the edges.
2. the other techniques you suggest are probably going to do very little to be honest but if you are just injecting saline that sounds like a pretty non-invasive therapy. my opinion is that it will probably do very little.
3. do NOT inject fat into a small atrophic scar. do a search in this forum and you will see why. fat is a live graft and is not bioinert so it can grow and get lumpy over time by doing selective injections. that is why i use it to gently contour the face. it is not like silicone. also, fillers between your eyes carries with them a distinct risk of skin loss. therefore, i only use restylane there not even silicone and you keep my phone number for the night of the procedure in case you have a problem. that area i rarely do due to the significant risks of filling but i do it when someone really needs it with proper consent and a way to reach me if an emergency arises. if a doctor does not explain these issues to you regarding between your eyes do not let that person inject you. if they do not carry hyaluronidase in the office, do not let him/her inject you. if they do not carry nitropaste in the office, do not let him/her inject you. i am specifically talking about the area between the eyes.
best,
sml
Samuel M. Lam, M.D., F.A.C.S.
Diplomate, American Board of Facial Plastic & Reconstructive Surgery
Diplomate, American Board of Otolaryngology Head & Neck Surgery
Diplomate, American Board of Hair Restoration Surgery
dr. lam
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Location: Dallas Texas
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