Maybe you can try spot erbium laser in full ablative mode. That will trim the indentation edges and will make it more rolling and less noticeable. Also it could be that tissue is connected to the deeper structures so spot subcision also could help.

So for those wondering what I am doing on this forum with a surgical scar. That is me above. I dont have access to the account anymore.

Well 10 years ago i blogged my treatment with Recell and dermabrasion for acne and hypopigmentation (i cant believe its been 10 years + 2 kids ). It was life-changing and i thought i didnt have to worry about scars anymore, or at least as much.

Anyway. Im not sure what lesson God wants me to learn (ego?) but here i am again 10 years later after having skin cancer excised. I am sharing the one on my cheek but i also had one excised on my forehead where the stitches split open from tension and i need it fixed but thats another story unless anyone is interested. In both cases (from acne and surgery) it appears that my skin depresses easy. As this surgical scar was sutured together how can this happen? i cant understand it other than that it is tethered down or something in the healing process?. It was evident immediately after the stitches were removed but seemed to be above the suture so perhaps the suture caused it? i.e the way it had pinched the skin together in the middle causing the top to cave in?. I had to wait 12 months for it to heal before I could look at it and it can be looked at again. As it was bright purple

@getsmart121 My first thought is that I would rather re-excise it than to go down the path of laser or filler. If you read my old blog, laser was what ruined my face. Albeit co2. Maybe 10 years later they are safer? but I think anything that damages the dermis, aka scarring the skin has a risk that i don't want to take.

Ive also reached out to my recell surgeon for advice but i want to educate myself a bit first as well

here is another shot but this pic makes it look alot better than it is. It is actually quite long so you see maybe 60% in this pic.

On 1/9/2022 at 11:00 AM, John_Smith said:

I was diagnosed with a pre-cancerous 5mm lesion on my check that that was excised.

The doctor promised that a longer cut would result in a better scar. He was so confident and has a very good reputation that i trusted him.

Anyway 10 months post op, the redness is mostly gone and im left with a 5cm linear scar that is indented.

Actually the line scar itself is fine but its like a long icepick scar with a "V" dent.

A deep suture was used in the middle cm that apparently pinched the skin up so the edges could be matched and attached perfectly. But above and below the suture it became indented. Ive stayed out of the sun for a hole year and applied silicon get consistently in order to give it the best chance at healing but im also fearful that there will be hypopigmentation. WHere there was redness around the cut its lighter colour in some places but not shiny white. Is this a sign of pigment loss or because ive been out of the sun for 12 months?

The pic below is with me smiling but if i dont smile its actually more obvious and wider.

I stay away from 2 o'clock shadow as that would look like i have a long ice-cream type groove down my cheek

Im hoping subcision would be sufficient to fix this but I guess it all depends on the cause. It may need to be re-excised but how can i be sure it will be flat? I dont want to go through another 12 months of healing and near depression if its not guaranteed. 

Im willing to travel to the right doctor (in Europe would be ideal) so any info on what i can do, what to expect and who can do it would be greatly appreciated.

 

Go to a scar revision expert in your area. sometimes re-excising the old scar more efficiently produces a better result. Weigh the risks too. It could be worse depending on a variety of factors. Consult with multiple scar revision experts before deciding and try to have some basic knowledge on scar revision techniques so that you can have questions prepared or an idea of how scar revision may work or not work for you. My point being, knowledge is power. Also, Examine their before and afters on scar revision patients usually found on their website or on realself.com. Unfortunately it takes a lot for mental work to find a suitable doctor/treatment/procedure for one specific issue, especially when every single doctor has their own way to go about a particular issue. 
 

You can try resurfacing the old scar or getting dermabrasion from a reliable and skilled doctor. 

You definitely have options. 

@Dontgiveupitsonlyscarsyes exactly. I emailed Dr Emil for an online consultation as it seems hes quite popular (no reply yet). So im trawling through these forums to find others as well. Then ill try and setup a consultation with them. Be happy to hear recommendations

No-one close to where i live is familiar with subcision so looks like ill have to go abroad. The ones that i did talk to so far want to use filler without even investigating whether its tethered down or offering alternatives.

I have a similar "botched" excision except it doubled the size of my old scar. The only advice I got from doctors is untether it then filler. Personally I don't think re-excising would help much as there is still material missing underneath and it would further traumatize the area. I could be wrong of course, but maybe it's specific to the person.

Another surgeon recommended fat transfer filler instead of temporary filler.

