The improvement of scars of either cosmetic or functional impairment is the goal of scars revision. Cutaneous scars are results of earlier surgery trauma, or inflammatory processes, e.g., acne. The injury may be cosmetically distressing or may distort functional anatomy.
Thus, the aim of scar revision is the achievement of an aesthetically pleasing or less visible scar. Scars can be categorized by various descriptive characteristics, including contour, shape, length, width, color, and function.
Numerous revision procedures are available to correct several types of injuries. No treatment or procedure is effective in correcting all types of scars. Therefore, knowledge, understanding, and experience using various techniques are vital to achieving acceptable results.
Recognition and analysis of these unique characteristics, along with the scars’ location and place, will aid in determining the proper technique or combination of procedures in revising a given scar.
Skin Scars Treatment or Revision. How to Approach?
Cutaneous scars are results of earlier surgery trauma, or inflammatory processes, e.g., acne. The scar may be cosmetically distressing or may distort functional anatomy. Thus, the aim of scar revision is the achievement of an aesthetically pleasing or less visible scar. Various surgical and non-surgical techniques are available for the correction of cutaneous scars.
Knowledge and experience in using these techniques are necessary to do desirable results. Scars can be categorized by various descriptive characteristics, including contour, shape, length, width, color, and function. Recognition and analysis of these unique characteristics, along with the scars’ location and place, will aid in determining the proper technique or combination of procedures in revising a given scar.
Scar revision aims to improve scars of either cosmetic or functional impairment. Numerous revision procedures are available to correct the several types of injuries. No treatment or procedure is effective in correcting all types of scars. Therefore, knowledge, understanding, and experience using various techniques are vital to achieving acceptable results.
The Elevated Scar Treatment (revision)
Elevated scars can be caused by the closure of wounds under tension or the opposition of wound edges at varying levels, creating a step-off deformity. Full-thickness grafts may also leave an elevated scar in the reconstruction site. Dermabrasion is a highly effective procedure in the effacement of higher scars. It is advisable to let the patient know that I may need dermabrasion before the first surgery.
The best time for performing the procedure is eight weeks of post-surgery. These scars usually respond well to injections of intralesional steroids. Triamcinolone acetonide at a dosage of 10-40mg/cc is injected directly into the scars at 3-4 weeks. Care not inject the injury with resulting dermal atrophy, telangiectasias, and hyperpigmentation.
Improvement can be achieved by excision of the scar in a fusiform fashion or by reducing undue tension by placing the excision in the direction of relaxed skin tension lines, further undermining the placement of buried absorbable intradermal sutures and precise apposition of wound edges. Additionally, the planning of the higher scar with a scalpel or razor blade has been used for flattening more elevated scars.
The Depressed Scar Treatment (revision)
Depressed or indented scars may result from performing a deep shave biopsy, curettage and electrodesiccation, suturing wounds with deficient wound eversion, or healing wounds complicated by the formation of hematomas or infection. A simple fusiform excision with attention to wound eversion can correct the indentation in most cases.
Wound eversion can be carried out using buried vertical mattress intradermal sutures. Cutaneous sutures are placed 90 degrees to the skin surface with eversion of opposing skin edges with a skin hook or forceps. Dermal vertical mattress sutures can also help in achieving good wound eversion. However, they may leave unsightly suture marks. Subcision or soft tissue augmentation employing injectable autologous fat or dermal fillers can elevate depressed scars.
The Widened Scar Treatment (revision)
Widened or spread scars occur with time in wounds closed under tension. They often form on the back, chest, or scalp areas. If possible, the injury can be excised parallel to the direction of the relaxed skin tension lines, widely undermined, and sutured with buried intra-dermal sutures.
Some advocate the placement of nonabsorbable buried sutures such as nylon or polypropylene. Permanent anchoring or tethering sutures placed to the underlying periosteum or perichondrium may also decrease later scar spreading.
The Long Linear Scar Treatment (revision)
Several techniques have been used to break up the appearance of a long unsightly linear scar. The rationale behind these techniques is that a scar formed of multiple small scars is less perceptible than one long scar. W-plasty or geometric broken line closures are designed as a series of “W” s or unpredictable geometric figures advanced to interdigitate with a similar pattern on the opposite side of the scar.
At times, a re-excision should be performed, followed by dermabrasion. These procedures, however, are time-consuming to build and execute with proper wound approximation and can worsen the appearance of a scar. Dermabrasion may be a more straightforward technique that gives better and more consistent results.
The Trap doored Scar Treatment (revision)
Trap dooring usually occurs after reconstructing severe defects with round-shaped or island pedicle flaps. Underlying wound contraction seems to cause elevation of the center and depression of flap edges. I can minimize the chances of trap dooring if the flap is thinned and placed flat in defect following extensive undermining.
Treatment of trap dooring consists of injections of intralesional steroids and, if necessary, an incision along the flap scar line and removal of underlying scar tissue with extensive undermining. Dermabrasion using a motor-driven abrader or performed by manual dermabrasion will also achieve improved cosmesis.
The Contracted Scar Treatment (revision)
Scars transversion concavities may contract and result in painful, unsightly scars. I can usually prevent this by designing the incision as curved rather than a straight line. Z-plasty, one of the original techniques employed in scar revision, is a transposition flap in which equal-size triangular flaps (two or more) are transposed. Using multiple Z-plasties makes it possible to elongate, regularize, and flatten the contracted surgical scar.
The main indications are increasing scar length, effacing and elongating tight contracted scars, changing directions of scars, effacing webbed scars, or shifting malposition facial landmarks. When used to lengthen a contracted scar, the degree of lengthening can be controlled by the alteration of the angles of the transposition flaps. The higher the angle, the greater the degree of lengthening.
