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Case 10 Use of Diode 1210nm for Scar
See Fig.(Fig. 16a–d).
H. Cartier et al.
Fig. 16 (a) In an immediate postoperative surgical proce-
dure: bar code for automatic settings. (b) Laser diode
1210nm in action. (c) Laser diode 1210nm: results after
1month without inammation. (d) Laser diode 1210nm:
results after 6months. Courtesy of Hugues Cartier
Lasers andEnergy-Based Devices inScar Therapy: APractical Use
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133
Laser asSoon asPossible After
theSurgery, intheFirst 3Months
Pulsed dye laser (PDL), ablative fractional laser
(AFL), and non-ablative fractional laser (NAFL)
are in the rst line.
The PDL can be used as soon as the sutures
are removed. This treatment performed in a
period close to the inammatory phase, and to
the beginning of the proliferation phase, uses the
vascular target due to vasodilatation and neoangiogenesis to interfere with the complex phenomena of scarring.
A Vascular Laser Only
– Several studies have analyzed and compared
the contribution of pulsed dye lasers (PDL),
using different parameters and starting the
treatment at different stages. Interesting
results are presented with the use of PDL
from suture removal, at low uences: e.g.,
10 mm 6 ms, 7 J/cm2. This treatment, per-
formed in a period close to the inammatory
phase and the beginning of the proliferation
phase, uses the vascular target due to vasodi-
latation and neo- angiogenesis, to interfere
with the complex healing phenomena [15]
(Fig. 17a, b).
– The same is true with the KTP 532 laser on
thyroidectomy scars. Each participant was
treated using a 532-nm KTP laser (Gemini,
Laserscope, San Jose, CA) two times at
2-week intervals. The laser treatment was
done 2–3 weeks (average 15.5 days) after
the total thyroidectomy surgery, which was
around the time at which a surgical wound
completes its epithelialization and the
sutures have been removed. The laser treatment setting for each surgical scar was as
follows: 10-mm spot size, 25-ms pulse duration, 8J/cm2 of uence, 1.5Hz, double pass.
After two sessions of laser treatments using
the 532-nm KTP laser, scars of the treated
group showed cosmetically better outcomes
than those in the untreated control group
[16].
Case 11 Scar of the Nose After Derm Surgery
for Basocellular Carcinoma
See Fig.(Fig. 17a, b).
ab
Fig. 17 (a) Nasoglabellar ap—vascular targets 1month
after surgery. (b) Result after 3 treatments at M1–M2–M3
with combined PDL/YAG Multiplex Cynosure setting
7mm handpiece PDL 10ms 9J short interval YAG 20ms
45J. Courtesy of Hugues Cartier
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H. Cartier et al.
Non-ablative Fractional Laser
In this indication, the early use of a non-ablative
fractional laser (NAFL) in the weeks following
surgery has also shown favorable results in several studies for low densities even comparatively
to Pulse Dye Laser [17].
In 2009, a Korean team treated linear thyroidectomy scars for 27 patients with a 1550 nm
NAFL, starting in the second week, three times a
month [18].
The same surgeon performed all the operations using the same surgical techniques. Each
patient was treated four times at 1-month intervals using the same parameters (5 × 10-mm spot
size, 10 mJ, 1500 spot/cm [2], static mode).
Initiation of the rst irradiation was made
2–3weeks after the thyroidectomy.
The scar prevention effects were evaluated
each month for 6months after the thyroidectomy.
The average Vancouver Scar Scale score (VSS)
was lower in the laser treatment group. The
global assessment also presented better cosmetic
outcomes in the treatment group than in the controls. The NAFL can be safely applied in dark
Asian skin without noticeable adverse effects.
Case 12 Traumatic Scar of the Glabella
See Fig. 18a–d.
