Scar Treatment

Elevated scars

Hypertrophic scars

• Caused by tension on skin after healing from a cutting injury or burn
• Treated effectively by pulsed dye laser when red, fractionated CO2 (ScarFX) x multiple, fractionated radiofrequency x multiple, excision and Z-plasty, microneedling
• Expected results 50-95% reduction
• Expected price per treatment $150+ (usually pulsed dye laser treatments can be submitted to insurance)

Keloids

• Caused by genetic predisposition or specific location (midline of our body)
• Treated effectively by steroid or combination steroid/fluorouracil injection x multiple, pulsed dye laser treatment if red x multiple, external cryosurgery x multiple, Cryoshape x 1 for appropriate size, excision followed by steroid injection x 3-4 at site every 2 weeks (applies to ear only) x 1
• Expected results 50-95% reduction
• Expected price per treatment (usually submitted to insurance) $50/$150+/$80+/$1000+/$200+

Scars under the skin

Stretch marks striae distensae

• Caused by stretch of skin with rapid growth in height or girth (teenage growth spurt, pregnancy, weight gain)
• Treated effectively by pulsed dye laser when red x 1-2, fractionated CO2 DeepFX x 1, long pulsed Nd:YAG laser x 2-4, 1540 non-ablative fractional laser (Starlux 500) x multiple treatments
• Expected results 100% of redness reduction, improvement of the stretched skin is fair
• Expected price per treatment $250+ (depends on the size of the treated area for PDL, CO2, and Nd:YAG; Starlux is not available in our office)

Depressed scars

Rolling scars

• Caused by dense cystic-nodular and inflammatory acne
• Treated effectively by subcision x 1-2, fractionated radiofrequency x 2-3, microneedling x 5-6, fractionated CO2 laser resurfacing x 3-6, fractionated Erbium laser 4-8, filler placement yearly
• Expected results 50% reduction
• Expected price per treatment $500/$500/microneedling currently not available in our office/$500/$500/$580 per syringe

Box Scar

• Caused by cystic-nodular and inflammatory acne
• Treated effectively by fractionated radiofrequency x 2-3/fractionated CO2 laser x 3-6, fractionated Erbium 4-8, picosecond laser x 3-4, energy powered microneedling x 5-6, filler placement very 1-2 years, subcision (if single scars) x 1-2, punch elevation x 1-2
• Expected results 50% reduction
• Expected price per treatment $500/$500/$500/$500/microneedling currently not available in our office/$580 per syringe/$150/$200 per spot

Ice Pick scars

• Caused by inflammatory and cystic-nodular acne
• Treated effectively by TCA CROSS x 1-2, CO2 DeepFX x 3-6, punch excision (single scar only) x 1, punch grafting x 1-2
• Expected results 35-50% reduction
• Expected price per treatment $500/$500/$200 per spot/$300 per spot

Pores

• Caused by significant oil production, acne
• Treated effectively by PDT x 3, fractional CO2 DeepFX x 1-2, glycolic acid daily
• Expected results 30% reduction
• Expected price per treatment $500/$500/$50 per year

Flat scars

Flat wrinkled (atrophic) scars

• Caused by injury and inability to tighten the skin (Ehlers Danlos Syndrome, elastin deficiency)
• Treated effectively with fractionated CO2 ScarFX, fractionated radiofrequency
• Expected results are fair
• Expected price per treatment $150+ (depending on size and number)

Flat red scars

• Caused by skin injury and inability to quickly resolve blood vessels that aid in healing initially, hence keeping inflammation for too long
• Treated effectively by pulsed dye laser x 2-5, time (our body will eventually resolve most blood vessels on its own, a process that can take several years)
• Expected results 75-100% reduction
• Expected price per treatment $150+ (depending on size and number)

High Intensity Fractionated Radiofrequency (Infini) treatments reach the second layer of the skin while protecting the top layer. They cause localized injury in the dermis which stimulates elastin production. With topical anesthesia, discomfort is minimal. Downtime includes redness for one day, mild swelling, and minimal if any scabbing for 3 days. It has been a game changer for rolling scars and it works very well for box scars.

Fractionated CO2 laser treatments can reach the deepest amongst all devices (DeepFX/ScarFX). They vaporize the tight strands that pull down scars in various depths of the skin and also refresh the skin surface on the outside of the scar (ActiveFX). They stimulate collagen production where they destroy the deep scars. Downtime is considerable with 4-5 days of swelling, oozing, scabbing, and several weeks of redness.

Fractionated erbium laser treatments can be performed similar to a peel (Pixel) or can be deep reaching (FRAXEL Restore). The first will gently resurface the skin by stimulating new skin growth in many minute islands. Skin is red and swollen and feels rough for 5 days. The latter will reach deep, vaporize minute columns of skin and scars, and tighten the skin within itself. DeepFx fractional CO2 laser treatments have largely replaced this deep reaching method because their effect is superior. Downtime of redness and swelling for 5-6 days are common. Topical anesthesia is preferred with both treatments.

Microneedling is based on minimal targeted tissue injury of the second layer of the skin (dermis) without heat injury. It can be performed at home with a dermaroller or in the professional office with a power driven microneedling pen (Dermapen). It usually requires some form of topical numbing and has a brief downtime of 1 day of redness and a few days of swelling and mild roughness.