The Webbed Scar Treatment (revision)
As mentioned above, scar transversion concavities can contract to form a short straight line. The result is a tented or webbed deformity when it occurs in the inner canthal area. Revision using one or more Z-plasties, as described above, can repair the defect by changing the direction of tension on the scar with the effacement of the webbing.
Distortion of Free Margins Treatment (revision)
Following reconstruction, with flaps or grafts, a resulting scar may contract against a free structure such as the vermilion border ensuing eclabium. The lower lid can also be pulled down by scar contracture, causing ectropion. Two or more small 60-degree Z-plasties are helpful to lengthen the scar and allow the pulled free vermilion border to return to its normal position. The repair of the ectropion of the lower lid is corrected with a full-thickness skin graft.
The incision is made in the lower lid and placed as high as possible under the lash line. The graft is sutured, and traction is placed on the graft with inter-marginal sutures (or Frost sutures). These sutures are left in place for one week to heal the graft in the maximally expanded state. In a few cases, skin grafting is combined with a horizontal tightening procedure as the skin replacement alone will not restore the lid to its original position.
The Notched Nostril Scar Treatment (revision)
I can use various techniques to repair pulling up or notching of the nostril or alar rim. Distortion or notching of the ala can lead to nasal reconstruction. Time alone may allow enough scar relaxation for the ala to return to its normal position. Intralesional steroids can hasten the process.
If, after 6-9 months, the ala has not resumed its normal position, I should consider one of the various revision techniques. A Z-plasty or the use of multiple convergent triangle flaps can shift the nostril base forward to the level of the alar margin.
Convergent triangle flaps are equal to various Z-plasties but more natural to execute and suture. Notching can be corrected by using a composite graft harvested from the helix, anthelix, anterior crus, or tragus, trimmed, and sutured in place.
With significant alar defects, a hinged flap can be created from the skin at once superior to the fault and serve as the inner lining over which a composite graft will be placed. A two-stage pedicle flap may be used from the nasolabial fold. The flap is turned on to supply an inner lining, and the pedicle is severed after three weeks.
Dermabrasion Skin Scars Treatment
Dermabrasion has many applications as a skin resurfacing technique and is used to treat fine perioral rhytids and fine wrinkles found in other regions of the face. Rhinophyma is another disease of the face often treated with dermabrasion. It is characterized by granulomatous infiltration of the nose, making it appear larger and bulbous.
I can sometimes treat premalignant and superficial malignant lesions of the skin with dermabrasion. With dermabrasion, the nose is debulked, and rapid re-epithelialization follows. Actinic keratoses, basal cell carcinomas, and squamous cell carcinomas have been successfully treated using skin-resurfacing techniques. Dermabrasion may also be used to revise scars from trauma, skin grafts, acne, and surgical incisions.
One of the most effective but operator-dependent therapies is dermabrasion. Dermabrasion was the first significant advance in treating atrophic and traumatic scarring. Its benefits include the removal of the skin surface and refined contouring of scars. Recently in a comeback for dermabrasion, various methods of derma-sanding have been added, using various carpentry tools such as drywall/plaster sanding screen or moistened silicon carbide sandpaper to manually dermabrader the skin.
It is best to treat grade 3 rolling scars and tighten the skin of an older patient with scarring. The sharp edges of some acne scars cast a shadow that emphasizes the lesion’s contouring reduces these contrasts, lessening their visible impact. I can achieve the essential removal of superficial scars and a reduction of deeper scars. In addition, it may be used as an adjunct to surgical procedures such as punch elevation or grafting. A few weeks before the performance of dermabrasion, patients can be pre-treated with tretinoin (Retin-A).
Hydroquinone, a bleaching agent, may be prescribed before the procedure for postoperative patients at risk of hyperpigmentation. This medication promotes wound healing by increasing collagen formation. Dermabrasion is performed in an office-based procedure room, surgery centers, and occasionally in the hospital. It is done under local anesthesia with the choice of sedation or general anesthesia.
Regional blocks are effective, and added topical anesthetics might be used to freeze the skin. If sedation or general anesthesia is used, I must check patients appropriately. The surgical team must wear proper sterile attire, including a mask with a face shield. Protection from blood exposure and aerosolized particles during the procedure is essential, especially when treating patients with a history of HIV or hepatitis.
The area to be dermabrader is marked and may be divided into sections when dealing with large surface areas to ensure uniformity. The skin is held taut with one hand or held by an assistant, and the dermabrader is moved across the skin with constant, gentle pressure. A good diamond frame tip or a wire brush is chosen and attached to the headpiece.
A back-and-forth motion is used for the diamond fraise tip, but the wire brush is moved in one direction. The borders of the treated area are feathered to prevent any noticeable transitions. The dermabrader’s skin depth is one of the most critical factors determining the outcome. Punctate bleeding is visualized when entering the papillary dermis. No bleeding is seen while treating the epidermis because of the lack of vasculature.
The papillary reticular junction is the ideal endpoint of dermabrasion and is found by increased, confluent bleeding. Dermabrasion beyond the reticular dermis can lead to significant scarring. Immediately following the procedure, you may temporarily place saline-soaked gauze moistened with dilute epinephrine on the open wounds to achieve hemostasis.
A moist environment is necessary to promote wound healing. Multiple petroleum-based products are available to keep a moist environment and prevent desiccation, such as Aquaphor and Xeroform gauze. The wound is cleaned daily, and the ointment is applied as necessary. Re-epithelialization has been completed 7 to 14 days following the procedure.
Patients should minimize sun exposure or wear proper sunblock for 6 to 12 months following the procedure to avoid hyperpigmentation. Hydroquinone may be used to treat any hyperpigmentation seen after dermabrasion. Residual erythema and edema should be expected to last 1 to 2months, and You should wear non-allergenic makeup. Recovering from dermabrasion usually lasts 2 to 4 weeks. Patients can return to work within two weeks.
