Non-ablative Fractional Lasers for Scars
Roberto Mattos, Juliana Merheb Jordão, Kelly Cristina Signor,
and Luciana Gasques de Souza
Abstract
The knowledge of microenvironment of tissue
repair enables better understanding of the
healing process and the techniques currently
employed for its correction. There are different
types of scars and the treatment should be
chosen according to lesion. Laser mechanism
of action on scars is based on two pillars, to
reduce blood flow and to reorganize collagen
fibers. Devices available for scar treatment
include intense pulsed light (IPL), in the vas-
cular mode, non-ablative lasers, and ablative
lasers. In this chapter we are going to discuss
non-ablative lasers for scar treatment.
Keywords
Non-ablative laser • Non-ablative scars •
Keloids • Tissue repair • Blood flow • Collagen
reorganization • Skin remodeling
R. Mattos (*) • K.C. Signor • L.G. de Souza
Mogi das Cruzes University, São Paulo, Brazil
e-mail: robmattos@uol.com.br; kellysignor@gmail.com;
luhsouza@hotmail.com
J.M. Jordão
Skin and Laser Center of Boom, Boom, Belgium
Department of Hospital Universitário Evangélico de
Curitiba, Curitiba, PR, Brazil
e-mail: Dra.julianajordao@hotmail.com
# Springer International Publishing AG 2018
M.C.A. Issa, B. Tamura (eds.), Lasers, Lights and Other Technologies, Clinical Approaches and Procedures in
Cosmetic Dermatology 3, https://doi.org/10.1007/978-3-319-16799-2_7
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
Stages of the Healing Process . . . . . . . . . . . . . . . . . . . . . . . 114
Scars . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Equipment Available for Scars Treatment . . . . . . . . . . . 116
Flashlamp-Pumped Pulsed-Dye Laser
(585 and 595 nm) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Q-Switched Frequency Doubled Nd:YAG
532 nm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Diode Laser (Laser-Assisted Skin Healing
810 nm) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117
Non-ablative Fractional Lasers . . . . . . . . . . . . . . . . . . . . . . 117
Laser Devices in the Market . . . . . . . . . . . . . . . . . . . . . . . . . 118
Treatment of Atrophic Scars . . . . . . . . . . . . . . . . . . . . . . 120
Treatment of Hypertrophic Scars . . . . . . . . . . . . . . . . . 120
Burn Scar Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Keloid Scar Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Before Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Parameters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
Post-Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 123
Take Home Messages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124
113
114
Introduction
In mammals, the wounds that occur in the fetus
until the first trimester of pregnancy heal by regen-
eration, creating tissue with the same characteris-
tics of the original (Ferguson et al. 1996). However,
after this period, the inflammatory process, with the
aim to control infection, results in scar, which is
different from the surrounding skin. It can present
as atrophy, hypertrophy, or keloid scars (Ferguson
et al. 1996; Mccalion and Ferguson 1996;
Ferguson and O’kane 2004). Knowing the micro-
environment of tissue repair, we can be able to
understand the healing process and the techniques
currently employed for its correction (Profyris et al.
2012; Martin and Leibovich 2005).
Stages of the Healing Process
Healing is divided into three stages: inflammatory,
proliferative, and remodeling. However, it is a
dynamic process, so at any point, a phase may
overlap another (Profyris et al. 2012).
Inflammatory Phase
It begins immediately after breaking the epithelial
integrity and lasts 1–3 days. When injury occurs,
the immediate priority is hemostasis that is
achieved through the extrinsic pathway activa-
tion. It constitutes a hemostatic plug of fibrin
that is solidified by the arrival of platelets. It also
acts as a mechanical barrier against microorgan-
isms’ invasion and avoids bleeding. It is a tempo-
rary matrix for cell migration and a reservoir of
cytokines and growth factors (Profyris et al. 2012;
Werner and Grose 2003).
Once the bleeding risk is finished, the next
priority is to remove dead tissue and to prevent
infection. During the first 5 days, neutrophils and
macrophages reach the injury zone, and through
phagocytosis and production of local proteases,
they eliminate microorganisms and remove dead
tissue. They also secrete multiple growth factors,
chemokines, and cytokines. These molecules are
essential to signal the events that will occur in the
proliferative phase (Profyris et al. 2012; Werner
and Grose 2003).
R. Mattos et al.
Proliferative Phase
It has the function of wound healing. It begins
around the fourth day and lasts about 3 weeks
(Park and Barbul 2004).
Granulation tissue is the hallmark of prolifera-
tive phase and has this name due to the granular
feature, formed by newly vessels (60% of its
composition) (Dvorak 2005). It replaces hemo-
static fibrin plug of the inflammatory phase (Park
and Barbul 2004).
The proliferative phase can be divided into
three steps:
The first step is represented by the increased vas-
cular permeability induced by cytokines, as
vascular endothelial growth factors (VEGF).
