3.5 months post-op scar tissue issues

[flatness13]

I had my final consult with my surgeon today. Unfortunately my nipples were a bit erect during it so he couldn't fully see my issues. My nipples are quite puffy now which I believe is because of scar tissue. The first week or so after the surgery everything was nice and flat and I hope to get back to that state.
First before surgery:
http://i1209.photobucket.com/albums/cc396/tanner151/before-gynoS%202.jpg

This was 2 weeks afterwards when stitches got removed, this is when scar tissue started developing and the incision sites felt quite hard.
http://i1209.photobucket.com/albums/cc396/tanner151/2weeks-post-gyn.jpg

And now 14 weeks since surgery:
http://i1209.photobucket.com/albums/cc396/tanner151/GEDC0690.jpg
http://i1209.photobucket.com/albums/cc396/tanner151/GEDC0692.jpg
http://i1209.photobucket.com/albums/cc396/tanner151/GEDC0691.jpg

Note the protrusion on the bottom of the nipples? I hope it's not a deformity but scar tissue pushing the arreola forward there.

Problem is I asked about kenalog shots for scar tissue but my surgeon said that he doesn't really want to do it. He seems to think puffy nipples are normal and kind of wants to avoid any criticsm. But I did tell him he did a good job, I do believe I have gotten a very good improvement on my chest. Now if only I could get rid of this scar tissue I think I'll be fully happy.

I am thinking about waiting a few more months and then sending the surgeon pictures of my nipples when they're soft so he can see it better and convince him. When is it not too early to get these injections, and is there a risk that they could make it look worse? I think he hinted at that.

[Dr. Elliot Jacobs]

From your sequence of photos, it appears that you have a nice result.  Scar tissue grows starting within a few weeks after surgery and continues for several months -- then it tends to improve by itself.  

You are only 3.5 months post op -- virtually at the peak of scar tissue production.  Why not be patient and observe for another 3 or more months before asking for treatment -- it may not be needed at all.

Dr Jacobs

[flatness13]

Thanks for your answer doc. With your experienced eyes, did you notice the disc-like protrusion on the bottom of the nipples? Is this a common sight when it comes to scar tissue build-up, or is it perhaps a more worrying sign than that, like say a deformity? On the left nipple it's slightly worse and there was more gland removed there, so there's that.

And I will take up your advice on waiting a few more months and I'll continue massaging. Would the 6 month mark be a good time to consider kenalog treatment? I'll probably make an update by that time too.

[Dr. Elliot Jacobs]

If the thickest part is under or near the incision, this is most likely due to scar tissue and healing in this area.  In fact, we call it a "healing ridge."  It should settle down with time or be easily amenable to kenalog treatment.  It is highly unlikely that it is re-growth of breast tissue.
Dr Jacobs

[flatness13]

Phew, that's a relief. Yeah it's all on the bottom of the nipples exactly on the incision spots, and it feels hard and different than it ever did before. I'm very confident that it's scar tissue.

I'm just gonna wait and heal a few more months and if my surgeon refuses to give me the kenalog treatment, I guess i'll try to get it done at the hospital with another doctor.

[Litlriki]

It is early to make a decision on the scar with respect to final outcome.  The scars will continue to evolve and flatten a bit, and while Kenalog can help that if the scarring is excessive, it may not be necessary, and use does have some downsides.  If the scar tissue does not settle down entirely, it's possible that an injection or topical therapy can help. In some cases, if there is an issue of mis-match with the incision closure, revision of the scar might be required.  This isn't common, but it occurs on occasion. 

[flatness13]

It is early to make a decision on the scar with respect to final outcome.  The scars will continue to evolve and flatten a bit, and while Kenalog can help that if the scarring is excessive, it may not be necessary, and use does have some downsides.  If the scar tissue does not settle down entirely, it's possible that an injection or topical therapy can help. In some cases, if there is an issue of mis-match with the incision closure, revision of the scar might be required.  This isn't common, but it occurs on occasion.

Could you elaborate some more on said downsides please?

[Litlriki]

It is early to make a decision on the scar with respect to final outcome.  The scars will continue to evolve and flatten a bit, and while Kenalog can help that if the scarring is excessive, it may not be necessary, and use does have some downsides.  If the scar tissue does not settle down entirely, it's possible that an injection or topical therapy can help. In some cases, if there is an issue of mis-match with the incision closure, revision of the scar might be required.  This isn't common, but it occurs on occasion.

Could you elaborate some more on said downsides please?

Treatment can cause changes to the color or character of the overlying skin, such as loss of pigment in the nipple, thinning of the dermis, or a redness at the site (a vascular pattern to the skin).  

[flatness13]

5 months post-op now and there's slightly more scar tissue now. No improvement yet.

And I have been reading a lot of stories of people getting steroid shots for scar tissue and some of them develop craters. It's pretty scary. Now I get why my surgeon really didn't want to give me those injections because it does have risks..

I want to wait it out for longer to see if it improves by itself, but how long? Would 8 to 9 months post-op be ok?

[Dr. Elliot Jacobs]

Steroid injections can be done at any time -- 6 months or many years after surgery -- and it is still effective.  There is no "magic" time.

If you are content to wait, then there is absolutely no harm in doing so.
As for injections once you decide to go for it, please go to an experienced gyne surgeon.  I have been injecting sub-areolar scar tissue for many years -- with excellent results.  It is a matter of choosing the right dosage and doing the injection the right way -- all of which comes with experience.

Dr Jacobs

[flatness13]

Another question: My surgeon isn't available for 3 months so they offered someone else to give me the shots. Is that risky? My surgeon knows exactly how he made the incisions and all, what if this other person shoots the cortisone outside of scar tissue areas or something? I'm just nervous because I've seen people get craters from incorrect injections post surgery.

[Dr. Elliot Jacobs]

Sorry -- can't help you with this question.  You will have to go with your gut feelings.  There is certainly no harm and no down side  in waiting until your original surgeon is available.

Dr Jacobs

[flatness13]

My clinic said the same thing. I think I'm gonna go through with it, I'll just ask them to use a very low dosage first. I will update later.