LAM FACIAL PLASTICS

Hi Dr. Lam, I have recently discovered your site, its amazing. Especially, the advice you give give is very impressive! I live in Ireland and I've been trying to find somebody with your level of knowledge, experience and conscientiousness here in Irleand or the UK. Unfortunately I've had no such luck so far. I really hope you can help me.

I have a cluster of about 10 hypertrophic scars on my chest (pictures attached). They are the result of acne from about 5 years ago. I'm 19 now. I went to a cosmetic surgeon who used steroid injections. The plan was to have 4 rounds of injections a couple of months apart, in the ones on my chest and a couple on the back of my shoulders. I had two rounds of injections. The results were not very good.

However, I had a very bad experience with this doctor, which resulted in me not going back. Now, its hard for me to trust in surgeons, but I see your site and I know there are still those conscientious ones out there who want to help people.

Do you think I'm a suitable candidate for excission, and maybe radiation? As I see this as the best chance of getting rid of the scars. Surgeons I have found seem to offer injections (I've lost a little faith in injections since the last treatment), but they don't really offer excission&radiation. What would you recommend?

If I could fly over from Irleand, would you be able to help me?
I really hope you can help as these scars really get to me! Looking forward to your advice.
Many thanks, James

james,
a few things:
1. i do not work on the body only the face, scalp, ears, and neck area. i am truly sorry about that. by focusing my skills only in a tiny area, i think i can offer more expertise.
2. that being said, when i work on the face and neck area, i totally argue in favor of surgical excision plus timed radiation. however on the chest, i am always worried of giving you worse scars there, as incisions on the chest typically heal very very poorly. sorry to disappoint you about that but want to be honest. if i were in your situation, i would do anything and everything in my power to avoid a physical incision. i think steroid injections and mixed with 5FU with a KTP type laser repeatedly every month until improvement with silicone gel may be advisable. however, i really should not be your surgeon for the point outlined in #1 and also because this may take many many sessions to get right and it is not right for me to do it if you live in the UK. i am sure someone there can help you. so sorry that you are so far away.
best,
sml

Thank you very much for your reply Dr. Lam.

It is a pity your a facial plastic surgeon and your so far away.
Is there anyone who you can recommend who specialises in body surgery?
Either in the UK or the US?

I know you recommended against any type of excision on the chest, but do you think it would still heal poorly if excision, radiation and somehow keep the tension off the wound while it healed? maybe with strips or something?

And if not excised you recommend injections with laser? I just have a couple of questions about that treatment.
(1) What kind of results can one expect - Is it possible to completely reduce the scars?
(2) Are the injections a skillful procedure from a surgeon's point of view? what i mean is, could one surgeon perform them better than the next. It's just that my injections the last time i got them didn't show great results, but as it turned out my surgeon wasn't very good. so my question is, if i find a better surgeon, would it be possible to get better results from the injections? Could the poor results be down to the way they were injected by the surgeon?
(3) From my two previous round of injections, some scars didn't reduce in size, and some did. However, the scars that did reduce in size, had a red/veiny kind of look. Is this normal? And does the laser improve the colour and the veins?

Thanks a million for the help!

Here are some bette quality pictures. There is one scar which is bigger than the rest. It looks like two smaller scars formed years ago into one big one. There is a close-up picture of the bigger scar.

It is a pity your a facial plastic surgeon and your so far away.
Is there anyone who you can recommend who specialises in body surgery?
Either in the UK or the US?
SORRY, I DON'T HAVE ANYONE.

I know you recommended against any type of excision on the chest, but do you think it would still heal poorly if excision, radiation and somehow keep the tension off the wound while it healed? maybe with strips or something? POSSIBLY. I WOULD PROBABLY ONLY TRY ONE TO MAKE SURE THAT IT DOES NOT WORSEN.

And if not excised you recommend injections with laser? I just have a couple of questions about that treatment.
(1) What kind of results can one expect - Is it possible to completely reduce the scars? NO, BUT THEY CAN BE MUCH FLATTER AND LESS VISIBLE.
(2) Are the injections a skillful procedure from a surgeon's point of view? what i mean is, could one surgeon perform them better than the next. It's just that my injections the last time i got them didn't show great results, but as it turned out my surgeon wasn't very good. so my question is, if i find a better surgeon, would it be possible to get better results from the injections? Could the poor results be down to the way they were injected by the surgeon? HARD TO SAY, I PERSONALLY BELIEVE IT IS NOT TECHNICALLY DIFFICULT TO DO BUT APPARENTLY THERE WOULD BE SOME DIFFERENCES BASED ON SOMEONE NOT EXPERIENCED DOING IT. HARD TO SAY TO ANSWER THAT QUESTION.
(3) From my two previous round of injections, some scars didn't reduce in size, and some did. However, the scars that did reduce in size, had a red/veiny kind of look. Is this normal? And does the laser improve the colour and the veins? YES, THE LASER HELPS. THE RED/VEINY LOOK MAY BE MORE A PRODUCT OF STEROID INJECTIONS THAN 5FU. BUT IT COULD STILL HAPPEN WITH 5FU.

Hi Dr Lam,

It has been a while since I last posted. I have had four steroid injections since. The scars on my chest have improved somewhat. Some have flattened dramatically, others not so much. I have attached new photos of the scars after the third injection.

The last time I posted I mentioned I was having difficulty finding a doctor who used excision and radiation on this side of the world (Ireland). Recently however, I found a doctor in The Netherlands who uses excision with radiation. However, instead of external beam radiation (which is what you use if I'm correct?), they use brachytherapy. This involves a small tube being left under stitches after surgery and removed the next day after all radiation has been administered ( 3x6Gy ).

I have only been in contact with the radiotherapist so far. He said he would talk to their plastic surgeon. I have not met the plastic surgeon yet. Therefore, I'm not sure what approach the plastic surgeon might suggest for the excision part. Are their any questions you think I should ask the plastic surgeon about the methods he's going to use? What type of techniques or methods would you use to excise hypertrophic/keloid scars on the chest? What would you recommend?

For instance, I'm not sure whether a straight excision or z-plasty or any other technique I've read about would be the way to go? I'd just like to have a better idea of the correct types of excision before I talk to any surgeon.

Once again, thanks for all your help,

James

honestly, i would not do fancy work like z-plasties or geometric lines because the more you cut the more you risk with these scars. i would do a simple excision that would be closed in at least 2 layers to minimize stretch back. beyond that you should speak with your surgeon about his experience with keloids.
best,
s.

Thanks for the quick reply.

I 'think' the plan might be a subcutaneous suture layer and a soluble intracutaneous layer. Is that the kind of thing you mean by 2 layers to minimise stretch back? (I'm sure those terms mean a lot more to you than they do to me haha)

I'm aware that the tension of the skin on the chest is a factor. Is there any way to reduce this tension while the healing takes place? I think I've seen you mention things like botox on this forum?


Also, what is the best follow up treatment that you recommend to try and achieve optimum healing and scar prevention? Things like medicated tape, lasers, silicone?


thanks,

James

just one layer below the skin and one on the skin should be sufficient. i don't think you need two under the skin. botox in the chest probably will not do enough because the muscles of the chest are huge. to botox it would be debilitating and expensive. the only thing i recommend is silicone gel or sheeting for the first 9 to 12 weeks following excision.
s.