Although dermabrasion is an effective skin resurfacing tool, there are associated complications that physicians and patients need to be made aware of. Abnormal scarring, including the formation of hypertrophic scars and keloids, can potentially occur if dermabrasion is performed beyond the reticular dermal layer. It is also seen in patients with a genetic predisposition, such as collagen disorders, and those taking certain medications.
I can avoid hyperpigmentation and hypopigmentation with proper patient choice and perioperative care. Patients with Fitzpatrick skin types I and II are less likely to experience pigment changes. Patients are instructed to avoid excessive sun exposure; however, I can prescribe Hydroquinone to treat unwanted hyperpigmentation. I can treat infectious complications with antibiotics and antiviral therapy. Patients with a history of a herpes outbreak are treated prophylactically with antivirals.
Dermabrasion should be cautioned in patients with active acne who may need antibiotic treatment before undergoing the procedure. The formation of milia, small white keratin-filled cysts, may be seen in the following dermabrasion and usually resolve spontaneously. Still, they can be treated with incision and drainage when necessary.
Dermabrasion remained constant in technique for over one hundred years, apart from some refinements in patient choice and end pieces. More recently, the literature on abrasive treatment has centered on adding cosmetic uses and proper anesthesia for this procedure.
Skin Scars Treatment. Surgery. Medium-depth TCA Chemical Peel & CROSS
It is a safe and effective modality in dark-skinned patients to treat post-acne scarring. It has also been combined with dermabrasion to increase efficacy and decrease postoperative pain and complications. The medium-depth peels are primarily considered 10% to 40% TCA solutions.
As with any resurfacing procedure, many patients will develop post-inflammatory hyperpigmentation. Chemical peeling is cost-effective, and where expensive recurrent laser technologies do not exist or are not practical, it is an excellent alternative resurfacing technique.
Application of TCA to the skin causes cellular necrosis of the epidermis and necrosis of collagen in the papillary and reticular dermis. A variation of chemical peeling involving 60% to 100% trichloroacetic acid, termed the CROSS technique, has raised interest in treating the smaller ice pick and boxcar type scars, which have always been used and proved a challenge.
This modality scars the inside of the already cylindrical scar, making it cosmetically more appealing. A similar concept has been discussed with the use of high-energy CO2 lasers. After 3 to 6 treatments, 90% of patients showed good (50%-70%) improvement. The peels considered deep are often phenol (carbolic acid) or croton oil-based. These can be more effective but have more significant potential for side effects.
Hair Transplant Surgery
FUE harvesting of grafts causes “pit” scarring, small, round, and typically white scars in the patient’s donor area where the grafts have been removed. FUE scarring differs from strip harvesting in that the latter procedure produces a linear scar in the donor area where the strip of skin was removed. The pit scarring from FUE and linear scar from strip harvesting are often problematic to detect when hair in the donor area is at an average length and a skilled surgeon performs the extraction.
While the outcome of the healing process, and thus the appearance of scar tissue, depends on several variables (including the type of extraction, the skill of the surgeon, and, in strip harvesting, the method of wound closure), in both FUE and FUT short, cropped hair or a shaved head will typically reveal some scarring.
Skin Scar Treatment Fat Injections
Fat Transfer for severe atrophic disease in which there is the destruction of the deeper tissues, fat remains the best replacement agent, first noted in 1893, to improve scars. The word autologous means material (fat) is harvested from one area and donated to another in the same individual.
Autologous fat grafting meets all the fundamental criteria of ideal augmentation materials: availability, low antigenicity, minimal donor morbidity, reproducible, predictable results, avoids non-auto graft disease transmission or incompatibility, not likely to elicit an immune response, last reported complications, and longer survivability.
Fat is not considered adequate for individual bound down ice pick scars. However, once the scar is freed, fat may be satisfactorily injected. Accordingly, autologous fat Transfer supplies a very appealing resource for soft tissue volume augmentation.
Fat should be considered the best filling and volumizing agent for widespread grossly atrophic disease combined with more profound tissue destruction. Fat is an excellent deeper augmenting injectable in scars. When higher volumes are needed, fat injections can save costs for the patient. I can combine a fat with other resurfacing techniques.
Any volumization should be performed first. While patients in their teens and early twenties may infrequently need volume, most older patients need enhanced volume. Volumizing smoothed and rounded the overall facial contour, which reduces shadowing. But the importance of overall facial volumizing is that a rounded facial contour has the same shadowing in most head positions. Issues of permanence are gradually being resolved.
Fat no longer appears to be as temporary as initially considered. Accurate long-lasting autologous corrections can result. Numerous factors may contribute to fat cell survival: harvesting method, manipulating fat, exposure to blood or lidocaine, recipient site, donor site, centrifugation, injection method including syringes and needle size, and overcorrection.
Fat should be injected deeply as a three-dimensional lattice with0.1–0.2-mL aliquots. The site is gradually built up to enhance the superficial layers in a lipo-layering technique. Injections can be on any tissue plane as determined by the subcision or within all three (intradermal, subdermal, and subcutaneous) tissue planes.
Only microdroplets are usually needed for intradermal or immediate subdermal placement. Often infusion is best accomplished as the needle is withdrawn. The endpoint is a slight overcorrection. Although microinjecting fat and intra-lesion within the scar after subsection, Prof Moawad still recommends instilling at least a small amount underneath to volume the area. This helps to stretch or distend some scars, making them more superficial in appearance.
Postoperative care usually only needs an antibiotic application to the injection sites. Postoperative pain is minimal, and oral antibiotics are not needed in the author’s experience. IT can treat significant edema with a short course of oral steroids. Fifty percent of transplanted fat should be expected to survive. Thus, touch-up procedures at three months may be needed.