Fig. 18 (a) Post-traumatic scar and corrective surgery at
3weeks with inhomogeneous contact between still swollen edges. (b) Erbium: YAG laser resurfacing + botulinum
toxin injection to relax the glabellar muscles. (c) Pulsed
dye laser 7mm, 6J/cm2, 10ms alternated every 2 months
3 times with non-ablative fractional laser 1550nm 50 mJ,
3ms followed by injection of a few drops of hyaluronic
acid in the scar line (beware of major vascular risk area)
while continuing with hyaluronic acid injections. (d)
Result in line with expectations at 1year with a discrete
non-invasive scar line. Courtesy of Hugues Cartier
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135
Comments
– Alternative to the Erbium: YAG laser, the CO2
laser also allows resurfacing but remains less
precise for abrading borders.
– Alternative to pulsed dye laser, KTP laser
532nm, 8 d/cm2, 4ms.
– Alternative to Erbium-glass laser 1550 nm,
other wavelengths 1565, 1540 and Nd-YAP
laser 1340nm are also possible.
Ablative or Non-ablative Fractional
Laser, Which toChoose?
The great difculty in most of these reported studies is to know the limits of one’s own devices. One
wonders on what criteria the authors base themselves to nd the right settings for any device.
– Ibrahim et al. evaluated the use of CO2 for
postsurgical scars. A total of 27 Egyptian
patients with recent postoperative scars were
enrolled in this study. Three sessions of fractional CO2 laser with a 1-month interval were
started 4weeks after surgery. Vancouver Scar
Scale (VSS) was used as an assessment tool at
1 and 3 months after the nal treatment.
Patients reported their satisfaction using a
subjective four-point scale. They demonstrated a statistically signicant overall average improvement of the VSS (5.33 ± 1.33)
before compared with (2.55±1.06) 3months
after the last laser treatment (P≤0.001). The
most signicant improvements were found in
pigmentation, height, and pliability [19].
– In a comparative study by Shin etal. [20], on
the treatment of postoperative scars using
non-ablative and ablative fractional lasers,
the results may provide more clarity. They
randomized 32 patients (mean age 42.1years)
of phototype III–V, with a thyroidectomy
scar of 2–3months. One-half of the scar was
treated with non-ablative fractional laser and
the other half with the ablative technique
(Mosaic™ laser, Lutronic corporation). At
the rate of two sessions 2 months apart, with
similar parameters for the two modes: high
energy 50–60mJ and low density 5–8%. The
evaluation was done on photographic images,
spectrophotometry, and durometer. Clinical
improvement was not signicantly different
between the two systems; however, AFL was
better at reducing scar hardness whereas
NFL was superior for lightening color. But
there is no miracle for vascular redness; the
vascular laser seems to be the most interest-
ing to use as soon as possible compared to
any fractional lasers.
Vascular Laser withFractional Laser:
AsSoon AsPossible
– Kim and coll. report their results on the
comparison of the pulsed dye laser (595nm,
10 ms, 10 J/cm2), and the fractional CO2
laser (AFL) (80mJ/mtz, density 8% in two
passes, spot 120μm), in a prospective, com-
parative study on the same scar, for 14
patients with postsurgical scars of the face
[12] and the abdomen. They observed com-
parable results between the two devices,
with the LCP having a logically better
action on pigmentation—vascularization—
color and the CO2 laser pliability—texture-
height—thickness of the scar [21] (Fig.
18a–d).
Comments
– Considering the vascular targets and the
neocollagenesis in the healing process, we
propose to our patients the combined treat-
ment associating successively in the same
session of LCP 595–10mm 6ms 7J and AFL
densities 5–10% for a power of 70–150
mJ.The results appear to us to be interest-
ing, in accordance with the various publica-
tions, on postsurgical scars of the nose. This
is an increasingly frequent situation after
the removal of skin carcinoma in this area,
in patients concerned about the visibility of
their scar.
– We particularly insist on the prerequisite of a
carcinologic surgery followed by a meticulous
and optimal repair, the laser being an addi-
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H. Cartier et al.
tional technique that can only be used after a
good repair surgery.
– The treatment is started at the removal of the
sutures, between D6 and D10, and repeated
twice at 1-month intervals.
– It can be debated that nose scars can improve
spontaneously. Experience shows that we
have no deleterious effect on the scarring pro-
cess at the proposed parameters of our lasers
(Fig. 19a–d).
