The best way to treat surgical incisions that ultimately ends up with the most obscure scars is controversial. How a surgical incision heals and looks aesthetically is influenced by many variables such as the instrument used to make it, where on the body it is loacted, and the techniques used for wound closure. Many incisions go on to heal exquisitely well with the tincture of time alone.

But some wound closures are not favorable ones and may benefit by early scar treatment therapies. Then there is also the psychotherapy benefit of the patient doing something early in the healing process, taking an active role in the scar outcome. This has led to a plethora of topical scar creams and gels, most of which contains silicone fluid or silicone particles. The scientific benefits of their use remain far from scientifically proven but they are certainly harmless and usually relatively inexpensive.

More ‘high-tech’ therapies have been similarly applied to help modulate scar healing including laser and pulsed light therapies. There are no well tested scar treatment protocols but various practitioners use either pulsed dye laser or high intensity light (IPL/BBL) treatments as one option. Others use superficial or lower power fractional laser resurfacing treatments in the early healing period. No studies have ever been done that I am aware of that has directly compared these two scar therapy methods.

From a biologic standpoint the use of pulsed light therapies in early scar treatments makes good sense and is less likely to cause any adverse effects. Affecting the vascular elements and how the collagen is cross-linked theoretically could make the redness in the scar fade faster, decrease the risk of hyperpigmentation and help it soften sooner, particularly if it is prone to scar hypertrophy. In essence, it may expedite what the body naturally does through its scar maturation process. Such light-based treatments can begin early as soon as two or three weeks after surgery. Interestingly, but never talked about, is whether shortening this scar process may weaken its ultimate tensile strength attainment. Does making a scar look better sooner affect what its primary role is…that of holding the wound edges together? On the face, however, this is probably not a relevant issue.

The use of early fractional laser scar treatment is now more popular based on how well it performs in wrinkles and acne scars. It is definitely more invasive given the tiny channels that it cuts into the scar tissue. Because of this biologic action, it should not be started too soon when the wound edges have barely mended together. But by three to four weeks after surgery, it should be  safe to begin. The small channels really introduce another wound element in an already healing wound. This would make good sense in delayed treatment when the scar tissue is mature but its merits in early after surgery scar care remain speculative for me.

What is the best early treatment for incisions/scars? Between topical, light-based and laser therapies is one better than the other or is there a good combination? The reality is that no one knows for sure and any claims otherwise are marketing/sales driven but not backed by good science. For a safe and cost-effective approach, topical scar methods are certainly harmless but probably minimally effective. Which one of the many topical scar products is better is open to debate. For a more aggressive early approach, I recommend pulsed light treatments starting at three weeks after surgery done once a week for one month. If a scar in the first few months appears problematic (beginning hypertrophy) then fractional laser treatments should be started.

Until we have more scientific studies evaluating these scar treatment methods, their use will have to be on theoretical science and clinical experience.  

Dr. Barry Eppley

Indianapolis, Indiana   

The treatment of problematic scars or the excessive buildup of scar tissue underneath the skin after surgery can be a very difficult problem. The most common treatment has been the use of intralesional injections using Kenalog. (triamcinolone acetonide) While this has proven effective for many scar problems, it does not always work and is associated with certain side effects, most commonly fat or skin atrophy. Some patients have been described as having resistance to Kenalog, although this probably has more to do with the quality of the scar than it does with some systemic drug resistance.

For those scar problems that do not respond to Kenalog treatment, there is an alternative injectable drug using 5-flourouracil. 5-fluorouracil (5-FU) is an antimetabolic cytostatic drug that inhibits DNA formation. In laboratory cultures, 5-FU barely reduces collagen reduction in normal fibroblasts, but produces a drastic reduction in collagen formation in altered fibroblasts. It also seems to counteract the capacity of growth factor TGF-1 to stimulate collagen production.

