Can Botox Really Fix The Scar On Scarface?

Dr. Furnas (00:13):
A scar is nature's super glue. As much as we hate them, we should also love them. If we leave a big open wound alone, it could get infected and even kill us. But evolution gave us scars to shrink the hole until it's closed. On the other hand, everyone knows Scarface is a bad guy. Just look at him. But if you're a good guy, you might want to get that scar fixed. But with Botox? Welcome to Skintuition. I'm Heather Furnas.

Dr. Korman (00:47):
And I'm Josh Korman. From pimples to wrinkles, our skin affects how we feel about ourselves as two plastic surgeons. We discuss what's new, what's safe, and what to look for, when you're ready to hit refresh.

Dr. Furnas (01:02):
We talk about scars as something bad, like psychological scars.

Dr. Korman (01:09):
Well, scars are bad, aren't they? Well, they kind of are bad, I think from little kids that, I mean our whole career is we have parents desperately worried about their children's injuries and make the scar disappear, make it like it never happened. But we don't really carry around erasers. But scars work at a lot of levels. They work at the very psychological level and scars are also very visible. When I used to work in Scotland a long time ago, there was a a very violent past in the city of Glasgow when there were things called the Glasgow Kiss and the Glasgow Smile. And the Glasgow Kiss is when somebody did a very big headbutt to somebody else causing an open wound. And a Glasgow smile was even worse when a Stanley knife was used to cut the face across from ear to ear and even get to the deeper structures like the nerves. So wounds and injuries and scars, they all go hand in hand, but we don't want them to all look bad. So we're here to talk about what can we do?

Dr. Furnas (02:24):
Okay, Glasgow scar, that sounds horrible. So when we have a real scar, we usually wanna get rid of it. So let's define a scar. Well, you have an injury, an open wound, and in order to heal it you have these white blood cells floating in the bloodstream and some of them turn into collagen making cells. We call them fibroblasts. And the collagen then is laid down and slowly closes in the edges of the wound and closes and closes until the wound is healed. And that's what a scar is, but it's immature.

Dr. Korman (03:02):
So what does that really mean, immature? It means it's young. Does that mean it's not, it's gonna get worse. What does that mean?

Dr. Furnas (03:09):
Yeah, you know, like acne and braces and all that, the collagen is like heaped up like straw and, and so it's thick and it's raised and to smooth out all that heaped up. Collagen we need energy and oxygen, and oxygen is carried by red blood cells. So the red blood cells need to be carried in vessels. So our scars actually form little capillaries carrying that red blood, which is why they tend to be red until all that collagen is flat and then it's mature grown up.

Dr. Korman (03:48):
So why is it when people have a scar, they want it gone like tomorrow?

Dr. Furnas (03:56):
There is a certain impatience, they want that thin white line, and they think that something is going wrong if it's, if it's a little bit thick and if it's pink. Now, then there's hypertrophic scars.

Dr. Korman (04:11):
But I think it's a little bit like people are used to getting a new car and driving it off a lot like a dealership off the lot when the scar, when the car is perfect, not the scar, the car, the scar, the car is perfect <laugh> and yet then it gets dinged up over time. The body's the reverse, it gets dinged up at the beginning and then it heals and gets a lot better.

Dr. Furnas (04:34):
Exactly. And then sometimes though the scar goes in overdrive and that's when we get what we call hypertrophic scars. So I kind of imagine like two pirate ships and you know those grappling irons, you know, people, the pirates would, would throw an anchor like thing with a rope to try and pull the two ships together. That's sort of what I imagine collagen is doing. It's trying to close that wound. And if you have a hypertrophic scar, it's on overdrive. It's just throwing tons of those ropes and it's getting thicker and thicker and it's still immature and it's red for a long, long time.

Dr. Korman (05:16):
I think it's about a balance, like a lot of things in the body and a lot of things in life is about a balance. And you have the collagen being built up and the collagen being taken down. And if there's an imbalance, that's when you get scars that are worse. And I think one thing that's really important to understand and to define scars appropriately because a word that's so popular and people think, oh, a keloid. So a keloid is the ultimate in imbalance between too much being built up and too much taken down.