Picosecond laser (Picosure) treatment stretches adhesions under the skin and stimulates elastin production. Because it is super fast and does not produce heat it causes very minimal if any discomfort and no downtime.

Subcision helps to lift rolling scars. After local anaesthesia, a small needle is inserted under the scarred area to free the adhesions that pull the scars down. Downtime includes bruising and swelling for up to 10 days.

TCA peels in various concentrations improve the skin surface with ice pick and rolling scars. The CROSS technique works best to shrink deep ice pick scars and small box scars. Discomfort lasts about 8 minutes and downtime involves 5 days of significant redness, swelling, peeling, and crusting.

Tissue augmenting agents like hyaluronic acid (Juvederm, Restylane), calcium hydroxyappatite (Radiesse), and polymethylmethacrylate collagen (Bellafill) achieve very good results in individual box scars. Hyaluronic acid and calcium hydroxyappatite fillers can also be used to augment areas of rolling scars. Redness can be present for 1 day while swelling can last for 3-5. Fillers within scars typically last 1-2 years.

Punch excision can be used for individual ice pick scars. After local anesthesia, the scar is excised with a miniature cookie cutter device and the wound edges brought together with a few very fine stitches. These are removed after 7 days and wound care is minimal.

Punch grafting is used to fill a defect after excision of larger ice pick scars. The scar is removed as described under “punch excision”. Instead of closing it, a similar piece of skin is excised elsewhere on the head or neck and placed into the void created after punch excision of the scar. This piece of skin is sewn in place and stitches are removed after 7 days. This usually requires CO2 laser resurfacing after 4 weeks to fully level the skin.

Punch elevation is used to adjust the level of the skin with rolling scars. The punch device is inserted into some of the most deeply depressed areas, but instead of removing the skin, the piece is sewn into place at a higher level. This will need to be followed by CO2 laser resurfacing. Its results are often disappointing.

Dermabrasion or CO2 laser assisted full ablation were almost the only way of treating a large area of scars until 2006. After local anaesthesia, the unaffected skin is sanded down to the level of the scars. This technique has become almost obsolete in the treatment of acne scars but might still be useful for the blending of certain surgical scars.

Microdermabrasion temporarily improves the surface of the skin by smoothing its texture, mobilizing pigment, and inducing minimal collagen production through dermal tissue pressure.

Cryoshape™ is the destruction of keloid tissue from the inside. After local anaesthesia, the Cryoshape™ probe is inserted through the long axis of the center of the keloid and cryogen is allowed to travel through this probe for 10-50 minutes. It works in one treatment when the diameter of the keloid is no larger than one inch. This tissue freezing will gradually shrink the keloid over 2-4 months.

Cryosurgery is the external application of liquid nitrogen at -196 degrees Celsius. It rapidly freezes the tissue which causes subsequent shrinkage. Freezing does not create the type of tissue injury that elicits keloids and can therefore be used externally and intralesionally.

Intralesional injection of steroid (triamcinolone) in various concentrations or a combination of fluorouracil and triamcinolone into a hypertrophic scar or keloid reduces pain and itching by shrinking these scars. Hypertrophic scars usually require just a couple of treatments while keloids may need many monthly injections. Needle-free injection with the Dermojet, a pressure injection device, is possible for thicker keloids.

Pulsed dye laser treatment reliably closes blood vessels that are initially needed for healing. When our body “forgets” to undo them, blood flow can keep inflammation alive which maintains a red color and paradoxically can cause further tissue damage. The treatment feels like a rubber band snap on the skin and causes bruising for up to 7 days.

Photodynamic therapy destroys oil glands and improves scars. Aminolevulinic acid penetrates into oil glands during a 30-45 minute exposure. Activation of this photosensitizing substance by light in the red and blue spectrum allows the destruction of the oil gland. Swelling and redness after this procedure are minimal whereas treatment of acne, pre-cancers, and cancers causes significant downtime lasting 14 days.

Glycolic acid or alpha hydroxy acid plumps skin cells through water influx and sheds off dead skin cells. This makes the skin surface look less porous, smoother, and more radiant. While its effects are temporary, pores can shrink by 30% when applied daily or with glycolic acid peels every 3 months. Even scarred skin will appear smoother.

Nd:YAG laser (long pulsed) treatment creates intentional injury in the depth of the second layer of the skin. This results in tightening of this plain and can be helpful when trying to minimize stretch marks which occur in this layer. Results are not very impressive but this is the only way to safely treat across all skin colors and there is no downtime.

Excision refers to the removal of a scar by cutting it out of the skin. The reason that scars form in an unideal way is often due to their location. Tension on the healing wound causes the resulting scar to spread or healing to overshoot (hypertrophic scar). Excision of an unsightly scar in an area of tension is often followed by Z-plasty. A keloid on the ear can be removed by excision as long as it is followed by agents that suppress keloid formation such as intralesional steroids or imiquimod. Keloid excision anywhere but the ear must be avoided at all costs.

Z-plasty is a surgical way to change the tension vector on a healing wound. As the name implies, it results in a Z-shaped linear scar.