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Archive for the ‘laser resurfacing’ Category

Total Hand Rejuvenation

Wednesday, July 11th, 2012

While the aging of the face seems the most visible and subsequently the most treated by plastic surgery, it is not the only visible and unclothed body part that ages. I have seen many older women whose face is quite smooth because of numerous facial rejuvenation procedures but whose hands give their age away. The hands simply don’t go with their face, age or lifestyle. The hands are as much exposed to the elements as the face but are far less pampered and protected.

Like the face, the hands age in a similar way. They lose volume through fat atrophy, the skin loses elasticity and becomes wrinkled and age spots appear. As the fat layer in the hands disappears, which is already thin to begin with, the skin becomes partially translucent and thinner. This creates the classic skeletonized hand appearance where the veins and tendons are clearly visible. The rows between the hand bones become sunken in. The skin when you pinch it on the back of the hands doesn’t bounce back due to loss of elasticity.

The aging of the hands can clearly be seen in many tabloids and magazines. Famous aging women with youthful faces and great bodies have old-looking hands. Their veins can clearly be seen bulging out on their emaciated hands. This may be why some performers wear fingerless gloves in an effort to hide the back of their hands.

Treatment of the aging hands can be done through various rejuvenation methods. The most common treatment by far is for the brown age spots or sunspots. Intense pulsed light (IPL) or broad band light (BBL) can quickly remove brown spots, many of which can be eliminated in a single treatment session of about 15 minutes. It turns them dark and speckled and they then fleck off over the next week or so. A touch-up treatment may be needed a month later to clear what remains. It is important to wear sunscreen on the back of the hands afterward to prevent reflaring of some of the brown spots. A minimum of SPF50 sunscreen should be used.

These light therapies can be supplemented with laser resurfacing to help tighten the loose skin and reduce the wrinkling. Fractional is the best laser method because it has enhanced collagen stimulation effects. Laser resurfacing can be combined with light therapies to get a better overall effect than either one alone. Laser treatments take the same amount of time to do, about 15 minutes per hand.

Most so-called ‘hand lifts’ employ the use of injectable fillers to plump out the atrophic subcutaneous tissues and ‘deskeletonize’ the back of the hand. Fillers like Juvederm, Restylane and Radiesse can be quickly injected in the office for an instant filling effect. Placed right under the skin near the wrist level, they can be pushed into the indented rows once injected right under the skin. While they are not permanent the filling effect will last anywhere from six months to a year.  Fat injections are another option and generally create a better result because the volume injected is greater. It is a minor surgical procedure where fat is harvested from inside the belly button, concentrated, and then injected just like synthetic fillers. Unlike off-the-shelf fillers, fat has the potential to be longer lasting.

Other hand treatment options included the use of skin tightening devices like Exilis and the sclerosing of hand veins by injection or their actual extraction like varicose veins of the legs. One treatment option that is not used is a formal hand lift where skin is excised and the skin tightened. While it can be done by making an incision at the wrist level, the scarring is not acceptable.

A complete hand rejuvenation approach is the combination of injectable filling, light therapy for brown spots and fractional laser for wrinkling and skin tightening. Both hands can be treated in one hour in the office with complete healing in just one week.

Dr. Barry Eppley

Indianapolis, Indiana

A Structured Approach to Treatment Planning of the Aging Face

Sunday, June 3rd, 2012

Patients with facial aging concerns frequently come in and want a general overall assessment of what can be done to improve their face. Others come in because they are looking for a very specific facial rejuvenation procedure, whether it is some type of tuck-up, filler or laser resurfacing. They are driven to these procedures largely because of something they have seen online. But despite the plethora of available internet educational forums, such as websites, blogs and even YouTube videos, wanting a specific procedure does not make one very educated about it. For many, the amount of available information is so overwhelming that they have no greater understanding  after they have digested the information than before.

 

While every face is very different in shape and appearance, the aging process affects them all. But the extent and progression of the aging process differs in every face  so, while they are many predictable changes, every face has varying degrees of them over time. When combined with what bothers any particular patient, it is fair to say that every aging patient needs a unique treatment approach. Despite the need for a unique treatment plan for every patient, there are only so many known facial rejuvenation treatment options. This is exactly how a plastic surgeon thinks when looking at a face…what procedures does the patient need and which ones will make the biggest difference?

 

Translating a facial aging treatment plan to a patient requires an organized and thoughtful approach if they are to understand the logic of what they need and the procedure(s) required. I find it most helpful to divide the face into thirds and break down their concerns and what can be done. The surface texture of the skin is the fourth facial element and is always discussed last.

