“I find that 90% of the time when you look at a thickened scar and you think, ‘Oh gee, I’m going to have to do some scar revision, the intralesional triamcinolone takes care of the problem,” he said. He usually injects the site at about 6 weeks post surgery using 10 mg/mL. If the response is inadequate he reinjects about a month later using 20 mg/mL. He generally avoids going to 40 mg/mL for facial scars. The goal is to make therapeutic use of the steroid’s major side effect – atrophy – to shrink the thickened scar. But because this can be a tricky business, of late he has turned increasingly to intralesional triamcinolone and 5-fluorouracil (5-FU).
Intralesional triamcinolone plus 5-FU. This combination causes less atrophy, hypopigmentation, and telangiectasias than full-on triamcinolone. He injects 0.9 mL of 5-FU at 50 mg/mL and 0.1 mL of triamcinolone at 40 mg/mL into and under the scar. The 5-FU inhibits fibroblast proliferation. It is rated pregnancy category D, so he avoids using it in women of childbearing age.
Spot dermabrasion. “To me, this is the go-to. After my intralesional steroids, if the scar hasn’t fully smoothed out, then I go to dermabrasion or the spot CO2 laser,” Dr. Hruza said.
“Dermabrasion is an old technology, but it’s actually still very useful,” he continued. “Do it at 6-10 weeks; that’s the sweet spot. Do it sooner and you can get into problems with dehiscence. And if you do it later than 10 weeks the improvement is much less because everything is stabilized and the collagen is set.” He uses a diamond fraise to abrade and sculpt, rather than sandpaper, which doesn’t allow him to go sufficiently deep once bleeding starts and the sandpaper gets wet.
Spot conventional CO2 or Er:YAG laser resurfacing. “I really find in my hands these ablative techniques are much more effective than using a fractionated laser, which only gives you a little bit of improvement,” he said.
Pulsed dye laser. Very effective for red, thickened scars. Dr. Hruza does two to four treatments at 4-week intervals. At wavelengths of 585-595 nm, a pulse of 0.5-1.5 millisecs, and 4-5 Joules/cm2, there is only minimal purpura.
The pulsed dye laser can also be employed preventively starting at the time of suture removal and then again at 4-6 weeks in order to reduce hypertrophy. “It’s something to consider in areas like the chest, upper back, and shoulders, where you’re trying to prevent problems. The only danger is occasionally patients have dehiscence,” according to the dermatologic surgeon.
Fractionated nonablative laser. Four or five treatments are typically required in order to achieve significant resurfacing.
Micropore tape. Dr. Hruza finds this works just as well as topical silicone gel sheets, rolls, and gels, all of which are quite expensive. A roll of micropore tape costs only a few dollars and will last a patient for a couple months. Patients are taught to apply the tape at the time of suture removal in a line parallel to the suture line, replacing the tape when it begins to peel off. As with the vastly more expensive silicone products, the tape needs to be left on 12-24 hours per day for 3-6 months in order to achieve a flat white scar. The benefit is thought to come from relief of mechanical stress coupled with occlusion.
Botulinum toxin A and other neurotoxins. Inject into muscle near the wound edges right after closing the wound, using 1-3 units at 1- to 3-cm intervals in order to prevent scar formation, Dr. Hruza advised. If the wound is on one side of the face, the other side needs to receive injections as well in order to spare the patient from several months of cosmetically undesirable asymmetry. However, Dr. Hruza rarely utilizes neurotoxin injections. “It’s a cost issue. I’m in the Midwest, where a lot of insurers are unwilling to pay for it,” he explained.
Flap defatting. Here the surgeon opens the flap and keeps digging with scalpel and scissors until the scar is slightly depressed, since there is likely to be some recurrence. Then it’s time to resuture the flap.
Technical scar revision procedures. The simplest of these is Z-plasty, which entails making two skin incisions to create a Z-shaped incision, then flipping the two sides to reorient the scar. The Z-plasty has two major uses: correction of a retracted lip or medial canthus webbing. “If you get either of these, Z-plasty is the way to go,” Dr. Hruza said.
Fillers for atrophic scars. “To me, this is the last thing to go to. The reason is that, if a patient has skin cancer surgery, they don’t expect to pay extra to improve that scar. And I can do dermabrasion with no incremental product cost to the practice,” he commented. The technique entails making a subcision to create a pocket for the filler. The products marketed as Restylane Silk, Belotero, and Radiesse all yield good results, he said.