Opinion
VIEWPOINT
David M. Ozog, MD Division of Mohs and Dermatological Surgery, Department of Dermatology, Henry Ford Hospital, Detroit, Michigan. Ronald L. Moy, MD Department of Dermatology, Keck School of Medicine of University of Southern California, Beverly Hills.
Related article
Corresponding Author: David M. Ozog, MD, Division of Mohs and Dermatological Surgery, Department of Dermatology, Henry Ford Hospital, 3031 W Grand Blvd, Ste 800, Detroit, MI 48202 ([email protected]). jamadermatology.com
Discussing Fractional Carbon Dioxide Laser and Other Physical Treatments for Scar Prevention With Patients One of the most common questions our patients ask, particularly after excisional surgery, is how to minimize postoperative scarring. They specifically ask us about the myriad topical treatments that are often advertised directly to consumers. Many of these products are used early in the postoperative course. We are rarely asked about the use of devices to minimize scarring. Has the time come for surgeons to discuss early treatment with lasers or other physical modalities with their patients? There is growing evidence that early physical treatments improve the ultimate outcome of a surgical scar. The first mention of this topic in dermatologic publications goes back to Kligman and Strauss,1 who, in 1956, had an incidental finding while studying pigmentation changes in African American patients. No visible scar was seenafterfull-thicknesswoundsweredermabradedatthe time of closure. They even referenced earlier plastic surgery publications on this topic. Despite much published work since that time, preventative physical treatments have still not entered into regular conversations with our patients. More recent study includes fractional ablative2-5 and nonablative lasers,6 pulsed-dye4 and diode lasers, dermabrasion, and botulinum toxins.7 Among the reasons for the failure to regularly discuss the reduction of postoperative scarring with physical intraoperative treatments are the limitations of the studies themselves, the duration and costs of these procedures, and a current lack of knowledge and acceptance of these treatment options as best surgical practice. Studies suggest that early, even intraoperative, treatment to the wound edges stimulates healing that mitigates scar formation consistent with an abrasion rather than a full-thickness incisional wound. This suggests a cytokine pathway that favors transforming growth factor β–3, which is seen in scarless fetal wound healing. Although initial reports were observational in nature, recent split-scar studies have had compelling results. In our own split-scar study of fractional carbon dioxide laser treatment of wound edges after placement of deep sutures, 9 of 10 patients (90%) preferred the outcome on the laser-treated side and requested that the untreated side receive laser treatment at the 3-month follow-up.2 Physician concordance that the treatment side was clinically superior was 100% (9 of 9 physicians) for the evaluated scars. A 2013 split-scar study of 15 patients who were treated with fractional carbon dioxide laser and similar parameters 3 weeks after surgery instead of during the procedure found that 13 of 15 patients preferred the outcome on the treated side.3 The final Vancouver Scar Scale score was 2.34 for the la-
ser-treated arm while the score for the control arm was 4.25. This was statistically significant and clinically relevant. To our knowledge, there are no split-scar studies using topical treatments that have results with similar statistical and clinical strength. If this were the case, patients and health care professionals would be aware of these treatments and they would be routinely used and recognized. Of the various physical treatment modalities for scar prevention, no early postoperative method has been proven to be unequivocally superior in either a blinded randomized study or a split-scar comparison. In fact, recent studies have moved past the question of whether scars can be minimized or prevented to which device will yield the best results. A 2014 article6 showed noninferiority in scar prevention for pulsed-dye lasers vs a nonablative fractional device. This was a split-scar study of 30 consecutive thyroidectomy scars. Three treatments were given, beginning 2 to 3 weeks after surgery. All patients had significant improvement in Vancouver Scar Scale scores during the treatment course. A second early postoperative split-scar study compared ablative fractional carbon dioxide laser vs pulseddye laser in 14 patients after Mohs surgery and subsequent repair.4 All patients had significant improvement in Vancouver Scar Scale scores during the treatment course. Results with the fractional carbon dioxide laser were superior in scar height and pliability while the pulsed-dye laser was superior for improvement of vascularity. It