Early fractional carbon dioxide laser intervention for postsurgical scars in skin of color

Defining the Treatment Window: Early Versus Late Pulsed Dye Laser Therapy for Posttraumatic and Surgical Scars in Asian Patients

OBJECTIVES

This retrospective study evaluates the effectiveness of pulsed dye laser (PDL) treatment in early versus late treatment groups for traumatic or postoperative scars. The study aims to determine the threshold between early and late treatment. Additionally, it investigates factors that may influence wound healing outcomes.

METHODS

The medical records of 147 patients who underwent PDL treatment at our institution between January 2018 and December 2022 were retrospectively reviewed. Inclusion criteria were patients receiving PDL treatment for traumatic or postoperative scars. Out of these patients, we selected those who were willing to receive telephone interviews or re-visit at a scheduled time. Eventually, 52 participants were included in our study. A standardized questionnaire was administered to all participants during telephone interviews, encompassing inquiries regarding their medical history, treatment experiences, and the patient component of the Patient and Observer Scar Assessment Scale. Among the enrolled patients, 38 were contacted and interviewed via telephone, while the remaining 14 patients attended follow-up visits where photographs of their current skin condition were captured. The pretreatment and latest follow-up photographs obtained from the clinical database were independently scored in a blinded manner by two dermatologist reviewers using both the Vancouver Scar Scale and the Manchester Scar Scale.

RESULTS

Among the 52 patients, 43 (82.7%) were successfully treated with good response. The correlation coefficients between week-to-treatment initiation and posttreatment MSS and VSS among patients with good response were 0.50 (p < 0.001) and 0.46 (p = 0.002), respectively. Given these findings, we established a treatment initiation threshold of 10 weeks, distinguishing patients into early and late treatment groups. The early treatment group showed borderline significantly lower posttreatment MSS and VSS scores than the late treatment group (MSS: 7.5 ± 2.1 vs. 9.3 ± 2.5, p = 0.011; VSS: 2.8 ± 2.0 vs. 4.5 ± 2.3, p = 0.011). Furthermore, both MSS and VSS of posttreatment showed significantly greater improvement in the early treatment group (4.4 ± 1.6 vs. 3.2 ± 1.9; p = 0.03 and 3.8 ± 1.8 vs. 2.8 ± 1.4; p = 0.04).

CONCLUSIONS

Early intervention using a PDL within 10 weeks post-injury achieved better outcomes in treating traumatic and postoperative scars based on both clinical and patient opinions.

A Comprehensive Review of Non-Surgical Treatments for Hypertrophic and Keloid Scars in Skin of Color

Hypertrophic and keloid scars are fibroproliferative growths resulting from aberrant wound healing. Individuals with Fitzpatrick skin types (FSTs) IV-VI are particularly predisposed to hypertrophic and keloid scarring, yet specific guidelines for these populations are still lacking within the literature. Therefore, this comprehensive review provides a list of various treatments and considerations for hypertrophic and keloid scarring in patients with skin of color. We constructed a comprehensive PubMed search term and performed quadruple-blinded screening on all resulting studies to achieve this objective. Our findings demonstrate 1) the lack of efficacious treatments for raised scars within this population and 2) the need to empirically investigate individualized and multimodal therapeutic options for those with skin of color.

Outcome Analysis of Two-Stage Paramedian Forehead Flap for Nasal Defects Reconstruction in Local Population: Experience of 3 Years at Our Center

The nose is a key aesthetic element of face. Nasal defect reconstruction by forehead flap has been done since ancient times. The aim of this study is to review our experience of the outcomes of two- stage paramedian forehead flap in nasal defects of various aetiologies in the local population. This prospective study was done from January 2020 to December 2022 in the Department of Plastic and Reconstructive Surgery at SMS Medical College and Hospital. A total of 29 patients were included in this study who were candidates for a forehead flap for nose reconstruction due to any aetiology. After informed and written consent, two- stage paramedian forehead flap was done and patients were followed up to 6 months for analysis of outcomes. 29 participants were included in the study. Age range was 18-72 years (mean age 38.5 ± 16.78). 21 (72.4%) were male and 8 (27.6%) were female.23 (79.3%) patients had multiple subunit involvement, 4 (13.8%) patients had single subunit defect and 2 (6.9%) had total nasal defect. Most common aetiology was trauma (58.7%). Early complications including flap and donor site healing related complications were present in 8 (27.5%) patients. Delayed complications were grouped into cosmetic and functional complications and were seen in 22 (75.8%) patients. Cosmetic dissatisfaction was high with the two- stage paramedian forehead flap. Forehead flap is an established gold standard reconstructive option for nasal defects. In a two stage paramedian forehead flap, flap and donor site related issues are minor but cosmetic dissatisfaction is high. With some additional stages, satisfaction among patients increases significantly.

Clinical Observation of Sequential Laser Therapy Combined with Tension Reducer for Postoperative Tension Incision Scar Growth

Objective

To investigate the clinical effectiveness of laser and secure wound-closure system (Tension reducer) in the treatment of postoperative scarring after tension incision.

Methods

A retrospectively observational study was conducted. Twenty-six patients who underwent surgical treatment in our department between June 2017 and December 2021 were selected, and those treated with laser and tension reducer were treated as a combined treatment group, and those treated with laser were treated as a conventional treatment group. Fifteen patients in the conventional group were treated with the pulsed dye laser and CO₂ fractional laser at 1-2 month intervals. Eleven people in the combined treatment group were treated with the laser in addition to a tension reducer for 3-6 months. The scar width, scar thickness, scar hardness, pruritus score, modified Vancouver scar scale and complication rates between the two treatment modalities were compared between the two groups at 6 months postoperatively.