Dr. Furnas (05:56):
Yeah, A keloid is actually not that common in Europeans. It's like one in a thousand. Among Africans it's like five to 10%, Asians, 1%. A lot of people come in saying, I have a keloid. And they actually have a hypertrophic scar. So a keloid goes beyond the boundaries of the scar. So if this is your scar, the keloid goes out like that. So think of a mushroom and the keloids, the head of the mushroom or stock of cauliflower and the keloid is that flower and dealing with a keloid is a lot tougher than dealing with hypertrophic scars.

Dr. Korman (06:37):
Yeah, with keloids you think as doctors, as patients just cut it out. But the problem is if you cut out a keloid, it can come back worse and you think, well why is that? Well again cuz it's too much the, there's an imbalance between what is built up. But I think one thing that I is interesting is I, I remember hearing for a long time that certain ethnicities were more prone to worse scarring. And one of the ethnic groups that I heard that from was about African-Americans. But actually in my experience, African-Americans tend to make actually really good scars. And that some of the pictures that are examples of scars in African-Americans are actually in Africans are from scarification techniques that are used in certain tribes. And that is scars on purpose for decorative purposes. But I found that actually African-Americans in general make really good scars, often even better than Europeans or Caucasians.

Dr. Furnas (07:50):
Yeah, I mean this, there's this tendency, and Josh is absolutely right, you have, I've seen African-Americans with beautiful scars and very pale Caucasians with really thick scars. So when you hear color of skin, that's only one factor. Genetics plays a really strong role independent of color of skin.

Dr. Korman (08:14):
I think another big thing is where on the body it happens because there's certain locations like shoulders and back and chest that really create generally worse scars than in other places. And I think a big part of that is tension.

Dr. Furnas (08:37):
Exactly. Yeah. Tension is when we, you know, kind of will use the term horse together. You know, try and get two edges of a wound together that actually don't wanna be together. And so you sew them with suture and you can see the blanching of each suture that is a wound being closed under tension and the skin is pulling away as a scar is trying desperately to close that. Uh, all those, those cells are producing collagen desperately trying to keep that skin from pulling apart. And so in order to prevent thick scars, we want to fight tension and we can do that with tape or gel sheets. And silicone gel has the advantage that it can reduce redness and itchiness and pain and thickness and even pigmentation.

Dr. Korman (09:34):
And sometimes it makes sense to do it in phases. Like if you're, if you're cutting out a scar to take out the middle of it and then wait a few months. The thing I try to understand is so many people, and I'm not sure where they get this from, they think that you can just laser it and it will magically go away no matter what kind of scar it is, just laser it. And I'm sure that lasers work in different ways, which we can talk about in a second. But I don't know why people think that lasers are the magic wand for making scars go away.

Dr. Furnas (10:11):
Yeah, lasers, I mean there, it really depends on the type of laser. And you know, for example, there are lasers that are ablative and they're lasers that are non-ablative. And the non-ablative lasers are like pulsed dye, and neodymium Yag and Diode. But there's also fractional ablative, Erbium Yag and and fractional ablative.

Dr. Korman (10:39):
So that's a lot of foreign language that I don't understand and I'm a plastic surgeon. So can we go back a little and talk about lasers? Laser is just an acronym actually for, for artificial light. And so I think they're the lasers that work like electronic sandpaper and they're kinds that go right after certain kinds of cells that don't break the skin. I think that's what ablative means, like sandpaper and, and non-ablative is going after certain cells like certain wavelengths of light like reds and browns. And that's how tattoo removals are done. That's how scars are treated. What I find is that you have to, just like in everything in medicine you have to diagnose before you treat. So I think you have to kind of classify scars. And what I try to do is, and try to explain to my patients is that color, texture, thickness and how high it is. So that means how much it's getting in the way because a scar that's flat and just a different color you treat differently than if it's really raised and also has a color problem.

Dr. Furnas (11:53):
So I'm gonna back up a little bit. We, we talked about pigmentation and when you have a scar and you go out in the sun, it can become sort of a blotchy brown and we call that post inflammatory pigmentation, which is not a great term cause it's actually during the inflammatory period when the scar is building up and being created that you see this kind of blotchy brown. So if you have an exposed scar, you want to wear sunscreen or use protective uh, clothing. And that goes for any type of scar, whether it's an acne scar or just a cut, road rash, or surgery.

Dr. Korman (12:34):
So how long do you think this people need to put sunblock on after they have a scar?