Overcorrection of about 10% is usually needed. As with the lipofilling of cosmetic defects, the procedure should be considered a multi-treatment program. Small volumes are needed even if multiple scars are infused, and as such, the use of frozen fat aliquots of single harvesting will save considerable time with future injection sessions.
The only relative drawback of fat injection has been the resorption of some fat volume. Fat can be stored in disposable syringes for up to one year or more without contamination or deterioration in its ability to survive. Frozen fat is a way to improve the patient and avoid extended first downtime gradually. It also allows to “touch up” areas where the fat may have dissipated or under-corrected. The best of all is fat grafting is forgivable while the mistake of permanent filler is permanent,” Prof Moawad says.
However, with proper technique, 30–70% of the fat is kept, Prof Moawad says. The Disputes about longevity and the technique variation have postponed the announcement of fat as the perfect filler, added Prof. Moawad. Recent advances in fat grafting include plasma-rich platelets (PRP), adipose tissue-derived stem cells (ADCs), or collagenase digest fat showing great promise with scars treatment.
Skin Scar Treatment PRP Injections
PRP is used to improve the healing of ablative fractional resurfacing wounds. Autologous Platelet Rich Plasma uses platelets prepared from the patient’s blood to support and accelerate hard and soft tissue regeneration. Platelets are injected into the dermis to control the delivery of growth factors.
They induce the proliferation of fibroblasts, promote the production of new collagen and other extracellular matrix components, stimulate stem cell migration proliferation and differentiation, and improve differentiation micro-vascularization.
Skin Scar Treatment Filler Injection
Volume change correction includes focal dermal filling of individual scars and volume fillers (e.g., fat Transfer, off-the-shelf fillers such as hyaluronic acid (HA), polylactic acid, and hydroxyapatite. Potential superficial skin products may include collagen or hyaluronic acid, and deep skin products include fat, synthetics, silicone, implants, and permanents.
An ideal filler material would be physiologic (incorporated into the body’s tissues), simple to place(injection), permanent (no degradation), and risk-free (no complications or side effects). Most of these apply to depressed scars such as the atrophic rolling variant.
Elevess is approved for injection into the mid to deep dermis to correct moderate to severe facial wrinkles and folds, such as nasolabial folds. ELevess is approved in the EU to correct soft tissue contour deficiencies, such as wrinkles, folds, and scars, and enhance lips’ appearance. ELEVESS is approved in Canada to correct soft tissue contour deficiencies of the face, such as wrinkles, folds, and scars. Poly-L-lactic acid (PLLA) is a biodegradable, non-toxic, synthetic, inactive material derived from corn starch.
It has been used in suture material, stents, and other biomedical implants. Due to the extensive bio-stimulatory effects of this product, it is considered a semi-permanent filler. The clinical effects can be seen for up to 2 years. The FDA approved Sculptra in 2004 for human immunodeficiency virus (HIV)- related facial lipoatrophy. It has PLLA microspheres in a powdered form. A common finding with this product is palpable but usually invisible subcutaneous “micronodules.”
More recent studies of PLLA using a diluted suspension of the product have resulted in a dramatically decreased rate of micronodule formation. Many practitioners use six ccs of sterile water for reconstitution, and in areas such as the hands and chest, even larger dilutions are used. Longer reconstitution times are also recommended, with the reconstitution occurring at least 8 hours before the injection of the product. It would be best if you took care to inject the product in the superficial fat and not in the mid-dermis, and the clinician should be careful not to inject the sediment at the end of the syringe.
Radiesse or Calcium hydroxylapatite (CaHA) is the mineral part of the bone; therefore, it should not stimulate an immune response, making it biocompatible. This material has been used previously in dental, orthopedic, urologic, and vocal cord applications. It acts as a scaffold for collagen ingrowth.
The FDA approved Radiesse in 2006 to correct facial wrinkles and folds and HIV-associated facial lipoatrophy. In 2009, it received FDA approval for cosmetic use in non-HIV patients. Administration of CaHA supplies immediate 1: 1 correction and does not expand beyond what was injected. Over time, the carrier gel is absorbed, and new collagen is formed around the microspheres.
Radiesse is commonly used to correct nasolabial folds, atrophic cheeks, and temporal wasting. The result is a longer-lasting implant with characteristics close to natural tissue. The longevity of correction ranges from 10 to 18months. The clinical results may last for 12 months or longer, although the carrier gel lasts no longer than six months, thus often resulting in a slight decrease in correction. I must take extreme care to avoid injection while withdrawing the needle out of the skin, which will result in the deposition of material into the dermis.
Liquid injectable silicone (Silikon 1000, Adatosil 5000, Bioplastique) Readily fulfills most of the criteria for an ideal filling substance. It is a clear, odorless, tasteless, colorless, and stable substance. Liquid injectable silicone does not harden or soften, is unaltered within the range of human body temperature, and is chemically unchanged by exposure to air, most chemicals, and sunlight. It can be stored for extended periods at room temperature and does not allow for the growth of microorganisms.
Although the technique is dependent, the advantages of liquid injectable silicone over other liquid injectable filler substances are its precision and permanence. Although not entirely biologically inert, liquid injectable silicone has been shown to have the least physiologic reactivity of most foreign materials. Additionally, it lacks mutagenic, carcinogenic, and teratogenic effects; no true allergies to silicone have been documented.
Despite concerns about its long-term safety and adverse inflammatory reactions, the long-term experience of physicians skilled in administering liquid injectable silicone has shown it to be safe and efficacious for soft tissue augmentation. With depressed, broad-based scar, the 1,000-centistoke viscosity liquid silicone is used with a 27-gauge one-half-inch needle. The microdroplet, the multiple-injection approach, provides a small amount of silicone injected at the correct depth in the tissue at monthly intervals, usually needing only a few treatments.