Increased permeability of microvessels allows
extravasation of macromolecules, such as
fibrinogen and other coagulation proteins,
which results in extravascular fibrin deposition
(Dvorak 2002).
In the next step, there are angiogenesis and migra-
tion of endothelial cells. Many molecules have
been implicated in this phase: fibroblast
growth factors (FGFs), vascular endothelial
growth factors (VEGF), transforming growth
factor (TGF) beta, angiogenin, angiotropin,
and angiopoietin-1. In addition, platelet-
derived growth factor (PDGF) is related to
cell migration and fibroblast activation, pro-
viding a structural network, over which endo-
thelial cells proliferate and produce new
vessels (Dvorak 2002).
Epithelialization is essential for reestablishing tissue
integrity. The epithelial coating cells, through
the action of specific cytokines, proliferate and
migrate from the borders of the wound in an
attempt to close it. This process is called
reepithelialization. The reepithelialization of a
wound by keratinocytes is performed by the
combination of the proliferative stage with the
migration of cells near the lesion. The migration
of keratinocytes occurs in the direction of the
remaining skin of the lesion to its extremities
(Profyris et al. 2012; Dvorak 2002; Martin and
Leibovich 2005). TGF beta is the mainly cyto-
kine involved in this step (Werner and Grose
2003; Santoro and Gaudino 2005).
Non-ablative Fractional Lasers for Scars
Remodeling Phase
It begins in the third week, lasts up to 1 year and
must be seen as an attempt of recovering the nor-
mal tissue (Santoro and Gaudino 2005). The third
phase of healing consists in remodeling, which
begins 2–3 weeks after the onset of the lesion and
can last for 1 year or more. The core aim of the
remodeling stage is to achieve the maximum ten-
sile strength through reorganization, degradation,
and resynthesize of the extracellular matrix. In this
final stage of the lesion’s healing, an attempt to
recover the normal tissue structure occurs, and the
granulation tissue is gradually remodeled, forming
the scar tissue that is less cellular and vascular. It
exhibits a progressive increase in its concentration
of collagen fibers. At this stage, there is a deposi-
tion of the matrix and subsequent change in its
composition. With the closure of the wound, type
III collagen undergoes degradation, and synthesis
of type I collagen increases (Profyris et al. 2012;
Mattos et al. 2009).
The main reason for failure in the reproduction
of morphologically identical tissue during healing
process is architectural layout of the new collagen
in parallel bands instead of the network of normal
skin, and, in addition, the absence of hair follicles,
sebaceous glands, and sweat glands is remarkable
(Profyris et al. 2012).
Scars
The clinical classification of scar guides the ther-
apeutic choice (Mattos et al. 2009; Mutalik 2005).
For treatment purposes, scars can be mainly
divided into three types (Osório and Seque 2012):
1. Hypertrophic
2. Keloids
3. Atrophic
Hypertrophic scars are erythematous, raised,
firm nodular lesions. The growth of hypertrophic
scars is limited to the sites of original tissue injury,
unlike keloids that proliferate beyond the bound-
aries of the initial wounds and often continue to
grow without regression (Osório and Seque 2012;
Sobanko and Alster 2012):
115
Keloid scars present as reddish-purple pap-
ules and nodules, often on the anterior chest,
shoulders, and upper back. They are more com-
mon in darker-skinned persons and, like hyper-
trophic scars, may be pruritic, anesthetic, and
cosmetically disfiguring. While the histology
of hypertrophic scars is indistinguishable from
other scarring processes, the histology of keloids
may be recognized by thickened bundles of
hyalinized collagen, haphazardly arranged in
whorls and nodules (Sobanko and Alster 2012;
Osório and Seque 2012; Mattos et al. 2009;
Mutalik 2005).
Atrophic scars, on the other hand, are dermal
depressions that result from the aforementioned
acute inflammatory processes. The inflammation
associated with atrophic scars leads to collagen
destruction with dermal atrophy. Atrophic scars
are initially erythematous and become increas-
ingly hypopigmented and fibrotic over time. The
most common causes are acne, postsurgical
injury, and burn (Osório and Seque 2012;
Sobanko and Alster 2012).
Acne scarring is the result of a deviation in the
orderly pattern of healing and can have profound
psychosocial implications for patients. For this rea-
son, they should be treated whenever possible.
Atrophic acne scars are divided into three types:
ice pick, rolling scar, and boxcar. Ice-pick scars are
narrow, v-shaped epithelial tracts that extend into
the deep dermis or subcutaneous tissue. Rolling
scars are wide and undulating, due to their tethering
from the dermis below. Finally, boxcar scars are
sharply delineated epithelial tracts that extend into
the dermis but, unlike icepick scars, do not taper at
the base. The use of this classification system allows
for treatments to be indicated to the specific type of
scarring (Osório and Seque 2012).
