Cosmetic Surgery Tips

Co2 Laser For Hypertrophic Scars

Some individuals are born with scars that are thicker than average, which can cause significant pain and discomfort. If you fall into this category, you are aware of how irritating it can be to cope with a scar that simply isn’t healing properly—it could even appear to be growing worse.

With this brand-new laser procedure, hypertrophic scars are being treated in a way that has never been done before. It functions by penetrating the skin deeply to promote collagen formation and aid in the body’s natural healing process. As a result, there is no additional pain or discomfort and the skin tone is smooth and natural-looking.

We’ve seen our fair share of lasers over the years, but this one stands out since it is strong enough to significantly alter the scar’s appearance while being delicate enough to avoid causing more harm or irritation. Hence, if you’ve been struggling with hypertrophic scars for a while, the moment is now!

In this post, we’ll also talk about hypertrophic scar laser treatment cost and co2 laser treatment.

Co2 Laser For Hypertrophic Scars

Have you ever wondered if CO2 fractional laser for hypertrophic scar is the right choice for you?

If so, you are not by yourself. Although it’s a fantastic treatment option, determining whether it’s appropriate for your skin can be challenging.

That’s why we’re here! We want to help you get the information and guidance you need to make an informed decision about whether CO2 fractional laser for hypertrophic scar is the right treatment option for your skin, or whether another type of procedure would be better suited to your needs.

Hypertrophic scars are irregular, raised scars that can cause debilitating symptoms including pain, pruritus, and restricted movement in nearby joints. There are also often significant psychosocial elements with these scars that are especially significant in the vulnerable pediatric population and their parents. Current scar treatment modalities are limited. In recent years, the advent of ablative fractional laser (AFL) resurfacing technology has shown great promise but there remains a need to expand high-level evidence and develop optimal laser treatment parameters for patients.

In order to create a treatment strategy that maximizes the safety and effectiveness of AFL therapy in the pediatric population, the researchers of this study set out to assess the effectiveness of ablative fractional CO2 laser treatment of hypertrophic scars in children. At Alberta Children’s Hospital, a prospective split-scar clinical experiment will be conducted. To detect a clinically significant improvement in the total POSAS score, our main outcome measure, a sample size of 44 scars will be adequate. The study may involve children (age 1- 17) who exhibit hypertrophic scarring after an acute injury or burn. All patients will receive standard scar treatment methods, and our plastic surgery experts and rehabilitation team will monitor them all. In order to identify the scars for assessment, each scar will be divided into two halves, each of which will receive a special “Site ID” that will be recorded in a data collecting sheet. Under a general anesthesia, all laser procedures will be carried out by a single surgeon at the Alberta Children’s Hospital using the UltraPulse CO2 Laser (Lumenis, Israel). For a total of 3 sessions, patients will receive laser treatments at intervals of 4 to 8 weeks. Depending on the unique patient and scar characteristics, a mix of the SCAAR FX and Deep FX therapy modes, with or without the Active FX treatment mode, will be used.

Demographic information and data about original burn are collected. The POSAS and SCAR-Q questionnaires, clinical pictures, and a cutometer will all be utilized as assessment tools to track changes in scar pathology and appearance over the course of the study. Between laser-treated and control scar sites, the mean values for the cutometer measures, the POSAS, and the SCAR-Q questionnaires will be compared. The Shapiro-Wilk test will be used to determine if each of these datasets is normal. Both parametric and non-parametric data will be compared using Student’s t-tests and the Wilcoxon signed-rank test, respectively.

Shady M Ibrahim,1 Wael M Saudi,2 Mohamed F Abozeid,3 Mohamed L Elsaie4

1Department of Dermatology, Al Azhar University, Cairo, Egypt; 2Department of Dermatology, Misr University for Science & Technology, 6th of October City, Egypt; 3Department of Plastic surgery, Cairo University, Giza, Egypt; 4Department of Dermatology, National Research Centre, Cairo, Egypt

Background: Fractional CO2 laser is one of the most effective treatment options used to resurface scars.
Objective: To evaluate the efficacy and safety of early treatment of postsurgical scar by fractional ablative CO2 laser.
Methods: A total of 27 Egyptian patients with recent postoperative scars were enrolled in this study. Three sessions of fractional CO2 laser with a 1-month interval were started 4 weeks after surgery. Vancouver Scar Scale (VSS) was used as an assessment tool at 1 and 3 months after the final treatment. Patients reported their satisfaction using a subjective 4-point scale.
Results: Results demonstrated a statistically significant overall average improvement of the VSS (5.33±1.33) before compared with (2.55±1.06) 3 months after the last laser treatment (P≤0.001). Among the individual parameters in the VSS, the most significant improvements were found in pigmentation, height, and pliability. Patient’s subjective satisfaction scores showed a significant greater degree of satisfaction after laser treatment.
Conclusion: Fractional ablative CO2 laser is an effective and safe treatment modality for surgical scars in the early postsurgical period.

