Laser Corrective Surgery with Fractional Carbon Dioxide Laser Following Full-thickness Skin Grafts

INTRODUCTION

Full-thickness skin grafts (FTSGs) are frequently used in dermatologic surgery. Skin grafts can stand out from neighboring recipient skin both in color and in texture, leaving suboptimal aesthetic results. Traditional methods of modifying the contour include dermabrasion, curettage, and camouflage techniques.

In our center, we frequently use laser technology to improve the erythema and contour irregularities of FTSGs. We present our experience of fractional carbon dioxide (CO₂) laser-assisted corrective surgery in five patients with FTSGs after Mohs surgery.

MATERIALS AND METHODS

Five patients who underwent Mohs surgery with FTSG at our center were treated postoperatively with multiple sessions of fractional laser resurfacing. The CO₂ laser corrected the contour of the FTSG, and any residual erythema was subsequently treated with vascular lasers. UltraPulse (Israel) fractional CO₂ laser by Lumenis was used in this study. This device was used in the Active Fx handpiece, 150 Hz, fluence ranging between 100 and 150 mJ and a computer-pattern generator set at 1-2-5. However, this was adapted in accordance with site and thickness and background skin color. Usually one or two treatment sessions, three months apart, were conducted. To “blend in” the resurfaced area, a larger spot size was chosen with lower density coverage in Active Fx mode over the entire treated area with a margin of 2–3 mm of the surrounding tissue.

RESULTS

Our case series reports the outcome of the treatment of FTSG with fractional CO₂ laser in five patients aged between 49 and 85 years. The results achieved in the present case series of five patients are summarized in Table 1. The successful endpoint of treatment was the achievement of flattening of the raised or uneven surface. The results were smooth transition from the FTSG to the surrounding skin, with improvement in contouring and also an improvement in color in some cases. Please see Figure 1 which demonstrates the scar pre CO₂ treatment, and Figure 2 which shows the improvement post CO₂ laser treatment.

Table 1 Results of FTSG treated with CO₂ laser

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Figure 1

Pre CO₂ Ablation

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Figure 2

Post CO₂ Ablation

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DISCUSSION

Lasers that have been used in the postsurgical period for amelioration or prevention of scarring include pulsed dye laser (PDL), nonablative fractional lasers (NAFLs), and ablative fractional devices.

It has been postulated that PDL works via neocollagenesis triggered by tissue hypoxia.[1] Nouri et al. assessed the efficacy of 585-nm PDL treatment commencing on the day of suture removal.[2] This was a blinded split-scar study (three treatments versus no treatment) in 11 patients. They found a significant improvement in scar appearance (with regard to pigmentation, vascularity, and pliability), as assessed by blinded clinicians (54% versus 10%). Furthermore, PDL was more effective depending on the anatomical location of the scar, with better improvement in the face, shoulders, and arms. Another uncontrolled study found an improvement in surgical scar outcome when PDL was used within two weeks of surgery.[3]

Fractional photothermolysis works by producing microscopic thermal wounds.[4] As the dermis is mainly targeted with no ablation, less downtime is experienced by patients with a greater safety.[5]

Tierney et al. carried out a randomized blinded split-scar study to compare NAFL with PDL (N = 12). NAFL was found to produce better results than by PDL (75.6% vs 53.9%, respectively), with respect to scar pigmentation, thickness, and texture. When compared to PDL, NAFL particularly improved the dyspigmentation (64.2% vs 45.8%).[6] The results of this trial are strengthened because the patients were blinded and randomized. However, it is limited by the fact that not all the scars were of the same anatomic location with a varied scar etiology and age. Of note, the authors did recognize that the blinding was not conclusive, as PDL creates a distinctive posttreatment purpura, recognizable to the evaluating clinicians.

One prospective clinical study investigated the efficacy of 1550-nm NAFL in facial surgical scars. Twelve of the 13 cases had scars after tumor extirpation and 2 of these were stated to be FTSGs. The patients overall reported an improvement in stiffness, thickness, and irregularity of scar posttreatment. One patient with FTSG received four treatment sessions and demonstrated an improvement in pigmentation at six-month follow-up, whereas the other did not. The authors of this study recognized the limitations of selection bias (patient volunteers) and lack of blinding; this study is one of the first to recognize the use of NAFL to treat FTSGs.[7] Another case study reported a 75% clinical improvement in a surgical skin scar, two weeks after a single treatment of 1550 nm.[8]

As far as fractional ablative lasers are concerned, there are hardly any studies of their use in patients with FTSG. CO₂ and Er YAG lasers are ablative devices capable of removing the epidermis in its entirety and hence having a more marked effect on contour, as well as yielding higher adverse outcomes such as infection and scarring.

The first successful use of unfractionated CO₂ laser in the revision of FTSGs was reported in 1988, whereby Wheeland found efficacious results of the CO₂ laser to revise hypertrophic scarring in FTSG.[9] The CO₂ laser treatment was shown to be useful in treating scar contractures secondary to split-thickness skin grafts in the forearms of three patients, who reported improved range of movement up to 15 months posttreatment.[10]

In this case series, we document the positive effect of fractional CO₂ laser resurfacing in patients with FTSG after Mohs surgery. In all patients within the case series, the corrective surgery led to an improvement in contour irregularity and any residual redness was treated with PDL. From the literature, it is clear that treatment of FTSG with lasers is a novel concept. To date, there are only a handful of examples looking at the laser corrective surgery after FTSG.

CONCLUSION

This case series shows that the treatment using CO₂ laser has a positive outcome in the appearance of FTSG after Mohs surgery. This case series is one of the first to demonstrate the effectiveness of CO₂ laser to revise FTSG contour irregularities.