Dr. Furnas (12:41):
Well obviously you always want to wear sunscreen for protective reasons. But as far as the um, post-inflammatory pigmentation, I tell patients while it's pink cuz that's when it's still inflamed, it's still building, it's still in its immature phase and that's when it's most likely to become pigmented.

Dr. Korman (13:02):
Yeah, I think people have all kinds of ideas about what's good for scars. Like some people think sun is good for scars, some people think cold, some people think pressure is good for scars. Well, pressure actually can be good for scars and it helps stop the, this imbalance between buildup and take down of scars. But sometimes it's hard to do pressure if it's in certain places on the skin. So what about in certain times of life, like during pregnancy cuz there's a lot of hormones going on and that's when scars can, can thicken a lot also in people with blood pressure issues. I mean there's is there are reasons when scars, why scars can be worse or better different times of life?

Dr. Furnas (13:52):
Yeah, so if you're pregnant and you have something that could be done at another time under local anesthesia, it's better to wait. And if you have high blood pressure and you're planning surgery, then get that blood pressure controlled, not just for your health but also to promote better scarring, to prevent scars. Let's say you have a history of thick scars, we mentioned Botox.

Dr. Korman (14:21):
Yeah, so I think, you know, Botox helps to soften lines. So I think like you have to figure out what does the scar actually look like? So I think one thing to understand is what kind of scar is it. Now as for Scarface, like we talked about before, Botox probably would be maybe too late for him if he had gotten stitched up right after the knife fight. Well just like after surgery, the Botox could help prevent a hypertrophic scar. In reality that book in the movie of Scarface are based on Al Capone whose nickname was Scarface and Capone's scar would probably have needed a surgical scar revision. I think scars are, it's interesting how scars are a sign of ruggedness in this world we live in today. People talk about different amounts of what's considered for gender or for ethnicity. So many different things. And part of the reason scars in the past were thought of of, oh, it's a sign of of you know, being tough. I don't think anyone really wants a scar. I think it's just that when it's hard to fix you have to live with it, especially if it's in conspicuous places.

Dr. Furnas (15:46):
Yeah, Al Capone was actually reportedly insulting a woman and that woman's brothers were right there and it was one of the brothers that slashed his face from ear to corner of mouth and it looks like he didn't get the best repair. And if you look, you know, the direction is directly opposite our natural skin lines and that's not so good.

Dr. Korman (16:13):
Yeah, well as we said before, that's the, you know, half the Glasgow smile. So it is, except if it gets fixed in utero, which doesn't really work in practical terms because it doesn't really allow, it hasn't been successful in having babies reach, uh, term and to be born. It is important to understand that scars that penetrate below the very superficial layers of the skin are, they're permanent. And the idea is to try to make them as invisible as possible. And we all have marks, we all have, that's part of what life is, but it's important to understand what we can do to make them better. And as Heather just said, understanding skin lines and skin tension lines. It's the easiest way is to understand that is if you look in the mirror and smile, you can see the natural creases of the face and those are the natural skin tension lines and scars that are lined up in the same direction as wrinkles and lines heal much better than scars that cross these lines. Or ones that are perpendicular to the lines and scars that are more likely to need surgery are often ones that are perpendicular to the skin tension lines. But that's for another, another topic. So to get back to understanding about thickened scars, Heather, what are the options?

Dr. Furnas (17:42):
Okay, well let's start from the least invasive. We'll talk about steroids and the Japanese actually do a lot of treatment of thickened scars and they have a tape that we don't make in the US that is, uh, steroid embedded into a tape and plaster. And so when the scar is still early, they will put the tape on and have patients wear it around the clock for at least three months and sometimes longer. And in lieu of the, the tape you can use, uh, steroid creams and ointments four times a day for at least three months.

Dr. Korman (18:22):
Does that mean you go to Japan to order it?

Dr. Furnas (18:24):
Well you can order it off, uh, Amazon, I don't know where else, but, but I've, I've ordered it before for a patient and yeah, it's this box of of tape. Very cool.

Dr. Korman (18:37):
Wow. So it's not really clear why steroids work. Steroids, they reduce inflammation, um, and probably stabilize the imbalance of the collagen cells getting built up and torn down. But it, it is a little confusing and, and people always think of steroids as being bad for you, good for you. I mean our bodies are full of natural occurring steroids, we need them to live. Um, and there are a lot of different kinds of steroids, but steroid injections are really popular option. What's interesting about, and I don't know how you do it, Heather, but when I learned how to do 'em, everybody said put some numbing medicine in along with the steroid and I think the numbing medicine burns more than the steroid does. So I usually don't put the mix it with numbing medicine, I just inject the little steroid medicine and goes quickly. And I find that is less painful for patients. How about you?