may be that as long as a significant portion of the surface area around the incisional wound is treated with some type of physical energy, the ultimate appearance of the scar will be improved. A recent early postoperative split-scar study5 using fractional carbon dioxide laser with a low 10% surface density did not show any objective improvement on the treated side. However, patients preferred the outcome on the treated side to that of the control side. As physicians, we are taught to first do no harm. When performed properly, intraoperative or early postoperative laser treatment and other physical procedures are safe, without additional adverse events. Use of early treatment is contrary to previous belief that physical treatment of scars should occur after they have entered the maturation phase. Part of this acceptance for waiting comes from the fact that many scars will naturally mature to a point at which they are acceptable to both the patient and the physician. However, it now appears that the ultimate trajectory of a scar may be altered, making this an important discussion to have with our patients. Some of the most interesting data in which (Reprinted) JAMA Dermatology Published online May 6, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a Nanyang Technological University User on 05/23/2015
E1
Opinion Viewpoint
this may occur come not from laser or physical abrasion of wounds but from a well-designed split-scar study7 that used botulinum toxin to prevent the formation of thyroidectomy scars. In that study, onehalf of the scar was treated with botulinum toxin while the other half was treated with normal saline solution, 0.9%. Blinded physicians rated the scars and had an 87% concordance that the site treated with toxin was superior to the control site. The clinical photographs in that study are compelling. Should surgeons be discussing fractional carbon dioxide laser and other physical treatments with their patients for scar prevention? Should intraoperative laser resurfacing to decrease scarring be used
for cesarean deliveries, lacerations, face-lifts, blepharoplasty, and any procedure in which scarring occurs? At the very least, dermatologists should be prepared to discuss the published advances in scar treatment with their patients. It appears that research is reaching a tipping point and 1 well-placed mainstream news article will quickly bring this fact to our patients’ attention. In our procedural clinics, physical modalities for scar prevention, such as intraoperative fractional carbon dioxide lasers and manual dermabrasion for sutured and secondintention wounds, respectively, are frequently used. It is time for all dermatologists to discuss this possible treatment with their patients and offer scar-prevention techniques.
edges to minimize scarring. Arch Dermatol. 2011;147 (9):1108-1110.
ARTICLE INFORMATION Published Online: May 6, 2015. doi:10.1001/jamadermatol.2015.0594. Conflict of Interest Disclosures: Dr Ozog reports that Lumenis has loaned equipment to the Department of Dermatology, Henry Ford Hospital. No personal compensation has been received. No other disclosures were reported. REFERENCES 1. Kligman AM, Strauss JS. Acne; observations on dermabrasion and the anatomy of the acne pit. AMA Arch Derm. 1956;74(4):397-404.
3. Lee SH, Zheng Z, Roh MR. Early postoperative treatment of surgical scars using a fractional carbon dioxide laser: a split-scar, evaluator-blinded study. Dermatol Surg. 2013;39(8):1190-1196. 4. Kim DH, Ryu HJ, Choi JE, Ahn HH, Kye YC, Seo SH. A comparison of the scar prevention effect between carbon dioxide fractional laser and pulsed dye laser in surgical scars. Dermatol Surg. 2014;40 (9):973-978. 5. Sobanko JF, Vachiramon V, Rattanaumpawan P, Miller CJ. Early postoperative single treatment
ablative fractional lasing of Mohs micrographic surgery facial scars: a split-scar, evaluator-blinded study. Lasers Surg Med. 2015;47(1):1-5. 6. Ha JM, Kim HS, Cho EB, et al. Comparison of the effectiveness of nonablative fractional laser versus pulsed-dye laser in thyroidectomy scar prevention. Ann Dermatol. 2014;26(5):615-620. 7. Kim YS, Lee HJ, Cho SH, Lee JD, Kim HS. Early postoperative treatment of thyroidectomy scars using botulinum toxin: a split-scar, double-blind randomized controlled trial. Wound Repair Regen. 2014;22(5):605-612.
2. Ozog DM, Moy RL. A randomized split-scar study of intraoperative treatment of surgical wound
E2
JAMA Dermatology Published online May 6, 2015 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a Nanyang Technological University User on 05/23/2015
jamadermatology.com
VIEWPOINT
David M. Ozog, MD Division of Mohs and Dermatological Surgery, Department of Dermatology, Henry Ford Hospital, Detroit, Michigan. Ronald L. Moy, MD Department of Dermatology, Keck School of Medicine of University of Southern California, Beverly Hills.
