Milwaukee Plastic Surgeons

Options For Hyperpigmentation of Breast Reduction Scars on Light Skin? (photo)

I had a breast reduction done 6 months ago at 19. I do wish more tissue had been taken, but that's not my main issue. I've had darkened pigmentation around the scars since shortly after surgery, and it has not improved at all in the 6 months after despite using silicone sheeting and BioOil. I have been trying to find other examples of women with a similar problem, but it seems much more common in darker skin. I am Caucasian with fairly light skin. What are my options to deal with this?

Pigmentation of the vertical scar following breast reduction can occur for two reasons. It either represents residual peripheral areolar pigment that was not excised, or occurred as result of the inflammation associated with surgery and the healing process (post-inflammatory hyperpigmentation, PIH).

In women who have large areolas, it may not be possible to remove all of the areolar pigment with the design of the breast reduction, and so some of the peripheral areolar pigment may remain in the region of the vertical scar. This is more likely to occur in women with a large areolar diameter who require less skin reduction. In order to prevent the vertical skin closure form being under too much tension, a small amount of this pigmented skin is left to promote better healing with less risk for wound dehiscence or scar widening. When healing is complete following breast reduction, it may be possible to excise this residual pigmented skin.

The inflammatory process can stimulate pigment production. Therefore, trauma, surgical incisions, infection, and the normal healing process call result in PIH. PIH is more common in individuals who have darker skin types, because more pigment is obviously present in the skin; but it may also occur in lighter-skin individuals. The extra pigment associated with PIH may be very difficult to address when present in scars. Chemicals such as hydroquinone, kojic acid, retinol, and others have been shown to reduce or suppress pigment formation and may be helpful for PIH. In darker-skinned individuals, where an increased risk for PIH is anticipated, these products are best used for 8 weeks prior to the procedure that will cause an inflammatory response; they are then continued for several months afterward while healing occurs. It is also worth noting that residual areolar pigment remaining in the vertical scar may darken as a result of PIH.

One other thought: There are situations where residual redness in a scar may give the visual appearance of a brown color. This is most often seen in scars that are still healing and have not yet matured; scars may at times have, blue, red, purple, gray, or brown hues. If you run your finger along these types of scars, the skin will blanch and the scar often looks better. This redness will often fade with time, and this maturation process may take one year or longer. Resolution of this redness can be hastened with intense pulsed light (IPL) and/or Laser Genesis procedures. Some scars remain pink because fine dilated capillaries are present within the scar and/or the immediately surrounding skin. These scars will blanch with finger pressure as well, and light-based therapies may offer improvement.

You should seek the advice of your surgeon to discuss these various options. If your scars do demonstrate hyperpigmentation, and you have no plans for future surgery, I would recommend a bleaching agent; these are more effective when started sooner. If the coloration stems more from redness, this will likely improve with time. If at some point you choose to have additional breast tissue removed, this pigmentation would be excised at that time as part of your operation. UV radiation is a huge stimulus for pigment production, so sun avoidance behaviors and the use of a broad spectrum sunscreen are critical to individuals concerned with, or treating, hyperpigmentation.

Best wishes. Ken Dembny

Kenneth Dembny, II, MD

Milwaukee Plastic Surgeon

Can Scars on the Neck Be Revised Using Scar Revision?

Can Scars on the Neck Be Revised Using Scar Revision?

Scar treatment or revision is a very individualized procedure that depends upon the appearance, characteristics, size, and location of the scar. Scars are visible because of color and texture changes; different treatments may be required to address these different characteristics. The history surrounding the injury or surgery is also helpful in trying to determine why unsatisfactory scarring occurred; the approach may be different for a post-traumatic scar compared with a post-surgical scar.

Scars may be difficult and frustrating for both patients and physicians because individuals want them to disappear following treatment.  Unfortunately, there are no medical or surgical treatments to remove scars completely. Surgical scar revision of any kind does involve certain risks.  These risks include changes in pigmentation (hyperpigmentation or hypopigmentation), possible red coloration or occasionally fine visible capillaries within a scar, infection, and surface texture changes (hypertrophy or atrophy). It is important to consider these risks when evaluating a scar for possible treatment, and these should be explained in relationship to the scarring you have, your skin type, and the procedure(s) recommended.

Scar revision by excision involves an actual surgical procedure to cut out the scar and then close the skin, followed by months of care to try to optimize the healing and maturation of the closure. Often times we will recommend certain skin care products and sunscreens be used before and after scar revision surgery.

Scars located in regions of significant motion, or that experience tension, often become less desirable because of widening, and the atrophy or hypertrophy that accompanies it. Areas on the upper back, shoulders, and upper/mid chest often develop raised (hypertrophic) scars that may be pink or red in color.  Areas near joints such as the shoulders, elbows, and knees often produce scars that are widened and thinned (atrophic) because of tension that exists across the scar line. Scars on the neck have the potential to heal nicely but may widen as a result of recurrent tension associated with neck movements.

Steroids, 5-fluorouracil, and colchicine have all been used to treat scar hypertrophy or keloids. These compounds can soften and flatten scars, and can improve symptoms such as itching or pain; they will not improve scar width.

If the scar is pink in color, Intense Pulsed Light (IPL™) may help to lighten that coloration; but it does nothing for the surface texture. We frequently use IPL to treat dilated capillaries and rosacea on the face with good results; but similar appearances in scars do not always respond as consistently. IPL can only be used on lighter skin types (I-III). Laser Genesis is another light-based treatment that may reduce scar redness, and sometimes even the thickness of a scar.

Laser resurfacing with a fractionated system such as the Fraxel laser or Pearl Fractional laser may be helpful as an additional modality to improve scars. Lasers are used more commonly to address textural issues and provide smoothing and blending. Depending upon the laser modality, resurfacing may be more risky in individuals who have dark skin colors. Laser resurfacing may provide better results if used while scar maturation is still occurring.

Patients with darker skin pigmentation may provide additional challenges. In the presence of increased skin pigmentation, scars or the surrounding tissue may be more likely to darken as well. Inflammation that occurs as a result of the initial injury and subsequent healing stimulates increased pigment production in the skin, a process known as post-inflammatory hyperpigmentation (PIH). In many instances once scar hyperpigmentation occurs, the only way to effectively remove the pigment from that scar is to excise the entire scar; and there are certain situations where that is impractical. Even treatments aimed at improving scar appearance can result in PIH. For this reason, sun avoidance and proper use of sunscreen remains critical in reducing the risk of PIH, even months after healing. Pre- and post-treatment with skin care products (bleachers, retinol, etc.) may help to reduce recurrent hyperpigmentation following scar treatments.

In general, most physicians will evaluate a scar and determine if some reasonable improvement can be obtained. Scar revision is better undertaken if there is good probability for at least moderate improvement. It is important that patients understand the risk and estimated outcomes so they can make a decision they will be happy with.

Best wishes. Ken Dembny

Kenneth Dembny, II, MD

Milwaukee Plastic Surgeon

What Do You Know About The Semielastic Scarless Serdev Suture Breast Lift?

I have been considering a breast lift, but am concerned about scarring and loss of sensation in the nipple. Today I found a procedure called the "Semielastic Scarless Serdev Suture Breast Lift". It appears that Dr. Serdev uses sutures to raise and secure the breast. I can't find any doctors who do this in the US. Couple of questions: 1. Does this really work, and is it practiced in the US? 2. How long do the results last? 3. Is the cost on par with traditional breast lift methods??

I agree with the answers posted by Drs. Zweibel and Grenley.  Ask the surgeon doing this scarless breast lift if the procedure has been published in any peer-reviewed medical journals (I doubt it).  I know of one study currently being carried out by two very accomplished plastic surgeons in this country using barbed suture to perform breast lifts, but they are not yet ready to say that it works, much less publish their results.  Unfortunately now more than ever, the old adage "buyer beware" applies to plastic surgery. I applaud you for trying to check this out first.

Paul W. Loewenstein, MD

Milwaukee Plastic Surgeon