Treatment of unsightly scars is a big challenge
for the dermatologist. Till the date, there is no
treatment considered ideal for scars. Gels or sili-
cone tapes are commonly used and recommended
in recent scars. Intralesional corticosteroid infil-
tration is the most common option for keloids and
hypertrophic scars. Application peels, subcision,
dermabrasion, and surgical excision are tradi-
tional options for atrophic scars (Mattos et al.
2009; Mutalik 2005).
116
Incomplete scar removal, scar worsening, tis-
sue fibrosis, and permanent pigmentary alteration
have limited the clinical utility of these treatments.
Advances in laser technology have led researchers
to study their potential use as a treatment for this
therapeutically difficult condition. Laser scar revi-
sion is a well-tolerated procedure with clinically
demonstrable efficacy and minimal adverse
effects and may be used in combination with the
aforementioned scar treatments (Sobanko and
Alster 2012).
In addition to its indication for treating
established scars, recent studies have brought a
new therapeutic possibility: the prevention of
hypertrophic scars in predisposed patients (Mattos
et al. 2009; Mutalik 2005).
Lasers
Much has been studied about the laser systems of
action in treatment and prevention of scars. The
mechanism of action of these technologies for
scars is still poorly elucidated. It is believed that
the therapeutic effect is based on two pillars:
1. Reducing blood flow: once the scars have four
times greater blood flow than the normal tissue,
maintained by angiogenesis and VEGF pro-
duction, therefore, the equipment should have
at least some ability to produce vascular injury
(Mattos et al. 2009; Mutalik 2005).
2. Reduction, reorganization, and remodeling of
collagen (Profyris et al. 2012).
Three genres of lasers have been shown to
improve scars, creating thousands to millions of
microscopic thermal wounds distributed through-
out the dermis, with or without some epidermal
injury. First, millisecond-domain pulsed-dye
lasers (PDLs) and similar devices produce selec-
tive photothermolysis of small blood vessels. Sec-
ond, nanosecond-domain Q-switched Nd:YAG
lasers produce selective photothermolysis of
microvessels and pigmented cells. Third, ablative
and non-ablative fractional lasers (NAFLs) pro-
duce arrays of nonselective, microscopic thermal
R. Mattos et al.
damage zones throughout the epidermis and der-
mis (Profyris et al. 2012; Anderson et al. 2014;
Kauvar 2014).
Equipment Available for Scars
Treatment
1. Intense pulsed light (IPL) in the vascular mode
2. Non-ablative lasers:
• Pulsed-dye laser (PDL) 585 nm or 595 nm
• Nd:YAG 1064 nm Long pulse
• Nd:YAG 1064 nm Ultrapulsed (genesis)
• Nd:YAG 532 nm
• Diode 800 nm or 1340 nm
• 755 nm alexandrite
• Erbium glass: 1550 m and 1540 nm
• Nd:Yap 1340 nm
• Thulio 1927 nm
3. Ablative lasers:
• CO2
• Erbium 2940 nm
Within the theme of this chapter, we discuss pref-
erably treatment with non-ablative lasers,
extending to vascular lasers given the importance
of the vessel approach, as stated earlier.
To determine which laser system is better for
scar treatment, it is necessary to know the type and
severity of the scar and the patient toleration and
expectations. Dyschromia (erythema, hyper-
pigmentation or hypopigmentation), scar type
(hypertrophic, flat, or atrophic), scar body loca-
tion (face, neck, or leg), and patient characteristics
(skin phototype and comorbid conditions) should
be considered (Profyris et al. 2012; Sobanko and
Alster 2012; Anderson et al. 2014).
Flashlamp-Pumped Pulsed-Dye Laser
(585 and 595 nm)
There is no consensus on the precise mechanism
whereby the PDL exerts its effect on scars. PDL
demonstrates to reduce transforming growth
factor-b expression, fibroblast proliferation, and
collagen type III deposition. Other plausible
Non-ablative Fractional Lasers for Scars
explanations include selective photothermolysis
of vasculature, released mast cell constituents
(such as histamine and interleukins) that could
affect collagen metabolism, and the heating of
collagen fibers and breaking of disulfide bonds
with subsequent collagen realignment (Mattos
et al. 2009; Mutalik 2005; Sobanko and Alster
2012).
In fact, the PDL has been successful in improv-
ing the depth of moderately atrophic facial acne
scars, likely due to stimulation of collagen
remodeling. In case of hypertrophic scars, most
evidence was found for the PDL 585 nm indi-
cating that it is the best-investigated device for
this treatment. As a consequence of this
research, the laser of choice in treating hyper-
trophic, erythematous acne scars and keloids is
the vascular-specific 585 nm PDL (Cynergy ®).