Keywords: scar, fractional, CO2 laser

Introduction

Wound healing is a complicated process, consisting of overlapping phases. These phases are hemostasis, inflammation, granulation, and remodeling.1 Any alteration in the process would lead to a variety of sequelae, including chronic wound healing and scars.2 Scars arise from either excessive or insufficient new collagen generation during the wound healing process and may appear as hypertrophic scars and atrophic scars.3

Scars affect ~4.5%–16% of the general population and, depending on the degree of disfigurement, can have a profound impact on the psyche of the patient such as low self-esteem and feelings of psychosocial isolation.4

Surgical scars take ~1 year to fully mature, although it is well recognized that scars continue to improve in appearance after 1 year. Surgical scar revision ~3 months after surgery may be considered, but laser therapy can be considered as early as a few weeks after surgery.5

Fractional photothermolysis is a laser technology that creates thousands of microscopic columns of thermal damage (referred to as microthermal zones [MTZs]) in the epidermis and dermis surrounded by islands of normal tissue, hence results in shorter recovery time and fewer adverse effects than traditional ablative laser resurfacing.6

In recent years, early intervention with laser devices has been suggested as a novel modality to improve scar quality. Some lasers are effective not only as a treatment for scars but also in the prevention of hypertrophic scars.7 Several studies have evaluated the efficacy of nonablative fractional erbium glass, pulsed dye laser (PDL), and potassium titanyl phosphate to improve early postoperative and post-traumatic scars and a few other studies have been evaluated on the efficacy of fractional laser treatment of postoperative scars during the early post-traumatic period.811

Therefore, in this study, we aimed to evaluate the efficacy and safety of early treatment of postsurgical scar by fractional ablative carbon dioxide.

Patients and methods

A total of 27 Egyptian participants (15 females, 12 males; Fitzpatrick skin types III–V) aged 15–47 years, who had recent postsurgical scars (4–6 weeks after operation), were included in the study. Candidates with active infections, history of keloid, recent isotretinoin intake, smoking, and pregnancy were excluded. The study was initially approved by the ethical committee of Al-Azhar University. Written informed consent was obtained from all participants before enrollment. Parent or legal guardian of any patient under the age of 18 years signed the informed consent.

Treatment protocol

After 4-6 weeks following surgery, three sessions of fractional CO2 10,600 nm laser (Smartxide square, Deka, Florence, Italy) were begun with a 1-month gap in order to treat the postoperative scar as soon as possible. A gentle cleanser was used to clean the treatment areas. A topical anesthetic cream was used (AstraZeneca AB, Sodertalje, Sweden; eutectic mixture of 2.5% lidocaine hydrochloride and 2.5% prilocaine; eutectic mixture of local anesthetics). The anesthetic cream was gently withdrawn to reveal a perfectly dry skin surface after an hour of application. According to the skin type, scarring sites were treated with fractional CO2 utilizing a power range of 10-15 W, a dwell period of 500 s, a stack of 2, and a spacing of 700 m. The sunscreen was still being applied. Following the session, a topical antibiotic cream was used twice daily for three days. Patients were advised to consistently apply a full-spectrum sunscreen.

Assessment

Photographic documentation using identical camera settings, lighting, and patient positioning (CyberShot digital, DSCH50, Sony, Tokyo, Japan) were obtained at baseline, before each treatment session, and 3 months after the final treatment session.

Vancouver Scar Scale (VSS) was used by two blinded dermatologists to assess the scars at baseline and 3 months after the final treatment. The VSS includes assessment of pigmentation, height, pliability, and vascularity of the scar. Each of the four parameters was assigned numbers according to the previously mentioned characteristics. Scores from all parameters were added together to attain a final VSS score. Patients reported their satisfaction with the treatment outcomes using a subjective 4-point scale. Patients were also questioned about the side effects of the treatment, especially bleeding, oozing, post-treatment dyschromia, crusting, and erythema at each session.

Statistical analysis

SPSS software version 18 was used. In comparison to the different sessions for each participant, we estimated a P-value at most <0.05; consequently, we confirmed the significant difference of statistical analysis in this clinical trial.

Results

With the help of VSS analysis, the current study was created to investigate the effectiveness and safety of early fractional CO2 laser treatment of postsurgical scars. The patients were between the ages of 15 and 47. Twelve patients (45%) were men and fifteen (44.44%) were women patients. Three patients had skin type V (11.11%), 11 patients (40.74%) had skin type III, and 13 patients (48.14%) had skin type IV. Three patients had scars following rhinoplasty, two had scars following blepharoplasty, eight had scars following surgery for trauma to the face, four had scars following abdominoplasty, three had scars following thigh lifts, three had scars following surgery for trauma to the arm, two had scars following neck surgery, one had scars following back surgery, and one had scars following cesarean delivery. The scars’ average age was 4.3 weeks, however they ranged from 2 to 6 weeks in age.

The outcomes showed a statistically significant overall average improvement in the VSS (5.331.33 before compared with (2.551.06) 3 months after the final laser treatment; this difference was statistically significant (P0.001) (Figure 1). The most notable changes were observed in pigmentation, height, and pliability among the various characteristics in the VSS (Figures 2 and 3).