– This protocol brings quicker results in reduc-
ing the visibility of the scar and provides satisfaction to patients who wish to care for their
scars after surgery.
Case 13 Nose Surgical Scar for a Basocellular
Carcinoma
See Fig. 19a–d.
Fig. 19 (a) Surgical scar at Day 7 after ap of the nose.
(b) Scars after 3 combined laser treatment PDL
10mm–6ms–7J and AFLCO2 density 0.8–1 mm or (5%)
uence 70–120mJ—start day 7 after surgery M1 and M2.
(c) Surgical scar at Day 7 after ap of the nose. (d) Scars
after 3 combined laser treatment PDL 10 mm–6 ms–7J
and AFLCO2 density 0.8–1 mm (or 5%) uence
70–120 mJ—start day 7 after surgery M1 and M2.
Courtesy of Hugues Cartier
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137
Key Point: Management of a Postsurgical
Skin Scar
1. PRACTICAL, SIMPLE, and QUICK
TREATMENT
PDL (or KTP)/AFLCO2 (or NAFL) laser
combination—3 sessions: at D7 (removal of
sutures)-M1–M2
2. MORE TECHNICAL IN THE OP ROOM
A diode laser 1210nm—especially plastic
surgery
3. NEW MODALITIES SKIN TREATMENT
BEFORE SURGERY
Skin treatment to prepare the healing pro-
cess before the operation: non-ablative
fractional laser (NAFL)
Comments
– There is no risk in offering laser sessions with
low enough uence parameters for a scar
“under construction.” In all the reviews, there
is no mention that the laser has had a deleterious effect on the scarring process.
– The studies are difcult to compare, and it is
not so easy to propose a codied protocol
except for the thyroidectomy scar feature.
– Among the lasers and other energy-based
devices (DBE), all can be of interest, and it is
the laserist doctor who picks from their toolbox, while estimating the settings they nd
most useful.
– In this respect, the easiest laser to set up is the
pulsed dye laser, as it is accepted that all that
is needed is to provoke a sub-purple reaction.
Whatever the situation, it forgives setting
errors and systematically comes back as a reference on the day of the removal of the wires,
or later for a scar that remains red or enlarges.
– The fractional non-ablative laser (Erbium-
Glass 1540–1550–1565 and Nd-YAP 1340) is
interesting when the scar hardens without
being inammatory. The depth of its radiation
limits it to scars less than 2mm thick to cover
the entire scar volume, but it can be proposed
for all phototypes.
– The CO2 or fractional Er-YAG laser can be used
as early as the removal of the sutures, on its own
or in association with the pulsed dye. During
the rst 3 months, it can also be used if the edges
of a scar are not well faced or if the scar is
hypertrophied in order to facilitate the penetration of a topical corticoid or uorouracil.
– IPL with short lters called vascular band,
KTP 532 also in vascular mode, and LEDs to
modulate the inammatory process are proposed alternatives.
– Of course, all scars must be put to rest so that
the inammation does not persist and induce
induration, hypertrophy, and enlargement. It is
essential to x it with a very thin hydrocolloid,
silicone patches, a plaster, or compression
garment according to the practitioner’s choice.
Finally, all these studies and comments tend to
show that only the doctor can take the decision to
offer a laser procedure. The problem being that most
doctors do not practice laser treatment, it is more difcult to persuade them, in any case much more so
than patients who are looking for recent technologies. It is obvious, but we all need a protocolization of
the act to be reproducible and to offer the maximum
to each patient. To date, the use of a systematic laser
is neither possible nor necessary because in most
cases, the scar will be ne, exible, and in line with
the expectations of the patient and the physician.
– The semi-late treatment of a scar tissue in the
making is variable and must be adapted to its
type (atrophic, excessive, vascular, or brous,
pigmented, or hypochromic...), its shape (sur-
face, volume, thickness...), its location, and of
course to the patient (history, age, ethnicity,
phototype...).
– Lasers and other DBEs can be of appreciable
help, but always combined with corticoids
and physiotherapy: xation-compression,
massage- petrissage, or even a medical-spa
treatment dedicated to the treatment of large
areas, but to be discussed on a case-by-case
basis. The choice of the device will depend on
its penetration and on the target to be reached.