There have been multiple recommended mixtures for 5-FU scar injections. One method uses a mixture of 0.9 ml of 5-FU 50 mg/ml and 0.1 ml triamcinolone 10 mg/ml per ml. Another mixture is composed of 1cc of 50 mg of 5-FUand 10 mg of lidocaine 1%. These mixtures are used primarily because 5-FU injections can be painful. The pain can be alleviated by these dilution measures or by giving a local anesthetic block prior to 5-FU injections.No more than 3 mls are injected in a single session in order to prevent potential systemic effects derived from the use of 5-FU. Although 150mgs (3 mls) is far below the dose generally administered in cancer treatments. (thousands of mgs)

The treatment schedule is more frequent than that used for Kenalog, being done on a weekly basis over the first four weeks, and then every two weeks thereafter. On an average 5 to 10 injection sessions are needed to achieve the best result. Side effects seen with 5-FU injections are pain and stinging and bruising at the injection site.

The results of intralesional injection with low concentrations of a solution of 5-FU and steroids has been shown over the past decade to be effective for reducing the production of collagen and aiding in the reorganization of scar fibers. 5-FU inhibits DNA synthesis and inhibits fibroblast proliferation inducing regression of keloids and hypertrophic scars. Intralesional 5-FU is associated with pain which is reduced by the addition of triamcinolone or local anesthesia. To be most effective, 5-FU injections need to be done when collagen and scar formation is actively being produced.

Dr. Barry Eppley

www.eppleyplasticsurgery.com

Indianapolis, Indiana

Scars remain a common patient concern for which numerous treatments are available. One frequently used approach is that of injection therapy. This historically has been done through the use of steroids and, more recently, with a chemotherapy agent such as 5-fluorouracil. These injectional approaches are designed to disrupt how collagen bundles are formed or to disrupt or unbundled those that have formed. There has been usually reserved for the most problematic of scars such as keloids and more severe forms of hypertrophic scars.

Very recently, Botox (botulinum type A) injections have been added to the injectional agent list for scar therapy. Not only have I seen patients who have had their scars injected locally but a few clinical papers in plastic surgery journals have been reported. The logical question is…what is the connection between wrinkles treatments and scar therapy? Does the use of Botox for scar therapy make sense?

As most of the general public is aware, Botox is an anti-wrinkle injection treatment for certain facial areas particularly in the forehead and around the eyes. It works because of its local muscle paralyzing effect, decreasing the presence of dynamic wrinkling. But what does that have to do with what makes scars look bad…or prevent them from ever getting to that point? While Botox has been given some ‘magical properties’ by some, it is not a injection cure-all for anything (and it is being used for a lot of diverse medical problems) and any potential effect must have a biologic basis for its use.

One of the many factors that influences scar outcomes is tension, pulling forces placed on the wound or incisional edges. There are two main factors that cause wound tension. The first factor is how tight is the wound closure, a force that comes primarily from the skin edges themselves. That is a wound influence that the plastic surgeon has some, but not much, control over. Wound suturing techniques help but when tissue as been lost or moved, the closure is going to be under some tension. The body relaxes this tension over time through scar widening and redness. The other tension factor, probably less significant, is the pulling of the tissues from the underlying muscle. This is primarily a potential issue in facial wounds and it has to have the right combination of scar orientation to the direction of the expressive muscle movement action. (scar must be oblique or perpendicular to how the muscle moves) Herein lies the theoretical benefit of Botox scar therapy. If the muscle action is lessened during the early phases of healing, scar widening could theoretically be reduced.

While the use of Botox in scar treatments makes some theoretical sense, its clinical use at this time is far more hopeful than proven. There are numerous factors that influence how a scar will eventually look and limited muscle action around a scar is but just one of them. Such Botox use would have to be done early (within the first few months) and would not have any chance of being effective in more mature scars. But the magical perception of Botox and the understandable anxiety of having a visible scar will likely lead to a lot of useless injection treatments. But hope is eternal and, for the sake of a few hundred dollars, there is no real downside to throwing this injection approach into the alchemy of scar therapies.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Indianapolis, Indiana

Surgical incisions and the scars they create are a concern for many patients. Nowhere is this more true than in the plastic surgery patient. Because it is a cosmetic procedure, most people ask how to take care of new scar so that it ultimately looks as obscure as possible.  This raises the important question of…does anything one does early change how a scar may look later?

This may seem like a silly question with an obvious answer of…of course it does! But such a simple answer belies a much more complex issue. How scars turn out is affected by a large number of factors including how the incision was made, is the wound closure under tension, how the incision was closed, age and race of the patient, skin type and thickness,  and location on the body…to name the major influencing factors. The interplay of all these factors will be responsible for how a scar looks.

