Treatment of atrophic facial scars with combined use of high-energy pulsed CO2 laser and Er:YAG laser: a practical guide of the laser techniques for the Er:YAG laser

Keloid and Hypertrophic Scar Formation, Prevention, and Management: Standard Review of Abnormal Scarring in Orthopaedic Surgery

Keloid and hypertrophic scar formation after orthopaedic surgical closure is a complex issue. The nature and location of procedures maximize wound tension, leave foreign bodies, and diminish dermal supply, all potentiating keloid formation. There is little discussion regarding the pathophysiology and management of this recurrent problem in orthopaedic literature. Keloid formation is a fibroproliferative disorder resulting in extensive production of extracellular matrix and collagen, but prevention and treatment is poorly understood. Patient and surgical factors contributing to the development of this condition are discussed. The treatments include both medical and surgical therapies that work at a biologic level and attempt to produce a cosmetic and complication-free management strategy. Medical options that have been investigated include combinations of intralesional steroid therapy, laser therapy, and biologics. Preventive surgical closure and excision remain mainstays of treatment. Radiation therapy has also been used in refractory cases with mixed results. Despite medical therapies and surgical excision aimed at treating the resulting scar, recurrence rate is very high for all modalities that have been studied to this point. Future work is being done to better understand the pathophysiology leading to keloid and hypertrophic scar formation in an effort to find preventive methods as compared to treatment strategies.

Evidence-Based Scar Management: How to Improve Results with Technique and Technology

BACKGROUND

Scars represent the visible sequelae of trauma, injury, burn, or surgery. They may induce distress in the patient because of their aesthetically unpleasant appearance, especially if they are excessively raised, depressed, wide, or erythematous. They may also cause the patient symptoms of pain, tightness, and pruritus. Numerous products are marketed for scar prevention or improvement, but their efficacy is unclear.

METHODS

A literature review of high-level studies analyzing methods to prevent or improve hypertrophic scars, keloids, and striae distensae was performed. The evidence from these articles was analyzed to generate recommendations. Each intervention's effectiveness at preventing or reducing scars was rated as none, low, or high, depending on the strength of the evidence for that intervention.

RESULTS

For the prevention of hypertrophic scars, silicone, tension reduction, and wound edge eversion seem to have high efficacy, whereas onion extract, pulsed-dye laser, pressure garments, and scar massage have low efficacy. For the treatment of existing hypertrophic scars, silicone, pulsed-dye laser, CO2 laser, corticosteroids, 5-fluorouracil, bleomycin, and scar massage have high efficacy, whereas onion extract and fat grafting seem to have low efficacy. For keloid scars, effective adjuncts to excision include corticosteroids, mitomycin C, bleomycin, and radiation therapy. No intervention seems to have significant efficacy in the prevention or treatment of striae distensae.

CONCLUSION

Although scars can never be completely eliminated in an adult, this article presents the most commonly used, evidence-based methods to improve the quality and symptoms of hypertrophic scars, as well as keloid scars and striae distensae.

Evaluation of combined fractional radiofrequency and fractional laser treatment for acne scars in Asians

BACKGROUND AND OBJECTIVES

Fractionated radiofrequency (RF) induces deep dermal heating and leaves the epidermis less affected. We studied the efficacy and safety of bipolar RF and fractional diode laser followed by fractional RF in Asians with acne scars.

MATERIALS AND METHODS

Twenty-four patients (skin types III and IV) with acne scars received up to five treatments of combined fractional 915-nm laser and bipolar RF using a Matrix IR applicator (Syneron Medical Ltd, Yokneam, Israel) with fluence ranging from 50 to 70 J/cm(2) , RF at 70-100 J/cm(3) , double passes followed by full-face bipolar fractional RF treatment using Matrix RF at energy ranging from 50 to 62 mJ/pin, at 4-week intervals. Changes in acne scars, skin texture, pore size, pigmentation irregularity, and complications were assessed up to 3 months post-treatment by standardized photographs obtained with Canfield Visia-CR system®. Subjective improvement and patient satisfaction were assessed by questionnaire.

RESULTS

Twenty patients (age 27.7 ± 8.4 years) completed the study. Modest but statistically significant improvement was noted in acne scars, with the mean grade decreased by 29% (P < 0.001), and 52% were rated with at least moderate objective global improvement at 3 months. Mean pain score was 2.6 on a scale of 0-4. There were also objective improvements in all secondary endpoints. Post-inflammatory hyperpigmentation (PIH) occurred mainly over bony areas in 6.5% of all treatments. Subjective improvement was moderate to significant for 36.8% of patients, and 63% reported being satisfied with the treatment results at 3 months despite considerable pain level.

CONCLUSION

Use of fractional laser with RF followed by fractional RF was shown to be safe and effective for acne scars with modest improvement and low PIH rate comparable to other resurfacing techniques in this Asian case series. Adequate pain control and recduced energy level when treating areas in close proximity to bone are advised. Lasers Surg. Med. 44: 622-630, 2012. © 2012 Wiley Periodicals, Inc.

Photoaging and Nonablative Photorejuvenation in Ethnic Skin

BACKGROUND

Advances in nonablative skin rejuvenation technologies have sparked a renewed interest in the cosmetic treatment of aging skin. More options exist now than ever before for reversing cutaneous changes caused by long-term exposure to sunlight. Although Caucasian skin is more prone to ultraviolet light injury, ethnic skin (typically classified as types IV to VI) also exhibits characteristic photoaging changes. Widespread belief that inevitable or irreversible textural changes or dyspigmentation occurs following laser- or light-based treatments has been challenged in recent years by new classes of devices capable of protecting the epidermis from injury during treatment. Demographic changes in the US population favor an increasing trend of older, ethnically diverse patients requesting treatment to recapture a youthful appearance.