Results

The scar thickness, scar hardness and modified Vancouver scar scale of 1.25 (0.14, 1.90) mm, 31.80 (21.00, 37.20) HA, (6.00 ± 2.17) in patients in the combined treatment group were less than those of patients in the conventional treatment group of 5.50 (4.00, 11.50) mm, 42.60 (32.50, 47.00) HA, (8.25±1.91), (Z=2.883, 2.718, t=2.904, p<0.05). The scar width and pruritus score in the combined treatment group, were 8.00 (5.00, 18.00) mm and 0 (0, 1) respectively, while the scar score and pruritus score in the conventional treatment group, were 5.50 (4.00, 11.50) mm respectively, with no statistically significant difference between the two groups. The complication rate was 55% in the combined treatment group and no adverse reactions occurred in the control group.

Conclusion

Sequential laser combined with tension reducer treatment can effectively inhibit the proliferation of postoperative tension incision scar.

Molecular Features of Hypertrophic Scars After Thermal Injury: Is There a Biologic Basis for Laser Therapy?

Significance: Hypertrophic scars (HTS) and keloids are common after thermal injuries and other trauma to deep regions of dermis of the skin. These abnormal scars can cause contractures and the thick masses of scar tissue that result in functional and cosmetic impairment. Management of these dermal fibrotic conditions includes a wide range of medical and surgical treatments, which can be time consuming, only partially effective, and often uncomfortable for patients. Recent Advances: The molecular pathophysiology of HTS has become more understood over the past two decades, where thermal injury to the reticular dermis results in an inflammatory response, fibrogenic growth factor release, and the formation of a dermal scar with increased collagen and proteoglycan composition in an abnormal morphology. Lasers are becoming a widely used form of treatment for these types of scars; however, the evidence for the beneficial effects of laser treatments and the understanding of their mechanism of action are still evolving. Critical Issues: Paradoxically, laser delivery of thermal energy to the skin is suggested to improve scar remodeling and wound healing, yet HTS is a well-recognized complication of excessive thermal energy delivered by laser treatments. This review aims to examine the current evidence for the use of lasers for HTS, and to investigate the molecular mechanisms where re-injury of a burn scar from laser treatment could result in overall improvements in scar quality. Future Directions: Improved design of clinical trials for the treatment of scarring in the future will evolve from new methodology and models of HTS in animals and humans.

A prospective study on the treatment of immediate post-operative scar with narrowband intense pulsed light under polarized dermoscopy

(a) To evaluate the efficacy and safety of narrow-band intense-pulsed light (DPL) in immediate post-operative scar. (b) To observe the process of scar formation under dermoscopy in the first 6 months. Nine patients with postoperative scars were enrolled in the randomized, prospective, split-scar study. Patients were treated in one half of the scar with DPL for cosmetic improvement at a wavelength of 500-600 nm and the other half was not treated as control. The laser treatments were initiated 2 weeks after the surgery and were given 3 times over a 4-week period. All patients were followed-up for 3 months from the last treatment. Photographs and dermoscopy digital images were collected each time. (a) Neither DPL or control produce statistically significant improvements in Vancouver Scar Scale. Moreover, comparatively, there was no statistical difference in Vancouver Scar Scale between DPL or control. However, 6 out of 9 patients treated with DPL had reduced scores in vascularity sooner compared with control. (b) Under dermoscopy, redness, and swelling were obvious from 2 weeks after surgery, but were gradually alleviated. The surface of the scar gradually became uneven and rough. DPL might be beneficial in early recovery of immediate post-operative scar.

Fractional CO2 laser to improve noticeable scars after skin cancer surgery: An appraisal by the patients, laypersons, and experts

Ablative fractionated carbon dioxide (fCO₂) laser may be a useful tool to improve noticeable scars after skin cancer surgery. Therefore we evaluated 40 patients who have been treated with fCO₂ laser for facial scars after skin cancer surgery. This retrospective study is based on blinded evaluation of pre‐ and postoperative photographs. Patients (n = 40), laypersons (n = 5) and experts (n = 5) evaluated the esthetics and the Vancouver scar scale as primary endpoints. Secondary endpoints included patient satisfaction and treatment safety. Patients, laypersons and experts consistently assessed a significant improvement of scar quality and appearance after fCO₂ laser treatment, which was paralleled by high patient satisfaction. In conclusion, ablative fCO₂ laser is effective in improving noticeable postsurgical scars. Patients are highly satisfied with post‐laser results.

Comparative Study between Nd-YAG laser, fractional CO2 Laser, and combined Nd-YAG with fractional CO2 Laser in the Management of keloid: clinical and molecular Study

BACKGROUND

Fractional CO2 laser and Nd-YAG laser have been reported to have promising results in the management of keloids. So far, there have been no comparative studies between these laser modalities.

AIMS

The study aimed to compare the efficacy of fractional CO2, Nd-YAG, and a combination of both in the management of keloids.

PATIENTS AND METHODS

Forty-five keloid patients were divided into 3 equal groups: the first received fractional CO2 only, the second received Nd-YAG only, and the third received a combination of both lasers. Each group received its designated treatment every 4 weeks for 4 sessions. The improvement was evaluated by the "Patient and Observer Scar Assessment Scale" (POSAS). Detection of procollagen I mRNA by RT-PCR analysis was done.

RESULTS

The assessment by POSAS showed the most significant clinical improvement in the combination group and a less significant improvement in the fractional CO2 group, while the least improvement was seen in the Nd-YAG group. Molecular assessment via procollagen I yielded matching results.

CONCLUSION

The study showed that the combination of fractional CO2 and Nd-YAG lasers has a synergistic effect being the most effective in the management of keloids, fractional CO2 being more effective than ND-YAG and Nd-YAG being the least effective.

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.