These factors are so significant that, quite frankly, anything put on top of a scar or used to treat it from the outside after surgery is trivial by comparison. While time and the mature healing of the scar tissue plays the greatest influence in the ultimate appearance of a scar, there are a variety of things a patient can do to affect both the speed of scar fading and how it may eventually look.

But first, not all incisional scars made in plastic surgery will benefit from early scar therapy. Location of the scar determines the merits of treating it. Eyelid (blepharoplasty) incisions, for example, heal so well that any such treatments are not needed and are also impractical to apply. This also applies to many facial incision areas such as that of a rhinoplasty, browlift, ear surgery, and a chin implant. Once could debate about the scars that run around the ears in a facelift but the more ‘visible’ frontal scar is worthy. Almost all body scars, particularly those from breast and abdominal surgery, will benefit.  

Before any of these scar strategies are implemented, it is important that the incision be healed. This means no open areas, sores, or spitting sutures. The epithelium (outer layer of the skin) must be closed so that the deeper layers of the skin and the wound are protected. This is necessary to prevent trapping bacteria causing infection or impeding further healing. Delayed wound healing is one factor that is well known to adversely affect scar appearance. For most incisions, this will be around three (3) weeks but the completeness of healing may make that time frame longer or shorter.

Early scar treatment can involve one of three methods; a topical crème or solution, occlusive taping, and light energy therapies. While there are proponents for each approach, it is important to understand that there is no proven science that has yet shown one to be better than the other. Cost, availability, ease of use and plastic surgeon recommendations are as important, if not more so, than any advertisement or promotional material.

Topical scar solutions come in a variety of serums, gels, and balms. All of them contain some form of silicone. How silicone exactly works for scar improvement is not really known but its effectiveness is widely accepted. Some preparations contain other ‘active’ agents including Vitamin E, mild strengths of hydrocortisone, CoEnzyme Q10, copper peptides, etc. Whether any significant differences exist between what one can purchase in a drugstore, on the internet, or in a doctor’s office is speculative. Their advantages are that they are easy and convenient to apply.

A wide variety of silicone gel sheeting, patches, and strips exist. Some can be cut into any shape and others come in preformed shapes that conform to breast and abdominal scars. Their use is more economical for the long scars that result from body surgery even though their ability to stay in place is more cumbersome than topical solutions. They also have the added value of applying some low-grade continuous pressure and occlusion, which may be of more value than any effect silicone may provide.

Light scar therapies consist of either pulsed light (e.g., IPL, BBL) and use of low power laser wavelengths specific for red colors. Each type has a similar purpose, to lessen scar redness that may occur or help get rid of it sooner than what time alone would do. They may also lessen the amount of excessive scar formation which can make some scars wide or raised. This is the most expensive form of preventative scar treatment because it emanates from an expensive device.  I usually only use this approach after revision of a problematic scar or in scars that beginto acquire some early unfavorable characteristics.

How long should prophylactic scar therapy  be used? There is no exact answer but its benefits are best realized in the first three months after surgery.  

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

On the Today Show yesterday, many may have seen the burned triplets who had their scars treated with a ’new’ laser technique. This is a very interesting story from both the perspectives of the girls themselves as well as the form of laser scar treatments that had been done on them. 

The Berns triplets were just 17 months old when they were trapped in a house fire in Texas that took the life of their mother. With burns that covered up to 30% of their body, they underwent a long initial hospitalization with multiple burn debridements and skin grafts. Fortunately they recovered and healed and have gone on to have a relatively normal life. Like most children with disfigurements, they were not overly focused on their scars until they passed puberty and were in high school. As is unfortunately common, others then pointed out their scars and they began to suffer the ridicule that such differences can bring.

Like all burn victims, the scars that result fall into two categories. Hypertrophic scars, which are thick and raised scars, from burned skin which has healed but did not necessarily need skin grafting. And scarring from areas that had been skin grafted, which looks like pebbly thickened skin, which creates a very uneven skin texture. Either way, the healing of burned skin (unless it is a very superficial burn) does not result in skin that looks or feels remotely normal. To the surprise of many, skin grafting in general and in burns in particular (due to the need to mesh it to allow it to expand to get more surface coverage out of it) does not make for a normal appearance. The primary goal of skin grafting is to get a healed wound…which they do well. The secondary goals of a normal appearance and function…they do rather poorly.