Silicone has been implicated in various local and systemic adverse inflammatory reactions. Allowing about a month between treatment sessions enables the scar to stretch, reconfigure, or accommodate the presence of liquid silicone. Concerns about its long-term safety and adverse tissue reactivity have been raised in many articles. Treatment-site reactions, including redness, pain, tissue hardness, discoloration, ecchymosis, excessive tissue elevation, and migration of the injected material to local and distant areas, have been reported — more severe complications, including subcutaneous bumps, lumps, ulceration, and local lymph node enlargement.
Following copious amounts of silicone injections, physicians have reported tissue destruction, scarring, and lung and liver inflammation. None of those mentioned above reports have associated such side effects or complications with silicone for acne treatment. Only tiny volumes of the material are employed.
Polymethylmethacrylate (PMMA) is an acrylic plastic that has been used in many medical applications for years, including bone cement, lenses, dental work, and pacemakers. PMMA supplies support for human collagen deposition. If PMMA is placed too superficially, It will lead to lumps formation. Most practitioners prefer a threading injection technique. Unlike the other dermal fillers, this dermal filler should be considered a permanent dermal filler.
This dermal filler is shown to correct the nasolabial folds, although used for scar and forehead furrows. Because results are permanent, it is often best not to achieve full correction in one session but to carry out the desired result over several treatment sessions.
Bellafill (previously known as Artefill) has been marketed and sold in the United States as a permanent dermal filler to correct nasolabial folds since 2007 and received FDA approval for acne scarring in December 2014. With this new sign, Bellafill is currently the only “on-label” dermal filler approved by the FDA to treat moderate to severe, atrophic, distensible facial scars on the cheeks of patients older than 21.
Scarring occasionally occurs in areas that are subject to recurrent movement. This may be less obvious when one is young, and the tissues are more able to resist the movement through the flexibility and springiness of the dermis and the subcutaneous volume overlying the muscle action. However, aging develops a combination of events such as photodamage, recurrent facial habits (smoking, elocution), and loss of volume that combine to make tissues naturally unable to resist the underlying muscular forces. This allows static wrinkles and lines to develop.
Suppose one is scared, mainly if this scarring is atrophic or mildly hypertrophic. Normal muscle movement may have an exaggerated effect because of volume loss from past acne activity and loss of dermal flexibility with scarring.
Although botulinum toxin has a role in treating scars in the upper face, especially when scars are present in the glabella or forehead regions, this is important in the lower face, where the marionette lines and chin are the two most affected areas. This is particularly true of grade 3 rolling atrophic scarring. In such areas, botulinum toxin may be used.
The use of dermal fillers and botulinum are synergistic in many cases. Botulinum toxin may be combined with fillers, although the fillers are usually administered later once the effect of the botulinum is proved. Most studies have focused on treatment rather than the prevention of post-surgical and traumatic scars.
Early management of surgical patients is more likely to yield better cosmetic outcomes and need fewer treatments and less time and expense overall. Standard precautions such as maintaining moisturization and decreasing tension or movement should be strongly encouraged. Botulinum toxin has been proven effective in minimizing post-surgical scars because of its ability to decrease movement and stress around a healing wound.
When treating scars by excision, neurotoxins may be used in a prophylactic method of scar minimization to aid in the best healing. Neurotoxins such as botulinum toxin A may be used at this level of scarring, often as an adjunct to surgery for acne scarring, such as cyst, scar, or sinus tract excision. Botulinum toxin may help decrease tension produced by muscular forces surrounding the scar. In addition, it has an inhibitory effect of botulinum toxin on fibroblasts, offering another potential mechanism.
Other treatment modalities around the time of surgery, such as LASH, PDL, non-ablative, and ablative lasers, may improve the appearance of wounded skin by promoting better collagen organization in healing wounds.
Energy Dependent Skin Scars Treatment
Non-ablative Laser therapies include multiple wavelength lasers, pulsed light, and other forms of energy delivery. Because these modalities are less aggressive, they are more useful for atrophic, rolling, or hypertrophic scars than icepicks, boxcar, or keloid scars.
The morphology of the scar is more predictive of results than the extent or amount. In addition, these therapies are more often used with darker skin types because ablative management tends to have a higher risk of pigmentary alterations. There is selective thermal stimulation of dermal collagen to increase local proliferation while the epidermis is spared, although cooling must ensure superficial protection.
The first to mention is the 532-nm KTP laser, which is safe and effective for improving acne (more so than scar treatment), thus preventing acne sequelae such as scarring. The 585-nm pulsed dye laser (PDL) is the best non-ablative laser for hypertrophic scars or keloids. Best results and most minor side effects are obtained on Fitzpatrick skin types I or II because of less competition with melanin.
This laser focuses on erythema and vascularity, so incidental scar improvement is possible because of decreasing vascularity (the scars are hyperemic because of angiogenesis) and associated secondary effects in the local field or other cellular alterations specifically about collagen. Improvement after use can be seen for up to a year.
As mentioned under vascular lasers in Grade 1 scarring above, other wavelengths such as the 1,064-nm long-pulsed and quality-switched laser have been successful in the non-ablative treatment of acne scarring. Furthermore, it has a role in the treatment of minor atrophic scarring. The 1064-nm Nd: YAG laser proves a common pigment effect with a higher vascular effect, causing hemostasis and resultant infections within the vessels. It could affect those just discussed for PDLs used on hypertrophic scars or keloids. However, repeated treatments are needed.
A minimal melanin absorption spectrum and deep papillary and mid reticular dermal treatment are achieved with the 1320-nm Nd: YAG laser. Those with a predominance of atrophic scars, defined as greater than 90% of the present, improved with mixed scars next.