Dr. Furnas (19:39):
I'll mix it, uh, half and half. And so if I have to go back, you know, I it at least it's numb then. But it does sting and you can inject too much and if you inject too much it atrophies tissue and blood vessels can appear like little red roads, you know, on a roadmap. And so it pays to be judicious, not overdue, don't inject beyond the scar. But when well done, it works really well and sometimes we can combine it with an anti-tumor medicine called five F U, that combination works and some people use bleomycin, which is another anti-tumor medicine and they say some people will say it's the best even better than steroid and five F U, but we'll use steroid and five F U.

Dr. Korman (20:32):
Yeah, I think combination treatments sometimes, uh, work particularly well. And I guess it depends. You try one thing and then try other things. But remember that it's genetics are ruling, they're the ruling class, so how the scars end up after surgeries or after injuries and how they respond to treatment is very much primarily a function of genetics. Obviously we can't do anything about genetics, so we do our best at trying these other, these other options. So we talked about lasers before. So do you think that ablative or non-ablative work best for the raised scars?

Dr. Furnas (21:15):
For the really aggressive raised scars? The ablative isn't so great and that's probably because you're, you're asking the wound healing of that person to kick in and we already know that that wound healing tends to go on overdrive. And so in those patients non-ablative lasers are gonna be better. How about you Josh?

Dr. Korman (21:40):
Yeah, I think i, I sort of try again, it depends what the diagnosis. Are they flat but red? Then I'd use non-ablative. If they're these very ropey type scars, I actually think as long as they're not keloids, as long as they're hypertrophic, I think excising them can be really good. And sometimes I'll follow that up with an injection of a steroid three weeks later. Um, I want it to heal but at the same time not get into a, a vicious spiral with the buildup and the breakdown and end up with another scar that's as bad as the first one.

Dr. Furnas (22:18):
Yeah, there is a limit to what we can do non-surgically and, and just as Josh said, you know, if you have a really ropey scar then uh, you know, just cut it out, add steroids and you can apply pressure. Interestingly, studies have shown that massage is fine with, uh, normal, you know, immature scars. But if somebody really has thick scars, you're adding tension. When you're massaging pressure is okay, but in massage you're actually moving the tissues away and you can pull that, uh, that scar and create tension.

Dr. Korman (22:56):
So we've been talking a lot about scars in general, but let's, uh, shift a little bit to, uh, affliction that many, many humans suffer from. And those are acne scars.

Dr. Furnas (23:07):
Yeah, and we often minimize the impact of acne scars because it's so common. You know, 80% of teens get acne and a lot of adults have acne as well. But acne scars can be devastating for people because it's right there, it's your face. And the scars can be hypertrophic or they can be atrophic, meaning, you know, from atrophy. So as Josh said, the scars can be very flat, they can be pink, but they can be very flat and they can be indented so that, you know, the scarring can actually impact the fat underneath.

Dr. Korman (23:48):
And it's also, I mean we all learn and teach that you're not not supposed to pop your pimples too much cuz that can make a pore and bigger hole. But there is more aggressive kind of acne called cystic acne that even if people don't touch it at all, it can really cause a lot of injury to the skin in the surrounding area. And then as we age, those acne stars can go from little pits to being more obvious because as the skin loosens and the elastin loosens and they do have big psychological impacts on patients and at any age, but obviously teenagers are very self-conscious and in our world of TikTok and social media where everybody puts the filter on, so it makes it look like they're just don't have a, a wrinkle or a pimple on their face. It can be really psychologically painful. And there are things that you can do for acne scars. I think we can talk about them a little bit because it's, important to make sure people understand that there are options.

Dr. Furnas (24:57):
First control the acne because you know, you don't want to have these treatments while you've got infections with, you know, abscesses or cyst pimples, pustules, that type of thing. So you need to control the acne. Um, and so when you're dealing just with the scars rather than active acne, what would you do, Josh?

Dr. Korman (25:18):
So I think it's a question of what is, again, the diagnosis. Do people have little holes? Do they have little pits that you can add little bits of filler to bring up the valleys from hills and the valleys? I found that it depends again on the type of skin on, uh, lighter skin patients, I think there are certain lasers actually that are fractional lasers that can go deeper, but with little skin bridges.