For the PDL 595 nm (VBean ®), a moderate
efficacy (34–66% improvement) was found
(Gira et al. 2004; Sobanko and Alster 2012;
Vrijman et al. 2011).
1. During implementation of PDL, the entire sur-
face of injury should be treated by adjacent
shots and not overlapping, single pass, or
until it reaches purplish erythema (end point)
(Gira et al. 2004).
Minimally purpuric settings have reduced ery-
thema with minimal risks. Non-purpuric settings
also improve erythema but appear to be associated
with less redness reduction per treatment session
(Anderson et al. 2014).
Parameters suggested are (Mattos et al. 2009):
• Fluency 6–7.5 j/cm2 with spot 5–7 mm.
• 4.5–5.5 J/cm2 with spot 10 mm.
• The most used pulse durations are 0.45 and
1.5 ms.
• You should reduce fluency into 0.5 in higher
phototype patients, in more delicate areas
such as the neck, chest, and eyelids if vesi-
cles and crusts are present in the previous
session.
• It is suggested to raise the fluency in subse-
quent sessions if the previous was suboptimal.
117
To select the best treatment option, the scar
size is very important, since for very large
scars, laser treatment may become impractical
by the higher costs of disposable (Gira et al.
2004; Mattos et al. 2009).
Q-Switched Frequency Doubled Nd:
YAG 532 nm
This laser is the only device that specifically tar-
gets pigmentation. One clinical trial with a small
number of patients and a high risk of bias reported
low improvement on the Vancouver General Hos-
pital scale (Vrijman et al. 2011; Osório and Seque
2012).
Diode Laser (Laser-Assisted Skin
Healing 810 nm)
Its mechanism of action has not been fully
established yet. It generates heat that causes
releasing of cytokines and the synthesis of pro-
teins involved into healing process (Osório and
Seque 2012).
Parameters suggested are:
• 4 mm spot.
• Fluency: 80–120 j/cm2 – Burn is reported with
higher fluences.
Non-ablative Fractional Lasers
Non-ablative fractional lasers possess superior
safety profile than ablative ones (Tziotzios
2012). This type of laser is better tolerated and
less invasive compared to non-fractionated, with
good results in several indications (Osório and
Seque 2012). It is considered safe even at higher
skin types, being the first choice for these patients.
Non-ablative fractional laser comprises an
array of 30 devices, whose wavelength corre-
sponds to the infrared, and its target is the water.
The aim is collagen stimulation, normalization of
color, and scar remodeling (Tziotzios 2012).
118
They causes coagulative, fractional, located,
thermal injury and epidermal necrosis on micro-
scopic treating zones (MTZ), separated by areas
of normal skin. From this intact tissue, epidermal
cells migrate into the damaged area performing
healing (Tziotzios et al. 2012).
The permanence of histologically intact stra-
tum corneum characterizes it as a non-ablative
laser; allows re-epithelialization in 48 h, preserv-
ing the epidermal barrier function; and minimizes
side effects (Mattos and Jordão 2012).
In an attempt to elucidate its mechanism of
action, Laubach et al. reported in 2006 that
non-fractional ablative lasers perform micro-
scopic epidermal necrotic debris (MEND) carry-
ing depth melanin to the surface, what explains
the improvement of skin color. Hantash et al.
showed elimination of elastic fibers by MEND.
Finally, Goldberg et al. showed that new melano-
cytes and viable skin keratinocytes occupy the
region (Mattos and Jordão 2012).
Armann et al. have studied ex vivo NAFL
effects on skin morphology and molecular effects
on gene regulation. Human three-dimensional
(3D) organotypic skin models were irradiated
with non-ablative fractional erbium glass laser
systems enabling qRT-PCR, microarray, and his-
tological studies at the same and different time
points. A decreased mRNA expression of matrix
metalloproteinases (MMPs) 3 and 9 was observed
3 days after treatment. MMP3 also remained
downregulated on protein level, whereas the
expression of other MMPs like MMP9 was recov-
ered or even upregulated 5 days after irradiation.
Inflammatory gene regulatory responses mea-
sured by the expression of chemokine (C-X-C
motif) ligands (CXCL1, 2, 5, 6) and interleukin
expression (IL8) were predominantly reduced.
Epidermal differentiation markers such as
loricrin, filaggrin-1, and filaggrin-2 were
upregulated by both tested laser optics, indicating
a potential epidermal involvement. These effects
were also shown on protein level in the immuno-
fluorescence analysis. This study reveals erbium
glass laser-induced regulations of MMP and inter-
leukin expression. The authors speculate that
these alterations on gene expression level could
play a role for dermal remodeling, anti-
R. Mattos et al.
inflammatory effects, and increased epidermal
differentiation (Amann et al. 2016).
