Dr. Niamtu

Dallas - Dr. Joe Niamtu III does not like to hear the words, "Call me back in a year and we will treat your scar when it matures."

"Many surgeons still subscribe to the adage that there is no benefit in the early treatment of facial scars," said Dr. Niamtu, who practices oral/maxillofacial & cosmetic facial surgery in Richmond, Va. "I think that this may be true in some cases, such as those requiring flaps, but there are many situations in which facial scars will respond beneficially to early treatment with the CO₂ laser."

Research studies

Published studies have shown that better results are obtained with early rather than delayed dermabrasion treatment of facial scars. In a seminal study published in 1988 (J Dermatol Surg Oncol 14:292-294), Yarborough evaluated treatment outcomes of 98 facial scars treated with dermabrasion four to eight weeks after the injury and 64 mature facial scars treated from three months to 13 years after the injury.

He concluded that visible residual cicatrization is eliminated from both accidental and surgical facial scars if dermabrasion is performed four to eight weeks after the primary wound.

In both groups, outlines of scars were essentially unchanged after re-ephithelialization, although contours were improved in the early-treatment group.

Differences in the two treatment groups were striking after six months. The 64 mature scars were all still apparent, unchanged or only modestly improved.

By contrast, cicatrization in the 98 scars in the early treatment group had completely resolved in most cases.

The results of this observational study inspired Dr. Niamtu and others to translate this early treatment to laser resurfacing.

Precise method

Another study (Greenbaum and Rubin, J Am Acad Dermatol 1999;40:988-90) confirmed the efficacy of early treatment of scars and showed that CO₂ laser was as effective as dermabrasion and resulted in similar post-treatment erythema. Notably, the CO₂ modality was considered a more precise method of ablation, without the bleeding associated with dermabrasion.

Much remains unknown about the wound-healing mechanisms that underlie the favorable outcomes associated with early scar treatment. Dr. Niamtu agrees with speculation that the smoother contour of the scar after early CO₂ laser treatment may be due to the restructuring and layering of collagen parallel to lines of tension before the molecular bonding of new collagen is complete.

In scar maturation, atrophy of adnexal appendages frequently occurs during the early maturation process of wound repair. Superior and lateral migration of epithelial cells from the adnexa before atrophy may also play a role in the improved outcome following early treatment.

Ideally, the surgeon should intercept the wounds as early as possible after the trauma or incision and treat them during the four-to-eight week window.

Before four weeks, wounds lack sufficient tensile strength to withstand laser treatment; after eight weeks, laser treatment is not as effective in eliminating the scar. The optimal window to initiate laser treatment is four to eight weeks after scar formation.

This five-year-old male sustained facial lacerations from a dog bite (figure A). Figure B shows his scars four weeks after suture removal. He was lasered with a single session of CO2 resurfacing at five weeks (figure C), and responded with no visual scaring at eight weeks post-laser treatment (figure D).

Children respond especially well to early intervention, as shown in the case of a five-year-old boy who received severe dog bite wounds to the face (see photos on page 16).

Finding favorable outcomes

Likewise, early CO₂ laser treatment of traumatic wounds from motor vehicle accidents and facial fractures can have very favorable outcomes, and a similar level of improvement has been seen following early laser treatment of incision scars from facial procedures such as facelift surgery.

In his clinic, Dr. Niamtu uses the Lumenis Encore CO₂ laser with settings 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.

Some scars respond well to a single treatment, while others will require multiple treatments performed at three-month intervals. "Most of the scars I have treated respond very favorably," said Dr. Niamtu. "Some deeper scars will significantly improve but may have hypo-pigmented areas, and the patient must be cautioned about this."

For extremely depressed scars, Dr. Niamtu will sometimes perform a w-plasty revision to blend the scar better before resurfacing.

Other approaches

In a more proactive approach, Dr. Niamtu suggests that immediate treatment of scars can also be beneficial. "For years, I have been performing immediate CO₂ laser resurfacing of upper eyelid blepharoplasty prior to suture closure, and I think it makes a superior scar." Botox injections may help to overcome the problem of potential wound dehiscence in scars treated before four weeks, according to Dr. Niamtu.

"Adding Botox to paralyze the muscular pull of unfavorable skin tension lines is another adjunct to giving the scar every advantage to heal favorably," he said. "Early CO₂ laser revision of surgical and traumatic scars certainly has a place in the armamentarium of all cosmetic surgeons, but old habits die hard," he added. "You will always have some practitioners not wanting to perform early revision."

Dr. Niamtu reports no conflicts of interest related to any company mentioned in this article.