Related article
Corresponding Author: David M. Ozog, MD, Division of Mohs and Dermatological Surgery, Department of Dermatology, Henry Ford Hospital, 3031 W Grand Blvd, Ste 800, Detroit, MI 48202 ([email protected]). jamadermatology.com
Discussing Fractional Carbon Dioxide Laser and Other Physical Treatments for Scar Prevention With Patients One of the most common questions our patients ask, particularly after excisional surgery, is how to minimize postoperative scarring. They specifically ask us about the myriad topical treatments that are often advertised directly to consumers. Many of these products are used early in the postoperative course. We are rarely asked about the use of devices to minimize scarring. Has the time come for surgeons to discuss early treatment with lasers or other physical modalities with their patients? There is growing evidence that early physical treatments improve the ultimate outcome of a surgical scar. The first mention of this topic in dermatologic publications goes back to Kligman and Strauss,1 who, in 1956, had an incidental finding while studying pigmentation changes in African American patients. No visible scar was seenafterfull-thicknesswoundsweredermabradedatthe time of closure. They even referenced earlier plastic surgery publications on this topic. Despite much published work since that time, preventative physical treatments have still not entered into regular conversations with our patients. More recent study includes fractional ablative2-5 and nonablative lasers,6 pulsed-dye4 and diode lasers, dermabrasion, and botulinum toxins.7 Among the reasons for the failure to regularly discuss the reduction of postoperative scarring with physical intraoperative treatments are the limitations of the studies themselves, the duration and costs of these procedures, and a current lack of knowledge and acceptance of these treatment options as best surgical practice. Studies suggest that early, even intraoperative, treatment to the wound edges stimulates healing that mitigates scar formation consistent with an abrasion rather than a full-thickness incisional wound. This suggests a cytokine pathway that favors transforming growth factor β–3, which is seen in scarless fetal wound healing. Although initial reports were observational in nature, recent split-scar studies have had compelling results. In our own split-scar study of fractional carbon dioxide laser treatment of wound edges after placement of deep sutures, 9 of 10 patients (90%) preferred the outcome on the laser-treated side and requested that the untreated side receive laser treatment at the 3-month follow-up.2 Physician concordance that the treatment side was clinically superior was 100% (9 of 9 physicians) for the evaluated scars. A 2013 split-scar study of 15 patients who were treated with fractional carbon dioxide laser and similar parameters 3 weeks after surgery instead of during the procedure found that 13 of 15 patients preferred the outcome on the treated side.3 The final Vancouver Scar Scale score was 2.34 for the la-
ser-treated arm while the score for the control arm was 4.25. This was statistically significant and clinically relevant. To our knowledge, there are no split-scar studies using topical treatments that have results with similar statistical and clinical strength. If this were the case, patients and health care professionals would be aware of these treatments and they would be routinely used and recognized. Of the various physical treatment modalities for scar prevention, no early postoperative method has been proven to be unequivocally superior in either a blinded randomized study or a split-scar comparison. In fact, recent studies have moved past the question of whether scars can be minimized or prevented to which device will yield the best results. A 2014 article6 showed noninferiority in scar prevention for pulsed-dye lasers vs a nonablative fractional device. This was a split-scar study of 30 consecutive thyroidectomy scars. Three treatments were given, beginning 2 to 3 weeks after surgery. All patients had significant improvement in Vancouver Scar Scale scores during the treatment course. A second early postoperative split-scar study compared ablative fractional carbon dioxide laser vs pulseddye laser in 14 patients after Mohs surgery and subsequent repair.4 All patients had significant improvement in Vancouver Scar Scale scores during the treatment course. Results with the fractional carbon dioxide laser were superior in scar height and pliability while the pulsed-dye laser was superior for improvement of vascularity. It may be that as long as a significant portion