Plastic Lesion with Procedure

Thank you for your referral on 2026-02-09 for a consultation about postoperative right carpal tunnel release.

The patient presents for follow-up after right carpal tunnel release performed on May 13th. The patient reports resolution of preoperative numbness and paresthesia. However, there is persistent significant pain localized to the right wrist, especially with movement or use of the hand. Activities such as sewing or opening a car door with the right hand exacerbate the pain, leading the patient to compensate by using the left hand. The area is described as tender, particularly around the incision site, and the patient is aware of internal sutures. The patient inquired about the persistence of discomfort three months postoperatively and expressed interest in interventions to soften scar tissue. No new neurological deficits or systemic symptoms are reported.

Past Surgical History:
- Right carpal tunnel release performed on May 13th.

Allergies:

Physical Examination:
The surgical site on the right wrist is firm and swollen, with tenderness noted around the incision area. Pressing on the area does not elicit pain. There is no evidence of new neurological deficits.

Assessment:
- Pain in right wrist (M25.531)
- Scar conditions and fibrosis of skin (L90.5)

Plan:
The patient was advised to initiate gentle massage of the surgical site to help soften the scar tissue. Topical anti-inflammatory creams, heat, or ice were recommended as appropriate options for managing inflammation and discomfort. Exercises were not advised at this stage, as they could potentially exacerbate the pain. A steroid injection is not being considered at this time due to associated risks, and it was explained that no cream or method is currently available to soften deeper tissue scars. The patient was instructed to return for further evaluation if symptoms do not improve within the next couple of months.