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CleanSlate

Subcision after care to prevent hematoma/lumps

Hello Beautiful community. I am very amazed by the wealth of knowledge some of you have shared on this board.  I am hoping some of you subcision experts can help me on my case...  If you just  bear with me till the end of my question :)

 

 I am less than 24 hours into my fourth subcision procedure. I also had  microneedling + cross & PRF. First three was done using nokor needle + microneedling & cross only.  The one prior to this subcision one was done November 2017.  Although overall I've had some improvement with the scarring I was one of those unfortunate patients who had persistent lumps, which have been more devastating to me than the scars.

 

My treating doctor whom many of you have referred (which is how I found him in the first place)  has been seeing me on and off for the past year trying to get these lumps under control. He's tried saline injections & cortisone which is limiting for me as even to lowest dose leads to dent/ atrophy in the surrounding area.  Only one time can I remember the lump on my R cheek seemed to go away but it came right back. I have a smaller lump in the L cheek which you can feel more than you can see but it definitely has distorted my cheek and feel hollowness/atrophy immediately next to and above the lump. 

 

My doctor has been supportive in not letting me lose hope and after a year of battling with these lumps he did talk me  into another subcision using the cannula method this time and assured that this method would not cause lumps and believes it can actually help the existing lumps and rearrange the fat in my cheeks. 

 

My question:  what can I do as of right now to help prevent hematomas/lumps from forming?  What is the best after care for subcision? 

 

Dr advised not to take asa and to docold compress to help with swelling. Swelling was dramatic this time to the point I wondered if this could result in loose skin. It's still tender and swollen right now ( not as much) but I can still see the area where the lumps were previously.  I can accept  if I still have to deal with the lumps that were there previously but I think I would lose it if I got new ones that become persistent. 

 

Pressure/massage?  I would appreciate your advice. Thank you in advance.

 

 

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@CleanSlate I had the same procedure done (my first) a month ago, I’m completely healed now, I used ice for the first few days to minimize some of the swelling, I also took arnica orally and topically which helped my body heal quicker as well, and I gently massaged some of the lumps but very very gently.  On a side note, if it wasn’t for the lumps you have gotten how much improvement have you seen after getting this procedure done 4 times? 

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@CleanSlate I would compress the scars, do not use the Chinese cupping method if you are. Once the wound closes you can use blood thinners if you wish or vasodialtors like topical asprin. Sadly if so many things cause dents and issues, they may need to use a tiny bit of filler if they inject them. 

I am surprised they did not give you a steriod pill to take, for the swelling.

Consult with your Dr before doing anything as he is responsible for your care. 

In your case your bound to get hematomas because of your sensitivity, Treat as much as you can and then worry about lumps. If it does not show it's natural filler under the skin. 

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 Thank you both for your replies, my post did  go through after all!   As for the swelling the MA did give me a kenalog 10 injection in my bum,  I was very reluctant but after I saw my face I said no way can I allow that much swelling to be present longer than it needs to be..   I was afraid of the adverse affects of that much swelling.  Swelling is much better now.

I have been using cold compresses and applying light to moderate pressure as I press it on to my face in hopes of prevention. Beautiful ambition, you are correct about avoiding Chinese cupping method & I have been avoiding this time around although I've done it 2 other times in the past.

 The other thing I'm noticing is the stiffness (maybe hematomas trying to form?) in the face that's present from the procedure/ healing process... so  today I have been stretching my facial muscles  by smiling;  puffing out my cheeks and making O's with my mouth. I can feel a release of tension in my face & something definitely gets loose so I am hoping this is helping. 

 I'm also applying McKesson's skin ointment as I read this would help with the wound healing better.

@49ersFan I am also doing the arnica pills,  thank you for the suggestion.  I would say there are definite improvement in the acne scars after the previous subcisions but it's only as good as the scars don't reattach and in my experience the reattachment has been inevitable  although not to the degree it was prior to the procedure. IMO it's the combination of treatment methods that give the best outcome.  My scars were  more on the shallow side so they weren't all too noticeable except under certain lighting. 

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Day 3 s/p subcision: general swelling is virtually gone now. @beautifulambition  Do you think switching to a warm compresses and massage would be OK at this point?  I took a few pictures but the lighting isn't too great but you can see one of the lumps more clearly than the other if it helps.  I can't tell that I got new lumps at this time,  although there is maybe some swelling around the initial lumps.

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@CleanSlate The lumps should resolve over time. Some have this for weeks after subcision it's normal. 

IF they don't resolve dilute steriod. Or subcision with saline flush to the lump. evacuate any blood etc... 