of the surface area around the incisional wound is treated with some type of physical energy, the ultimate appearance of the scar will be improved. A recent early postoperative split-scar study5 using fractional carbon dioxide laser with a low 10% surface density did not show any objective improvement on the treated side. However, patients preferred the outcome on the treated side to that of the control side. As physicians, we are taught to first do no harm. When performed properly, intraoperative or early postoperative laser treatment and other physical procedures are safe, without additional adverse events. Use of early treatment is contrary to previous belief that physical treatment of scars should occur after they have entered the maturation phase. Part of this acceptance for waiting comes from the fact that many scars will naturally mature to a point at which they are acceptable to both the patient and the physician. However, it now appears that the ultimate trajectory of a scar may be altered, making this an important discussion to have with our patients. Some of the most interesting data in which (Reprinted) JAMA Dermatology Published online May 6, 2015
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a Nanyang Technological University User on 05/23/2015
E1
Opinion Viewpoint
this may occur come not from laser or physical abrasion of wounds but from a well-designed split-scar study7 that used botulinum toxin to prevent the formation of thyroidectomy scars. In that study, onehalf of the scar was treated with botulinum toxin while the other half was treated with normal saline solution, 0.9%. Blinded physicians rated the scars and had an 87% concordance that the site treated with toxin was superior to the control site. The clinical photographs in that study are compelling. Should surgeons be discussing fractional carbon dioxide laser and other physical treatments with their patients for scar prevention? Should intraoperative laser resurfacing to decrease scarring be used
for cesarean deliveries, lacerations, face-lifts, blepharoplasty, and any procedure in which scarring occurs? At the very least, dermatologists should be prepared to discuss the published advances in scar treatment with their patients. It appears that research is reaching a tipping point and 1 well-placed mainstream news article will quickly bring this fact to our patients’ attention. In our procedural clinics, physical modalities for scar prevention, such as intraoperative fractional carbon dioxide lasers and manual dermabrasion for sutured and secondintention wounds, respectively, are frequently used. It is time for all dermatologists to discuss this possible treatment with their patients and offer scar-prevention techniques.
edges to minimize scarring. Arch Dermatol. 2011;147 (9):1108-1110.
ARTICLE INFORMATION Published Online: May 6, 2015. doi:10.1001/jamadermatol.2015.0594. Conflict of Interest Disclosures: Dr Ozog reports that Lumenis has loaned equipment to the Department of Dermatology, Henry Ford Hospital. No personal compensation has been received. No other disclosures were reported. REFERENCES 1. Kligman AM, Strauss JS. Acne; observations on dermabrasion and the anatomy of the acne pit. AMA Arch Derm. 1956;74(4):397-404.
3. Lee SH, Zheng Z, Roh MR. Early postoperative treatment of surgical scars using a fractional carbon dioxide laser: a split-scar, evaluator-blinded study. Dermatol Surg. 2013;39(8):1190-1196. 4. Kim DH, Ryu HJ, Choi JE, Ahn HH, Kye YC, Seo SH. A comparison of the scar prevention effect between carbon dioxide fractional laser and pulsed dye laser in surgical scars. Dermatol Surg. 2014;40 (9):973-978. 5. Sobanko JF, Vachiramon V, Rattanaumpawan P, Miller CJ. Early postoperative single treatment
ablative fractional lasing of Mohs micrographic surgery facial scars: a split-scar, evaluator-blinded study. Lasers Surg Med. 2015;47(1):1-5. 6. Ha JM, Kim HS, Cho EB, et al. Comparison of the effectiveness of nonablative fractional laser versus pulsed-dye laser in thyroidectomy scar prevention. Ann Dermatol. 2014;26(5):615-620. 7. Kim YS, Lee HJ, Cho SH, Lee JD, Kim HS. Early postoperative treatment of thyroidectomy scars using botulinum toxin: a split-scar, double-blind randomized controlled trial. Wound Repair Regen. 2014;22(5):605-612.
2. Ozog DM, Moy RL. A randomized split-scar study of intraoperative treatment of surgical wound
E2
JAMA Dermatology Published online May 6, 2015 (Reprinted)
Copyright 2015 American Medical Association. All rights reserved.
Downloaded From: http://archderm.jamanetwork.com/ by a Nanyang Technological University User on 05/23/2015
jamadermatology.com