If you have any success/ideas, I'm all ears personally. For the record, the "redness" in the middle generally stays that way, albeit the sides/edgeslighten. But I can confirm 10 years later, the middle redness doesn't entirely fade, the linear line stays generally light red.

Thanks @harmlessboy1441

What was the result of your subcision and filler?

I have filler on my left cheek every year where i had acne. It lasts about a year but i hate the fact that it needs to be maintained. so over the 12 months it disappears and the scars become more prominent. Would fat transfers be better? permanent?

The surgeon i saw (referred by the dermatologist) was promising me perfect results so I felt confident going into it. And here is the kicker...when he sent the excision to the lab it had no cancer. You can imagine how i felt hearing that. Mistake? or did the biopsy itself remove all of the bad cells? I dont know.

What i noticed after the excision was where the skin was joined/sutured, it was purple but a 4mm area around the line was also purple so it really exaggeratedthe scar and made it look larger. Its taken 10 months for it to fade. I had to keep out of the sun all of 2021 and even thenits still reddish. Is this normal or a overreactive immune response? which may play a part in scarring. I really want to understand this as this would certainly be pivotal to everybody'sscar journey. i.e how would your skin react. Also why the skin gets tethered down, and how to prevent that.

If i could be confident in only having a line scar without it being depressedafter an operation, id do it again but not without assurances.

I know that Dr Fiona Woods is working on a scarless healing cream:PXS-6302

First human trials for scar-less wound healing cream (uwa.edu.au)

Im going to try and find out more. Perhaps its already been mentioned on these forums

So far ive only had one recommendation from photos only and that's to subcise and use fat transfer. Ill keep you posted but also curious to hear your journey and recommendations

Fat transfer isn't permanent either, so they say, but it's "more permanent" like 5-10 years maybe, or maybe a portion retains.

What do you use every 12 months, juvederm? And does it really last 12 months for you? As for me, I didn't have subscision/filler yet, that's the only thing they are recommending with either a fat filler or juvederm type thing.

I can't speak for how yours or mine are "tethered". I can only say that after 10 years of having a linear excision scar, the middle does not fade, it stays mostly red. The edges only fade.

I don't know if I want to gamble on fat filler to be honest, and juvederm seems too short/traumatizing. During the 12 months is there any noticeable improvement from the filler (like any regrowth?)

Ok i have a few in-person consultations coming up.

Have tried constantly to contact Dr Emil by phone and email and either cant get through or no reply to my emails.

I also raised the question on realself

Raising / improving surgical scar on cheek - options? (photos) (realself.com)

I see that one reply is from a common replier on realself is Dr Emer who doesnt appear to have a great name on these forums? patient followup? 

Firstly, please let me know your progress because I literally have the exact same scar from a botched excision although it's about 1/3rd less size than yours It appears. The answer from Paul Miller MD is the same answer I got from my own surgeon consult. He said he would suggest untethering it with a needle and doing a fat graft with fat from my other areas. I balked because of the risks of clumping or limited duration but not removable if it clumps(5-10 years permanent from what I read), on top of some surgeons I spoke with said it could reabsorb if the talent of the doctor doing so is lacking. Meaning 1 surgeon told me that from the spinning test tube to application/injection, the cellscould literally die off if poorly done.

All of that made me just nervous in general but I will say this, from what I researched that appears to be the most logical attempt. But the skill of the surgeon is probably very important and you can't touch it at all after it's applied. The other suggestion was juvederm which really sucks. Reabsorbs in 1-6 months for most people and can you imagine untethering it each time in sensitive areas just for a few months at best.

Let me know your consults go, if I go for any more I'll let you know.

@harmlessboy1441Yes of course and thanks for the information. Very valuable.

I will have a busy friday

Will speak with my current surgeon to find out what he did exactly, what he thinks went wrong and what he would propose etc

Midday i speak to Dr Emil

late in the evening to one of the doctors that replied to me on realself. Dr Chris Miller

Monday a consultation with a cosmetic and plastic surgeon near me (who currently does my fillers)

Will keep you posted but im guess its either subcision/filler/fat or re-excision.

On 1/26/2022 at 10:43 AM, John_Smith said:

@harmlessboy1441Yes of course and thanks for the information. Very valuable.

I will have a busy friday

Will speak with my current surgeon to find out what he did exactly, what he thinks went wrong and what he would propose etc

Midday i speak to Dr Emil

late in the evening to one of the doctors that replied to me on realself. Dr Chris Miller

Monday a consultation with a cosmetic and plastic surgeon near me (who currently does my fillers)

Will keep you posted but im guess its either subcision/filler/fat or re-excision.