Another laser variant is the 1450-nm diode. Water’s efficient absorption is seen but minimally by melanin when using the 1540 Er: glass laser. The primary depth is within the papillary dermis, where collagen tightening and neo-collagenesis are achieved — progressive improvement and long-term benefit after treatment with this modality.
It says that outcomes are often gradual, with increased dermal collagen seen in 6 months after four successive treatments, and continued improvement occurs several months after the session. These lasers use conducted heat from the chromophore to produce a diffuse dermal injury, heating to >50°C and inducing collagen remodeling.
The following few therapies are not accurate lasers but rely more on different energy forms to achieve their effect. The first is intense pulsed light (IPL). These machines emit a wide range of wavelengths from their source that can be precisely narrowed using wavelength filters. Other parameters, such as pulse length, pulse delay, and joules, can also be adjusted.
“IPL offers a therapeutic alternative to the gold standard PDL [for treating hypertrophic scars. One treatment approach involves pre-treating the first keloid elements with a corticosteroid, followed by short IPL emissions. The Ellipse IPL treatment directs well-controlled light pulses into the upper skin layer. This works by attacking the vascularization of the scar.
A typical regimen includes up to four treatments spaced four weeks apart. This approach reduces the scar’s redness and stimulates collagen reorganization, thus reducing its size. All these options, in combination, allow for tailoring therapy to a defined goal.
Radiofrequency devices use electrical energy to transfer heat to the dermis at low temperatures. These devices are intended to resurface the skin but induce thermal damage to dermal collagen while sparing the epidermis. Resistance and the resultant degree of thermal damage are determined by the depth and composition of the treated tissue.
When applied over a period, thermal energy contracts and thickens collagen fibers, disrupts hydrogen bonds, and alters the conformation of the collagen triple helix. It also induces a more prolonged wound-healing effect associated with sustained remodeling, reorientation, and new collagen bundles over later months, resulting in effective skin tightening with minimal recovery time.
The fibrous septa that separate fat lobules under the skin are also preferentially heated, leading to further collagen denaturation and contraction, accounting for the immediate tightening and lifting effect on the skin.
Because RF energy uses an electrical current rather than a light source, it does not affect epidermal melanin; therefore, patients of all skin types is a suitable candidates for RF, but it is of particular significance to those who do not like invasive surgical intervention and are still young for surgery. Contraindications include implantable medical devices like pacemakers and defibrillators and active dermatologic conditions like collagen vascular disease.
Monopolar systems deliver current using one electrode that contacts the skin and another that acts as a grounding pad. The electrode contacting the skin delivers electric current to the skin. The epidermis is spared by applying a cooling while the dermis is heated uniformly and volumetrically. Aside from rhytids reduction, successful treatment of moderate to severe cystic acne, acne scarring, and cellulite has been reported.
The use of more extensive, faster tips, lower energy levels, and multiple passes have diminished associated pain but not cut it. The low-level multiple-pass approach needs 4-6 sessions every two weeks. The procedure can be repeated everyone year as needed to keep the results.
The main difference between bipolar and monopolar RF is the configuration. The bipolar configuration consists of two active electrodes placed a short distance apart, overlying the intended treatment area. The monopolar RF devices have one active electrode placed on the skin and a grounding electrode.
The current flows between the two electrodes. The depth of penetration is half the distance between the two electrodes. The significant limitations of the bipolar RF devices are the depth of penetration. The mechanism of action for simple bipolar RF devices is like that of monopolar RF devices.
A combination of light devices has been used to overcome this limitation. Bipolar RF devices are often combined with light-based technologies, termed electro-optical synergy (ELOS). The ELOS system uses the synergistic effects of light and RF-based devices. The light energy preheats the target tissue through photothermolysis, which lowers the tissue’s impedance.
The lower impedance makes the tissue more susceptible to selectively targeted RF parts. Therefore, lower energy levels of the light and RF parts are needed to produce the desired effect with fewer side effects. The optical part also targets fibroblasts, blood vessels, and dyschromia.
The most widely used ELOS systems use intense pulsed light (IPL), a diode laser, or infrared light. RF devises the Polaris™, and ReFirme™ from Syneron™ uses bipolar RF at the ends of laser systems (780–910nm diode for the Polaris and seven hundred–2000nm infrared light) the ReFirme™.
It is another system used with the bipolar device that uses a vacuum to maximize and control the penetration of the electric current. The vacuum is used to fold the skin to a predetermined depth, which allows for closer alignment and deeper penetration with the RF energy than with traditional monopolar and bipolar devices. However, a significant drawback of this therapy is that it needs many treatments at 2- to3-week intervals, which may achieve only mild to moderate improvement.
FACES-based devices are composed of an RF generator, a handpiece, and a tip with two parallel electrodes. The volume of treated tissue is limited to that found between the electrodes at the special vacuum tip, so lower energy levels can be used to meet the energy density needed to reach an effective and lower the incidence of side effects.
Although the combination systems are better tolerated than the monopolar RF systems, I may use topical anesthetic creams to alleviate any associated pain at the physician’s discretion. Modest results have been reported about the efficacy of the ELOS systems for facial laxity, acne, scars, vascular and pigmented lesions, hair removal, and cellulite.
Fractional laser treatment is a non-invasive treatment that uses a device to deliver a laser beam divided into thousands of microscopic treatment zones that target a fraction of the skin at a time. This is analogous to a photographic image being enhanced or altered by a pixel. Fractional laser treatment has bridged the ablative and non-ablative laser techniques used to treat sun-damaged and aging skin.
While ablative laser treatments work on the epidermis (surface skin cells) and non-ablative treatments work solely on dermal collagen (mid-layer of skin) only, fractional laser treatment works at both epidermal-dermal layers of the skin. FT was developed as a way for laser surgeons to get closer to ablative laser resurfacing clinical outcomes with less patient downtime and fewer overall adverse events.