A number of studies have demonstrated mild to
moderate improvement in atrophic acne scars
using these non-ablative lasers. In this case, only
patients with boxcar and rolling acne scars are
excellent candidates for laser resurfacing as they
are distensible scars. Most ice-pick scars with
deep bases respond better to punch excision than
to fractional lasers, whereas rolling scars might
require subcision followed by fractional laser
treatment. Because acne scars are usually a mix
of ice-pick, boxcar, and rolling scars, the final
effect of fractional lasers would depend more on
the predominant scars than on the fractional laser
used (Tziotzios 2012; Sobanko and Alster 2012;
Sardana et al. 2014).
Recent studies have shown increasing evidence
of NAFL role in hypertrophic scars. Those one
younger than a year have the best results. Scar
pigmentation and elasticity are parameters that
have better response; vascularization and elevation
are the items with most discrete results. Several
authors suggest beginning laser treatment of scars
for about 2–3 weeks after surgery (Tziotzios 2012).
Some authors suggest the use of fractional ablative
or non-ablative laser to prevent the development of
hypertrophic scars after surgery. Jang J et al. have
compared the use of fractional ablative laser and
fractional non-ablative laser in recent thyroidec-
tomy scars. After four laser treatment sessions,
both types of fractional laser treatments were suc-
cessful; however, their results indicated that higher
effectiveness may be obtained from the use of abla-
tive and non-ablative lasers for hypertrophic scars
and early erythematous scars, respectively (Jang
et al. 2016). Keloid scars should avoid being treated
with non-fractional ablative lasers by the risk of
worsening (Sobanko et al. 2015).
Laser Devices in the Market
• 915 nm diode: This laser was recently intro-
duced in the market and associates fractional
non-ablative laser with radiofrequency in the
same shot. It is widely used in localized areas
(periocular and perilabial) to further warming
Non-ablative Fractional Lasers for Scars
and improved outcomes. In bony areas, radio-
frequency energy should be decreased because
there is an increase in intensity of heat as well
as the risk of side effects. Erythema is fleeting
(Sobanko and Alster 2012).
– Long pulse 1320 nm Nd:YAG: It is associ-
ated with an epidermic temperature sensor
and a cryogen spray for skin protection. It
has a high diffusion rate of heat in dermis. It
is applied on a stamp mode, and spots vary
from 3 to 10 mm. Prospective studies with
the 1320 nm Nd:YAG laser for atrophic
acne scars have shown modest efficacy
without notable adverse events (Sobanko
and Alster 2012).
– 1340 nm Nd:YAG: It has the lowest water
absorption coefficient, which increases pen-
etration in the dermis. Pulse duration ranges
from 3 to 10 ms, handpiece’s density varies
from 100 to 400 MTZ. The laser energy is
delivered to the dermis by the stamp mode.
It is mandatory the use of epidermal cooler
to protect the epidermal layer from burning.
The most important advantage of this tech-
nology is the absence of consumables
(Mattos and Jordão 2012).
– 1440 nm Nd:YAG: This very fast handpiece
has increased risk of burns and post-
inflammatory hyperpigmentation. Pulse
duration ranges from 3 to 10 ms; handpiece
options are 10, 12, and 15 mm; energy
ranges between 2 and 80 mJ/microbeam.
The tip has a cooling system to ensure the
epidermal protection. These technology
doesn’t have consumables (Mattos and
Jordão 2012).
– 1450 nm diode: Its fluence ranges from 8 to
25 J/cm2; handpiece options are 4 and
6 mm; it is coupled to a cryogen spray.
This diode laser showed greater clinical
effect with less adverse effect (Sobanko
and Alster 2012).
– 1540 nm Erbium glass laser: It is applied in
stamp mode; pulse duration ranges from
10 to 100 ms; energy varies from 20 to
100 mJ/cm2. It has sapphire cooled tip,
slower speed of shots, and no consumables
(Mattos and Jordão 2012).
119
– 1440 and 1540 nm in the same devices: It
provides an increase of 20–50% in thermal
damage depth. It has cooled sapphire tip,
which increases their safety (Mattos and
Jordão 2012).
– 1550 nm Erbium glass: It allows automatic
control of density width and depth of the
coagulation column. Its administration is
quick, but painful. This NAFXL can deliver
up to 70 mJ energy with 300–1400 mm of
depth; selection of MTZ density is allowed,
providing adjustment of the percentage of
skin treated to 5–48%. It is possible to apply
several passes in different directions with
some cooling intervals to avoid side effects.
Considering that the estimative of facial
skin depth (forehead, nose, medial and lat-
eral cheeks, lips, chin) is approximately
2196 lm, which consists of the epidermis
(105 lm), papillary dermis (105 lm), and
reticular dermis (1986 lm), a recent review
examined the correlation between depth and
energy for all fractional lasers. This review
found that, for the 1550 nm fractional laser,
for every mJ, the depth of coagulation
increased roughly by a factor of 10 lm
(10 mJ/100–150 lm). Thus, with a dose of
70–100 mJ, a depth of 700–1000 lm can be
achieved, which would be sufficient to ame-
liorate most superficial and some deep atro-
phic scars (Sardana et al. 2014).
