Scars & Tattoo Removal - Not Always Lasers or Injections

In the world of aesthetic medicine, the default answer for a scar or an unwanted tattoo is almost always the same: topical creams/gels, steroids or some kind of "healing" injection, or laser packages. When these methods fail, or worse, mask a deeper issue, the conversation needs to change. Often, what's required is a structural approach and a surgical solution to address the actual cause.

Case 1 - The "Keloid" That May Not Be a Keloid

A patient presented with a recurrent scar on the chest, in the sternal area near to the nipple. This is an area known for its tendency to form keloids. He had previously undergone excision and local tissue arrangement (Z-plasty) for what had been described as a "flat keloid" measuring about the size of a 20 cents coin. The lesion had "recurred", and it was now looking aggressive, extending well beyond its original borders.

The first question I asked was straightforward: was histology sent at the time of scar excision? He did not know, and no histology report was available.

This IS a problem. The term "keloid" is descriptive, not diagnostic. A "flat" lesion labelled as a "keloid" is already an oxymoron in itself - keloids are by definition raised and have grown beyond its original borders. More importantly, a lesion that recurs aggressively after excision and Z-plasty in the chest area, with no histological confirmation of its nature, must prompt the clinician to consider alternative diagnoses such as a dermatofibrosarcoma protuberans (DFSP). DFSP is a low-grade soft tissue sarcoma that commonly presents on the trunk, often as an innocuous-looking "keloid" in its early stages, and recurs aggressively after incomplete excision.

The only way to diagnose them is a biopsy for laboratory analysis (histology). I asked the patient to find out about this (if any) from the public hospital where the original excision was done. He has not been back since.

That response, or lack of it, is not unusual. It is not me, as the surgeon, trying to be difficult. Rather, the clinical obligation remains. Until DFSP is excluded with tissue biopsy, it cannot be assumed to be negative in such a case. A scar that behaves like this, in this location, without a tissue diagnosis, demands investigation before any further treatment.

Case 2 - Multi-Colour Tattoo Removal: Why Laser Is Not Always the Answer

A patient consulted me for removal of a large tattoo spanning the biceps and medial arm. It contained multiple colours - red, black, and yellow. Laser tattoo removal is colour-dependent as different wavelengths target different pigments, and multi-coloured tattoos require multiple laser types over multiple sessions, with variable and often incomplete results. Red pigment in particular is notoriously resistant to standard laser wavelengths.

Surgical excision is an underused alternative for tattoos in anatomically appropriate locations. In this case, the tattoo's geometry worked in our favour: it was composed of discrete rectangular segments, which made it amenable to serial excision with advancement flaps rather than a single large excision, which would place the wound under undue tension.

The plan was therefore, to stage the excision by removing sections in sequence, allowing each wound to heal before proceeding, with the final scar designed to approximate a brachioplasty incision along the medial arm where it would be least conspicuous. The patient however, did not return after the consultation. Perhaps he was not able to visualise the final outcome, or perhaps he had been conditioned to expect laser packages as a non-surgical alternative. That is his choice and it is respected.

The case is included here because the surgical options for tattoo removal is rarely discussed and frequently overlooked. For the right tattoo in the right location, a well-planned serial excision produces a more predictable and complete result than laser. A single linear scar can oftentimes, be more acceptable than years of incomplete fading, and sunken costs in laser "tattoo removal" packages.

Case 3 - Poor Scarring from Inadequate Wound Closure After Liposuction

A patient contacted me after liposuction performed overseas, concerned about the appearance of her access incisions. The wounds, likely, had not been properly closed after the procedure and hence, the widened and raised appearance of a hypertrophic scar (see below).

This is NOT acceptable, at least to me, especially in cosmetic surgery. Liposuction access incisions are small but they are still wounds. The entry point had most certainly been traumatised repeatedly by the liposuction cannula, the wound edges are irregular from whichever energy device (or not) that was used, and without proper closure there is nothing guiding the healing process toward a fine linear scar, which is what one would expect.

My approach, regardless of VASER, traditional, or any other liposuction modality, is to excise the access point cleanly and close it primarily with fine sutures, just like freshening a deep cut before stitching it close as I do in all lacerations. This takes but a minute and makes a significant difference to the final result.

In an attempt to improve the scarring, she had undergone multiple sessions of PDRN and CO₂ laser, with no guidance or opinion from the original surgeon, and perhaps most damningly, from the treating doctor(s). Unsurprisingly, neither made a meaningful difference other than "try again". PDRN and laser treatments can support scar maturation and improve texture in certain contexts, but they cannot remodel a widened, poorly healed scar that was never properly closed.

Revision of a poorly healed liposuction scar is still possible but obviously comes at further cost to the patient, especially after the PDRN and CO₂ laser treatments. I gave her an honest quote for surgical scar revision and again, unsurprisingly, I have not heard from her since. As with all scars, the best outcome comes from getting the closure right the first time.

Why These Cases Matter

A diagnosis never confirmed, leaving a potentially serious condition; and surgical options not offered, leaving patients with years of sunken costs through futile treatments and false hope. Scars are not just skin; they are the physical manifestation of how a wound was treated, managed, and monitored. Getting it wrong at any stage, from the initial diagnosis to the choice of treatment, has downstream consequences that can last a lifetime. If you are dealing with a scar that isn't behaving as expected, or you have been told a treatment "will just take time" despite a lack of improvement, it may be time for a second opinion.

Written by Dr Ng Zhi Yang, UK & Singapore accredited Plastic Surgeon.

References

• Ward J, Odili J. Dermatofibrosarcoma protuberans (DFSP) arising from a keloid scar: a case report. JPRAS Open. 2018 Oct 2;18:65-69. doi: 10.1016/j.jpra.2018.09.002. PMID: 32158839; PMCID: PMC7061627.

• Mustoe TA, Cooter RD, Gold MH, Hobbs FD, Ramelet AA, Shakespeare PG, Stella M, Téot L, Wood FM, Ziegler UE; International Advisory Panel on Scar Management. International clinical recommendations on scar management. Plast Reconstr Surg. 2002 Aug;110(2):560-71. doi: 10.1097/00006534-200208000-00031. PMID: 12142678.

• Ogawa R, Akita S, Akaishi S, Aramaki-Hattori N, Dohi T, Hayashi T, Kishi K, Kono T, Matsumura H, Muneuchi G, Murao N, Nagao M, Okabe K, Shimizu F, Tosa M, Tosa Y, Yamawaki S, Ansai S, Inazu N, Kamo T, Kazki R, Kuribayashi S. Diagnosis and Treatment of Keloids and Hypertrophic Scars-Japan Scar Workshop Consensus Document 2018. Burns Trauma. 2019 Dec 27;7:39. doi: 10.1186/s41038-019-0175-y. PMID: 31890718; PMCID: PMC6933735.