Non‐ablative scar revision using a long pulsed frequency doubled Nd:YAG laser

Laser Treatment of Traumatic Scars and Contractures: 2020 International Consensus Recommendations

BACKGROUND AND OBJECTIVES

There is currently intense multidisciplinary interest and a maturing body of literature regarding laser treatments for traumatic scars, but international treatment guidelines and reimbursement schemes have not yet caught up with current knowledge and practice in many centers. The authors intend to highlight the tremendous potential of laser techniques, offer recommendations for safe and efficacious treatment, and promote wider patient access guided by future high-quality research.

STUDY DESIGN/MATERIALS AND METHODS

An international panel of 26 dermatologists and plastic and reconstructive surgeons from 13 different countries and a variety of practice backgrounds was self-assembled to develop updated consensus recommendations for the laser treatment of traumatic scars. A three-step modified Delphi method took place between March 2018 and March 2019 consisting of two rounds of emailed questionnaires and supplementary face-to-face meetings. The panel members approved the final manuscript via email correspondence, and the threshold for consensus was at least 80% concurrence among the panel members.

RESULTS

The manuscript includes extensive detailed discussion regarding a variety of laser platforms commonly used for traumatic scar management such as vascular lasers and ablative and non-ablative fractional lasers, special considerations such as coding and laser treatments in skin of color, and 25 summary consensus recommendations.

CONCLUSIONS

Lasers are a first-line therapy in the management of traumatic scars and contractures, and patients without access to these treatments may not be receiving the best available care after injury. Updated international treatment guidelines and reimbursement schemes, additional high-quality research, and patient access should reflect this status. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

The Subunit Principle in Scar Face Revision

Facial scaring is considered one of the most difficult cosmetic problems for any plastic surgeon to solve. The condition is more difficult if the direction of the scar is not parallel to relaxed skin tension lines. Attempts to manage this difficult situation included revisions using geometric designs, Z plasties or W plasties to camouflage the straight line visible scaring. The use of long-lasting resorbable sutures was tried too. Recently, the use of botulinum toxin during revision improved the results. Fractional CO2 lasers, microfat grafts, and platelet-rich plasma were added to the armamentarium. The scar is least visible if placed in the junction between the facial subunits. The aim of this study is to investigate the use of the subunit principle to improve the results of scar revision. Four patients were included in this study. Tissue expansion of the intact part of the subunit allowed shifting the scar to the junction between the affected subunit and the adjacent one. Tissue expansion, delivery of the expanders, and advancement of the flaps were successful in all patients. The fact that this is a 2-stage procedure and sacrifices some of the intact skin from the affected facial subunit, makes this technique reserved to patients with ugly facial scars who are ambitious to improve their appearance.

Mesenchymal Stem Cells Synergize with 635, 532, and 405 nm Laser Wavelengths in Renal Fibrosis: A Pilot Study

OBJECTIVE

To address whether a single treatment of one of three visible light wavelengths, 635, 532, and 405 nm (constant wave, energy density 2.9 J/m²), could affect the hallmarks of established renal fibrosis and whether these wavelengths could facilitate mesenchymal stem cell (MSC) beneficence.

BACKGROUND DATA

Chronic kidney disease is a global health problem with only 20% receiving care worldwide. Kidneys with compromised function have ongoing inflammation, including increased oxidative stress and apoptosis, peritubular capillary loss, tubular atrophy, and tubulointerstitial fibrosis. Promising studies have highlighted the significant potential of MSC-based strategies to mitigate fibrosis; however, reversal of established fibrosis has been problematic, suggesting that methods to potentiate MSC effects require further development. Laser treatments at visible wavelengths have been reported to enhance mitochondrial potential and available cellular ATP, facilitate proliferation, and inhibit apoptosis. We hypothesized that laser-delivered energy might provide wavelength-specific effects in the fibrotic kidney and enhance MSC responses.

MATERIALS AND METHODS

Renal fibrosis, established in C57BL6 mice following 21 days of unilateral ureter obstruction (UUO), was treated with one of three wavelengths alone or with autologous MSC. Mitochondrial activity, cell proliferation, apoptosis, and cytokines were measured 24 h later.

RESULTS

Wavelengths 405, 532, and 635 nm all significantly synergized with MSC to enhance mitochondrial activity and reduce apoptosis. Proliferative activity was observed in the renal cortices following combined treatment with the 532 nm laser and MSC; endothelial proliferation increased in response to the 635 nm laser alone and to the combined effects of MSC and the 405 nm wavelength. Reductions of transforming growth factor-β were observed with 532 nm alone and when combined with MSC.

CONCLUSIONS

Specific wavelengths of laser energy appear to induce different responses in renal fibrotic tissue. These findings support further study in the development of a customized laser therapy program of combined wavelengths to optimize MSC effects in the treatment of renal fibrosis.

Update on scar management: guidelines for treating Asian patients

BACKGROUND

Following injury, Asian skin has a tendency towards hyper-pigmentation and scar formation, and therefore the prevention of scarring is particularly important in Asian patients. Since publication of an International Clinical Recommendation on Scar Management in 2002, there have been numerous publications in the field of scar management. Advances in understanding scar formation have also led to the introduction of new treatments as well as a better understanding of established therapeutic options.

METHODS

A literature search for abstracts, clinical trials and meta-analyses evaluating scar prevention and treatment was performed using PubMed and the Cochrane Database of Systematic Reviews. Based on this data a panel of experts formulated treatment recommendations for Asian patients.

RESULTS

Following surgery, scar prevention should be initiated in all Asian patients due to the high risk of poor scars. There is strong evidence for the efficacy of silicone based products, and due to their ease of use, they can be considered first-line therapy. Silicone gel (versus silicone gel sheets) products have demonstrated efficacy. For patients who fail to respond to first-line therapy, intralesional steroid injections, radiation therapy, and intralesional 5-flourouracil injections have achieved widespread acceptance. Laser treatments have been increasingly used, although the evidence remains largely anecdotal without a clear consensus on optimal wavelength, or amount of energy. Surgical approaches have increased in sophistication with recognition of the impact that tension has on scar formation.

CONCLUSION

Updated scar management recommendations will benefit practitioners making decisions regarding optimal, evidence-based treatment strategies for their patients.

Scar Revision

Classic techniques of scar revision in general are ablative and remain the gold standard, although newer nonablative laser therapies, such as the frequency-doubled neodymium:yttrium-aluminum-garnet laser, can help. Ablative therapies and techniques are examined.