Scar Revision: Part of the Laser Revolution
By Edward B. Lack, MD, John D. Rachel, MD
Published on August 01, 2006
Scars come in many sizes, shapes, and colors. They can be red, brown, blue, or white. Some are raised, while others are depressed, indented, or bound down to underlying bone or muscle. Some are hard and some are soft. But while scars may vary in shape and color, they are universally unwanted and disliked. In worst-case scenarios they are disfiguring.
Until recently, scars had to be erased with surgical procedures like dermabrasion, chemical peeling, or surgical removal that left new, hopefully less conspicuous scars. Unfortunately, these procedures do not leave the area entirely unscarred; instead, they sometimes leave a scar of their own. Enter the field of laser biomodulation.
In nature, when a scar is formed, bodily cells produce collagen in the scar much like a spider spins a web. Technically, these cells, known as fibroblasts, lay down fibers, dissolve some of them, and then make others. This 'remodeling' process continues until the newly formed scar is as smooth and contoured as possible. But sometimes the scar is not as well contoured as the patient would like. Sometimes, including following procedures like the ones mentioned above, the area where the scar was does not blend in with the surrounding skin and body structures. This is where laser biomodulation comes in. It can be used alone or with other techniques to modify the scars again.
Biomodulation wakes up the fibroblasts in the skin to tell them that they didn't finish their work. It works by stimulating them to again remodel the scars and is used to erase color, even out surface texture, or flatten the scar. Biomodulation can also soften hard scars and produce more elasticity in the skin so that distortions may vanish.
Lasers produce intense light with a specific wavelength that may be translated into a specific color. Each laser has its own wavelength, much as a radio station has its own frequency. When you turn your radio dial to 670, 780, and 1,000 you receive three different radio stations. Yet they all transmit sound. Similarly, a laser may be 585, 680, or 755 nanometers (nm). The nanometer measurements used to identify different lasers correspond to different emissions in the light spectrum, but all represent emissions of light.
When a cell absorbs energy, it is stimulated to become active and productive. When fibroblast cells absorb light energy (i.e. from the laser), they repair defects in the skin by producing collagen and remodeling it to fit the body where the scar is being formed.
Lasers that induce biomodulation, or in this case stimulate fibroblasts, can be ablative lasers or non-ablative lasers. Ablative lasers vaporize the epidermis, the outer layer of the skin. Two types of lasers, the CO2 and the Erbium-YAG laser, are ablative lasers. After the surface of the skin is ablated (vaporized), new skin forms in a matter of days.
Meanwhile, underneath the surface the fibroblasts are stimulated and begin the process of creating collagen for new scar tissue. The skin on the surface becomes red and slightly swollen, and while swelling usually resolves within the week, redness frequently persists for 1-2 months. This type of laser treatment is usually performed one or two times on scars and it is the most dramatic improvement seen with laser scar revision. It is most effective in smoothing the skin surface and evening out irregularities.
However, some patients cannot tolerate one to two months of redness. Many patients cannot stay away from work for the week it takes for swelling to disappear from ablative laser surgery. And some patients need a change in the texture of the scar, such as patients with indented or bound-down scars, or firm, raised scars. This is where non-ablative lasers come in. Non-ablative lasers come with various wavelengths and many names: VLS, Pulsed-dye laser, N-lite, and Cool-touch to name a few. All of these lasers treat the skin from within so that the surface of the skin remains undamaged. Patients return to work immediately with little color change and little or no swelling of their skin. This procedure requires 3-6 relatively painless treatments, usually at one-month intervals. Following the procedure scars slowly fade from view. The bound-down scar releases, and the indented scar rises. The raised scar softens and begins to flatten and color fades to a natural skin tone.
The advent of laser scar remodeling has arrived and scars can slowly improve and fade with a combination of laser treatments. The earlier a scar is treated, the greater the degree of improvement, so waiting for a scar to "mature" is not in anyone's best interest. Best results are obtained from surgeons with training and experience in laser surgery. Ask cosmetic surgery offices what kinds of lasers they use and request before and after pictures to evaluate the quality of their results.
Edward B. Lack, MD and John D. Rachel, MD, have practices in Chicago and Des Plaines, IL. For more information on the authors, please visit The Center for Liposculpture and Cosmetic Laser Surgery's website.