Dr. Pavan N Murdeshwar
plastic surgery-reconstructive and cosmetic surgery
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hi doctor,
I have been bitten by a dog three months ago. I have multiple scars but the worst one is above the upper lip. Unfortunately, I went to a dermatologist recommended by family and he insisted to apply Yag Laser at 55 days post-bite. I asked if it was not too soon but he said it was harmless and would only be targeting the vessels that were giving the scar the red color. I trusted and it hurt a lot. Immediately after it was horrible looking but the doctor said it was normal and not to worry. The next day I had blisters that resolved two weeks later. One month and a half later my scar that was a red line is now horrible and has local indentations. Seems that I have lost tissue on the blisters site. 15 days ago the dermatologist said it would resolve and I would not be worst than before the laser. Now I returned to his office and he tells me that it may pass but it will take two years. I am devastated and so depressed. It has been psychological hell.
Can the sunken areas really fill with time and become a line scar again? I am more than a month and a half now. I have red people burned by YAG laser and never recovered. I have been applying Cica Care (silicone sheet) but I do not see any improvement. The doctor wants me to apply Hydroquinone but I stopped to trust him really. Also in a few months, if the skin does not return to normal level, will scar revision work on this site to give me a virtually invisible scar? I am so scared because the burn area with the scar is now wide. Can the revision be made without lengthening the scar? Do I have hope? What techniques of revision should be approached? Would it require multiple stages? Please help me.
Hello,
Welcome to icliniq.com.
First of all, sorry for the unfortunate events you are going through. I have seen your pictures (attachment removed to protect patient identity). The first scar was definitely a small linear one which could have been corrected by few non-interventional methods than the lasers as you said it was just 55 days old. However, the YAG laser is known for its potential to decrease the increased vascularity in such scars and help improve the outcome. So I do not think your dermatologist is wrong in suggesting you this. The post-laser picture shows that it second-degree burns, which is a common side effect of YAG, which had to be explained to you by your dermatologist beforehand, and you could have taken a better decision. Right now the scar is having two main problems, that is the depression and the pigmentation which is making it look worse. My suggestion would be to ask for micro-needling with PRP (platelet-rich plasma) or fat nano grafting underneath the scar will give you the elevation in the scar. And as suggested, the Hydroquinone with an Isotretinoin based cream will help in depigmenting it. Both these methods has to done in a proper protocol. Do discuss these things with your dermatologist, or a new skin specialist and let him or her come to the best decision after personal examination of the scar.
Patient's Query
Hi doctor,
Thank you for the response.
I have been searching about micro-needling and scars with or without platelet-rich plasma (PRP) injections, and I do not see any significant improvement. Also, many who have done it alerts of additional scarring. Is this true? What about scar revision surgery? Unfortunately, the way it is, it seems that it is the only definitive way to handle a big scar. Do you think in this place of the face, with the surgery, I can achieve a thin line that, with time, can become virtually invisible?
Thank you.
Hello,
Welcome back to icliniq.com.
The scar revision surgery is for the scar. I would not have preferred it, as it is on the face, and the second thing is that the scars are in a line against the tension lines. That will cause tension in the revision suturing. However, suppose you are going for the revision. In that case, you can opt for botox injections post suturing that will paralyze the underlying muscles for two to three months and will help heal the suture line better. The micro-needling with platelet-rich plasma (PRP) is a choice with which we have good results. At least, that is what is followed commonly, and I would have preferred that over the revision and botox. Please discuss all these options with a certified plastic surgeon with whom you are thinking of getting the surgery. You will get good results, do not worry.
Thank you.
Patient's Query
Hi doctor,
Thanks for your response.
I am planning to see a plastic surgeon in a month. Could it be with a derma pen when you recommend micro-needling with PRP? When do you think it is recommended for me to start with it? Should I wait more time, expecting the scar to heal or fill up? It is five months post-bite and three months post-burn laser on scars. I have no follicles in the burn area. Does it mean the derma pen will not be effective, or can it cause additional scarring? I have read that follicles are needed for healing. The last photo does not show much indentation, but it is still there, very indented and seeming like holes in harsh lighting. There's this site when someone used castor oil for nine months and healed a two-year-old scar, an indented one that got filled up. More than two people commented on the same regime and filled over time indented burn scars. Do you think I can try applying castor oil, expecting some healing and filling up?