The laser beam is divided into thousands of tiny but deep columns of energy into the skin. These are called microthermal treatment zones (MTZs). Within each MTZ, old epidermal pigmented cells are expelled, and penetration of collagen in the dermis causes a reaction that leads to collagen remodeling and new collagen formation. MTZs, the laser targets and treats intensively within the zone while surrounding healthy tissue remains intact and unaffected. These MTZs vary from device to device.
Some are non-ablative dermal injuries only; because others are associated with ablative changes in the skin, causing both epidermal and dermal injury patterns. MTZs also vary significantly in their diameter of effect and the degree of depth they make to create the injury.
Once injured, the skin begins a very rapid process of repair. After a 48- to 72-hour phase of acute thermal damage, a phase of skin healing and repair starts, mediated by the adjacent skipped areas of intact tissue. In this 30-day phase, the areas of thermally ablated tissue are invaded by fibroblast cells and the epidermal stem cell to produce new collagen. reproduction
Fractional thermolysis (FT) can be divided into several classifications. The easiest has been to classify FT devices into non-ablative and ablative FT laser systems. This classification was “easy” at the beginning when only several devices were available.
It is now a little more complex, especially between the ablative laser systems. Ablative FT laser systems originally were divided into classifications based on laser type: CO2, Er: YAG, or (YSGG, 2790nm). What has changed is that different ablative FT laser systems emit light differently, with penetration depths that may be considered “superficial” and others that may be considered “deep.” This new terminology seems prudent now.
Thus, a new classification system seems practical at this point. Ablative FT lasers have been classified into “micro-ablative FT laser systems,” which would include those lasers that produce epidermal and dermal damage to a depth less than 750 microns, and “deep dermal ablative FT laser systems,” which would include those lasers that produce damage beyond 750 microns in the skin.
The repair mechanisms seen in fractional occur through the trans-epidermal delivery of treated necrotic skin into the stratum corneum, where it is exfoliated away quickly. This fractional treatment results in a faster healing process than if all tissues in the treatment area were exposed to the laser. This process is known as microscopic epidermal necrotic debris (MENDs).
MENDs or another term that appears unique to fractional technology. With the formation of MENDs, selective extrusion of melanin pigmentation after the thermal injury during Fractional laser resulted in significantly improved cutaneous pigmentation.
This milestone had yet to be achieved with the earlier generations’ non-ablative lasers. After a 48- to 72-hour phase of acute thermal damage, the healing and repair phase starts, mediated by the adjacent columns of intact tissue. In this 30-day phase, the areas of thermally ablated tissue are invaded by fibroblast-derived neo-collagenesis and epidermal stem cell reproduction.
Furthermore, the rapid recovery times seen with fractionated CO2 laser mark a significant improvement over traditional CO2 and Er: YAG laser resurfacing because of the differences in wound healing mechanisms. Traditional ablative laser wounds heal by migrating stem cells from hair follicles. In contrast, with fractional ablative resurfacing, re-epithelialization occurs more rapidly because of the migration of neighboring cutaneous stem cells.
Ablative FT laser systems originally were divided into classifications based on laser type: CO2, Er: YAG, or YSGG, 2790nm. What has changed is that different ablative FT laser systems emit light differently, with penetration depths that may be considered “superficial” and others that may be considered “deep.”
Thus, a new classification system seems prudent at this point. Ablative FT lasers have been classified into “micro-ablative FT laser systems,” which would include those lasers that produce epidermal and dermal damage to a depth less than 750 microns, and “deep dermal ablative FT laser systems,” which would include those lasers that produce damage beyond 750 microns in the skin.
Indications for non-ablative FL include mild to moderate acne scarring, dyschromia, hypopigmented scars, fine wrinkling, and texture changes associated with photoaging on the face, chest, neck, and hands.
The non-ablative FP systems include; Fraxel restore 1550nm, Fraxel refines 1410nm, Affirm 1440nm, StarLux 1540, Matisse 1540 Dermablate1540nm, Mosaic 1550nm, and Sellas 1550nm. The non-ablative devices produce minimal patient discomfort. Some patients may need a topical anesthetic before the procedure and forced fantastic air cooling during the procedure.
After treatment, most patients notice erythema and some edema, which can last for up to 48 hours following the treatment, followed by skin desquamation for several more days. With all non-ablative fractional devices, there is usually a need for multiple treatments to achieve the result. Most contend that 4 to 6 treatments must reach the desired outcome for most clinical indications. Fractional radiofrequency is a newer non-ablative approach.
There are two ways to deliver fractional RF. Whereas some “Matrix RF” devices use electrodes, others use an array of microneedles arranged in pairs between which bipolar RF energy is delivered ePrime system. Another system Miratone FRF system uses a microneedle electrode array.
The fractionally delivered energy creates zones of affected skin next to unaffected areas. The unaffected areas found in between affected areas initially keep skin integrity but, in the long term, serve as a reservoir of cells that promote and accelerate wound healing. The treated areas result in thermal damage in the deep dermal collagen, stimulating wound healing, dermal remodeling, and new collagen, elastin, and hyaluronic acid formation.
A new device has been developed that combines fractionated optical energy with a 915-nm diode with a fractionated bipolar RF. This integrated system targets the epidermis and superficial dermis. Using the RF part synergistically, less energy is used to heat the collagen in the deep dermis and stimulate new collagen formation and contraction Matrix Laser.
This device has been associated with significant improvement in acne scarring, texture, and pigmentation. Small papular scars that may appear on the nose and chin respond well to fine wire diathermy, not a new technique but recently described for this subgroup.
If there are few scars, their augmentation by temporary or longer-term autologous or external agents may be proper. Combinations of subcision, blood transfer, non-ablative or vascular laser, and skin needling may be helpful for more significant scarring.
