What is Traumatic Scarring?

Traumatic scarring may occur in people of all ethnicities and ages. Atrophic scars are lower and thinner than the surrounding skin. Hypertrophic scars are thickened and elevated above the skin but remain within the boundaries of the initial injury. Keloid scars are elevated and extend beyond the boundaries of the initial injury. Traumatic scars may affect patients physically, psychologically, and socially. Scar tightening (contractures), especially over joints, may limit normal movement and the ability to participate in normal activities of daily living. Disfigurement can affect the way people perceive themselves and the way others perceive them, possibly even leading to feelings of depression or anxiety. Traumatic scars can frequently cause pain, itch, and other abnormal sensations.

Diagnosis and Testing

Scar types and their associated problems are determined primarily by medical history and physical examination performed by a physician. Therapists may perform measurements to assess movement. Biopsies and laboratory tests may be of limited use.

Treatment options for Traumatic Scars

There is no permanent cure for traumatic scarring, so injury prevention and effective early wound care are important to minimize scar formation. Physical therapy, pressure, and other treatments can help minimize contracture formation after injury. Medical teams that treat scars can include dermatologists, plastic surgeons, physical and occupational therapists, and psychologists. Other professionals may assist with scar camouflage.

Common treatments include topical and injected

1. Medications:

corticosteroids, injected chemotherapeutic agents (eg, fluorouracil)

2. Silicone gel sheeting:

Silicone gel sheets are soft wound covers composed of cross-linked polymers reinforced with or bonded to mesh or fabric. Indicated to prevent or improve the appearance of old and new hypertrophic and keloid scars. Hypertrophic scars occur from poorly designed surgical wound closure, too much tension applied to a surgical wound closure, a wound infection or partial- and full-thickness burns. 3. cryotherapy with liquid nitrogen, and irradiation.

3. Atrophic scars may be treated with tissue fillers.

Dermal fillers, also known as injectable implants, soft tissue fillers, or wrinkle fillers are medical device implants approved by the Food and Drug Administration (FDA) for use in helping to create a smoother and/or fuller appearance in the face, including nasolabial folds, cheeks and lips and for increasing the volume of the back of the hand.

The FDA has approved dermal fillers made from absorbable or temporary material for the correction of moderate to severe facial wrinkles and skin folds, such as nasolabial folds, which are the  wrinkles on the sides of your mouth that extend towards the nose often referred to as “smile lines.”
The FDA approved a dermal filler made from non-absorbable (permanent) material ONLY for the correction of nasolabial folds and cheek acne scars in patients over the age of 21 years.

4. Lasers that target blood vessels are commonly used for red scars, and newer ablative (destructive) and nonabrasive fractional lasers have advanced treatment substantially for some patients with traumatic scars, although multiple treatments are usually needed. Severe scars and contractures may require surgery.

LASERS AND SURGERY: SYNERGY FOR THE TREATMENT OF SCARS

The treatment of scars is a multispecialty endeavour. A combination approach by medical experts yields optimal scar improvements. If an injury heals in the presence of tension, hypertrophy often ensues. This condition is characterized by deposits of excessive amounts of collagen, as previously explained, giving rise to a raised scar. Understanding the role of tension in the development of a scar is essential to designing a successful treatment strategy. If there is significant hypertrophy or contracture present in a scar, surgical intervention is necessary to relieve the tension or there is a high likelihood the scar will reform. After tension relief, hypertrophic and contracture scars are more elastic with new remodeling of collagen and are more amenable to treatment with laser. However, if a scar has had initial fractional laser therapy this often makes surgical intervention easier to perform because the fractional laser therapy helps to create thinner collagen bundles.

LASER THERAPY FOR BURN AND TRAUMATIC SCARS?

Erythematous scars (reddened scars caused by a dilation of superficial blood vessels in the skin, or erythema), and hypertrophic scars (scars with excessive deposits of collagen that cause a raised-scar appearance) are seen frequently in the first year after injury. Vascularspecific lasers and light devices, especially the 595-nm pulsed dye laser (PDL), are already well established for such applications. PDL is often combined with fractional laser therapy—either in the same treatment session or in alternating sessions. Hypertrophic burn and traumatic scars are best improved by ablative fractional lasers. Ablative lasers, when compared to other lasers, have a significantly greater potential depth of thermal injury. One such laser modified for the treatment of scars reaches 4.0 mm in depth. Furthermore, tissue ablation appears to induce a modest immediate photomechanical release of tension in some restrictive scars.