 

The upper face consists of the frontal hairline, forehead skin, brows and the upper eyelids. This is a unit because changing one aspect of the upper face affects all others. How much excessive eyelid skin is there, what is the position of the eyebrows, what is the vertical length of the forehead skin, how much muscle activity and lines exists in the forehead skin, and what is the location of the frontal hairline and its hair density? These determine whether only an upper blepharoplasty is needed or whether it needs to be combined with a browlift and what type of browlift would be best?

 

The middle third of the face involves the lower eyelids, cheeks and nasolabial folds. Is just a lower blepharoplasty needed and what type? Do the cheeks need lifted or will just more volume do? Does the patient have tear troughs or malar bags? How best to reduce the depth of the nasolabial folds? The relationship between the lower eyelid and the tissues beneath it is a complex and challenging one and there are many options available today.

 

The lower face includes the neck and jowls, lips, mouth and chin. Does the patient need a full facelift or only that of a more limited variety? Does the neck need platysmal muscle plication or just liposuction with the facelift? Will chin augmentation improve the shape and definition of the jawline? Do the lips need vertical wrinkle reduction, corner of the mouth lift, or vermilion lip enlargement? The central mouth area can not be separated from the neck and jowls in improvement of aging.

Lastly, skin texture must be considered. Lifts and tucks will not reduce fine wrinkles, give the skin a more youthful glow, reduce pore size or get rid of brown spots. Simultaneous or delayed skin resurfacing with laser or chemical peels is a great asset to all other tissue lifting or excisional procedures. More commonly, skin resurfacing is being done simultaneously at the time of surgery.

 

If you break down the face into its four structural elements and go through it a sequential fashion, patients are more likely to understand and retain the options given to them. This should lead to less misunderstanding and disappointment after surgery.

 

Dr. Barry Eppley

Indianapolis, Indiana

Fractional Laser Resurfacing of the Neck

Wednesday, May 30th, 2012

Resurfacing of the facial skin for wrinkle reduction is well known to be effective. Such laser improvements have been particularly enhanced by the use of fractional ablative laser treatments. The deeper penetration of the vertical laser columns, albeit on just a fraction of the skin’s surface, causes collagen production and skin tightening not previously seen. But venturing off of the face onto the neck and chest, however, is more precarious with laser resurfacing or even deeper chemical peels.


Although the neck is right under the jawline and adjacent to the face, it reacts differently to skin resurfacing efforts. Complications such as delayed wound healing and pigmentation changes are not rare and have been seen with every laser approach. The conclusion historically is that only very light laser treatments with minimal improvements can reduce the risks of these after treatment problems.

Why the neck and chest is different has been theorized due to a change in the anatomy of the skin. The dermal component of the skin is definitely thinner and has less pilosebaeous units per square centimeter. Since most skin cell regeneration (re-epithelization) comes from these hair-sweat gland follicles, healing is slower and more challenged by thermal injury. The thinner dermis also lends itself to greater thermal injury at similar laser setting that are used on the face.

Fractional laser resurfacing offers a theoretical improvement to traditional laser resurfacing of the neck. Its microscopic vertical columns leaves normal skin tissue between them, acting as a reservoir of uninjured fibroblasts and pilo-sebaceous units to provide a good healing source. With a treated to untreated skin ratio ranging from 5% to 22% (Sciton Fractional Laser), there is plenty of healing cells available to expedite wound healing. The traditional higher incidence of complications in neck resurfacing should therefore be appreciably reduced with fractional laser techniques. In my experience this is certainly true and much better skin improvements are seen. Skin texture, wrinkle reduction and small amounts of skin laxity are improved.

An important distinction, however, should be pointed out between improvements in neck skin texture and laxity. I see too many people who erroneously believe that neck laser skin resurfacing is going to create the effect of a facelift. (neck-jowl lift) This is certainly not the case except in the slightest of degrees. The amounts of improvements seen in laxity reduction will not make most of the patients I see happy. This is asking too much of laser therapy even though some make market it as a non-surgical facelift.