Yeah seems to be the only/best procedures most suggest. I am petrified of a re-excision though. But in the middle mine is basically reddish scar tissue, it won't even fade. My guess is that's just "injured" (the middle) permanently.

That said, yeah let me know. Hopefully you get a good outcome.

So the plastic surgeon who performed the treatment

• Nothing he can do and wouldnt risk another re-excision again
• When asked about why it turned atrophic he told me that maybe i had acne there, and/or my skin in porous and could be the reason
• When asked about what he did exactly, where were the sutures located and what type,he told me that he doesnt record such information and cant remember.I asked this question as where he used a disolvable suture that pinched the skin up, its flat. But that was only in one location.
• Had never heard of subcision.
• i have uneven skin texture, i.e different texture at different parts of my face (dunno what thats got to do with anything)
• Recommended that i get another opinion

Basically no analytical thought process andhe either didn't like being questioned (i was very diplomatic) or wanted me gone. If anything it confirmed my thoughts about the guy.

Dr Emil and Dr Mittenmiller were both very very patient, clear, caring and professional. They listened to me and patiently clarified what they felt would be good treatment and why. Basically subcision + filler would be safe and i should hopefully get great results. possibly with a follow up of laser (not sure which one) to tighten the skin and maybe reduce the line scar. re-excision always risks turning out worse and without knowing what the plastic surgeon did, they cant be sure.

Dr miller also expressed / reconfirmedwhat @harmlessboy1441mentioned. that fat transfer is great but the doctor has to be good or i can get lumps. Also that scar tethering has to be gone or ill get a worse outcome. Finally that its hard to find anyone that can do subcision.

I have one more on tuesday/wednesday with a local cosmetic+plastic surgeon and then ill have the information that i need to make up my mind. So 99% ill see Dr Emil

8 hours ago, John_Smith said:

So the plastic surgeon who performed the treatment

• Nothing he can do and wouldnt risk another re-excision again
• When asked about why it turned atrophic he told me that maybe i had acne there, and/or my skin in porous and could be the reason
• When asked about what he did exactly, where were the sutures located and what type,he told me that he doesnt record such information and cant remember.I asked this question as where he used a disolvable suture that pinched the skin up, its flat. But that was only in one location.
• Had never heard of subcision.
• i have uneven skin texture, i.e different texture at different parts of my face (dunno what thats got to do with anything)
• Recommended that i get another opinion

Basically no analytical thought process andhe either didn't like being questioned (i was very diplomatic) or wanted me gone. If anything it confirmed my thoughts about the guy.

Dr Emil and Dr Mittenmiller were both very very patient, clear, caring and professional. They listened to me and patiently clarified what they felt would be good treatment and why. Basically subcision + filler would be safe and i should hopefully get great results. possibly with a follow up of laser (not sure which one) to tighten the skin and maybe reduce the line scar. re-excision always risks turning out worse and without knowing what the plastic surgeon did, they cant be sure.

Dr miller also expressed / reconfirmedwhat @harmlessboy1441mentioned. that fat transfer is great but the doctor has to be good or i can get lumps. Also that scar tethering has to be gone or ill get a worse outcome. Finally that its hard to find anyone that can do subcision.

I have one more on tuesday/wednesday with a local cosmetic+plastic surgeon and then ill have the information that i need to make up my mind. So 99% ill see Dr Emil

For what it's worth the doctor who advised me I could do fat transfer filler on the same scar as you and also suggested a little under my eyes given some small fat loss, he and his people said he's done 100s if not thousands and never had any significant adverse effects. Whether I can trust that or not I don't know, but they did seem quite sincere and kind of surprised I asked the question too. The other doctors I asked did say what you said, it can lump or the cells can die before even injecting if the doctor doesn't have the talent or maybe even if your layers are screwed up who knows.

As for subscision, isn't that just another word for using a needle to untether? Because basically most fillers for tethered scars have to be subscised or untethered first, which makes me wonder why it's hard to find a doctor for you who does it? I would think anyone who does fillers and has any talent with acne scarring knows what to do, am I wrong? Because this is all new to me (fillers etc) I put it off for a while now.

Good luck with your appt's. I wonder if I'll just mimic what you do and take a chance. I don't see much of a downside to subcision and some sort of filler. Worst case, probably 10-20% collagen grows back ad it re-tethers perhaps, right?

I have subcision+filler with Dr Emil on Friday. Flying out tomorrow.

