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Dr. Barry Eppley

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Double Board-Certified Plastic
Surgeon Dr. Barry Eppley

Posts Tagged ‘scar treatments’

Fat Injections For Scar Therapy

Monday, August 4th, 2014


Fat injections, also known as autologous lipofilling, continues to expand in usage in plastic surgery. While initially perceived as just a soft tissue filler, it has become known for improving the quality of the tissues into which it is injected. The precise mechanisms as to why this happens is not known but observations and anectodal reports have demonstrated better skin quality and appearance. This is particularly impressive in helping reverse the effects of radiation as is now commonly used as an adjunctive technqiue in breast reconstruction surgeries.

In the August 2014 issue of the Journal of Plastic, Reconstructive and Aesthetic Surgery,  a paper appeared entitled ‘Improvement of Facial Scar Appearance and Microcirculation by Autologous Lipofilling’. In this study over a four year period, 35 facial scars on 26 patients were treated by fat injections. The scars were assessed before and after treatment by photo documentation, laser dopper spectrometry, tissue oxygen saturation, hemoglobin levels and microcirculation at various periods over the first three months after surgery.

All fat-injected scars show visible improvement with high patient satisfaction. They showed improvements in reduced pain, better color, less stiffness, and improved pliability. Microcirculation was initially reduced but returned to normal at the end of the study period. This study demonstrates that fat injections have a useful in extensive or complicated facial scars.

The use of fat injections for scar treatment is a natural and logical extension of its use in other areas of reconstructive surgery. This would not be for many simple and uncomplicated cars that can be treated by conventional scar therapies such as excision and laser resurfacing. Its use would be for very difficult scars such as in burns, those that cross joints with established contracture and problematic scars that have failed to show improvement with other treatments. Its use would be particularly helpful in atrophic scars where the tissues are very thin.

Despite the popularity of fat injections, the actual mechanisms that produce tissue improvement are incompletely understood. It is presumed that the combination of growth factors and stem cells mixed in with the fat are what is responsible for its remodeling effects and improved tissue quality.

Dr. Barry Eppley

Indianapolis, Indiana

Fat Injections as a Potential Scar Therapy

Monday, September 30th, 2013


The re-emergence of fat grafting and its now widespread use can be credited to many factors. But one of the most significant of these is the realization that fat is a ubiquitous connective tissue which contains a plethora of stem cells. Many of the improvements in tissue quality seen after fat grafting have been credited to these stem cells that come with the graft. This has not yet to be conclusively proven but it is understandable why that is a reasonable supposition.

The clinical uses of fat injections knows few boundaries. Its ease of injection and being a natural tissue lends itself to being tried for a wide variety of augmentations and the treatment of pathologically altered tissues. One of these potential applications is in the treatment of problematic scars.

In the October 2013 issue of the Journal of Craniofacial Surgery, an article was published entitled ‘Autologous Fat in Scar Treatment’. In this paper, the authors present their observations after 6 years of autologous fat graft experience in scar remodeling. In twenty (20) patients that had painful and retracted scars around joints, they were injected with microdroplet fat injections. They were assessed using an observer scale and durometer (firmness) measurements.

In all fat injected scars, a measureable improvement was seen in both appearance and function. Scars were less painful and were more supple with increased range of motions. All scars were less hard by durometer assessment compared to other scars treated by sham saline injections.

While this is not a large patient enrolled study, it shows that fat placed into and around a scar can change both its feel and its biologic behavior. It is not certain whether this is due to actual fat interpersed into the scar helping to break up the dense collagen fibers or whether it is extraneous factors outside the scar delivered by the fat graft that helps modify the collagen fibers.

While fat grafts show some promise as a scar treatment, it is not just for any scar problem. Its use would be indicated for difficult scars like those from burns and caused by the tissue altering effects of radiation. These broad-based pathologically-altered scar types would benefit most by whatever ‘tissue normalizing’ effect fat grafts may have to offer.

Dr. Barry Eppley

Indianapolis, Indiana

Plastic Surgery Product Review: Embrace Scar Device

Tuesday, August 14th, 2012


Scars remain a challenging problem. This is demonstrated by the sheer number of scar treatment products and strategies that exist, all of which claim to offer improved scar outcomes. A new scar device, called Embrace by Neodyne Biosciences, has released study results which show improvement in abdominoplasty scars. The Embrace device is an FDA-approved single-use adhesive silicone sheet which is applied to the incision/scar with a disposable applicator that transfers a predetermined amount of strain to the sheet. This device employs the concept of mechano-modulation (active compressive strain) to the injury site. This unique method of action provides a uniform compressive strain or stress-shield around the wound closure which can minimize collagen formation and scar widening. Abdominoplasty scars were used for the study because of the large amount of tension that is known to exist across the closure site. This is a good test for a scar device whose purpose is to offload the tension on the healing scar. In 28 abdominoplasty patients studied for six months after surgery, expert blinded evaluations of the scar appearance between the Embrace-treated vs the standard-of-care treated incision sites showed consistently better results with the Embrace treatment.

This device has already received FDA-approval in September 2011 and this released study is done in preparation for market release later this year. While this scar device has demonstrated benefit in high-tension scars, it is interesting as to whether it offers similar benefit in scars exposed to less tension. But what really matters in effective scar treatment is those wound closures that are predisposed to hypertrophic scarring or those scars undergoing surgical revision.

