Scar Wars

By Daniel I. Wasserman, M.D.

Physical trauma of any sort or severity ultimately leads to the development of a scar. Nearly every person at one time or another has injured himself or herself from a cut, scrape, burn, surgery, or even acne. The resultant appearance of these scars often lead to significant physical or emotional debilitation, ultimately leading individuals to seek their improvement.

The commercial industry for treating scars is enormous. Treatments include, but are not limited to, over-the-counter scar gels, products sold in physicians’ offices, surgical revision, and lasers. The latter has experienced a boom in our understanding and their application over the last 15 years.

It is important to understand how scars develop. Some physical injury takes place that transmits a signal to the body to repair it. These injuries can include physical trauma such as a laceration or surgery. Thermal injuries from fires or cooking accidents can lead to a large spectrum of scars such as minor skin pigment disturbances to physical mutilations with loss of function. Certain inflammatory medical conditions can lead to scarring, the most common one being acne.

Once the injury takes place, cells in the skin’s dermis called fibroblasts will begin producing new collagen meant for repair of the injury. The body will respond based on the needs of the local anatomy. For instance, a surgical scar on the chest may heal with a thickened nature due to the constant stretching and pulling from either the use of one’s limbs for the activities of daily living or simply from the weight of a woman’s breasts. Horrible burn scars are usually due to a total loss of the body’s microanatomy such as the dermis’s reservoir of fibroblasts thereby limiting the body to effectively heal itself. The infinite causes of scarring ultimately lead to their diverse presentation and symptoms.

Treatments are usually aimed at either treating a scar’s appearance or its symptoms. The inflammatory pathways that are triggered for the healing of a wound can often lead to lasting symptoms such as pain or itching. The increase in blood flow to an injury is necessary to aid in its repair, but may also leave a persistent redness alerting others to its presence. Lasers work by either targeting a scar’s network of blood vessels or their abundance of collagen.

Vascular lasers treat scars by eliminating the superfluous capillaries in the superficial portions of the scar in order to lessen the redness of these scars. Additionally, the controlled heat that this generates will often help to remodel a scar’s appearance and diminish their symptoms of pain or itching.

Carbon dioxide (CO2) lasers work by causing a deliberate, mathematical injury in a grid-like array, much like the pixels of a printer, penetrating the skin at varying depths. These microinjuries cause a cascade of reparative events to help remodel the physical appearance and nature of a scar.

Nearly all treatments are applied after an injury, treating it in hindsight. At Skin Wellness Physicians, we use these same laser technologies when performing skin cancer surgery, not after a scar is healed, but at the time of surgery to mitigate the extent of scarring. Using careful technique, we will often limit the number of sutures placed above the skin to zero or just a few so that less trauma is caused to the skin. The absence of these top sutures allow us to then directly use these lasers, most specifically our CO2 laser so that we can trigger these remodeling enzymes at the time of surgery in order to control the outcome. This leads to less redness, better scars, and less discomfort by avoiding the suture removal process altogether in most cases.

Scars are a banal part of human existence, but as humanity advances, so do our abilities to improve the outcome of scarring, hopefully relegating them to nothing more than a minor nuisance. When seeking treatment for your scar, or when considering a procedure where a scar is expected, please ensure that you are consulting with an experienced physician. Many of the lasers used for the treatment of scars are regulated by the State of Florida and require them to be handled by physicians or licensed physician assistants or nurse practitioners.

Daniel I. Wasserman, MD Fellowship-trained Laser and Cosmetic Dermatologist Fellowship-trained Mohs Surgeon Board Certified Dermatologist

Dr. Wasserman is a board certified dermatologist with fellowship training at Harvard Medical School in laser and cosmetic surgery, as well as fellowship training in Mohs skin cancer surgery. He has contributed as a dermatology expert for online and print magazines. In addition, he frequently lectures to professional societies and organizations on his diverse research. For more information about skin care visit the Skin Wellness Physicians website at www.skinwellnessflorida.com

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