– Consensus guidelines on NAFXL (non-
ablative fractional laser) treatment parame-
ters for acne scars have been proposed for
different skin phototypes. Using 1550 nm
Erbium glass, for lighter skin phototypes
(I–III), the recommended settings are
30–70 mJ energy, treatment level of 7–11,
and 8–12 passes. For darker skin photo-
types (IV–VI), energy settings of
30–70 mJ are advocated with fewer passes
and lower treatment density in order to
decrease postinflammatory hyper-
pigmentation (Sobanko and Alster 2012).
– 1927 nm thulium laser and 1550 nm +
erbium glass associated in the same
handpiece: The shots are quick in a scanner
way. The integrated cooling system
120
provides comfort and comes with system
where you can select the percentage of cov-
erage and aggression. The number of passes
is calculated by the device and requires the
use of different spot sizes according to
selected energy. The combination of two
wavelengths allows effective treatment for
skin surface and dermis (Mattos and Jordão
2012).
Treatment of Atrophic Scars
Atrophic scars are dermal depressions that result
from a relative paucity of collagen after an injury
or that are associated with conditions such as
acne. The goal of laser treatment in this setting is
to stimulate neocollagenesis and remodeling
within the atrophic areas. New collagen synthesis
is strongly stimulated by fractional laser therapy,
and previous studies have demonstrated consis-
tent efficacy for atrophic scars resulting from acne
and trauma. For relatively atrophic, shallow, or
flat scars, the NAFXL appears to achieve results
similar to those of the AFXL (ablative fractional
laser) (Vrijman et al. 2011; Anderson et al. 2014).
For acne scars in phototypes IV, V, and VI,
including oriental skin, NAFXL is an effective
and safe option compared to placebo (Yang et al.
2016). Although NAFXL is generally better tol-
erated than AFXL, more than one session may be
required (Vrijman et al. 2011).
Another option for atrophic scars is PDL, with
satisfactory results on improvement of depth of
moderately atrophic facial acne scars, likely due
to stimulation of collagen remodeling (Vrijman
et al. 2011; Sobanko and Alster 2012).
Treatment of Hypertrophic Scars
On the basis of available data from randomized
controlled trials, silicone gel or sheeting is the
preferred first-line therapy for the treatment of
linear hypertrophic scars. In cases where a
2-month course of silicone gel or sheeting does
not prove effective or when the scar is severe,
R. Mattos et al.
pruritic, or both, adjunctive use of intralesional
corticosteroid injection or 5-fluorouracil (5-FU)
is indicated. For cases when the initial steps fail,
laser therapy should be considered (Gold et al.
2014).
The first lasers used in the treatment of hyper-
trophic scars were ablative (CO2 laser) and
showed recurrence rates of 90% and higher
(Vrijman et al. 2011). The incidence of adverse
events was also quite high. Therefore other alter-
natives were developed (Tziotzios et al. 2012).
Fractionated lasers and intense pulsed light (IPL)
are relatively new techniques used to treat scars.
Another category that has been used for hyper-
trophic scars is lasers with wavelength directed
against oxyhemoglobin, as the PDL 585 nm or
595 nm, 1064 long pulse, and phosphate-
titanium-potassium (KTP) 530 nm. These lasers
injures the blood vessels, decreasing the eritema,
telangiectasias and inflamatory process. Through
the thermal damage, PDL act modifying collagen
fibers. These sinergistic effects make PDL the
ideal treatment for hypertrophic scars and keloids
(Mattos et al. 2009; Gira et al. 2004).
It is known that these technologies have a
variable response in scars, depending on (Mattos
and Jordão 2012):
1. Thickness: better response in less thick scar
2. Etiology: better response in organized scars,
like those by surgical procedure
3. Maturity: superior results in recent scar
To improve the response of resistant hypertro-
phic scars, a combination of silicone gel and laser
therapy is suggested. The use of concomitant
intralesional corticosteroids or fluorouracil with
PDL has been shown to provide additional benefit
in proliferative scars. Intralesional injections of
corticosteroids (20 mg/mL triamcinolone) are
more easily delivered immediately after (rather
than before) PDL irradiation because the laser-
irradiated scar becomes edematous (making nee-
dle penetration easier). An additional consider-
ation is that when corticosteroid injection is
performed before laser irradiation, the skin
blanches and becomes less amenable for
vascular-specific irradiation (Osório and Seque
2012).