Early Incisional Scar Therapies – Do They Make Any Difference?

Wednesday, December 16th, 2009

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 cream 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 begin to 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

Indianapolis, Indiana





Scar Treatment Strategies after Plastic Surgery

Monday, April 6th, 2009

Scars of some sort are the inevitable result after all plastic surgery procedures. Some scars are considerable in length and others are much smaller and more obscure. Regardless, they are of concern to all patients given the elective nature of the surgery. Most patients want to know how to take of a surgical scar so that it looks as obscure as possible.  While the simple passage of time and healing of the wounded tissue plays a major role in the final appearance of a scar, there are some basic strategies I recommend in my Indianapolis plastic surgery practice to my patients. Employing these scar strategies can affect both the speed and final look of surgical scars.

Immediately after Surgery  If your stitches are left open at the end of the operation, as would be most common in facial surgery, they should be keep covered with antibiotic ointment 2 to 3 times per day. The choice of antibiotic ointment is irrelevant. Contrary to what many believe, the purpose of the antibiotic ointment is to keep the sutures soft so that they are easier to remove. The antibiotic ointment probably has little effect on the risk of infection. Once the stitches are removed, it is not necessary to continue to apply the ointment.

Early Scar Therapy  The beginning of actual scar treatment can begin when the surgical incision has gone through primary healing. This means that the outward skin surface of the incision is healed without any open areas. This does not mean that the entire scar has healed but that the outer skin layer (epithelium) is closed. The incision is sufficiently healed to start topical scar therapies. Generally, this is about 3 to 4 weeks after surgery.

While there are many topical scar creams and ointments, there are no studies that have ever compared any of these. Therefore, it is no possible to claim that any of them are necessarily better than any of the others. At the least, the use of any of them is probably better than not using any at all.

My preferred topical scar product isScarguard, a proprietary blend of Vitamin E, hydrocortisone (steroid), and silicone. These are the only three topical agents that are generally accepted to have a positive effect on healing scars. Whether this cocktail of scar agents is better than any one of them is not really known, but the concoction seems logical. It has the advantage that it is easy to apply (paint on), dries quickly and invisibly and does not stain clothes. I tell my patients to apply Scarguard between three weeks and three months after surgery, twice a day.

During this early scar phase, mild to moderate exposure to the sun may cause the scar 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 recommend applying sunscreen with a dual SPF/SFA sun protection. These broad-spectrum sunscreens provide good scar protection.

Intermediate Scar Therapy In the first 3 to 6 months after surgery, scars are susceptible to pulsed or high-intensity light therapies. Known as IPL or BBL (broad band light) treatments, these quick and non-harmful light treatments may be effective at accelerating the removal of scar redness or softening the hard feeling of a scar. They can be done  a week or two apart and it is usually best to do anywhere from 3 to 6 treatments depending upon how the scar is responding.

Late Scar Therapies After a year from surgery, no topical treatment or light therapy will have any effect on an unsightly scar. If the scar is raised, injections with steroids (Kenalog 10) may be tried and has a history of successful use. For scars that are wide or indented, however, surgical excision and reclosure will be the best strategy.  (scar revision) If a scar is still red, treatment with a red photoselective laser (like for telangectasias and small veins) may be effective.

 Dr. Barry Eppley

Indianapolis, Indiana

5-Fluorouracil Injections for Keloids and Hypertrophic Scars

Sunday, February 8th, 2009

Certain types of scars are particularly problematic, not only because of the way they look, but due to their tendency to become raised, thickened, and painful. Keloids and hypertrophic scars represent an abnormal scar healing process. Many different treatments have been tried for these difficult scars including surgical scar revision, steroid injections, and radiation therapy, often in combination. Any new scar therapies are welcome.

Anectodal reports exist for numerous new pharmacological treatments, one of which is 5-fluorouracil. (5-FU)  5-FU is a well-known drug used as a chemotherapy agent against cancer for several decades. It works by inhibiting DNA replication which is important in stopping cancer cells which usually multiply faster than normal cells. In dermatology, 5-FU is most commonly used topically (as a cream) for treating actinic (solar) keratoses and some types of basal cell cancers of the skin. (e.g.,  Efudex or Carac) It is thought that it might work in scar problems because it appears to block collagen synthesis which might help to control excessive scar formation.

 In the January 2009 issue of the journal Plastic and Reconstructive Surgery, 5-FU treatment of problematic scars was reported. Keloids were treated by excision and 5-FU injections after in 32 patients and hypertrophic scars were treated by 5-FU injections only in 21 patients. The dose of 5-FU injections was 50mg mixed with lidocaine given one month apart for 10 injections until the maximum dose of 500mg was reached. For keloids, the recurrence rate was 19% at one year. For hypertrophic scars, the response rate was 86% with a 50% reduction in scar volume at one year.

While no scar study will ever be perfect and no two scars are ever the same, it is hard to know from this study if 5-FU offers a real improvement over steroid injections. You could argue that a prospective study using steroids and 5-FU would be helpful in addressing this question. But given the relatively poor response to treatment of most keloids with steroids, I will consider 5-FU injections for future cases. For hypertrophic scars, I am not so sure but the apparent lack of any side effects (steroids are well known to cause tissue thinning and atrophy) gives it some appeal. 5-FU is not a ‘magic bullet’ but it does offer another option for difficult scar problems.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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