Verticle and Indented Scars from Blackhead Extractor

Q: An aesthetician in my dentist office wanted to try and solicit business, so I
let her do a free facial on me. She used an extractor to remove blackheads. The
result is that I now, 2 months later since the procedure, have about 30 broken
capillaries on my nose (they’re fine but give the nose an overall red
appearance) and about 4 “scars”. 1 is in the shape of the extractor, the others
are the shape of vertical lines. She used her fingernails and tissue and some
point because the extractor wasn’t getting them. She told me it was supposed to
be painful and it’s the only way to get them out. I read online and I’m learning
that it’s not supposed to be painful and the face should be steamed. Mine wasn’t
other than a moist cloth. First is the issue – what home care can I do to
improve this? Will the scars resolve on it’s own over time or solidify if I
don’t act fast in some way? I have in my cabinet Refissa, Vitamin E oil, Mederma
and some Obagi products she suggested. Next, I have an appointment with a
dermatologist that has about 9 different lasers I’m told. My concern is making
things worse or adopting a new side effect (like hardening of the skin,
hyper/hypo pigmentation), etc; Next is the fine capillaries (I have big pores).
Some office told me to use Erbium Laser, another said it’s too aggresive and to
use an IPL. What kind is best. I have sensitive skin (apparently) or I received
a traumatic evident. Last, and I’m not a “sue”-type. But, I was not given any
informed consent prior to. Should I ask her to pay for the treatments (I have
before and after pics) and if she doesn’t (which I don’t expect her to agree
with), that’s fine, I just want it fixed if possible.

A: I’m sorry you are going through this tough time. It is really unfortunate when
treatments which are supposed to make you look better, backfire and make you
look worse.

First is the issue – what home care can I do to improve this?

The indented scars which you have developed are in the
category of acne scars. Small icepick, box or rolling scars can develop after
aggressively squeezing or extracting the skin. The intent of extraction is to
squeeze out the “keratin” or dead skin cells (whitehead and blackheads) which
can fill the pore. After extraction the pores can appear smaller, since it is no
longer filled with the keratin debris. Unfortunately, sometimes aggressive
facials can actually squeeze out more than just blackheads and whiteheads. The
person performing the extraction, sometimes the person themselves in a mirror,
or someone performing a facial, and sometimes a family or friend may be doing
it, may “go after” what appears to be a whitehead. It can appear white, and look
like a miniature piece of rice, is not actually skin debris which is what
whiteheads and blackheads are, but is actually a follicle of hair or sometimes a
small piece of fat. If this piece of tissue (follicle or fat) is removed from
the skin, it will leave an indentation in the skin. I don’t know of any home
care treatments which can be performed to make these indented scars look better.
If you google “Acne scar treatments,” you will find more information about what
treatments are available, and which ones work and don’t work. None of the
treatments work 100% of the time and give perfect results. I only offer a few of
the acne scar treatments and those don’t work 100% of the time either. I can’t
comment online regarding the treatments that I don’t offer.

Will the scars resolve on it’s own over time or solidify if I don’t act
fast in some way?

Sometimes the scars may improve on their
own. This is a possibility, but it may not change either. Both are
possibilities. Since the fat or follicle is already removed from the skin, I
can’t think of any home treatments which would fill that indentation to make it
smooth.

I have in my cabinet Refissa, Vitamin E oil, Mederma and some Obagi
products she suggested.

Refissa is a gentler form of
Retin-A or retinoic acid. It helps to improve the texture of the skin, but may
not do much specifically for the indentations. Vitamin E and Mederma are useful
in scar treatments, but these scars are typically incisions from surgery or a
laceration (accidental cut) which was sewn back together. The incision which was
sewn back together can sometimes be red and raised. The Vitamin E, Mederma, and
silicone strips help to reduce redness and smooth and flatten the raised scar.
Whether it will help with an indented scar, I don’t know if it would since I
don’t have my patients use the scar reducers for indented scars only for raised
scars. Obagi is a medical grade skin care company which uses Retin-A in
conjunction with Hydroquinone in a 6 bottle kit. The Hydroquinone helps to
reduce pigmentation and can help to reduce freckles and age spots, as well as
residual pigmentation of a scar. This may help with the overall appearance of
the skin, but will not fill in the indentations, based on my experience.