These triplets, like many thousands of burn victims, have to live with these burn scars forever. Over the years, numerous non-surgical methods to improve burn scars have been tried, including laser resurfacing. Significant improvements in their appearance have yet to be consistently obtained.

The triplets were showcased on TV because they were treated with a variation of fractional laser resurfacing. While touted as a medical miracle and a new laser innovation, this is a significant overstatement. Fractional laser resurfacing as well as more traditional out surface laser skin removal is not new. The fractional or fractionated laser approach to skin treatments has been around for several years now. It is based on the concept of punching holes into and through the skin over just a portion or fraction of the treated area. By going deeper into the skin, its deeper layers or dermis is stimulated to heal by creating more collagen. This is in contrast to superficial laser resurfacing where 100% of the skin that is treated undergoes more superficial layer removal.

The one innovation, from a laser design standpoint, that these triplet scar treatments represent is that the manufacturer has combined both types of laser treatments into a single laser device and treatment. But their combined use is certainly not new. I have used this combination superficial and partial deeper approach in my Indianapolis plastic surgery practice now since early this year. I am certain that the recognition of the skin benefits to treating both depths simultaneously is recognized by many other plastic surgeons as well. My current approach is to use a needle roller of up to 2mms to get the ‘aeration’ of the scarred area and then do a more superficial (up to 50 micron) total laser resurfacing of the scarred area. Whether fractionating the skin (cutting these deeper holes) with a hot method (laser) or cold method (needle) is better, or any different, is as of yet unknown.

By attacking both the deeper and superficial levels of difficult scars, the scope of the scar problem is more thoroughly treated. In my opinion, this is clearly a better biologic approach than anything that has been done before. This approach in my experience is particularly helpful for refractory scar problems such as acne and burn scars. Two points should be emphasized however. First, we are talking about improvement in the scar appearance, not complete elimination. Secondly, multiple sessions or a series of laser treatments are required to obtain a significant level of improvement in the appearance of these scars.

I think these dual laser treatment approach offers an improvement over traditional scar treatment methods. But I would stop short of calling it a medical miracle.  

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

Surgical incisions and the scars they create are a concern for patients of all kinds. After surgery, most people ask how to take care of a scar so that it looks as unnoticeable as possible. While time and the mature healing of wound tissue is a major element in the ultimate appearance of a scar, there are a variety of things that you can do to affect both the speed at which it heals and final look of your scars.

1) If your surgical incisions are left open at the end of the operation (usually occurring in facial procedures), keep them covered with Bacitracin ointment 2 to 3 times per day. Contrary to popular belief, the purpose of the Bacitracin is to keep the incision/sutures soft (for easier removal), not to decrease the risk of infection. Once the sutures are removed, apply a very light layer of Bacitracin ointment twice a day for an additional week.

2) If the surgical incisions are taped (usually body procedures), leave the tapes on until Dr. Eppley removes them. It is perfectly acceptable to get the tapes wet in the shower. They will not easily fall off as they are glued in place. When your tapes are removed for the first time, new tapes may
be put back to cover the incisions for another week.

3) Scar management strategies, and your participation, begins three (3) weeks after your surgery. At this time, all sutures and tapes have been removed and the incision is sufficiently healed to start topical therapies.

4) The best topical treatment to apply is SCARGUARD, a proprietary blend of Vitamin E, hydrocortisone (steroid), and silicone. These are the only three topical agents that are known to improve scars. Three weeks after surgery, apply SCARGuaRD twice a day-in the morning and evening. It is easy to apply, and dries quickly and invisibly.

5) Apply SCARGUARD between three weeks and three months after surgery.

6) Scars that are exposed to the sun in the first 6 months following surgery have a tendency to darken and become rougher in texture. Exposure to UV rays does not have a positive effect on the final look of scars, so it is crucial to protect them during outdoor activities. I recommends applying a sunscreen that has both UVA and UVB protection prior to any UV exposure.