Non-ablative Fractional Lasers for Scars
Burn Scar Treatment
1. Burn scar treatment is complex and it often
requires combination or alternative therapies
including silicone gel sheeting; individualized
pressure therapy; massage, physical therapy, or
both; corticosteroid application; and surgical
procedures. Massage, hydrocolloids, and anti-
histamines may be added to the therapeutic reg-
imen to relieve pruritus (Michael et al. 2014).
The last clinical consensus for burn scar treatment
is that fractional lasers are significantly more
effective for burn scar improvement than are
PDL or Q-switched Nd:YAG lasers. Few con-
trolled, prospective studies have evaluated the
comparative efficacy of various fractional
devices, but early reports and our clinical experi-
ences suggest that the AFXL has the capacity to
induce a more robust remodeling response than
the NAFXL. Current AFXL devices have a sig-
nificantly greater potential depth of thermal injury
compared with NAFXL devices (approximately
4.0 and 1.8 mm, respectively) (Mattos and Jordão
2012).
Most patients report significant improvement
in pain, itch, and physical mobility within days to
weeks after each treatment. Typically, rapid
improvement is seen in depigmentation, followed
by gradual improvement in the texture and possi-
bly range of motion. Pulsed-dye and fractional
lasers have distinct and possibly synergistic roles
in burn scar treatment. Inflammatory, erythema-
tous scars encountered within the first few years of
injury are most amenable to treatment with PDL.
Ablative fractional lasers typically produce the
greatest improvement for hypertrophic and
contracted scars, with or without the addition of
intralesional or topical medications (e.g., cortico-
steroids) (Michael et al. 2014).
Non-ablative fractional lasers are effective and
approximately equivalent to AFLs for treatment of
atrophic or flat, mature scars. Pigmentary abnormal-
ities (hypopigmentation, hyperpigmentation, or
depigmentation) seem to improve more rapidly
than the textural abnormalities during a course of
fractional laser treatments (Mattos and Jordão
2012).
121
Early intervention (within weeks and months
of injury) may be advantageous in mitigating scar
contracture formation and trajectory with signifi-
cant benefits in patient rehabilitation, representing
a potential breakthrough in the treatment of trau-
matic scarring (Mattos and Jordão 2012).
The optimal time to begin fractional laser treat-
ment is undetermined. However, in our opinion,
AFXL and NAFXL appear to be well tolerated
significantly earlier than 1 year after injury. Treat-
ment of freshly healing wounds with unstable
epidermal coverage in the first 1–3 months after
injury may lead to unpredictable and potentially
harmful outcomes. However, clinical experience
suggests that wounds that are epithelialized and
relatively mature with focal erosions and ulcera-
tions may experience more rapid healing after
AFXL treatment. Younger scars (within the first
year of injury) are often less tolerant of aggressive
treatment than more mature scars, and laser vari-
ables should be selected judiciously in regard to
settings and combination therapies. A minimum
treatment interval of 1 month between fractional
laser treatments is suggested, and the treatments
are continued until a therapeutic plateau or treat-
ment goals are achieved (Mattos and Jordão
2012).
Keloid Scar Treatment
First-line therapy for the treatment of minor
keloids involves the combination of silicone gel
or sheeting with monthly intralesional corticoste-
roid injections. Contact or intralesional cryother-
apy is a potentially useful adjunct for these
lesions, but it has yet to reach widespread use for
keloid management in clinical practice. Adminis-
tration of an oral analgesic and intranslesional
local anesthesia can be used to reduce pain expe-
rienced during cryotherapy. If improvement with
conservative therapy is not observed within
8–12 weeks, 5-FU in combination with
intralesional corticosteroids and, ultimately, laser
therapy or surgical excision may be considered
(Michael et al. 2014).
Keloids have unpredictable response to any
treatment. It may not have any answer to laser-
122
reduced response in each session and is prone to
relapse, especially when the sessions are not
performed at regular intervals (Mattos et al. 2009).
Procedure
Before Treatment
After choosing the laser, it is recommended to
take photography before and after treatment to
evaluate clinical response. Patient should sign
the informed consent term. Past history of medi-
caments and chronic diseases should also be
questioned (Gira et al. 2004).
Everyone in the procedure room must wear
protective eyewear.
The skin is cleaned and topical anesthetic solu-
tion should be applied about 1 h before the proce-
dure. Reducing laser speed application and using
cooler equipment may minimize patient discom-
fort (Degitz and Hautarz 2015).
Parameters
The energy level depends on the device used and
on the color of the lesion (amount of chromo-
phore). The redder the lesion, the more the ves-
sels, resulting in abundant target and higher heat
production. In these cases, less energy should be
used in the first session. Energy should be gradu-
ally increased over the course of sessions
(Michael et al. 2014).
It has been shown that the use of high-energy
settings and multiple passes promotes better clin-
ical results for rejuvenation and atrophic scars.
For hypertrophic scars, it is the opposite: high-
Fig. 1 Pulsed-dye laser
695 nm. Fluence 7 J/cm2.