My face seems very different from what it was before the dog's attack. The dog bites me all around my nose. One inferior eyelid always seems more profound than the other, and like I have been punched not long ago. I was bitten there too. Do you think I have lost some fat there, or have I got extra skin on the eyelid? I feel my face is very asymmetric. Can it be corrected? I went to see an otolaryngologist because of my nose. An x-ray taken three weeks after the injury revealed no fracture but a CT taken one month later revealed a comminuted fracture on one side. After five months of injury, where I am now, my nose seems very different. The tip is at least twice the original size, and it seems very asymmetric, as the photo shows. The first otolaryngologist said there was nothing wrong with my nose (that the fracture was not perceptible). The second said that I have depression on one side, making the nose seem asymmetrical. What is most strange is that when I bend my face or lie down on the left, the tip seems to shift to one side. Also, my face gets visually distorted in a side position, even if I bend my head to one side or other. It seems like muscles do not follow. But if I smile and raise my eyebrows, it is symmetrical. Can a hidden paralysis justify this change in face shape as I lay or bend my head to a side? Will my tip volume ever be normal again? The second doctor said it was risky trying to correct my nose. But being used to having a tiny nose makes me look not me anymore.
If I opted months from here for a scar revision, could multiple stages (serial excision) be effective? I am sending you photos: one showing the scars without light, one showing the scars in the light revealing the indentation, one showing my nose - the thin bridge and the large tip, and one showing my nose before the bite.
Thank you.
Hello,
Welcome back to icliniq.com.
First of all, the derma pen is a good option for micro-needling. You can go ahead with the procedure and the platelet-rich plasma (PRP). If it is already five months, then this is a good time for you to begin with the procedure. I can see that the scar has already settled down, and there is no more erythema. The pigmentation and depression, however, are a concern. Sorry to say, but I am truly not aware of the therapeutic effects of castor oil in cases of a depressed scar. The eyelids are not visible properly in any of the pics u have sent (attachment removed to protect the patient's identity). However, if it is the lower eyelid depression you are worried about, then there are instances where the fat regression happens post-trauma, resulting in such deformity. Getting it checked with a good plastic surgeon will help you. As far as the nose is concerned, I can see mild asymmetry and a bulge of the tip. A physical examination will help know the bone and cartilage status and hence the next step in correction. Lastly, if you are genuinely considering the scar revision, then for the size of scar you are having, a single sitting will be enough along with botox, as I said. If the body reacts well, then no other interventions might be required.
I hope the answers are helpful.
Thank you.
Patient's Query
Hello doctor,
Thanks for the detailed explanation.
I hope scar revision will be the last option for me. You say that only one sitting would be necessary, but that way, considering the wideness of the scar, would it be possible to maintain the length of the original, or would I end up with a long scar? I am looking forward to avail derma pen. What realistic expectations can I get with it, referring to scarring and indentations? Please tell me about your experience. Can the indentation be reversed with the derma pen? The second dermatologist I visited wanted me to do a Co2 laser. I am totally out of it as I was burned by one laser, and I never saw a photo of improvement in indentations with the Co2 laser. I have read that micro-needling is way safer. Do you think the same?
What do you think of subcision, needling, and suction for indentations? When I stretch my inferior eyelid, it seems normal. Is it trauma-induced skin laxity? What would you recommend in that case? Is it blepharoplasty or fat injection? The fat injection has a very high risk and is not permanent, right? I have seen photos of people disfigured in the eyes by it. Can I ask one more thing. Based on your experience, who should I consult if I am trying to correct my nose? Should I consult the otolaryngologist or the plastic surgeon?
Thank you so much.
Hello,
Welcome back to icliniq.com.
The scar revision might extend the scar by one-third, but that will be a more linear scar. A scar revision will be safer than the Co2 laser, as you already got the burns due to lasers. Subcision with platelet-rich plasma or nano fat grafting is an alternative choice to the derma pen. If it is more of skin laxity, opt for blepharoplasty rather than a fat graft. For a disfigured nose and rhinoplasty, choose a plastic surgeon over an otolaryngologist.
Thank you.
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