LAM FACIAL PLASTICS

Hi Dr. Lam,

Several years ago I was in a car accident, and a hypertrophic scar developed at the injury site. I am a Chinese with type IV skin, which I believe is genetically more susceptible to hypertrophic scarring than Caucasian skin. The scar is red, thick, and wide (5mm). I know sunlight exposure would cause hyperpigmentation so I have been keeping that to a minimum. I have also tried applying silicone gel sheets, but they do not seem to help much.

I would like to undergo surgical scar revision to reduce its width to a flat, thin line. However, the scar site is located in an area where it is subjected to tension trying to pull it apart, which I believe is a major factor in causing scar widening.

I would like to ask: After the scar is excised and closed under favourable conditions, what can I do post-operatively to prevent scar widening and fade the redness? Since I already know that I am prone to hypertrophic scarring, I would like to take preventative measures to stop HS before it has a chance to develop.

Would any of the following help?

To prevent scar widening:
- how effective is the application of paper tapes on the incision, bridging it to minimize the tension? For how long would I have to apply them?
- are Botox injections effective? How many injections would be needed?

To minimize redness and thickness:
- should I have Kenalog steroid injected into the scar? If so, should it be injected during the surgery, or a couple of weeks afterwards? How many injections are needed and how frequent?
- is laser therapy effective in reducing the redness? I have heard that 585nm pulsed dye is the laser of choice for hypertrophic scars. Is that true? If so, how soon should I begin?
- should I apply some sort of pressure on the scar immediately after the operation in order to prevent thickening?

Please also suggest other methods not mentioned above. Thanks a lot for your attention!

Hi,
1. As far as Asians being more prone to this, yes.
2. Sounds as if scar revision is your best bet. I would consider doing a z-plasty if the angles of the scar face the wrong way or are contracted. Or, if there is enough laxity (which you are suggesting no), I would consider a geometric broken line repair. I would have to evaluate it personally to determine that.
3 Botox and taping are important and recommended. I really just do Botox one time. Taping you can do for the first 2 to 3 months.
4. If it gets red, I do recommend a vascular laser. I use the KTP which is a 532 nm and works just as well as the PDL. I do that starting 3 weeks post as needed. Every 3 to 4 weeks as needed.
5. I don't believe in kenalog in almost any skin types due to the risk of color issues and/or atrophy. I tend to prefer 5-FU (5-flourouracil), which I find just as effective and also far less risky.
6. One of the huge ways that I reduce stretchback is a two layer closure with interrupted sutures in the deep layer. That really helps minimize stretchback. Can I promise you no stretchback? No, I can't but it does help significantly.
7. All other creams and stuff are useless. Silicone sheeting is only really valid for frank keloids not really for hypertrophic scars. Silicone realigns collagen bundles which you do not need to do with hypertrophic scars.
best,
sml

Dr. Lam,

Thank you very much for your detailed response. I have a few more questions:

1. Would 5-FU, a commonly used drug for cancer chemotherapy, pose significant side effects? I have heard that during the course of chemotherapy treatment, patients experience serious fatigue, hair loss and diarrhea.

2. If 5-FU were to be used to prevent hypertrophic scarring, typically how many injections would be needed and how frequent? Would the 5-FU be injected at the time of surgery, or a few weeks post-op (already knowing that I am prone to hypertrophic scarring)?

3. What kind of tapes should be used to minimize scar tension for the first 2-3 months? Are Steri strips made by 3M a good choice, or are there better alternatives? Is Matisol or Benzoin normally used to increase the tape adhesiveness?

4. I have heard that some surgeons prescribe Retin-A to be applied on the incision site, then cover the incision with paper tapes to reduce scar tension. Do you think this is a good way to prevent HS?

5. Do you think applying Aldara after scar excision can be used to prevent hypertrophic recurrence?

6. With Asian patients who are prone to hypertrophic scarring, after surgical scar excision, would it be sufficient to rely solely on paper tapes and laser to prevent hypertrophic recurrence? I am worried that injectibles would cause negative side effects, so I want to avoid them if at all possible. I received one shot of Kenalog in a segment of the scar; as you have mentioned, a colour change problem (hypopigmentation) occurred.

1. Would 5-FU, a commonly used drug for cancer chemotherapy, pose significant side effects? I have heard that during the course of chemotherapy treatment, patients experience serious fatigue, hair loss and diarrhea.

NO.

2. If 5-FU were to be used to prevent hypertrophic scarring, typically how many injections would be needed and how frequent? Would the 5-FU be injected at the time of surgery, or a few weeks post-op (already knowing that I am prone to hypertrophic scarring)?

HARD TO SAY HOW MANY. ANYWHERE BETWEEN 1 AND MANY (LIKE 5 TO 6). IF SOMEONE HAS A REAL RISK OF HYPERTROPHIC SCARRING OR KELOID, THEN I CAN AND SOMETIMES PUT A LITTLE 5-FU IN THERE. FOR EXAMPLE, I REMOVED A MASSIVE KELOID FROM THE BACK OF AN EAR TODAY THAT I USED 5-FU IMMEDIATELY IN THERE. IN GENERAL HOWEVER, I WAIT A FEW WEEKS TO START.

3. What kind of tapes should be used to minimize scar tension for the first 2-3 months? Are Steri strips made by 3M a good choice, or are there better alternatives? Is Matisol or Benzoin normally used to increase the tape adhesiveness?
JUST PLAIN PAPER TAPE IS FINE. STERI-STRIPS ARE TOO EXPENSIVE. IF YOU CAN GET MASTISOL (OR BENZOIN) THAT IS NICE BUT NOT CRITICAL.
4. I have heard that some surgeons prescribe Retin-A to be applied on the incision site, then cover the incision with paper tapes to reduce scar tension. Do you think this is a good way to prevent HS?

I HAVE NEVER DONE THAT.

5. Do you think applying Aldara after scar excision can be used to prevent hypertrophic recurrence?

I THINK ALDARA IS A GREAT IDEA FOR KELOIDS. I THINK THAT IS NOT A BAD IDEA FOR HYPERTROPHIC SCARS TOO. THEY WON'T MELT SCARS BUT THEY CAN HELP LIMIT THEIR RECURRENCE, AS YOU SUGGEST.

6. With Asian patients who are prone to hypertrophic scarring, after surgical scar excision, would it be sufficient to rely solely on paper tapes and laser to prevent hypertrophic recurrence? I am worried that injectibles would cause negative side effects, so I want to avoid them if at all possible. I received one shot of Kenalog in a segment of the scar; as you have mentioned, a colour change problem (hypopigmentation) occurred.
5-FU IS MUCH SAFER AND I USE IT ALL THE TIME. IF YOU ARE TRULY PRONE TO HYPERTROPHIC SCARRING AND IT BEGINS TO OCCUR, THE 5-FU IS NECESSARY TOO.