As it not a major procedure, i can re-evaluate the approach depending on the outcome

2 hours ago, John_Smith said:

I have subcision+filler with Dr Emil on Friday. Flying out tomorrow.

As it not a major procedure, i can re-evaluate the approach depending on the outcome

Awesome good luck. What filler? Let us know how it works out. I will have to do something eventually too. Since my scar from excision is literally identical to yours except slightly smaller, I'll probably do subcision too I just don't know what filler to do.

Very nice guy and very professional. Will take a photo tomorrow as im at airport and flying back home shortly. The procedure was very quick as the tethering is really just in a line. So small total area. he used the needle also to test if the scar was tethered and could be raised so that after subciding to ensure there wouldnt be donut effect.then he injected the filler.

but¦the filler is a temporary one and the idea is to make sure it stays where it should. If it does then next time hell do something more longer lasting. I really like that approach.
We also spoke about what can be done with the line scar as its red and we agreed to plan that in 5 months. Maybe laser or rf needling. Well see. will maybe need a few subcisions over the year.

he did the other cheek too. There was insane amounts of fibrosis on that side from acne. The sounds of scar tissue getting cut was interesting. So im really hopeful there as well. You have to check my old posts for before photos. Never had the option of subcision 10 years ago so maybe this will finish off the treatment i need on that side.

Will update tomorrow  thanks for the support. So far im very glad i came.

Its very flat. Just the line is visible as its red. Very very  pleased. But perhaps its still swollen so ill keep an eye on it over the next few days.

The other cheek is a balloon. So swollen so guess that'll take longer

I like the temporary first to test shifting anything like that, but I'm going to guess is it juvederm you used? Did he suggest any others he might use next time?

It's true and that's why I said the line scar from excision stays red and linear. I had my excision like 12 years ago and the middle of the area is still red to this day, so it clearly never fades without something further. Without the redness the line would be far less noticeable.Did he say once untethered the redness may fade at all? Does he expect any growth/collagen from the subscision once the temporary is reabsorbed? Any laser specifics on that one scar?

Clearly it's nearly all flat and is imo a lotbetter than before even if the scar line from the excision needs a strategy, the flatness is much better.I would probably do the same given the flatness improved and my scar is the exact same. I have a question what do you mean he did the other side of your face (subscision)? What exactly was he trying to accomplish if you don't mind me asking?

Hi @harmlessboy1441

They didnt user Juvaderm. I was given alot of information when i was there and Ive forgotten some of it. I thought it would be on the receipt but i just checked and it isnt. Let me reach out and confirm. I just remember that it was a filler that was made in Switzerland that can be extracted if necessary. That was part of the rational, i.e If there was shifting they can extract it easily. But let me find out.

He mentioned that each time a subcision in done, the scar will be naturally raise higher due to natural collagen production. But we didnt have that much time to go into future plans. I go back in 5 months to see what needs to be done. I also need to decide what treatment i want for the line scar. Laser or rf needling. Something i need to investigate but i actually told him when i was there that i didnt want to treat the superficial scaring yet. One step at a time.

But this cheek took like 2 minutes to do. I think he used a sharp needle (Kotor?)

What would you think would be the best approach for the line scar? Im afraid of lasers as ill explain now.

In regards to my left cheek. This is something i posted about 10 years ago

These are pics from before my treatment 10 years ago. The original thread is in my original post.

In summary

20+ years ago i had cystic acne which was localised on my left cheek and left extreme atrophic scaring in the middle of my cheek. Ruined the best years of my life might i add.

I had co2 fully ablative laser resurfacing to smooth it out. This left me with hypopigmentation/white skin.

10 years ago i wanted to fix the white skin and further improve the scar so had dermabrasion with recell. Results were amazing but there was still a depression on the cheek that could be seen under bad light. I managed this with Juvaderm. Had to be done every year so was a pain but alot of it never left my skin so the last time i had it done was over 2 years ago.

Obviously back then subcision wasnt a thing so when i saw Dr Emil i told him the story and we agreed to subcise this cheek as well. He turned out the lights to see the area in bad light (both cheeks), outlined the depressed area with a pen and then subcided with a blunt Canulla?

It was full of scar tissue obviously. Im not sure what others have experienced but it was probably 5 minutes of breaking up scar tissue. Sounded like a wood saw and quite often impenetrable so he had to come in from different angles . So the treatment on this cheek was aggressive and the cheek is very swollen. I need to check some other threads to make sure I know what to expect. Im supposed to massage the filler upwards but as my cheek is still a balloon i have no idea where it is and whether i should as its full of blood as well.