Vitamin K ;-P

 

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@FredM thank you for sharing those links, that is very helpful information! Luckily I don't have the other systemic factors that could lead to impaired wound healing but I'm sure topical vitamin k would still be helpful in any case. I have been taking vit K2 internally though not regularly. Since the skin is pretty much healed, I'm not sure if I can get any added benefit from the topical K at this point but I would give it a try. 

Just an update, I haven't had any new lumps aside from the 2 lumps from the previous nokor subcisions although one of the lumps is still overall bigger & very tender with numbness on the skin over the lump. 

Additionally, I've noticed deeper scar pits which I think is from the cross, but I'm hoping this is part of the cross remodeling, looks worse before it looks better? Weren't too noticeable before but definitely noticeable now.

I have one small atropic area right just above the lump on my R cheek that literally showed up yesterday & not sure what that's about. 

Overall, it's not better that before, in fact looks a bit worse at this point but I think it's too soon to judge....so I hope. 

 

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On 1/2/2019 at 7:47 AM, beautifulambition said:

@CleanSlate The lumps should resolve over time. Some have this for weeks after subcision it's normal. 

IF they don't resolve dilute steriod. Or subcision with saline flush to the lump. evacuate any blood etc... 

Vitamin K ;-P

 

My first follow up will be on the 16th, I'm thinking to just go with the dilute steroid (though even this results in atrophy in surrounding areas) but I would rather do weekly saline flushes to reverse the atrophy from the steroid then endure the painful lump. 

Dr. Lim had mentioned in response to another physician's question regarding a persistent lump that he would recommend doing an ultrasound. Dr. Rahimi from LA also mentioned this. Anyone know what the point of the ultrasound would be?

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8 hours ago, beautifulambition said:

@CleanSlate Unltrasound would show them the depth under the skin and what is going on with the veins and artery's that is why. 

I will ask if this is something the doctor would order for me. I just wonder how the info would change or help guide tx. Any idea? I'll ask during the follow up and update. Thanks!

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@CleanSlate No it's not typically something they order you, ... perhaps they could. Typically plastics or derms might have a probe/machine in the office with a laptop to show the depth of what is under the skin with a probe over it. But I am sure they can order Ultra sounds from a radiography place if needed. 

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@beautifulambition  that makes more sense.. if they have the ultrasound machine at the place, they can see in real time what's going on.  I do know that the lump has changed since the last subcision  procedure on my left cheek.  

It is definitely much more tender & more firm to where if I accidentally touch it it's super painful.  With this said and the numbness I'm experiencing right over the area I am sure the scar tissue or whatever the lump is made of has enwrapped a nerve.

 

 The really weird thing is right above the lump I'm starting to experience fat atrophy. I don't think it's reappearance of scars it's a feeling of hollowness right above the lump which wasn't there before and this is without any cortisone injections. 

 

 I am continuing to do hot compresses plus massage as painful as it is to touch it.  Hopefully being more consistent with this helps.

Day 12 (Picture was taken on January 8) in addition to the lump you can still see some depressed areas that is actually from the cross. And pls excuse the peeling skin,  not sure if this is a result of the cross so micro needling but skin has micropeeling 

IMG_1425.JPG

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 Lump on on the right side of my cheek is mostly visible when I smile. Looks like a mini cheek on my cheek. Not flattering 

 This was also taken on day 12.

 

IMG_1429.PNG

Edited by CleanSlate

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@CleanSlate I get these issues often, ... especially in ethnic patients. IT could take months to heal. Your right about nerve damage this can happen when they slice things up. A Dr will have to intervene most likely to clear/treat the hematoma, and then filler perhaps. Hence the ultrasound to see the condition under there. Subcision is great but there is risk and reward, some get side effects and you had some unfortunately. If they did use Nokor, don't use that next time if you decide to further do Sub.

 

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@beautifulambition thank you so much for your input. I'm pretty sure that was the last subcision for me. Not sure I could expect more evenness if I do more anyway. I will continue treating scars but will limit it to external methods, except for the fillers which at this point I think I don't have an option but to do.

I believe  my acne scars are shallow enough where I can now "resurface the road" 

I'm sure this has been addressed before but any significance in the order of filler/micro needing/peels? I'm thinking to keep up with microneedling and peels. I've read tca peels are a good choice. If you have any suggestions I would love to hear it. 

Thank you again. 

I forgot to mention, I have retin-a microspheres gel  that I have been using on and off to help prevent/ treat acne/scars.  I haven't used since my procedure. But since the remodeling hasn't completed from the cross procedure would it be wise to resume at this point or wait? 