The treatment is often long, 12–18months. Is
it worth it? Certainly, if the physician and the
patient are determined and ... patient!
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H. Cartier et al.
Scars, What ToDo After
the100Days
However, it is questionable whether to propose
a laser treatment at an early stage without
knowing the scarring prole, even if we know
its potential for risky situations; after the third
month, we can more than suspect that the scar
will not evolve as expected if it is already pathological or unsightly.
The analysis of the scar (color, height, suppleness, rmness, and the patient’s phototype)
remains the basis for considering a laser or EBD
procedure regardless of the type of scar: inammatory acne that leaves a depression, after effects
of a burn or recent trauma, postsurgical scar. We
must not neglect the patient’s expectations and
demands, for whom a mark, often on exposed
areas, is the source of requests for treatment and
medical and pharmaceutical nomadism. Also,
while being reassuring on the often very favorable
evolution, we must know how to propose risk-free
treatments which may even bring benets that we
consider minimal, but which encourage compliance with the recommended measures.
If theScar Tissue Is Still Red But
Supple
Even if it tends to enlarge or thicken, only the constraint of a compression dressing is necessary.
The use of dermocorticoids or patches is possible,
as are pulsed dye lasers or vascular laser lamps,
but no one knows whether they do not tend to
encourage relaxation and therefore enlargement
or perpetuated inammation. Photo biomodulation by exposure to LEDs, particularly red
(630nm) and/or infrared, is a debated alternative
that carries minor risk of aggravating the process.
If theScar Thickens, Hardens, Itches,
But Remains Red
There is a risk of hypertrophy, which may appear
before the 100days. For keloids, this is often the
starting point for induration, but the genetic and
topographical context must be put into perspective because the evolution is different from that of
hypertrophic scars. The keloid must go beyond
the scarring process, itches much more, and has
ab
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139
no tendency to improve within 18months in contrast to the hypertrophic scar.
In any case, we always recommend a pressure
bandage with or without laser. We can add massaging—kneading and injectable corticoids in
small quantities every 6–8 weeks or with the
LADD procedure. Diprostene© is preferred to
Kenacort-Kenalog©, which is more atrophying,
for scar tissue that is not very thick and not yet
indurated.
If theScar Is Just Red or Pink, It Is
Never Too Late forVascular Lasers
– Pulsed dye laser in sub-purple photothermoly-
sis mode preferably.
– Nd: YAG laser scanning has very low uence
(5J/cm2) and short times (0.5ms) but it takes
several hundred shots to heat beyond the sac-
rosanct 52 °C for a certain ill-dened time,
and many sessions in the series that have been
published for Nd:YAG.
– The sub-purpuric mode of the latest genera-
tions of KTP laser or intense pulsed light with
vascular lters and pulse durations of less than
3ms is an alternative to pulsed dye laser.
If theScar Thickens, Hardens, White
inColor
– It is more likely to be a brosis-type scar. It is
therefore necessary to break the scar tissue
either with a non-ablative or more aggressive
ablative fractional laser.
Case 14 Nose Surgical Scar
See Fig. 20a, b.
Fig. 20 (a) Just before Erbium: YAG resurfacing-sculpting of a total skin graft in a partially necrotic wallet. (b) Result
in a single session. Courtesy of Hugues Cartier
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H. Cartier et al.
– Microneedle radiofrequency is an alternative
to soften the indurations laser. The use of cor-
ticoids is always interesting for their atrophy-
ing and softening effect but be careful with the
quantity and concentration (to be diluted espe-
cially for the face or for children). It is possi-
ble to induce too much atrophy, giving the
scar a stretch mark appearance with ne telan-
giectasias on either side, and their hypochro-
mic effect.
If theScar Falls Apart andSags, Like
aRiver Bed Without Water
– The connective tissue can be strengthened by
recommending fractional ablative or non-
a
ablative lasers (Fig. 20a, b) and the injection
of hyaluronic acid to strengthen the scar wall
(Fig. 21a–c). Some have tried tissue inducers
such as highly diluted polylactic acid or calcium hydroxyapatite or platelet- rich plasma
after microporation with inconsistent results.
