Scarring and Stretch Marks
what causes them?
The appearance of scarring can be unpredictable and varies from person to person. Not only will the scars remind you of what you had to deal with, but it may also make you dissatisfied with your skin and affect your confidence.
Scarring results from abnormal healing after damage to the second layer of the skin, the dermis. Patients with atrophic scarring have an altered inflammatory cell profile and tend to experience a prolonged inflammatory response that causes collagen destruction. Raised scars as in hypertrophic or keloid scars result from an over-exuberant healing response and excessive collagen deposition.
to treat scarring and stretch marks safely and effectively
Fractional Infrared Lasers
Fractional laser resurfacing involves the deposition of a pixelated pattern of microscopic laser wounds surrounded by healthy tissue resulting in both greater efficacy and shorter downtime compared to non-fractionated treatments. It can be further subdivided into ablative and non-ablative. Ablative fractional lasers have longer wavelengths (e.g. CO2 10600nm) and lead to full thickness destruction of skin, whereas non-ablative fractional lasers have shorter wavelengths (e.g. Erbium Glass 1550nm) and leave an intact skin surface. CO2 has greater efficacy compared with Erbium Glass but longer recovery time and a higher risk of complications.
Fractional Infrared Lasers have a good body of research evidence demonstrating safety and efficacy. They are the gold standard treatment for scarring against which other treatments are compared.
Fractional Picosecond Laser - Discovery Pico Plus
Discovery Pico Plus is a second-generation triple wavelength picosecond laser that generates the highest peak power in the world. A special microlens array further focusses the energy into numerous micro-beams 2mm under the skin. The highly concentrated energy produces laser-induced optical breakdown (LIOB) stimulating scar remodelling with almost no downtime.
Fractional Bipolar Radiofrequency
Fractional Radiofrequency creates a pyramidal thermal injury zone (a relatively large coagulation zone deep in the skin with minimal surface damage) as opposed to the columnar shape of ablative lasers. Hence Fractional Radiofrequency has a favourable side-effect profile (such as downtime, post-inflammatory hyperpigmentation) in comparison to fractional lasers.
Fractional Microneedle Radiofrequency
Scar remodelling requires heat delivery to the deep part of the skin. However, in most machine-based treatments for scarring such as lasers, much of the energy is dissipated at the skin surface and little reaches the deep layers. Fractional microneedle radiofrequency overcomes this using insulated microneedles to spare the upper part of the skin and deliver radiofrequency energy precisely up to 4mm deep in the skin, resulting in faster recovery, higher efficacy and increased safety.
Vascular lasers / Intense Pulsed Light
Vascular lasers (such as pulsed dye lasers, yellow lasers, long pulsed diode or NdYAG) target haemoglobin in blood vessels destroying them. They are useful for hypertrophic / keloid scars and fresh stretch marks. Intense Pulsed Light used together with special vascular filters can be used for similar purposes as well but is generally less powerful
Chemical Reconstruction of Skin Scars (TCA CROSS) uses the precise placement of highly concentrated chemical peel (such as Trichloroacetic Acid) to lift the base of deep scars.
Subcision and Filler
In subdermal incision (subcision), surgical tools inserted under the skin via small needle punctures are used to release tethered skin scars stuck down to the deeper fascia by abnormal scar fibres.
Filler is then interposed to prevent the two layers from sticking back together during the healing process.
Excision is used for isolated ice pick scars or narrow boxcar scars. The scar is removed and the skin closed with either a skin graft or sutures.
Intralesional steroid injections
Corticosteroid injections decrease over-active inflammation and collagen synthesis hence improving the appearance and symptoms of keloid or hypertrophic scars.
dr wan's perspective
Dr Wan believes that scar treatment should be tailored to the individual. The patient’s skin type, scar configuration, lifestyle and budget are particularly important. Although fractional lasers are well established and widely available, Dr Wan does not believe in the repeated application of many sessions of fractional laser in the hope of improving all types of scarring.
A detailed examination is essential to formulate a treatment plan which addresses all aspects of the patient’s scarring. It is important to have a wide range of cutting-edge treatment options available. Dr Wan prefers a multimodal approach with a customised combination of specific treatments for each scar. The more obvious or deeper scars should be specifically addressed, together with overall treatment such as fractional energy devices to blend the edges and treat the shallower scars.
- broad depressions with sloping edges
- commonly stuck down to the underlying Superficial muscular aponeurotic system (SMAS) layer by networks of fibrous scar tissue
- subcision and filler should be done first for tethered scars
- Fractional Radiofrequency, Fractional Lasers, Fractional Microneedling Radiofrequency will improve rolling scars. Dr Wan feels that Fractional Microneedling Radiofrequency gives the optimal balance between downtime and results
Ice Pick Scars
- deep, narrow, pitted scars
- CROSS reliably produces significant improvements
- targeted CO2 laser can also be used
- deep, larger isolated ice pick scars may be better treated with excision
Box Car Scars
- broad depressions with sharply defined edges
- can be stuck down to the deeper layers - these require subcision and filler
- small boxcar scars can be treated with CROSS
- isolated boxcar scars may be treated with excision, depending on the size and area
- soft skin coloured elevations around hair follicles
- ablative laser can produce flattening
Post Inflammatory Erythema (PIE)
- localized skin redness following skin inflammation that may progress to scarring
- should be understood as a scar with erythematous components and not as a simple erythematous or vascular lesion
- Fractional Radiofrequency, Fractional Lasers, Fractional Microneedling Radiofrequency improve both PIE and concomitant active acne and scarring
- if there is no depressed scarring, Fractional Radiofrequency may be most suitable
- stretch marks or striae distensae represent dermal scars with epidermal atrophy
- early treatment shows a better response
- fresh stretch marks are reddish (striae distensae rubra) and respond to vascular lasers
- old stretch marks are white (striae distensae alba) should be treated with fractional resurfacing such as Fractional Radiofrequency, Fractional Lasers, Fractional Microneedling Radiofrequency
- topical treatments such as vitamin A and chemical peels also help
Hypertrophic / Keloid Scars
- steroid injections combined with vascular laser or fractional laser / radiofrequency
- topical silicone and steroids, pressure
- certain keloids may be treated by excision combined with steroid injections / fractional laser