Dr. Furnas (25:52):
So Josh, what's a fractional laser?

Dr. Korman (25:56):
So a fractional is like a half, a quarter, three eighth, no, that's a fraction <laugh>, A fractional, a fractional laser is designed that instead of having just electric sandpaper going all the way down, there are these little cores, little pinpoint cores of that the laser goes deeper, but leaves micro skin bridges. So think of these boring needles that can go pretty deep, but because they're so close to each other, they preserve these little bridges of skin between, and that instead of causing a lot of damage, actually heal quite well. And there's a variety of this technology. There's fractional lasers, there's microneedling, there's coring, there's lots of technologies, but the idea is to be able to go deep enough but to preserve the skin in between so that the healing is quick and reliable.

Dr. Furnas (27:04):
Yeah, as Josh said, you've got normal skin. If you have, like I mentioned at the very beginning, a big open wound, so you've got no skin and the skin contracts and eventually closes the whole, but if you have just different cores, you've got skin all around those little tiny cores so you can heal quickly and it really reduces the risks of loss of pigmentation or scarring, uh, that type of thing. That can happen more frequently with a completely ablative laser. And then, uh, the microneedling RF. So RF is radio frequency, so the microneedling, you've got little tiny needles just barely getting into the, the skin. They're very short needles and then they're insulated. And you've got radio frequency, which is a long wave longer than laser long wave energy and it heats up the deeper tissues, deeper skin, and that can be effective in treating acne scars. And some people though with darker skin, do better without any type of heat. No laser, no radiofrequency. So microneedling is helpful for those patients. Plus, in some instances, some studies have shown that microneedling with P R P is really helpful. So what's PRP?

Dr. Korman (28:29):
So yes, <laugh>. So Heather, you fractionated fraction. What is P R P?

Dr. Furnas (28:36):
Do you wanna answer?

Dr. Korman (28:38):
Yeah, so P R P stands for platelet-rich plasma. And basically the way it works is you take a little tube of blood and you spin it in a centrifuge and that separates the red blood cells from everything else. And the everything else is plasma and platelet rich plasma. So in the plasma are the platelets and it's the, if you spin the blood, the red blood cells are the dark red that we all think of blood. And the lighter color is the plasma that has the platelet rich plasma and it's used for so many things.

Dr. Furnas (29:13):
So it's the liquid part of blood with these goodies floating within it.

Dr. Korman (29:17):
Right. And it's used for many, many things. It's used in orthopedics for joint injuries, joint problems, uh, a wide, wide variety of, it's, it's almost for any, anything that ails you, P R P is helpful. It's used in to inject in the scalp to help thicken hair. So it, it's used for many things, but in combination with the microneedling, the little needles open the pores so that the P R P with all their goodies can be injected deeper and help the skin recover. So P R P with microneedling can really help, especially with darker skin patients that won't tolerate some of the ablative lasers. You can help the acne quite a bit.

Dr. Furnas (30:03):
Yeah, so if you do have significant acne scars and you want your scars to be treated, I would not expect perfection. Your skin can look better, but uh, if you really have, you know, irregular skin pitting and whatnot, there will be a limit. Now the, these machines, the lasers, the radio frequency microneedling, P R P, can really help improve the depressed scars. But then as Josh mentioned, you may need filler after that to kind of help even out. It'll never be perfect, but that combination of the shrinking, all those little scars, filling them in can be boosted with a filler.

Dr. Korman (30:49):
So there are so many treatments for scars, and that's mostly because there is no perfect and there is no perfection. But there's a lot of, a lot of different treatments and, and new treatments coming all the time. And it's important to have hope. And obviously the best thing is to prevent the scar. Al Capone would've been better not to insult the woman at the bar, uh, <laugh> he probably would've not been Scarface that way. But life happens. And then once you have a scar to deal with, there's a lot of, a lot of ways to treat them.

Dr. Furnas (31:27):
Yeah, as Josh said, you know, once you have a scar all the way through this skin, nothing's gonna make it go away. The scar is a scar, but there's a lot we can do to help. Thank you for listening to Skintuition. I'm Heather Furnas.

Dr. Korman (31:44):
And I'm Josh Korman. See you next time.