Dr. Barry Eppley
Indianapolis, Indiana

Plastic Surgery’s Did You Know? Laser Resurfacing at a Fraction

Tuesday, May 1st, 2012

Laser skin resurfacing has now been around for several decades and involves a simple treatment principle…uniform removal of the outer layers of the skin. This can be done from very superficial to deep depending upon the power settings of the laser and the depth of the skin contour problem. Fractional laser treatment represents a paradigm shift in laser skin resurfacing by treating just a fraction of the skin’s surface, hence the name. But each area treated or laser dot penetrates much deeper creating vertical columns down into the deeper layers of the skin. This results in much greater collagen stimulation. But because less skin is injured (5% to 22%), it heals much faster. This has been a revolutionary advance in the treatment of previously difficult problems like scars.

Fractional Laser Periorbital Rejuvenation of the Eyelids and Brows

Wednesday, April 18th, 2012

The eyes may be the window to the soul but they are also a measure of aging. Because of the expressive movement of tissues around the eye and the thinness of the skin, this area shows the first sign of aging changes on the face. The sphincteric action of the orbicularis oculi muscle generates an array of radiating wrinkles to the side and below the eye and exerts a downward pull on the eyebrow. Because we look at this area with great frequency, often the first thing we look at in a mirror, the development of wrinkling is quickly discovered.

Surgical removal of eyelid skin (blepharoplasty) and elevation of the eyebrows (browlift) are well known and effective strategies for periorbital aging. But they are best used in moderate to advanced stages of aging. In addition, some people simply don’t want surgery whether it is because of the recovery or the cost.

The use of lasers for facial wrinkle reduction is well known and has been around now for over two decades. But their use around the eyes and on the eyelids where the skin is thinner is the use of lesser depth laser treatments known as micropeels but with more restricted depths of penetration come less results as well.

The newer fractional laser treatments offer a paradigm shift is how laser energy is delivered. Rather than being ablative to 100% of the treated skin, the fractional laser treats but a portion of the surface. Rather than producing a complete layer of burn tissue, columns are created instead. This leaves a lot of uninjured skin between the vertical columns which allows for faster healing and less risk of scarring. But each column does deeper down into the dermis, creating a collagenous remodeling effect.

When fractional laser treatments are applied in the periorbital area, significant improvements have been reported in numerous clinical studies. Measurable improvements have been seen in reduction of wrinkles, skin tightening and eyebrow elevation. This was found to be true in all skin types, including those with darker pigmentations. The results come exclusively from the changes in the skin and such problems as fat herniation, significant malar and brow sagging and orbicularis muscle hypertrophy will not be improved by this or any form of laser resurfacing.

The caveat to success with fractional laser periorbital rejuvenation, and being able to treat the eyelids directly, is the use of low energies and multiple treatments. This allows for both safety with minimal risk of any adverse scarring and very quick recoveries in the order of a few days. Spaced about six weeks to eight weeks apart, a series of three or four treatments is needed to get the best results. One should anticipate a single maintenance treatment per year. It is also important to use a good topical regimen daily with both exfoliative and regenerative agents such as retinoic acid and ascorbic acids.

The use of the fractional laser offers a new treatment option for the aging eyelids and brows. Some have termed this the fractional eyelid lift or the ‘Madonna Lift’. But names aside, this laser treatment provides an intermediary step before surgery that can serve as an effective treatment for those with early sign of aging or as a delay manuever before blepharoplasty surgery is done later.

Dr. Barry Eppley

Indianapolis, Indiana

Fractional Laser Treatments Of Acne Scars

Sunday, April 15th, 2012

While many methods for skin rejuvenation have been developed, few such methods are helpful for acne scars. The typical skin treatments of microdermabrasion, chemical peels, intense pulsed light and even ablative CO2 laser resurfacing do not produce substantative improvements in the unique contour problems caused by acne. Traditional CO2 laser resurfacing is the best of the bunch but results are often left wanting. The most effectve treatment is dermabrasion but it carries with it risks of hypopigmentation and even hypertrophic scarring.

Acne scars can be divided into two main types; atrophic and proliferative. Atrophic acne scars are identified as either ice-pick or macular-type forms. Proliferative or hypertrophic acne scars are raised and are more like keloids. Atrophic acne scars are particularly difficult to improve because the collagen degeneration extends down into the dermis. Regeneration of the dermal layers is virtually impossible so traditional ablative laser resurfacing has tried to bring down the surrounding more normal skin layer to the depth of the dermal depression…with limited success.

Fractional laser resurfacing has introduced a new concept in skin surface treatments. Rather than bringing down the entire outer surface layer of the skin, it only treats a portion of it hence the name fractional. In essence think of a dot pattern of individual laser spots penetrating the skin distributed over a grid pattern by a computer delivery system. But each laser spot penetrates much deeper, reaching the dermis and causing collagen stimulation/regeneration. While each laser spot goes deeper, the smaller portion of skin treated (anywhere from 5% to 22% of the total surface area) results in more rapid epithelial healing and a faster recovery.

