LAM FACIAL PLASTICS

dear dr lam,

I'm a 24 year old male from the uk. 3 weeks ago i walked into a low balcony and got a 1 inch cross shaped scar on my forehead. i had 3 stitches. 6 days later the stitches were removed and the scar seemed to have healed remarkably well. unfortunately, as the scab began to come away, it became apparent that the scar had turned hypertrophic. obviously as it's at the centre of my forehead, i'm keen to do whatever i can to bring the scar down. i've started using the cica care silicone gel pads at night and am applying dermatix in the day. i've read that steroid injections can help, but was wondering what your thoughts on this would be? is it too early to consider this or some kind of steroid or laser treatment, or is it better to act fast? should i be massaging it to help break up scar tissue? how long do you think it roughly takes before you see an improvement in a hypertrophic scar in the forehead if you are using these products?

i know it may seem like i'm over reacting, but i've read the best time to help a scar heal better is early on, so i'd like to do everything possible to help it heal well. thank you for your time.

hi,
although i cannot exactly advise you on your situation, i can say in general that i do not use steroids because of a risk of atrophy of the skin. i prefer 5-fluorouracil but it must be injected slightly deeper to avoid skin color changes. if you don't have that, a laser like a pulsed-dye or KTP laser can typically manage the thickness and any redness. i tend to try to do it earlier like at a month or so because i can get better control earlier. silicone will help too so probably continue that. i like both laser and injection but sometimes not treating it still will progress well. you need to see a dermatologist or knowledgeable plastic surgeon to help manage your situation.
best,
sml

thanks so much for taking the time to reply to me. I'm certainly looking into the laser and the 5-fluorouracil treatments with interest. I guess my main concern i wanted to run by you before I invest money in either of these is whether you think the hypertrophic scarring will ever settle down to look like or return to normal skin? If the best case scenario (after the 5 flourouracil/laser treatments) is that it could settle to leave a thin layer of pale collagen over where the wound was, would I not be better to save my money, wait 6 months and then get it revised and hope this time it settles (like most forehead scars seem to) to a thin line? I've uploaded a few photos of how it currently looks to give you a better idea. thanks again for your time - i hugely appreciate it!

in general, i always like to manage a hypertrophic scar even if you are planning a scar revision for two reasons. first, one might be able to avoid a scar revision. second, if the scar is a ton less angry, it might not do the same thing when it is made angry again by a scar revision. hope that makes sense but remember that is how i manage scars. some doctors may have other ways to do things. don't use me as gospel but that is how i best practice medicine.
best,
sml

thanks so much dr. i have been looking into the treatments you mentioned, but can't seem to find any doctors who can offer the 5fu injections anywhere in the UK or Los Angeles (where I spend a lot of time). Do you happen to know of any? I met one plastic surgeon who offered me a steroid injection, however the 'possible atrophy' seemed a bit of an unnecessary risk to take.

i know it may be hard to tell at this stage, but judging from the photos do you think my scar could be successfully managed with injections/lasers, or would it benefit better from a revision? from my research, it almost seems like a series of laser/injection treatments would cost more than a revision, and as i probably don't have enough money to afford to do both, i want to spend what i have wisely.

i don't know of anyone per se. i don't know how to advise you. it is hard for me to suggest a revision without starting with laser and injections based on my above comments. that is something you will have to see a doctor to help you determine the best course of action in your situation.
best,
sml

Dear Dr Lam.

I wanted to write to you to update you on the progress since I last posted on here. I am now in los angeles and have been to see a couple of plastic surgeons out here and had a pulsed dye laser treatment. The laser has taken a lot of the redness out of the scar, however there is still a fairly thick layer of collegen left behind (as you can see from the attached photo).

I hope you don't mind me writing again, but I am a little confused as the advice from the 2 plastic surgeons I saw seemed to contradict one another. One thought I'd be best having the thickened portion of the scar revised. He said as it was 'barely hypertrophic' it would be pretty risk free. The other plastic surgeon seemed to think i'd be 'crazy' to have it revised, and that a laser followed by a subcision would fix the problem. Obviously I'm keen to get the best result possible and am a little unsure which of these options would be best. I wanted to write to you to ask what you'd recommend doing, as your advice really helped me last time. I was also wondering if you thought either a fraxel restore laser or micro-dermabasion would help at all?

Thanks so much for taking the time - I really do appreciate it, and truly value your input.

fraxel repair and microdermabrasion in my opinion won't help. subcision probably won't do much but it might. that is more a conservative approach. sometimes just waiting may improve it with time, but not perfectly. revision is an option but obviously has risks with it in making it worse. i would have to see how lax the area is and how it is improving. if it is improving, you might want to leave it. if it is static and not improving, i would probably consider a revision so long as you know that it will take another year to look good. i tend to prebotox the area 2 weeks before and once after so that the area does not stretch back. i also would do a limited geometric broken line to make the line less irregular. finally, i would go with at least a 2-layer closure. those are my thoughts.
best,
sml

thanks so much dr. It does seem to be improving so I think I will leave it for the next few months and maybe try a subcision in the meantime to see if that helps. If I'm still unhappy with it or if it hasn't improved much after then - i will look into having it revised.

Thanks again for your input!

my pleasure.

dear dr lam,

i'm sorry to have to write to you again, but i just wanted to ask one more quick question.. the scar on my forehead has not improved in the last few weeks and i've decided to have it revised next week, while i'm still in los angeles. as it's only about 2 cm and runs along a rstl, the plastic surgeon is going to do a small fusiform excision. i just wanted to write to you as my biggest fear is that it could go hypertrophic again, and i was wondering if there' was anything you would recommend i do to help prevent this? do you think a small injection of very diluted steroid would be a good idea? i know there's the possible risk of atrophy, but i'm thinking that's a risk i'd prefer to take than possible hypertrophy. if there's any other things you can think of that i can do to help the scar in the early stages - i'd be most grateful for your advise! many thanks.

basically, i am opposed to steroids in hypertrophic scars. to manage hypertrophic scars i use silicone sheeting or gel after the first week for the first 12 weeks. i also see my patient at 3 to 4 weeks to begin KTP laser and 5FU injections. i believe managing a scar with these techniques early can help minimize hypertrophic scars. obviously, good surgical technique is the most important starting point. good luck.
best,
sml