LAM FACIAL PLASTICS

Hello Dr Lam,

I am hoping so much that you can help me. I came to see you a couple years ago for what I thought was bad acne scarring; now I only wish that was my problem.

I developed a huge cyst last August; it has morphed into a big scar and I am hoping you could provide some insight as to the best course of action to take.

It has multiple issues; first the surface of the skin has something like grooves/icepick scars around the edge of it. These showed up recently within the last month. They are not from me messing with it so I believe it is rapidly forming scar tissue; tethering down deep and pulling tight around it. This would make sense because it kinda looks like a lump and it appears encapsulated.
So for the surface of the skin would TCA cross fix the surface lines/crevices/pinhole scars around it?
The other issue is the mound of tissue of where the cyst used to be. I wanted to know if 5-FU would treat this effectively? Do you favor that over cortisone? I'm not sure if it would be considered hypertrohpic; it's not raised above the skin; it just appears that way because it's pulling the skin down so much around it.
And thirdly I'm considering subcision to break the hold on the surrounding scar tissue. I think that might work on this because I've had success before with that. But I think it would need to done the same time as the 5FU injections.
I read about the combo of subcision and 5FU with steroids on here: http://www.aao.org/publications/eyenet/ ... astics.cfm
Those doctors subcised the scar tissue with the needle before they inject the 5-fu and that combo worked well for them.

I have also considered excision but that's my last choice because because I'm really scared about being scarred with an even bigger surgical scar. One of the surgeons told me it would leave a horrible scar if I had it excised within 6-9 months of having cortisone injections.........is that true?
I've seen 2 plastic surgeons so far and they both said to give it time and let it heal, but that was before it started looking like this and they aren't specialists with facial issues like you are.
The problem with giving it time (besides that every day is miserable like this) is that is everything' I've read says scars are easier to treat when they're newer and that the older the scar is the harder the tissue is to treat. Infact the doctor interviewed in the above article said 5Fu is best used withint the 1st 10 weeks of the scars appearance. Is that true?

I've had skin issues my whole life but have never ever had a scar that looked like this; it was always just shallow atrophic scars. I'm terrified that my face is ruined.
Thank you for your thoughtfulness on this forum.

here are my thoughts. if there is a sebaceous cyst underneath, that is a cyst that is still there, the whole thing must be surgically excised or it will continue to recur. if it was just an acne cyst, then disregard the above comment because it should be gone.

yes, i would try 5FU alone without cortisone and light IPL or KTP or PDL laser to the area in combination to see what happens. i personally don't like cortisone for anything that is not terribly large like a keloid because of the risks of atrophy. i think 5FU works well in any stage of scarring but it is always better to get it early before scars get worse. plus, i disagree that surgery is worse after steroids or that it is worse later. it is actually better later when the scar is not as angry or reactive. that being said, if conservative measures fail, you should consider a geometric broken line repair excision, which will expand the area but should make it better in the end (not perfect) but better with the right surgeon and with good after care (meaning possible laser, 5FU, dermabrasion). i would also consider silicone gel or tape to the area to help it also in the healing phase. silicone unfortunately is more effective in the first 3 to 4 months after scar formation. hope that helps.

Ok, thanks.
Are you saying silicone now? Or after I do a procedure?
And how would the laser help me? Is that for the surface icepick/groove type of scarring that you're suggesting that?
I am glad to hear you dont' think the cortisone shots would prevent surgery recovery. I still don't think I should do that yet but glad to know if it comes to that I don't have to worry about the kenalog shots.

i am saying silicone sheets can help now and after surgery. it is hard to say how much the laser would help partly because i need to see and feel the scar to determine that and also how you respond to it is clearly variable.

Hi Dr Lam,
I went and saw Dr X in NYC and he felt it was very much a hypertrophic scar. He suggested a few more cortisone shots and if it doesn't respond to the cortisone to do a shave excision.
I had never heard of shave excision,Do you do them? Do you recommend them for hypertropic scars??
If not, what is your normal treatment for hypertrophic scars?
Thank you so much again!

sorry, i removed the name of the physician to follow forum guidelines. i supposed you can shave it. that could make it come back angrier. for me, if it fails injection methods, i cut it out and restitch the area.
s.

Ok, sorry, I didn't know about that rule.
When you say "cut it out", does that mean cutting all the way around it? Or could you cut a slit in the middle of it and remove the cyst/scar tissue with minimum incision and scar that way?

Also was wondering how long would the 5fu take to work? Can you tell within a few days? Is it as fast as cortisone?

sometimes but sometimes you don't see as much change for a few weeks.

Ok, thank you.
Also, if there is still some type of active "cyst" in there would the 5FU have any negative effect on it?
I doubt that that is the case because its been so many months and feels very hard but I wanted to know just in case.
Thanks!

the only thing is i would not like to pop a cyst and spill its contents and cause more scarring so that a cyst would be harder to remove so it really depends what you have and what is going on to answer your question better.

Ok.
I have also noticed it is looking often very white in the middle lately; like in the last 3 weeks.
I saw a local plastic surgeon and he said "Maybe the white part is cortisone/kenalog granules; I've seen that happen before".
I don't know if you've heard of that but I wanted to know; If that is what's going on here; is there a way to get the cortisone/kenalog out?
I know it normally just fades away but I'm wondering if because I've had so many kenalog injections and because its so walled off; perhaps it's granulated and stuck in there?
It kind of makes sense because it doesn't hurt at all.
What do you think?

the only thing i can think of is what your PS has said because cortisone can cause atrophy of the tissue which can show up that way. that is why in general i am very very conservative with kenalog, typically diluting it and only using it in combination with 5FU and only when 5FU fails.
s.

Ok, so if there's kenalog stuck in there is there any way to disperse it?

And if there is is no way to manually get it out, how long does cortisone/kenalog stay in the tissue?

Thanks again!

kenalog is gone. the effect is not. you will just have to wait and hope that all effects dissipate over time. they don't always do but in most cases they do over several months to a year.