Figure 1 Vancouver Scale Score (VSS) (total and parameters) before and 3 months after laser treatment.
Figure 2 A 29-year-old female patient with recent postsurgical scar (rhinoplasty), before laser treatment (ACE) and 3 months after laser treatment (BDF).
Figure 3 A 47-year-old female patient with recent postsurgical scar (blepharoplasty), before (A) and 3 months after laser treatment (B).

Patient’s subjective satisfaction scores showed a greater degree of satisfaction after laser treatment, wherein six patients were very satisfied (22.2%), eight were satisfied (29.6%), seven were slightly satisfied (25.9%), and six were unsatisfied (22.2%) following three sessions of fractional CO2 laser (Figure 4). No side effects of the laser treatment were noted except one patient who showed postinflammatory hyperpigmentation.

Figure 4 Patient’s satisfaction score before and 3 months after laser treatment.

Discussion

Conventional laser resurfacing and mechanical dermabrasion can potentially destabilize a healing tissue bed or disrupt the protective epidermal barrier prior to the incision seal. Nonablative, pulsed, or fractionated lasers place minimal mechanical stress on the tissues making an option for earlier treatments.12

Early laser intervention for treatment of scars has always yielded better results. The optimal time for laser treatment was during the premature phase of scar formation at a few weeks postsurgery.12,13

This current study aimed to evaluate the possibility of early intervention of fractional CO2 laser for improving the appearance of postsurgical scars. Assessment of the erythema, height, pliability, and pigmentation was done using the VSS, which was originally designed to assess subjective parameters in an objective way. Regarding total VSS, there was a significant improvement in VSS for postsurgical scars, 3 months after last session by fractional CO2 laser. The improvement was significant in all parameters of VSS score, with higher significance in terms of height, pigmentation, and pliability, while less significant in terms of vascularity. In the current study, there is a significant improvement regarding patients’ satisfaction grades.

Several reports have addressed the utility of PDL, nonablative fractional lasers (NAFLs), or ablative fractional lasers (AFLs) for scar prevention. One article mentioned the superiority of 1,550-nm NAFL compared with PDL on postoperative scars, and others reported the clinical effect of the PDL followed by AFL on surgical scars.9,14,15

The effect of PDL and fractional Er:YAG laser for scars was demonstrated, especially in term of pliability, as a combined approach on post-thyroidectomy scar on the day of suture removal.16 Another study has compared the effect of PDL and fractional CO2 laser and revealed that both PDL and AFL produced statistically significant improvements. However, comparatively, there was no statistical difference between them. In each variable, AFL was more effective than PDL in the improvement of pliability and thickness. In contrast, PDL was superior to AFL in the improvement of vascularity and pigmentation.17

Fractional photothermolysis, first introduced by Manstein et al in 2004,18 is the latest in the available phototherapeutics for scars. Fractionation refers to a technology in which thousands of laser MTZs are directed at the skin surface while sparing islands of healthy skin around it, so bulk heating and confluent epidermal damage is avoided, thereby reducing the risk of irreversible nonspecific thermal injury to the dermis, which may worsen scarring. Mechanism of action is through initial induction of proinflammatory cytokines and growth factors followed by dermal collagen remodeling.19 In another study, AFL showed better results in the overall appearance and the visibility of the incision line of fresh surgical scars than NAFL.20

In another study on 16 postoperative scars of 15 patients, a greater decrease in VSS score was noted in half of the treated scars after two sessions of fractional CO2 laser, especially in terms of texture and thickness. Patients also expressed a significantly greater degree of satisfaction with the treated side as assessed using a subjective 4-point scale.21

These previous studies coincide with our results which revealed that fractional CO2 laser could result in improvement in height and pliability. The improvement was highly marked in terms of scar height and pliability and less marked in terms of pigmentation and vascularity, but the overall VSS and each variable showed a significant improvement.

Although the mechanism of fractional photothermolysis in the treatment of atrophic and hypertrophic scar is not known exactly, the columns of thermal injury characterized by localized epidermal necrosis and collagen denaturation may initiate a cascade of events that eventually results in a normalization of the collagenesis–collagenolysis cycle.22 Regarding the early fractional CO2 laser intervention, it can, in theory, normalize collagen and realigns abnormal collagen fiber by thermal effect of laser treatment.

Hypertrophic Scar Laser Treatment Cost

The cost of hypertrophic scar removal treatment in India is variable. Check out the following cost details to make an informed decision that suits your budget:

  • Laser Therapy: Comes at a price range between Rs 7,000 to Rs 20,000 per session.
  • Topical Medications: Priced between Rs 900 to Rs 7000.

Co2 Laser Treatment

Carbon dioxide laser skin resurfacing is a technique effective for both cosmetic and medical applications. It is an excellent modality for treating and preventing wrinkles and skin laxity that occur with photoaging. It is also effective in the treatment and prevention of keratinocyte skin cancers.

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