OBJECTIVE

The purpose of this article is to review the recent literature regarding clinical recognition and treatment of photoaging changes in ethnic skin. This article provides a basis for classification of current and future nonablative technologies with regard to the safety and efficacy of treatment in ethnic skin.

CONCLUSIONS

Nonablative technologies have emerged to meet the public demand for no-downtime treatment of aging skin. As these technologies continue to evolve and improve, physicians are challenged to define realistic goals, expectations, and limitations for treatment. Whenever possible, ongoing and future studies should attempt to address treatment in ethnic skin types. Photoaging changes in ethnic skin can be recognized and successfully treated with nonablative technology with minimal risk and downtime.

Novel Opportunities in the Treatment and Prevention of Scarring

Numerous treatments have been described for the treatment and prevention of scars, but the optimal management strategy is yet to be defined. In this article we present and evaluate new opportunities for the treatment and prevention of hypertrophic scars, keloids, and atrophic scars. Clinical, animal, and in vitro studies reporting novel techniques for the treatment and prevention of scarring were identified primarily from the MEDLINE/PubMed database. We found that a variety of new treatments exist with potential effectiveness for the treatment of hypertrophic scars and keloids, including interferon, imiquimod 5% cream, tacrolimus, botulinum toxin, 5-fluorouracil, bleomycin, and verapamil. For atrophic scars, different types of lasers represent modern treatment modalities with satisfactory results. Several agents have been reported to be effective in reducing scarring in vitro and in animal studies, representing potential opportunities for scarring management. We conclude that several novel modalities may be potential therapies for scarring.

The Safety and Effectiveness of Single-Pass Erbium:YAG Laser in the Treatment of Mild to Moderate Photodamage

BACKGROUND

There are several treatment modalities for mild to moderate photodamage. The demand for effective treatments with minimal side effects has increased.

OBJECTIVE

The objective of this study was to determine the effectiveness of short-pulsed erbium:YAG laser in treating mild to moderate photodamage.

METHODS

Twenty patients were treated with the short-pulse erbium:YAG laser on the face and neck. One pass was given over the entire face with two to three passes over the perioral and periorbital regions. Patients were evaluated for improvement of pigmentary irregularities, skin texture, and fine wrinkles. All side effects were recorded at follow-up visits. Two lasers were used, Sciton and Cynosure CO3, under local anesthesia.

RESULTS

There was a 58% reduction in pigment irregularities and a 54% improvement in skin texture. There was minimal improvement in fine wrinkles with one pass. Two and three passes resulted in a 50% reduction in wrinkles. The procedure was minimally painful. Side effects included 3 to 5 days of erythema and edema. Patients returned to work within 3 days on average. There were no infections. Patient satisfaction with the procedure was rated as very good. There was no difference in efficacy or adverse effects with either laser.

CONCLUSIONS

One-pass short-pulse erbium:YAG laser in treating photodamage of the face and neck is safe and effective. There are minimal side effects and patients heal within 3 to 5 days.

Surgical treatment of facial acne scars based on morphologic classification: a Brazilian experience

BACKGROUND

Acne scar treatment remains a challenge in the medical literature. It is very difficult to compare the efficacy of different therapeutic approaches because of the lack of consensus regarding acne scar description and classification.

OBJECTIVE

To establish a morphologic classification of acne scars and to assess the efficacy of different therapeutic options based on scar type.

METHODS

During an 8-year period, 228 patients were prospectively studied. Their acne scars were morphologically classified and customized, staged rehabilitation programs were established for each patient. The assessment of treatment efficacy was conducted 18 months after the end of treatment and was based on patients' and physicians' opinions ranked on a semiquantitative basis as percentage of improvement from baseline.

RESULTS

Among the 168 patients who finished the study, 26 completed three stages of the treatment plan, and 142 were submitted to one or two therapeutic stages, depending on lesion types. Eighty-six percent of the patients considered the results excellent or good compared with 76% by the authors and 78% by three independent dermatologic surgeons.

CONCLUSION

The classification and the staged therapeutic plan for acne scarred patients facilitated treatment and improved outcomes and may allow development of protocols by comparing results among different authors.

Treatment of atrophic facial acne scars with a dual-mode Er:YAG laser

BACKGROUND

Scar revision with CO2 and Er:YAG lasers has become popular in recent years. Reports on the newest (modulated, dual-mode) Er:YAG systems have been limited mostly to the treatment of photodamaged skin and rhytides.

OBJECTIVE

To prospectively evaluate the efficacy and safety of a dual-mode 2940 nm Er:YAG laser for atrophic scar revision.

METHODS

Twenty-five consecutive patients with moderate to severe atrophic facial acne scars received treatment with a dual-mode Er:YAG laser. Clinical assessments using a standard grading scale and photographic documentation were performed at 1, 3, 6, and 12 months postoperatively. Postoperative recovery was monitored and the rate of side effects and complications recorded.

RESULTS

Average clinical grading scores reflected good to excellent response of atrophic scars to the dual-mode Er:YAG laser system. Side effects and complications were limited to transient hyperpigmentation and acne flare-ups. No hypopigmentation or scarring was seen. Prolonged erythema (longer than 1 month) was observed in 1 patient (4%).

CONCLUSION

Dual-mode Er:YAG laser skin resurfacing is a safe and effective modality for the treatment of atrophic facial scarring.