LAM FACIAL PLASTICS

Dr. Lam-
As a child, I was burned with boiling water and had a very large scar about 3 square inches on my neck/cheek. I am 26 now. One year ago I went to a plastic surgeon who reccommended I could have a serial excision performed to take out a large portion of the scar. I have had three serial excision procedures under local anesthesia and now have a linear scar on my neck that measures 4 inches in length. At first the scar was beautiful. It closed very tightly and I could hardly tell I had a procedure. Now the scar has became very thick, painful and hypertrophic, and is about 1/2 inch wide. This hypertrophic tendency occurred within 8 weeks of each operation. Is there any way to keep this form happening? I would like to have a future excision of the hypertrophic scar. I am half-pakistani (1/2 caucasian) and I am skin Type IV. I feel as if the reason the scar becomes hypertrophic is because my skin does not stretch well and it is not very elastic. I would like the scar to stay the way it looks within 2-6 weeks after surgery. Is there a way to stretch the skin around the scar without insertion of a tissue expander? I really don't want to have a large bulge in my cheek for 2-3 months. What do you reccommend? btw.. thanks for helping people by answering questions for people in need. You are a great physician. Thanks, Alex

hi alex,
thanks for the nice remarks. in the future, a z-plasty can lengthen a contracted scar but it can also realign the direction so it is something i use sparingly. what i do in the early phases of almost all wounds if possible are three things to limit hypertrophic response:
1. silicone gel applied for the first 9 to 12 weeks every day.
2. KTP laser on the wound at 1 week, 1 month, and every month if need be.
3. 5FU injections at the earliest signs of thickening.
theoretically you could radiate it but i don't know how that works with hypertrophic scars, but i do know it works for keloids. i time the radiation to do that within 24 hours after excision.
best,
s.

Dr. Lam,

Thanks for the great advice.

I actually tried radiation after the last excision, but it was unsuccessful in preventing the reoccurrence of the hypertrophic scar. It was also very expensive. $10K for 3 sessions of radiation. Thank goodness for insurance. I will try to find a local physician to perform a KTP laser surgery after the next excision. Have you ever injected botox around the incision to limit tension on the wound? I read a recent study in a medical journal that this may help. Thanks, Alex

let me clarify: was your radiation performed within 24 hours of excision? if not, the success rate goes from 95% down to 30% or less. botox helps only if you are working in the upper face or sometimes in the neck. not in the middle face as much. so yes, i do do botox before all scar excisions that do not fall in the mid face. the lower face is too difficult because it screws up your speaking. the neck and upper face, yes botox is something i routinely do.
s.

Also, is the KTP laser more effective than fraxel? Would fraxel also help from the reoccurrence of the hypertrophic scar? Thanks, Alex

i believe fraxel will worsen it, considerably. the laser is meant to modulate the collagen not sear it with holes. that will engender more scar tissue.

Yes, the radiation was performed about 4 hours after the surgery and I had three consecutive sessions in three days. There was not any reduction in the hypertrophic scarring as a result of the radiation. My next excision is scheduled for 12/9 and it is just to remove the hypertrophic scarring. Also, the location of the excision scar is almost exactly in line with my jaw line (from my ear lobe to about 4 inches down my jaw). Should my plastic surgeon already have 5-FU, and I can request it during the surgery (performed under local anesthesia), or should I call beforehand? Also I will definietely try the KTP laser. Do you reccommend botox in this area, or do you think it will affect my speaking ability? I can send you a picture if you like. Thanks, Alex

if you have things teed up, definitely ask your surgeon. however, a few things:
1. for keloids, radiation is for 5 days not 3.
2. botox sounds reasonable and may be worth the temporary risk of speaking issues. i do this about a week or two before the procedure to let it settle and bind in.
3. i don't do 5FU until a few weeks out to minimize poor wound healing.
4. KTP or pulsed dye laser both work well. i would start that 1 week after and continue every couple of weeks if possible.
best,
sml

Dr. Lam,
Today I had the excision of the hypertrophic scar, and it looks like it will heal very nice (at least for the first 2 months). My surgeon also put a small amount of kenalog into the area after it was closed. I asked my surgeon about 5-FU and he is familiar with it as a chemotherapy/skin cancer drug, but he hasn't ever heard of it as a remedy to reduce hypertrophic scarring. I asked if he would be willing to inject it into the excision area in 1-2 weeks to prevent hypertrophic scarring, he said no. He also refused to inject botox in the area around the scar to reduce tension. He said the tape will serve the same purpose. I found a dermatologist to use the Pulsed-dye laser on my incision on 12/22/11. Will the scar come back if there is not any 5-FU added to the excision area, and only the laser is performed? I am very concerned and I don't want to have another surgery for excision of the hypertrophic scar. Is there another way I could obtain 5-FU and inject it myself? I have a small amount of medical training because I hold a biology/pre-med degree, but I never went forward to med school, I went for an MBA instead. The 5-FU is something I would like to have done, I just can't find a local doctor who is willing do it.

Thanks,

Alex

don't worry too much about the 5FU. there are very few people doing it. i would not advise a non-physician to do that. pulsed dye is a great idea. that will be important to limit this from coming back.

Dr. Lam,

What intensity should the doctor be using the pulsed dye laser? The hypertrophic scar has started to return, and I am extremely worried. I am actually freaking out!!! Dr. X has been doing a pulsed dye with 4 Joules intensity.

Thanks,

Alexander

hi,
first, i took out the doctor's name since i do not allow comments about other docs even if they are relatively neutral comments. second, i do not use a pulsed dye laser so i cannot speak as to the fluence that should be used. i am sorry about that.
best,
s.