Anyway I thought that if i have to live with a new "Geralt of Rivia" scar then lets try and reduce the scaring on others. I really hope this works

I see, that makes sense,good luck on the left side's subscision after the swollen-ness fades. I do agree that injury underneath the left side via subscision should raise it due to just some healing/collagen,so with luck it will be more to work with in 5 months.

Either way the filler looks decent, completely flat, far less pronounced than before, just that excision line that remains. I wonder what I'd try on that given it's superficial yet red/noticeable. Given your prior reaction to laser that's a tough decision to make on how to handle the redness/line, but it could've been a different laser or way it was done. Might want to just discuss/rely mostly on what the doctor suggests at this point considering the risk vs reward.But you have several months to figure it out.

yes i agree. If a laser is recommended then maybe i have a small area done to see how i react. Im not really up to date with the latest lasers. Just that if the dermis gets damaged then there is a risk but has a better result in other ways.

The line scar is still red. Well all depends on what light im in. Might even consider Recell again to reduce the risk. Ill reach out to my old surgeon and see what he thinks.

1 hour ago, John_Smith said:

yes i agree. If a laser is recommended then maybe i have a small area done to see how i react. Im not really up to date with the latest lasers. Just that if the dermis gets damaged then there is a risk but has a better result in other ways.

The line scar is still red. Well all depends on what light im in. Might even consider Recell again to reduce the risk. Ill reach out to my old surgeon and see what he thinks.

If you feel the subcision and filler was done very well I would take his advice and yes I would prefer testing but at the same time if you're flying far it's kind of hard to test spots and all and go back idk.

That said, I'm trying to do the same within the next 45 days. If you ever get the name of the filler or the technique or any details I'm going to choose a doctor too for the same linear scar.

Just for clarification, for the linear scar, it was subcsized correct? And temporary filler? But even then it will still be improved when the filler is reabsorbed correct (presumably).And one doctor I went to used the words "untether" I'm going to guess that was his way of saying subscision right? I'm not that experienced in subscision methods really that's why I ask.

I don't think the redness will fade even with filler or subscision. Mine is still red smack in the middle of the excision and assuming I get a good result like you, I have no clue how to tame that redness.

Ill confirm the name of the filler.

I kind of gathered that subcision was probably what i needed so that made me search almost specifically for practitioners for this treatment. When I searched for recommendations I saw that so many others on this forum (and others) had great experiences with Dr Emil Henningsen and that he was legit. Depending on where you are? he may be too far away in which case there should be other recommendations on this forum. Doesnt hurt having a facetime consultation with him like i did, show him your scar and ask him the questions.Then when you talk to another surgeon youll quickly get a feeling for them.

But yes, the scar was subcised (untethered = same thing). He used a very fine needle with a sharp end (kotor?). He poked under the linear scar to find resistance and cut it away when he did then also with the needle he tested the scar by lifting it up. I guess this is a test to make sure the filler will not produce a doughnut effect and that it can be raised. Really similar to this video below but with a much much smaller needle so no need to worry. Then the filler was injected into the gap that he made. This was my understanding anyway.

Yes he told me that when the filler gets reabsorbed ill still have improvement and each time he does it, it will be better and better. I beleive this as i had that improvement with Juvaderm on my left cheek without any subcision. I hope this eventually becomes permanent but ill keep you posted.

Honestly the procedure for the surgical scar took less than 5 minutes. I had 12 months of anxiety for a 5 minute procedure. Ok arguably its not permanent...yet.

Ill find out about the red line too. Got to be something we can do. Maybe even microneedling can help as a least risk approach.

The cheek with the depressed scarring is fantastic. that subscision is incredible.

The filler on the surgical scar did not last long though  so I had fat transfer 10-11 weeks ago and that has been great. I know there are risks of lumpiness etc. but i did not experience this.

The doctor told me that he would overfill the scar as roughly 50-60% of the transferred fat would be reabsorbed. 10 weeks later is still there but 50% is gone or its become softer. Not sure.

What it did was to give my face its contour back. Kind of like a general raising of the skin and not so much a targetted filler on the deepest part of the scar.

What im not sure is, how long does fat transfer last and when will i know what the permanent outcome is?

It would be sad if it all disappears again.

The doctor also sadi that filler in the dermal later of the line scar itself would be the last thing he advises. i.e the indented line scar itself. Not sure if that is different to what i had done with Dr Emil. Have to ask him