7) In some cases, occlusive taping or silicone sheeting of the scars (e.g., breasts, abdomen) may be recommended in certain body areas that are prone to poor scarring. Materials and application instructions will be provided at that time should this scar technique be felt to be advantageous.

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana

Indianapolis

The creation of a scar is the end result of the wound healing process, specifically the third phase of wound healing when new collagen is laid down. It is commonly believed that the inflammatory component of the wound healing process is essential for not only healing of the wound but the development of a scar as well. As a result, potential scar therapy innovations are looking at inflammatory mediators in the hope that less scar will be formed by controlling the inflammatory process of the wound healing sequence.

Currently available scar reducing therapies include steroids (triamcinolone injections), 5FU (5-fluorouracil, bleomycin, laser therapy, silicone gel sheeting, pressure therapy, radiation, and cryotherapy. All of these have been shown to have some effect and can be part of many contemporary scar treatment strategies.

I like to rank these agents based on their risk of potential side effects. No risk therapies would be silicone gel sheeting, topical silicone gel and pressure therapy. Despite their frequent touting and use in scars, the actual evidence that they really do prevent or improve poor scarring is very weak. But their no risk of side effects makes them popular. Low risk therapies include laser and pulsed light treatments. Their benefits are more theoretical (currently) than proven, but other than the potential for some mild hypopigmentation they have very little risk to their use in experienced hands. Injection therapies, such as steroids, and cryotherapy fall into the moderate risk use category. They do have a proven track record of success which accounts for their intial use in many problematic scars. But they frequently have some side effects as well including subcutaneous fat atrophy, skin thinning, and hypopigmentation. Controlled and limited use is the key to avoid these potential problems. Overdosing or chronic use of injectable steroids will eventually exhibit these adverse cosmetic outcomes. Higher risk strategies include surgical excision and radiation. While both can work well, they are usually at the end-stage of treatment options and are reserved for the most problematic of scars or those that have failed previous less risky treatment options. In the worst of scar problems, a combination of treatments is often done, such as surgical excision and steroids or surgical excision and radiation. This combined approach is almost always reserved for the pathologic true keloid of which recurrence is high no matter what is tried.

Emerging scar-reducing therapies are coming from the TGF-beta family of growth factors. Several such containing products are in clinical trials currently. TGF-beta is a known key agent in the inflammatory wound healing cascade and offers the theoretical hope of controlling inflammation and scar production but perhaps with less side effect than traditional injectable steroids. COX-2 inhibitors, a well known mechanism in many non-steroidal anti-inflammatory drugs, is of interest topically. It works by modulating prostaglandin production which can potentially limit the amount of collagen production and possibly scar formation. Both of these approaches are of great interest currently but are years away from becoming an actual clinical therapy. 

Dr. Barry Eppley

http://www.eppleyplasticsurgery.com

http://www.ologyspa.com

Clarian North Medical Center, Carmel, Indiana

Clarian West Medical Center, Avon, Indiana’

Indianapolis

Scar revision is a common request and a frequently performed procedure in plastic surgery. Whether it is scars from an accident from a surgical encounter, many patients have concerns about their scars. As a result, there is much interest in scar improvement whether it is immediately after the scar event has occurred or even years later. The sheer number of over-the-counter scar treatments attest to the public’s interest in eradicating these unsightly and disfiguring marks.

 
As a general rule, there are no specific scar creams or ointments that will make any significant improvement in an established scar. Topical scar treatments do have a role to play in early scars but not in older scars. Only the concept of some form of scar revision has any hope of improvement at this point. Scar revision can consist of a variety of treatments including excision and rearrangement (cutting out and reclosing), laser therapies, and mechanical methods of dermbrasion or sanding. All are not equal, meaning that each has a specific role to play and can be beneficial if used in the right kind of scar.

 
There are several extremely important points that one needs to understand about scar revision. First and foremost, no method of scar revision can completely erase a scar’s appearance. The skin were the scar lies is never going to be normal…..ever. Scar revision is about lessening its appearance, not completely eliminating it. As a plastic surgron, I have no magical wand or an eraser at most disposal The critical question before contemplating scar revision then is….how much improvemennt can be had and is it worth the effort. That is where the value of a consultation with a plastic surgeon is…….determining what degree of improvement may be possible.