During the late 1990s and early 2000s, the gold standard for the treatment of facial lines and wrinkles as well as acne and traumatic scars was, at least from a laser point of view, the carbon dioxide (CO2) laser system. Carbon dioxide laser was first used for post-acne scarring, replacing dermabrasion and intense chemical peeling. The CO2 laser emits a 10.600nm wavelength, strongly absorbed by tissue water.
The penetration depth depends on water content and is independent of either melanin or hemoglobulin. This treatment is more aggressive and more profound than a chemical peel but stays at 20 to 30 um specific depths with thermal damage of 50 to 150 um. It is usually bloodless but still achieves total ablation of the epidermis and a part of the dermis. In addition to the destructive nature, the procedure may also stimulate collagen stimulation.
The usefulness is primarily for hypertrophic scars, boxcar scars (preferably shallow), and, less effectively, keloids. Some achieve quick results, visible as soon as two weeks, but improvement because of the wound-healing phases continues for at least 18months. Downtime with the CO2 laser typically lasted about one week or more. Depending on the device and the aggressiveness of the clinician utilizing the device, potential adverse effects became more significant.
Although traditional ablative laser resurfacing was able to achieve results for skin tightening, which rivaled surgical correction, the potential adverse effects included pain, edema, persistent erythema, infections, post-inflammatory hyperpigmentation, and the most problematic of all, hypopigmentation following the ablative procedure, seen in some patients two years following the laser surgery significantly limited the application of this technology.
The Er: YAG laser was introduced to counter these potential adverse events. It emits a wavelength of 2940 nm in the infrared range, which is close to the absorption peak of water and yields an absorption coefficient 16 times that of the CO2 laser.
This provides a more precise skin ablation with minimal thermal damage to the surrounding tissue, resulting in less severe side effects and faster healing times. Depending on the power used, the downtime may still be from 5 to 7 days. Er: YAG lasers still can occur, and other problems like the CO2 laser. Again, this may benefit hypertrophic scars, rarely keloids, and shallower boxcar scars.
Ablative Plasma skin resurfacing. Laser skin resurfacing has been employed to treat many skin conditions, but photoaging and scarring are the two most common indications. A device for performing ablative resurfacing has been developed, which works by passing radiofrequency into nitrogen gas.
The “nitrogen plasma” causes rapid skin heating with limited tissue ablation and minimal collateral thermal damage. The results are gentle CO2 and Air: YAG laser resurfacing. The more aggressive the treatment, the higher the fluence, and the more impressive the results.
Dermatologists Only Skincare Products
Pre-conditioning Treatment Program of the skin with Vitamin A and lactic acid with or without bleaching cream or lotion (Hydroquinone, arbutin, licorice Kojic acid, and Azelaic acid) has become a standard protocol at MSI. It is essential in darkly pigmented skin treated with ablative resurfacing techniques. IT treated the skin for several weeks before the procedure.
Pre-conditioning programs are essential to tighten the skin, reduce wound healing, and decrease the chance of dyspigmentation. In the first 2-3 weeks, the skin goes through an accommodation phase and is often red and irritated. In conjunction with ablative/non-ablative treatment and laser therapies, well-chosen MSI skincare products will result in enhanced results and maintenance of the improvement seen.
To protect the skin, you can apply topical healing ointment under a semi-occlusive dressing for the first few postoperative days. It would be best to clean treated areas daily with water and hydrating cleanser gently. Postoperative redness typically lasts several (4–6) weeks after laser treatment and can receive help from Red Out cream with vitamin K to hasten redness resolution. Strict sun avoidance and photoprotection should be advocated until complete healing to reduce the risk of pigment alteration.
Skin darkening is transient and will fade out using our advanced whitening formula with a unique combination of bleaching agents such as Hydroquinone, arbutin, licorice Kojic acid, and Azelaic acid. Another treatment modality used focuses on hypertrophic scars, and to a lesser degree, the keloid is silicone dressing.
There is variable support to the silicone itself, with results more likely attributable to occlusion or hydration. The pressure-supported mechanism and other rationales include temperature, increased oxygen tension, electrostatic properties, or immunologic effects. Although silicone elastomer sheeting has not been completely elucidated, it effectively treats and prevents
Intralesional corticosteroid injections have become a mainstay in treating hypertrophic scars and keloids, combined with other therapeutic procedures. Corticosteroid applications can soften and flatten keloids but cannot narrow hypertrophic scars or cut keloids. We recommend beginning with direct serial intralesional corticosteroid injections in an already developing keloid or hypertrophic scar.
The most used drug for steroid injection is triamcinolone acetonide (TA) at a dose of 5 to 10 mg/mL, which should be injected with a 25- to 27-gauge needle into the upper dermis of a developing hypertrophic scar every 3 to 6 weeks. Injections are discontinued when the scar is stable, surgical intervention is indispensable, or side effects such as tissue atrophy, hypopigmentation, or telangiectasia.
The treatment of preexisting keloids should begin with three monthly, intralesional injections of TA at a dose of 40 mg/mL mixed with equal parts of 2% lidocaine. Some authors also recommend the addition of hyaluronidase, which helps to disperse the injection.
Because tissue absorption through intact or sutured skin is poor, the use of topical steroids is shown only for superficial lesions, such as those occurring from dermabrasion. More recently, intralesional verapamil at a concentration of 2.5 mg/mL (0.5–2mLinjected volume depending on the size of the scar) or topical imiquimod has been suggested as postoperative adjunctive treatment to surgical excision of keloidal.
Intralesional cytotoxic, including fluorouracil, bleomycin, and mitomycin, are used for hypertrophic and keloidal scars. Fluorouracil can be used at a 50 mg/mL concentration and has been mixed 80:20 with low-strength intralesional steroids. However, it may also be used alone, with approximately 1 mL used in each scar.