Next, I have an appointment with a dermatologist that has about 9 different
lasers I’m told. My concern is making things worse or adopting a new side effect
(like hardening of the skin, hyper/hypo pigmentation), etc;

You are wise to worry about these side effects.
Pigmentation issues are a real concern. Typically the best patients for laser
treatments are fair hair, fair skin, and light colored eye patients. These
patients are least likely to have pigmentation issues. Other skin types need
more careful assessment to decide whether or not laser treatments are best for
them. I am skeptical regarding how well lasers can really help with isolated
indented acne scars. I think that after a laser treatment, the whole face can be
swollen, which may make the indented areas look more filled in, but after all of
the swelling goes away, often times more than not, the acne scar looks the same.
If we imagine the indented scar as a loss of fat or follicle in the skin, I find
it hard to understand how lasering the whole face helps to add new “tissue”
exactly where the indented scar is located. With today’s fractionated lasers,
the laser beam is shot in a grid-like pattern, which may or may not hit the
indented scar area.

There is a treatment called TCA Cross, which I don’t
offer, but it uses nearly pure TCA (tricholoroacetic acid) to treat ice-pick
scars. A toothpick or a pointed wood applicator is dipped in the full strength
TCA and paint the inside of the indented scar. As the skin damaged by the TCA,
the skin will coagulate and eventually peel off. The raw surface of the indented
scar will then heal on its own from the base of the indentation upwards. The
skin surrounding the ice pick scar will heal. According to the doctors and
surgeons who offer this treatment more than one treatment may be necessary. This
makes more sense to me than lasering the whole face. Lasers are concentrated
light energy which causes a controlled burn to the skin. The different
wavelengths of light (different types of lasers) work differently, by being
absorbed by specific colors better, and leaving the surrounding healthy tissue
alone. For example, some lasers are absorbed well by the color red, and are
better for reducing blood vessels, because it mainly gets absorbed by the vessel
itself which “cooks” and “seals” the vessel and the body absorbs the “cooked”
blood vessel.

Next is the fine capillaries (I have big pores). Some office told me to use
Erbium Laser, another said it’s too aggresive and to use an IPL. What kind is
best. I have sensitive skin (apparently) or I received a traumatic
evident.

IPLs can work, but may require multiple
treatments. The V-beam is a pulsed dye laser which is considered the
gold-standard for treating surface blood vessels. It is also known as a
“bruising” laser, so sometimes after the treatment, you may get a small bruise
in the treatment area, so you should be prepared for that. This may also require
more than one treatment, but often times vessels can be treated with a one time
treatment. After the vessels gets absorbed, sometimes the skin wants to make a
new blood vessel to replace it. If this is the case, then more than one
treatment is likely required, because even though the original vessels was
“lasered” and absorbed, a different new blood vessel grew in its place. The
bottom line is there are no guarantees.

Last, and I’m not a “sue”-type. But, I was not given any informed consent
prior to. Should I ask her to pay for the treatments (I have before and after
pics) and if she doesn’t (which I don’t expect her to agree with), that’s fine,
I just want it fixed if possible.

You can always ask, but if the aesthetician is just starting out, and does not have much business, the
aesthetician may not have much money to help you out. Just think, this
aesthetician is giving out free facials in hopes of getting new business, and if
your experience is anything like her other clients, she may have even less money
to offer you,. Her position in the dentist’s office may be in jeopardy, so she
may be out of business entirely, which doesn’t help you either.

If the aesthetician works with a doctor, surgeon or dentist (in this case), the
practice can offer you some complimentary treatments to help remedy this
unfortunate result. The reason they can do this, often the treatments they can
offer you are already sitting in the office, generating income, or sometimes
collecting dust. If they can help you without adding more cost to running their
own business then they will often do everything they can within their “toolkit”
to help you. If they don’t offer any other treatments, it will be difficult to
get the dentist to pay for another doctor or surgeon to treat you at full price.

I hope this makes sense. Most people who write on this forum have had
cosmetic procedures (injections, lasers, chemical peels, or facial surgery), so
your post is particularly important, since it shows that even simple
non-surgical procedures such as a facial performed by non-medical professionals
can pose significant risks to the clientele who have
them.

Best,

Dr. Yang