An appropriate degree of surrounding thermal coagulation appears to facilitate the subsequent remodelling response. To determine the appropriate laser pulse energy settings (treatment depth), scar pliability and thickness is estimated by the physician through palpation, or physical exam by touch. Pigment-related abnormalities of scars (hypopigmentation, or a lack of colouring; hyperpigmentation, or darkening; and depigmentation, a loss of pigment) can also be improved with fractional therapy. Flat or atrophic scars from burns and trauma also respond well to fractional laser therapy. Atrophic scars are dermal depressions that occur due to collagen destruction during an injury. The goal of laser treatment for atrophic scars is to stimulate collagen production within the atrophic areas. Neo-collagenosis, or collagen production, is most stimulated by fractional laser therapy, making it the best choice for flat or thin scars.

FRACTIONAL LASER TREATMENT: WHAT TO EXPECT ?

Any part of the body may potentially be treated with fractional laser therapy. The majority of fractional laser treatments can be performed in the clinic setting using a commercially available topical cream anesthetic preparation, which is applied under occlusion, or covered, 1 hour prior to treatment. Some patients may benefit from systemic preoperative analgesics (pain medication) or anxiolytics (anxiety medication). Conscious sedation or even general anesthesia can be employed in instances of large surface area involvement or anticipated poor patient tolerance of the procedure while awake. This is a particularly important consideration in children, as multiple treatments are usually required and children do not tolerate repeated painful interventions well. Patients experience minimal to no postoperative pain and little post-procedure downtime, resuming most normal activities after 48 hours. With previous discussion in mind, fractional laser treatment technique, parameters, and adjunctive treatments should be applied thoughtfully to minimize the degree of cumulative thermal injury to the tissue. Each treatment is customized at every session according to individual scar characteristics and interval changes.

LASERS FOR MATURE SCARS

Fractional lasers are not only effective on new scars. Mature scars, whether 1 or 60 years old, all respond well to laser therapy. For the past decade we have treated scars of all ages. A minimum treatment interval of 2 to 3 months between fractional laser treatments is recommended to give the compromised scar tissue time to heal. Even after just 1 treatment session, a patient may continue to have improvement for many months up to 1 year. Problems associated with mature scars include burning, itching, pain, discomfort, disfigurement, contracture, and limits to form and function.

Fractional laser treatments have been successful not only in the appearance of scars but improving range of motion, while fractional ablative lasers also can have dramatic improvement in pain, itching, and burning.

LASERS FOR NEW SCARS – INTERVENE EARLY FOR POSSIBLE PREVENTION OF SCARS

Traditionally reconstructive efforts have been delayed until 1 year after injury, at which point many patients have formed hypertrophic scars and have significant decrease in range of motion. In fact, burn and traumatic scars worsen during the proliferation of wound healing between 3 and 7 months after injury. Early anecdotal evidence suggests that using fractional ablative laser in the early phases may improve wound healing and decrease hypertrophic scar formation.

The discrete ablative columns likely have various wound-healing advantages, including novel laser photomicrodebridement, biofilm disruption, and stimulation of deep dermal cells. Fractional lasers in photo-aged (sun- or UV-damaged) and scarred skin have been shown to stimulate growth factor secretion, increase collagen production, and improve the cosmetics of skin, while producing negligible local trauma.

This provides a unique opportunity in this patient population to improve short-term and long-term healing and has implications for all wound healing in medicine. For the past 5 years in our office we have been treating patients with lasers after burn and trauma injuries within 3 months of injury.

We have found that with early intervention fewer treatments are needed and that laser appears to have a powerful scar preventative effect. I am currently at the end of a 2-year clinical trial prospectively studying early intervention of fractional ablative CO2 laser with 830-nm LED phototherapy for acute burn injuries. Early laser intervention, especially in children, seems to melt away the scars, and fewer treatment sessions are needed.

Benefits

Since their introduction, fractional lasers have helped many adults and children who have scar deformities. Patients and their families are grateful for these medical devices. Personally it is very rewarding to be a physician who is part of improving a scar, regardless of whether the patient is an infant or an adult. The medical success of fractional lasers has added greatly to our ability as physicians to help heal our burn and trauma patients.