Mitigation of Postsurgical Scars Using Lasers: A Review

Ofir Artzi, MD; Or Friedman, MD, MD; Firas Al-niaimi, MD; Yoram Wolf, MD; Joseph N. Mehrabi, MD

Disclosures

Plast Reconstr Surg Glob Open. 2020;8(4):e2746 

In This Article

Discussion

Postsurgical scars are ideally flat, narrow, pale, and pliable. Abnormal scars may range from hypertrophic to keloid. Abnormal scars can be unsightly, painful, functionally, and socially limiting. Various scar mitigation options exist.[19] This study provides a systematic review of trials performed over the last 2 decades that investigate mitigation of postoperative scars using a variety of single laser modalities and treatment protocols.

Four studies out of 14 did not demonstrate statistical significance with the treatment of postsurgical scars. Alam et al[6] employed a single PDL treatment immediately postsurgery and concluded that more treatments are necessary to achieve a therapeutic effect. Buelens et al[16] and Sobanko et al[14] failed to show statistically significant improvement using fractional CO2 laser monotherapy. However, higher patient satisfaction was statistically significant for treated scars.[16]

Statistically, significant scar improvement was found in the remaining 10 studies. Diode, PDL, and CO2 lasers were reported to have the best results compared with controls. Although the exact mechanics are not entirely understood, diode lasers have been shown to increase heat-shock-protein 70 induction, which is known to induce collagen proliferation and modulate transforming growth factor beta (TGF-β) expression, and remodeling.[8,20,21]

PDL and KTP lasers best target the oxy- and deoxyhemoglobin chromophores and are best utilized to alleviate the erythema associated with highly vascular postsurgical scars.[22–25] Also, PDL has been shown to upregulate p53, inhibiting cell proliferation, and reducing angiogenesis that contributes to abnormal scarring.[26] Optimal results were achieved after 3 PDL treatments.[5–7,15] Treatment intervals ranged from 2 to 10 weeks. All 4 studies started treatment on the day of suture removal and proved to be safe and efficacious.[5,27]

Both KTP and PDL lasers exhibited substantial improvement in similar categories of scar treatment; however, neither have had statistically significant results when compared with the other.[28] KTP lasers have been associated with more posttreatment pain, erythema, and edema.[28,29]

The chromophore targeted by CO2 lasers is water, found in tissues. CO2 laser treatments are considered more aggressive and lead to considerable dermal matrix remodeling, hopefully leading to favorable remodeling of the scar.[25,30] Half of the studies exploring the treatment of postsurgical scars using only CO2 lasers reported statistically insignificant results with a collectively low SMD.

Combining different modalities may augment scar mitigation. A synergistic effect can be achieved from combining PDL treatment, targeting scar vascularity and pigmentation, followed by fractional CO2, and aimed at improving the texture, pliability, and height of the scar.[31–33] Also, combination of laser treatment with triamcinolone injection has shown promising results, perhaps by inhibiting fibroblasts and TGF-β.[25,31,34–36] Combining Er:yttrium aluminum garnet (YAG) fractional ablation after PDL treatment improved scar pliability in addition to scar appearance.[37]

Our review is inherently limited by its attempt to compare different studies using various measurement scales and patient populations. This made it difficult to compare among protocols, devices, and parameters. Also, aside from 2 listed patients in one study,[7] only patients less prone to hypertrophic or keloid scarring are evaluated. Future studies should explore high-risk patients such as patients with abnormal scarring history or patients undergoing midline or limb incisions. Moreover, standardized objective measuring tools such as 3D, infrared cameras, and standard scar scales should be encouraged.

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