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."
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
Differences in the two
treatment groups were striking after six months. The 64 mature
scars were all still apparent, unchanged or only modestly
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.
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
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
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
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.
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).
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).
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
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
For extremely depressed
scars, Dr. Niamtu will sometimes perform a w-plasty revision
to blend the scar better before resurfacing.
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