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@CleanSlate Yes it's very important the order. For instance as you said with ""resurface the road,"" we don't resurface the road before the pits or potholes have been filled enough and raised. As such I am not a advocate of blasting the face with laser first. You have done your manual methods first so your good with that. Perhaps you could do some rf needling if you wanted to deal with some of the box cars (a few sessions) or some laser to deal with the smaller pits - if you want to skip this you can. The peel(s) are typically done at the end of treatment for surface texture. 

That is different if you mean at home peels as they are a lower %, and yes that can be done 1 month apart to 1.5 months apart, ... depends on how you heal. Some don't have the down time for peels so they do 2 of them or 3 a year at home. The acid peel guide pinned to the top of scar treatments would be helpful as well. 

Sure you can start the retin-a, if things are healed up from the cross (Scabs gone), to regenerate the skin a bit. 

 

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@beautifulambition  I guess I'll have to look into how RF micro needling is advantageous over a micro needling alone as I have been doing micro needling  for quite some time now and it definitely helps with scarring but feel it's something you have to keep up with. 

I most likely will stick with @ clinic peels  with the dermatologist for now.  I am reluctant to do lasers because of possible adverse effect of fat atrophy.

 I had my appointment with M.D. and had ILCS dilute w/  saline  injected into it prior.  He used the saline needle to poke holes at it like manual micro needling.

 The lump is no longer round but irregular sic part of it shrunk down. He was able to squeeze some liquefied blood but don't  think it was much. I think time is of essence with this one and since it had already been two weeks probably too coagulated to drain. 

He did mention that my acne scars are distensible so  that if you gently pull on the skin is the scars disappear so  I think he will be recommending fillers. 

Definitely will wait until those lumps completely disappear,  fingers crossed,  then consider fillers although not sure the advantage of sculptra versus silicon whatever or juvaderm/Restylane.  I'll see what he recommends. 

 I'm just hoping that these things will help make my skin appear better and not give me more things to worry about.

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@CleanSlate Rf microneedling is like a laser without damaging the epidermis like a laser with energy, hence insulated tips. Thus it's safe for ethnic skin types. One has to do prior work before doing it, we don't pave a road before the manual work has been done to fill those potholes as much as possible. 

Manual microneedling is well manual, slow process, and for some if they heal poorly or have sensitivity can make the scars worse. You know your skin best. If you do fine with microneedling then you can do it monthly. It's a slow process. Without also doing acid peels in conjunction (varying months or a few times a year)you won't see much improvement. 

Yes you have to keep up with microneedling, as it's doing only a few channels, and the body is slow to heal, thus it's not like energy stimulating faster results, but it is devoid of many side effects.

See someone good if you get rf needling done, they should have treated hundreds if not thousands of your skin type. You can always do a test spot on one area of the face first before doing the whole thing.

Sounds good that it shrunk, maybe repeat whatever shrunk it before with the protocol of your Dr. If it's hardened the act of needling it to break it apart is also helpful, ... does not have to be liquid.

Filler is great if the scar is distensible ;-)

If you are prone to lumps, or hypertrophic scarring please please consult with your Dr before discussing Sculptra, it must be dilute and injected deeply or guess what we get more lumps in those with this condition. Discuss this with him or her. 

Well if the lumps do not show, leave them, they are natural filler. 

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@beautifulambition TY so much for always getting back to me! It takes a lot to keep up & it's greatly appreciated. 

I will look into doing RF microneedling & for those qualifications you mentioned, doesn't seem box scars respond all that great to subcision, have a few in my temple area, overall scars aren't so  bothersome.

So I went back to my dr today for another dilute 1 kenalog for that lump in the L cheek which I think became more condensed over this past week but still very noticeable...definitely causing a social obstacle for me at this point.

I have to say though, recall when I mentioned that when the lump became more firm after my subcision, that I noticed atrophy/hollowness right above the lump? Even the dr agreed that he saw atrophic like changes but was convinced it can't be atrophy which is understandable but the fat cells definitely were displaced. Well I find out today as he  injected that area with saline that the lump  below the area had formed a contracture pulling in the area above it causing a dent. So for anyone else reading this, this can happen for the aforementioned reason.  

So what did he do? He basically did a mini subcision with that same saline needle to release the teathered down skin, heard a lot of snaps as he was doing it and I think he was surprised himself to see how much had formed. 

My concern is, if my body is responding to subcision (or maybe just near the lump) by increasing its hold on to the scar tissue (like instead of strings holding down creating acne scars it's turned into ropes making the pull create more like a dent than a pit, then can repeated subcision (even a mini one to realease the newly formed contracture) be the solution if it keeps responding this way??

Just a thought... I guess I will find out, at least I know why I was seeing "atrophy" I hope it doesn't keep retethering & at the same time I don't know how I can prevent it aside from suctioning which I would say would be contraindicated for me.

 

 

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