Three treatments
R. Mattos et al.
energy settings and high density should worsen
the scar (Anderson et al. 2014).
High density is more likely to result in
increased incidence and severity of erythema,
edema, and hyperpigmentation. For any equip-
ment, lower parameters should be used for
patients with high skin phototype (Degitz 2015).
Safe treatment is based on the avoidance of
excessive thermal injury. General principles appli-
cable to laser selection and treatment technique
for fractional laser therapy include minimizing the
number of concurrent therapies, applying frac-
tional treatments at low densities, using a narrow
beam diameter, applying a short pulse width, and
minimizing the number of passes. Higher pulse
energies require a concomitant decrease in treat-
ment density to minimize the risk of worsening
scarring. Results are frequently optimized with a
series of treatments. Although individual treat-
ment courses vary widely, patients most com-
monly receive a series of three to six treatments
(Michael et al. 2014).
Results
After the first session, the improvement is very
discrete and the results become more visible after
two to five sessions (Figs. 1, 2, and 3). Hypertro-
phic scars may show considerable improvement
in the second session, but the response of keloids
is often unpredictable. Improvement can be
observed on the thickness, erythema, flexibility,
texture, and scar itching (Michael et al. 2014).
As with other treatment modalities, better
results are achieved with a combination of tech-
nologies, such as combining laser and IPL (Degitz
2015).
Non-ablative Fractional Lasers for Scars
Fig. 2 Ultrapulsed NdYag.
Fluence 16 J/cm2. Four
treatments
Fig. 3 Non-ablative
fractional laser 1550 nm.
Fluence 45. Density 4. Four
treatments
Some studies have demonstrated better results
when associating laser with triamcinolone or
5-FU infiltration comparing to each treatment iso-
lated (Degitz 2015).
Post-Procedure
Edema and erythema are expected. The swelling
usually improves within 48 h, and ice packs can
be used. Anti-inflammatories and oral steroids are
indicated for intense edema (Anderson et al.
2014).
Erythema usually improves within 3–5 days
and, in extra facial regions, can extend to 7 days.
Recently, the use of LED (light-emitting diode)
immediately after the use of NAFXL has
decreased the duration of the erythema (Anderson
et al. 2014).
The most common adverse effect for treatment
with the PDL is postoperative purpura, which
often persists for several days (Anderson et al.
2014).
123
Complications
Complications are inherent of any technique.
Focal hemorrhages can occur between 12 and
24 h, with spontaneous resolution without sequel
(Ha et al. 2014).
Superficial erosions may occur at an inappro-
priate contact of the tip with the skin surface and
this may course without scars (Sobanko and
Alster 2012).
Burns (bullous and indurated erythematous
areas) are rare but can occur when a high energy
is chosen or a technical error occurs. Hypo- or
hyperpigmentation can occur as a burn evolution
(Ha et al. 2014).
The post-inflammatory hyperpigmentation
usually resolves spontaneously in a few months
and can be prevented, preparing the skin using
bleaching (combination of hydroquinone with
retinoic acid) and appropriate photoprotection. It
is more common in high phototypes, in the eyelid
area, or in areas that were used with high fluence
(Kim and Cho 2009).
124
The hypochromia is an unusual and late-onset
complication, appearing after a few weeks. It is
usually related to high fluence, especially in high
phototypes. It is commonly preceded by appear-
ance of crusts. It is reversible with the use of
steroids, with tacrolimus at the beginning, and
with retinoic acid in a later stage. In case of
resistant lesions, phototherapy can be a good alter-
native (Ha et al. 2014).
Infections in the first week have the risk of
delayed wound healing. The most common
pathogen is herpes simplex that can be avoided
from prophylaxis started 1 day before procedure
and continued for 5–7 days. There is divergence
among authors regarding the herpes prophylaxis
in all patients or only in those with past history
of herpes or only when using ablative laser (Kim
and Cho 2009). In our practice, herpes prophy-
laxis is formerly recommended for patients with
previous herpes history in treatment with abla-
tive laser.
Take Home Messages
1. There is no treatment considered ideal for
scars.
2. The mechanism of action of lasers on scars is
based on two pillars: reducing blood flow
and reorganization and remodeling of
collagen.
3. The chosen laser system to be used depends
upon the type and severity of scar.
4. Non-ablative fractional lasers possess superior
safety profile than ablative ones.
5. Non-ablative lasers are the first choice in
higher skin types.
6. Non-ablative fractional lasers appear to
achieve results similar to those of the ablative
fractional lasers for relatively atrophic, shal-
low, or flat scars.
7. Lasers have a variable response in hypertro-
phic scars. Better response is observed in less
thickness scar, in organized scars like those by
surgical procedure, and also in recent scars.
8. Keloids have unpredictable response to any
treatment.
R. Mattos et al.
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