The injection of hyaluronic acid can be
repeated every 6 weeks but without reusing
the laser at the same time so as not to damage
the hyaluronic acid structure. At least 3months
should be allowed for the hyaluronic acid to
play its role as a tissue inducer if one wishes to
combine the two.
Case 15 Facial Laceration Scars
See Fig. 21a–c.
b
c
Fig. 21 (a) Traumatic atrophic scar (laceration). (b)
Three sessions of non-ablative fractional laser 1550nm,
40mJ, 2.7ms and ller injection with hyaluronic acid to
elevate the scar fold. Injections were done just after each
session, 2months apart. (c) The result is incomplete with
a scar that reappears on its upper half. And it is possible to
reinject hyaluronic acid. The alternative would be the Er:
YAG laser, which gives less depigmentation than CO2.
Courtesy of Hugues Cartier
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Comments
We recommend the use of AFL or NAFL by
adapting the parameters to the topography and
skin texture of the scars, combining or not the
PDL laser in the same session if an inammatory aspect persists. The thicker the scars, with
less and less exibility, the more AFL is
indicated.
– For young atrophic scar, PDl or KTP or IPL
rst and as a second option NAFL and then
AFL
– For established atrophic scars, NAFL then
AFL or MRF and if necessary combined with
soft tissue llers and collagen inductors
Inammatory, Hypertrophic Scars
andKeloids [22]
Inammatory scars are dened by a redness that
persists beyond the normal range. It is extremely
variable from one subject to another because a
scar can evolve over 1 year or more. It will
remain so if its natural inammation is prolonged. The hypertrophic scar is the volumetric
translation of an inammatory scar that expands
to create indurated cords but without extending
beyond the scar. Most of them fade spontaneously in 18 months, helped using corticoids,
plasters that limit its movement and a gentle
massage, to be decided on a case-by-case basis.
If the healing process extends beyond the scar, it
can be considered keloidal evolution like the
classic buttery scar. Both are inammations but
laser management is much more complicated,
and we nd in many publications a confusion
between the two [23].
What ToDo withaHypertrophic Scar
That Has Already Formed?
– The scar must be compressed with all the
technical devices available: hydrocolloid,
custom- made elastic fabric, and silicone
patches almost permanently for at least
3months when it is possible.
– The patient is advised to massage and knead
the scar twice a week, either manually or
mechanically, while continuing the permanent
compression xation.
In general, the combination of compression
and massaging allows the scar to improve within
6weeks to 3months.
Nevertheless, it depends on the topography
of the scar and whether it is under permanent
tension. In this case, we do not recommend
any massaging or compression to avoid overstressing the scar inflammation which will
thicken even more if elongation movements
are provoked. It is a case-by-case decision,
and the use of lasers is subject to the condition
of a real interest and not to perpetuate the
inflammation.
– Our rst line of treatment is based on the use
of corticoids topically (cream or patch), but
we keep the use of Pulsed Dye Laser (PDL) to
reduce vascular and inammation compro-
mising in inammatory phase.
We propose to our patients a treatment combined in the same session PDL (7 or 10mm—3
or 6 ms—6–10 J/cm2) followed by an intralesional injection of acetate of triamcinolone
(TAC), 3 sessions spaced out of 1 month to
weeks. Or a combination in some cases: removal
with CO2 laser followed by the prevention of the
recurrences by sessions of AFL CO2 followed at
once by the topical application of TAP, “laserassisted drug delivery” (LADD).
Inject corticoids into the scar either conventionally with a needle or by the LADD procedure with a fractional ablative laser to facilitate
the penetration of drugs deeply into the skin
(laser- assisted drug delivery), or using a roller
with spikes or radiofrequency with penetrating
needles is possible to create also small dermal
holes. The interest of electric currents is to break
the inammatory bridges before they brose.
The goal of using corticoids is to gain time
because a hypertrophic scar typically does not
improve over 18months. However, a thick surgical scar will evolve by widening and by inter-
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