It Doesn’t End Until the Fat Scar Sings (or Flattens Out or Just Doesn’t Become One)

by Or Friedman, MD (@Friedman_MD)

“Doctor, it won’t leave a scar, right?” Well, ma’am, it will. But…

Scars are an essential part of the wound healing process. Abnormal healing that results in hypertrophic scars or keloids may produce significant morbidity and impair quality of life.

The second International Scar Treatment Conference took place in Tel Aviv, Israel, in March and was a great place to learn about the current and future trends in scar prevention and treatments. The meeting had a wide variety of attendants and was endorsed by both the dermatological and plastic surgery professional organizations.

Our training teaches us how to solve complex problems, but at times it seems like one of the most prevalent ones, scarring, is neglected or put aside once the surgery is over and healing takes place. For me, this was an opportunity to learn from our dermatological colleagues and re-assess my approach to scars and healing. Below are some of the concepts I picked up from the conference and would like to share with you.

1. Scars are Treatable

Conventional management of scars has included massage, compression garments, silicone sheeting, steroid injection, surgical adjacent tissue transfer (z-plastic), and direct excision. Scar rehabilitation requires a combination of therapies including injectable antimetabolites, surgery, lasers and laser-assisted delivery to restore skin to its former condition of health. 

2. Time is of the Essence

Most of the speakers agreed that scarring is inseparable from the healing process, and starts at the time of injury. Our mentors would advocate atraumatic tissue handling, discriminant use electrocoagulation, maintaining an aseptic or clean surgical field and layered tensionless closure. A hot topic at the meeting was early intervention in the scars such as the use of botulinum toxin injection immediately after wound closure or using a pulsed-dye laser on a surgical scar as early as the day of suture removal. As soon as the physician notes that a surgical scar’s healing is suboptimal, it can be treated with a combination of lasers. 

3. Laser-assisted Delivery for Scar Treatment

Fractional ablative tunnels can be utilized for laser-assisted delivery systems (LADS) of a variety of drugs, topical agents, and the living tissue. Ablative fractional laser-assisted delivery has been used to treat hypertrophic scars using triamcinolone acetonide + 5-fluorouracil. Calcium hydroxylapatite, Poly-L-lactic acid, and Hyaluronic acid are tissue stimulators typically injected subcutaneously for facial volume correction. Preliminary results of laser-assisted delivery of tissue stimulators combined with the properties of fractional ablative resurfacing seem to indicate stimulation of fibroblast proliferation and neocollagenesis. 

4. Acne Scars

Topographical features of acne scarring include perpendicular bundles of collagen which anchor the skin of the scars down.  Deep acne scars need deep laser re-surfacing for maximum improvement. The goals of laser resurfacing are to stimulate neocollagenesis to “plump” up these areas of collagen loss. Treatment modalities should be capable of affecting dermal remodeling at least 1mm below the skin. By combining Fractional laser and injection of a tissue stimulator (Calcium hydroxylapatite, Poly-L-lactic acid, Hyaluronic acid), impressive improvement might be gained, and currently, multiple groups are researching this synergistic approach.

5. Burn and Traumatic Scars

Burn and traumatic wounds are the most challenging to treat because these are typically the worst scars seen in clinical medicine. Erythematous and hypertrophic scars are frequently seen in the first year after injury. Vascular-specific laser and light devices, especially the 595-nm pulsed-dye laser (PDL) may be applied alone for small hypertrophic scars but is often combined with fractional laser therapy in either concurrent or alternating treatment sessions. Either ablative or nonablative fractional lasers best improve hypertrophic burn and traumatic scars. Tissue ablation appears to induce a modest immediate photomechanical release of tension in some restrictive scars. Often patients have an increase in a range of motion within 24-48 hours after one fractional ablative therapy treatment. 

6. Treatment Algorithm

– Small scars: Inject antimetabolite (triamcinolone acetonide + 5-fluorouracil) in small quantities

– Scar under tension: Z-plasty, W-plasty, release

– Red scar: Vascular laser

– All scars: Fractional laser

– Larger hypertrophic scar: Fractional laser and laser-assisted delivery of antimetabolite

– Depressed scar: Fractional laser and laser-assisted delivery of tissue stimulator (Calcium hydroxylapatite, Poly-L-lactic acid, Hyaluronic acid)

Featured Image: Live demonstration of Acne scar treatment by Dr. Greg Goodman.

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