Improvement in a 15-year-old traumatic scar (top panel). After a single debulking treatment with a straight handpiece (middle panel). Followed by treatment using the computer pattern generator (bottom panel).

To minimize scar formation, intercept facial wounds as early as possible, and treat them during the four-to-eight-week window after the trauma or incision, advises Joseph Niamtu III, D.M.D., an oral/maxillofacial and cosmetic facial surgeon based in Richmond, Va.

"Before four weeks, wounds lack sufficient tensile strength to withstand laser treatment," he says, "And, after eight weeks, laser treatment is not as effective in eliminating the scar. The optimum treatment window appears to be four to eight weeks after scar formation."

Dr. Niamtu

Adnexal atrophy As the scar matures during the process of wound repair, adnexal appendages often atrophy. The pilosebaceous units allow the epithelial cells to migrate from tissue surrounding the scar. This migration of epithelial cells into the scar may play a role in the improved outcome following early treatment.

As scars mature, the adenexal appendages atrophy. Early treatment may take advantage of these regenerative cells prior to atrophy. With early CO₂ laser treatment, collagen can be restructured and layered parallel to the lines of tension in the skin before the molecular bonding of new collagen is complete. As a consequence, the contour might be smoother when the scar eventually forms.

"Don't postpone interventional treatment of common types of facial scars," Dr. Niamtu advises. "Early CO₂ laser treatment can result in better cosmetic results."

Excellent results have been seen following early laser treatment of incision scars from facial procedures such as facelift surgery. In addition, younger patients, even those as young as 5 years of age, respond especially well to early intervention.

Dr. Niamtu generally uses the Lumenis Encore CO₂ laser at a setting of 80 mJ and a density of 6 — a setting that translates to 300 mJ and 60 watts with the Coherent Ultrapulse 5000c laser. Treatment typically involves two to three passes at this fluence, frequently with additional passes at lesser fluence and density to "feather out the scar" or "shoulder" the raised areas.

Multiple treatments Although many scars respond well to a single treatment, others will require multiple treatments performed at three-month intervals.

"Most scars I have treated respond very favorably," Dr. Niamtu says. "We treat many scars that are decades old and still usually get good results, but these scars may require multiple procedures."

For hypertrophic scars that require significant tissue debulking, Dr. Niamtu prefers to use the straight 2-mm handpiece. At a 12-week follow-up appointment, he again uses the manual handpiece, this time in combination with the computer-pattern generator, to smooth and blend the scar.

For depressed scars unfavorable to the resting tension lines, Dr. Niamtu sometimes performs a w-plasty revision to blend the scar better before resurfacing.

"Some deeper scars will improve significantly but may be left with hypopigmented areas, and the patient must be cautioned about this. If the scar is white before treatment, it is not likely to repigment. Treatment will result in a more aesthetic scar, but it will still be hypopigmented."

In certain situations immediate treatment of scars can also be beneficial.