Fractional laser resurfacing has been shown in numerous studies to be very effective for atrophic acne scars. Delivered in a punctuate pattern, the epidermis and a part of the dermis is vaporized. At the same time, collagen contraction occurs by its heating effect causing skin tightening. This skin tightening effect is thought to be very beneficial for acne scars. Multiple fractional laser treatments will be needed and they should be spaced about a month apart to allow for complete epithelial regeneration. Histologic and electron microscopic studies have shown the regeneration of elastic-like fibers with fractional treatments, a sign of dermal remodeling.

The fractional laser allows for different parameters to be set including power, pulse width, and dot pitch being the distance between each laser point. It is not clear as to the optimal setting for any individual patient and consideration has to be given to the patient’s concern for recovery. Given the challenge of atrophic acne scars, deeper depths of penetration up to 350 microns are best used.

Dr. Barry Eppley

Indianapolis, Indiana

Options in Early Scar Treatments

Wednesday, April 4th, 2012

The best way to treat surgical incisions that ultimately ends up with the most obscure scars is controversial. How a surgical incision heals and looks aesthetically is influenced by many variables such as the instrument used to make it, where on the body it is loacted, and the techniques used for wound closure. Many incisions go on to heal exquisitely well with the tincture of time alone.

But some wound closures are not favorable ones and may benefit by early scar treatment therapies. Then there is also the psychotherapy benefit of the patient doing something early in the healing process, taking an active role in the scar outcome. This has led to a plethora of topical scar creams and gels, most of which contains silicone fluid or silicone particles. The scientific benefits of their use remain far from scientifically proven but they are certainly harmless and usually relatively inexpensive.

More ‘high-tech’ therapies have been similarly applied to help modulate scar healing including laser and pulsed light therapies. There are no well tested scar treatment protocols but various practitioners use either pulsed dye laser or high intensity light (IPL/BBL) treatments as one option. Others use superficial or lower power fractional laser resurfacing treatments in the early healing period. No studies have ever been done that I am aware of that has directly compared these two scar therapy methods.

From a biologic standpoint the use of pulsed light therapies in early scar treatments makes good sense and is less likely to cause any adverse effects. Affecting the vascular elements and how the collagen is cross-linked theoretically could make the redness in the scar fade faster, decrease the risk of hyperpigmentation and help it soften sooner, particularly if it is prone to scar hypertrophy. In essence, it may expedite what the body naturally does through its scar maturation process. Such light-based treatments can begin early as soon as two or three weeks after surgery. Interestingly, but never talked about, is whether shortening this scar process may weaken its ultimate tensile strength attainment. Does making a scar look better sooner affect what its primary role is…that of holding the wound edges together? On the face, however, this is probably not a relevant issue.

The use of early fractional laser scar treatment is now more popular based on how well it performs in wrinkles and acne scars. It is definitely more invasive given the tiny channels that it cuts into the scar tissue. Because of this biologic action, it should not be started too soon when the wound edges have barely mended together. But by three to four weeks after surgery, it should be  safe to begin. The small channels really introduce another wound element in an already healing wound. This would make good sense in delayed treatment when the scar tissue is mature but its merits in early after surgery scar care remain speculative for me.

What is the best early treatment for incisions/scars? Between topical, light-based and laser therapies is one better than the other or is there a good combination? The reality is that no one knows for sure and any claims otherwise are marketing/sales driven but not backed by good science. For a safe and cost-effective approach, topical scar methods are certainly harmless but probably minimally effective. Which one of the many topical scar products is better is open to debate. For a more aggressive early approach, I recommend pulsed light treatments starting at three weeks after surgery done once a week for one month. If a scar in the first few months appears problematic (beginning hypertrophy) then fractional laser treatments should be started.

Until we have more scientific studies evaluating these scar treatment methods, their use will have to be on theoretical science and clinical experience.  

Dr. Barry Eppley

Indianapolis, Indiana   

Options in Hand Rejuvenation

Saturday, March 17th, 2012

 

The face ages with a classic set of findings including the development of wrinkles, loose skin, fat atrophy and age or brown spots. The rest of the body ages as well but most of it does not have the amount of sun exposure to which the face is exposed. Therein lies the differences in appearance that occurs in skin that has a long history of being covered than the skin that hasn’t. The one place on the body that ages similarly to that of the face due to sun exposure is…the hands.