 
Secondly, there is no single method of scar revision that will work for all scars. Much ballyhoo goes on about the use of lasers, but quite frankly, lasers are not the most common method of treating scars. They may seem like an ‘eraser’ but their use is restricted to treating early or persistent redness of scars and some light skin resurfacing of scars. Both of these laser effects produce mild degrees of improvement but it is not effective for many types sof scar problems. By far, excision and primary closure (cutting the scar out and reclosing it) or excision and tissue rearrangement (cutting the scar out and realigning it through geometric rearrangements such as z- or w-plasties) is most common. Scar excision is probably the most effective method of scar improvement, if the scar problem permits, as it is removing the scar first and creating a fresh wound. Dermabrasion and deeper laser resurfacing may be helpful for wide scars that are raised that do not lend themselves to excision.

 
Lastly, scar revision, no matter what method is used, takes time. I tell patients that scar revision is a process that usually involves takes a step back (to allow healing) in the hope that in the long term you have jumped two steps forward and it looks better. It requires a commitment of time and a leap of faith that the ‘effort’ will be worth the result.

 
Dr. Barry Eppley
http://www.scarscription.com/
http://www.eppleyplasticsurgery.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis

Concern about scars, those one already has or those that might occur from an upcoming surgery, is a frequent patient concern. As a plastic surgeon, I see patients weekly that have existing scars from injury or surgery and would like them improved. While scars come in many varieties (see my scar website, http://www.scarscription.com/) and can be treated by numerous methods, a common treatment method is excisional scar revision. Simply put, the actual cutting out of the bad tissue (scar) and putting it together with fresh unscarred skin. While this creates a ‘new’ scar, the goal is that the new scar is better looking than the old one. The fundamental concept is…..no scar can be completely erased (we are physicians, not magicians) but can be made less noticeable.

Scar excision (revision) is appropriate for scars that are wide, raised, depressed, or are a relatively straight line that crosses the relaxed skin tension lines (RSTL) of the face. (RSTLs are the natural cleavage lines of one’s skin that become quite evident when we get old……as wrinkles and folds….scars that lie parallel to the RSTLs will stay narrower and are less noticeable than those that cross it at angles or run perpendicular to them) No amount of time or any other form of scar treatment will make a scar narrower or make its edges flush with the surrounding skin. When a scar is cut out, it can be put back together in numerous geometric ways….depending upon what scar configuration will look better.

If putting the scar back together allows it to lie in a straight line parallelling a RSTL (for example, a horizontal orientation in the forehead or part of a circular pattern around an arm or leg), then a simple straight line closure would be most favorable. If, however, closing the scar makes a line that runs at angles to the RSTL…then a more geometric scar closure pattern may be used.

Geometric scar revision is based on a simple visual concept…..the eye has a harder time following an irregular line than a straight one. If the cutout of the scar and the way it is put back together creates an irregular pattern, then the scar may ultimately be less noticeable. These geometic scar patterns can be done as running Ws (like the pattern created by pinking shears), intermittent Ms, or a variety of other configurations. This type of scar revision is known as a broken-line closure or pattern. The most well-known geometric scar revision is the Z-plasty. Creating a Z along the line of a scar is the ultimate use of geometry. Z-plasties are most commonly used in scars that cross a moving surface (and have created a tight band or scar contracture) such as a joint or when the scar lies directly perpendicular a RSTL on the face. Skin flaps are cut around the skin crease or RSTL and the limbs of the scar flaps interposed. (criss-crossed) A Z scar is subsequently created but, equally important, the scar is actually lengthened across this area. Mathematically, the angle of the skin flaps that are cut determines how much scar length is actually gained. This technique is particularly valuable in the release of scar bands as reorientation and extra length is usally needed so that they do not recur after scar revision.

Geometric and broken-pattern scar revisions are an essential technique for improving many types of scars. These scar revision techniques require a good dose of time after surgery to see their benefits.

Dr Barry Eppley
http://www.eppleyplasticsurgery.com/
http://www.scarscription.com/
http://www.ologyspa.com/
Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis