What's best to remove a depressed scar?

An excision is an option.  With all excisions, the resulting scar may be worse or better.  Only so much is under the control of the surgery and surgeon.  How you heal is very important.  Have a consult with a Board Certified Plastic Surgeon and evaluate your options.

Our treatments use combination therapy to improve the epidermis and dermis for most deep scars. The options available for acne scars depend on the character of your scars, in terms of topography and contour. We see atrophic and hypertrophic acne scars, as well as scars that have hypo and hyperpigmentation. We begin each scar evaluation with an assessment of scar quality and subtype. Our main concern is rebuilding collagen and that is why we use a HIDEF protocol that includes combination therapy. Morpheus 8, scar subcision, fibrous release, fractional laser, CO2 laser, Thulium laser, PDL Vbeam laser, and fractional resurfacing can be used in addition to TCA Cross and chemical peels to further improve skin. Patients should start Melarase AM and Melarase PM for active hyperpigmentation. Always begin with a consultation to decide whether early subcision should be started.

Best,
Dr. Karamanoukian
Realself100 Surgeon

There are two components to a depressed scar that must be addressed in order to achieve maximum improvement. The first is to elevate the depressed central portion so that it becomes flush with the surrounding skin. The second is to try to improve the surface texture and coloration to whatever extent possible so that the area blends as seamlessly as possible with the surrounding normal skin. 

Subcision is a simple, inexpensive and tried-and-true approach for elevating all kinds of scars (e.g. surgical, traumatic, acne, chicken pox). In this procedure, following local anesthesia, a sterile needle is inserted directly under the scar and moved about in all directions in order to break up the thickened, fibrotic scar tissue collagen fibers resulting in freeing of the bound down, depressed surface of the scar allowing it to float freely to the surface. Being flush with the surface eliminates the "craters of the moon" shadowing that often accentuates the scar defect. During the ensuing four to six weeks, new, normal collagen is synthesized to replace the scar collagen and remains to buttress the surface of the scar.

Generally, two to four subcision treatment sessions are required for sufficient new collagen to be made so that the surface of the scar is at or close to the surface of the surrounding normal skin. Since all the cutting is done below the skin surface, there is essentially no surface wound healing and no wound care or activity restrictions are needed.

Often patients find the improvement or elimination of the depression to be sufficient improvement to warrant no further treatment. However, if the disparity between the surface texture of the scar and the surrounding skin remains troubling, a series of medical microneedling treatments might be considererd. Medical microneedling, which may be performed mechanically using rollers (e.g. Dermaroller) or electrically operated (Dermapen) essentially consists of going over the area with an array of needles that penetrate and break up the surface of the scar and some of the underlying abnormal fibrous tissue.

Disrupting the surface of the scar allows for the possibility healing with a smoother surface texture to the scar. In addition, the use of the needles crossing between normal and scar areas allows for the possibility of micro-auto-transplantation of pigment cells from the normal periphery into the scar area, which may help to somewhat further even out the pigmentation. Following medical microneedling, the treated area may appear sun-burned for about 12-24 hours. There is little to no downtime, however, and I permit patients to return to routine skin care and makeup the following day.

To hasten the results, I frequently perform the subcision and microneedling procedures in the same treatment session. 

The main option for fixing your depressed scar would be a surgical revision, although a fractionated laser such as the Profractional laser or Fraxel would be reasonable to try if you were surgically averse.

The best way to approach this is to do a very thin re-excision of the scar and bring the edges together appropriately and to make sure that there are internal sutures placed to remove any tension from the surface.

If the edges of the skin are brought together flat to each other, the end result is a depressed scar.  If the edges are everted or turned out a small amount, that elevates the wound edges while healing and the scar normally heals flat with the skin.

The lips are a highly mobile area.  In mobile areas scars tend to be more red and spread somewhat.  So while the scar is healing (and a particularly vulnerable time is the first could of weeks after suture removal) I don't recommend biting into big pieces of food or any other activity that would stretch the skin of the lips.

The resultant scar will still be linear but it should be flush with the skin.  If the results need to be improved after that, some dermabrasion or laser abrasion can be used.

On my photo gallery page there is an example of an excision of a large skin cancer on the hand with the proper approximation of the edges of the wound.  The scar is almost invisible 2-3 weeks later.

Your lip scar is a common result of a surgical reconstuction in a straight line on the lip.  I personally feel that your scar looks to be a good one, but with constant movement as can be expected with the upper lip, the scar is pulled and the weaker scar tissue causes a collapse that gives the impression of a depressed scar. 

Excision is defeinitly an option, but poses the risk of causing the same problem.  

Laser may help blend in the edges a bit, but would eliminate the problem, but you may find that it has helped enough that you do not want to do anything more.  

Sometimes less is more.

In my opinion the best option to improve your particular scar is surgical scar revision, ie excision as you mentioned. This essentially involves cutting out the scar and re-closing it.

Other options include topical scar treatments, trying to "plump up" the scar by injecting fillers, skin resurfacing (eg laser), or a combination of these. These will likely fall short of your expectations and could easily end up being more costly by the time you are done.

If you do decide on scar revision (excision) and want to use a scar treatment to improve the appearance of the final scar as much as possible, I recommend a silicone based product (and preferably one that contains vitamin C).

After scar revision, once the scar has healed, you should also massage the scar and use sun block. Scar massage helps soften the final scar and sun block prevents it from become permanently pigmented (dark or red) with sun exposure.

I hope that helps.

Dr C