 

It is a well known observation that you can look at many female facelift patients in their mid-50s and beyond whose hands do not match their face. The hands look a lot older than the face who has had rejuvenative treatments such as surgery and  numerous topical skin care products. The hands undergo an identical aging process which includes the loss of skin elasticity, the development of wrinkly skin, near complete fat volume loss and the development of numerous brown spots and patches. What is unique about the hands is that as the thin fat layer absorbs with thin skin over the back of the hands, the veins and tendons become very apparent. This is known as the skeletonization of the hands. While one is not looking at the bones, the hands become so thin that it looks like it.

 

There are now a variety of hand rejuvenation procedures that are available. Sometimes called ‘hand lifts’, this term lends an erroneous impression that skin is removed like in a facelift. This is never done as the scars would be visible and would not look very good as widening of them is inevitable. The hand lift concept is really about plumping them up which lifts and fills them out to create a less skeletal look. Various synthetic filler materials are used of which the most common are Juvederm or Radiesse. Just like injectable fillers in the face, they are placed in a simple office injection session lasting about 15 minutes. They will last about as long as that of the face until they are naturally resorbed and depends on the filler material used. (about one year for Juvederm and Radiesse)

 

The other filling option, and my preferred approach, is the use of fat. Like the buttock procedure, the Brazilian Butt Lift, fat is taken from elsewhere on the body and injected into the back of the hands. Placed right under the skin at the wrist level, fat injections are massaged into the subcutaneous space between the fingers. This technique avoids injuring the large prominent veins which would cause a lot of bruising. Fat is a natural material so rejection or inflammation to it does not occur. Like when it is injected elsewhere in the body, how much fat is retained and is permanent is variable. Between the fat harvest and injecting into the hands, I prefer to perform this procedure in the operation room under either local anesthesia or with a little IV sedation.

 

Besides the introduction of volume into the aged hands, the skin can also be treated. The brown spots can be very effectively treated with high intensity pulsed light therapies such as IPL or BBL. As a quickly done office procedure, brown spots can be remarkedly reduced or completely eliminated. Many hand rejuvenation patients choose to do this brown spot reduction alone. The skin can also be smoothed and some wrinkles reduced through fractional laser resurfacing. Just like on the face, fractional laser us much better at skin tightening and wrinkle reduction than traditional full surface laser resurfacing. Sun protection, using a combined UVA/UVB product should be generously used after these light and laser treatments to prevent brown spot recurrence with ongoing sun exposure.

 

There are also treatments for hand veins such as sclerotherapy and stripping out some of the prominent veins. But there are risks in so doing including prolonged swelling, bruising and thrombophlebitis. As a result, they are less popular and often unnecessary with good dorsal hand filling.

 

Complete hand rejuvenation includes a combined approach of an injectable filler, BBL for brown spots and fractional skin resurfacing. All of these can be done in a single procedure. Expect the hands to take up to two weeks to recover and show the full benefits.

 

Dr. Barry Eppley

Indianapolis, Indiana

Skin Wrinkle Types and Their Treatments

Sunday, March 11th, 2012

Wrinkles are a part of aging and there is no way to completely prevent many of them from happening. While topical creams and lotions once were the only players for wrinkle prevention and treatment, that has changed significantly over the past decade. Botox, injectable fillers and various energy-based device treatments (e.g., laser) have moved in to now play major roles in wrinkle treatment.

 

But those facial lines which develop are more complex than they appear. They are numerous causes of wrinkles which range from the movement of facial muscles to gravity and sun damage. This creates different types of facial wrinkles which are structurally different. Getting the best treatment results depends on matching the facial wrinkle type with the appropriate treatment.  Facial wrinkles and lines can be divided into four general types.

 

The most common facial wrinkles are known as dynamic expression lines. They have become well known because of Botox injections, which are used to specifically treat them. They are known by a variety of names such as smile lines, crow’s feet and the ‘11s’. They develop due to the repetitive movement of muscles of facial expression and the wrinkling of the skin appears perpendicular to the direction that the muscle moves. The most obvious example are horizontal forehead wrinkles which develop because of the movement of the vertically-oriented large forehead frontalis muscle which runs from the eyebrows to the back of the head. By weakening these expressive muscles with Botox injections, the lines become less evident with movement. This works well around the eyes because less movement is always good. Around the mouth, however, less movement can affect how one smiles so injections are done more carefully or not at all.

 

Elastic skin creases occur in areas that are exposed to skin folding and have high sun exposure, most frequently on the cheeks and at the base of the neck. They are not the result of muscle movement but occur in those areas where the skin frequently becomes ‘creased’. This could be the result of sleeping repetitively on the side of one’s face (e.g., vertical or oblique skin creases in the forehead) or other external force that sheers against the skin. The best prevention is to avoid activities that crease the skin and keep it well moisturized.

 

Gravitational folds are not really wrinkles per se but lines that form from the effects of falling skin. They are the result of skin sagging and falling. The most well known are the nasolabial folds and marionette lines. Nasolabial folds appear and deepen as the cheek tissue above them descends, pushing lower cheek tissues against the fixed and non-falling upper lip tissues. The same occurs as jowl and facial tissues fall downward against the fixed tissue of the chin, creating marionette lines. Gravitational folds are best treated by either lifting procedures  that pull the weight of the descending tissues upward and back (e.g., lower facelift, cheek lift) or by plumping the fold with an injectable filler material.

 

Atrophic wrinkles occur from thinning skin and loss of its elasticity. These are the fine smaller wrinkles that often appear between and around dynamic expression lines, elastic creases and facial folds. They create what is known as creapy skin and usually appear as one of the last wrinkle types to occur. Excessive sun exposure and smoking make huge contributions to their occurrence and are what creates the ‘prune-face’ appearance in those with a long-history of sun bathing and have developed a more leathery skin appearance. Exfoliative skin treatments such as laser resurfacing and chemical peels are very effective because these wrinkles are often very superficial and their appearance can be lessened by removing some of the outer skin thickness.     

 

Between topical skin products, Botox, fillers, lasers and surgery, a wide variety of skin wrinkle treatments exist. But these treatments must be applied to the wrinkle type in which they work the best to get good results. Most patients need three or more of these over time to lessen the inevitable appearance of facial wrinkling.

 

Dr. Barry Eppley

Indianapolis, Indiana

Combined Fractional Laser and Topical Steriods For Hypertrophic Scars

Saturday, January 21st, 2012

Scar therapy consists of a wide variety of possible treatments from injections, lasers and light devices and surgical excision. There is no one type of scar treatment which is uniformly effective for all scars. There are simply too many types of scars and differing skin types and body locations for any uniform approach to improving the appearance of scars.

While scar revision by excision still remains a mainstay for many scar patients that I see, it is not effective for scars that involve large surface areas. Broad hypertrophic scars, particularly from burns and other forms of trauma, pose unique challenges for improvement. While in some cases complete excision and skin grafting may be useful, patients may either not want that approach or want to try non-surgical methods first.

One non-excisional treatment approach, and the only that I find effective for established scars, is that of combined laser resurfacing and topical steroids. When referring to laser resurfacing, I am not talking about a uniform ablative approach but specifically that of fractional CO2 ablation. This ablative CO2 laser creates channels from 400 to 600 microns or more deep into the dermis/scar. Such channels provide many points of entry for topical agents such as steroids. The early introduction of intradermal steroids helps to control the inflammation that the laser causes as well as suppresses collagen synthesis to reduce scar thickness  

This scar treatment approach can be done under either topical or local anesthetic. Usually topical is better because wide hypertrophic scars are typically hard to inject under and get good pain relief. Numerous topical anesthetic creams are available but ones that contain a combination of benzocaine, lidocaine and tetracaine penetrate and work the best. Once adequately anesthetized, the broad scar is treated by the fractional CO2 laser to create intradermal pores. Thereafter, the steroid triamcinolone acetonide suspension (kenalog) is applied over the laser-treated area. Different concentrations of the steroid can be used from prepared concentrates of 10, 20 and 40mg/cc. In some cases, intralesional steroid injections may be given as well if the scar is very thick. The topical steroid suspension is held into place over the scar treated area by a clear adhesive dressing for 24 hours.

Few wide hypertrophic scars respond well to a single treatment and a series of fractional laser resurfacing and topical steroids is needed to get the best result. Typically it requires three or four sessions spaced four to six weeks apart.

This combined laser and steroid treatment is fairly novel but makes biologic sense with its multimodality approach. The synergism of these two treatments  strives to create a flatter scar that is more supple, not necessarily complete scar removal. Breaking down existing scar tissue, without creating a lot more, is the only realistic goal for this type of hypertrophic scar.

Dr. Barry Eppley

Indianapolis, Indiana


Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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