A Randomized Split-Scar Study of Intraoperative Treatment of Surgical Wound Edges to Minimize Scarring

For ablative resurfacing of surgical scars, the recommended time frame for treatment has remained relatively constant at 8 weeks postoperatively.¹ However, Strauss and Kligman² were aware as early as 1956 that dermabrasion to the wound edges at time of closure would improve the final appearance of sutured wounds. In 1980, Caver³ reported that dermabrasion to wound edges at the time of surgery had been used successfully in his practice for over 20 years. In recent years, 2 studies using ablative laser resurfacing of wounds at the time of closure have shown promising trends.^4,5 Ablative fractional resurfacing has been shown to quantitatively improve atrophic surgical and traumatic scars.⁶

The improved safety profile of fractional carbon dioxide lasers vs their fully ablative counterparts and the ability to treat nonfacial sites makes them well suited for scar treatments. Our study aims to quantify the improvements resulting from intraoperative fractional carbon dioxide laser treatment. To our knowledge, this is the first prospective fractional laser study for this indication and the first to evaluate nonfacial sites.

This study was approved by Western Institutional Review Board, Olympia, Washington. Ten subjects were enrolled. Patients were recruited when a linear complex closure longer than 2.0 cm was planned for repair after excisional surgery.

The surgical defects were divided into 2 halves along the planned closure axis. After the subcuticular 4.0 buried sutures were placed (Vicryl; Ethicon Inc, Somerville, New Jersey), but before placement of the superficial sutures, half of the wound was treated with 1 or 2 passes of a fractional carbon dioxide laser (Lumenis; Santa Clara, California) (active FX energy range, 80-125 mJ; density, 4). A coin toss was used to randomize which half underwent laser ablation. The lower range of settings (1 pass/80 mJ) was used for neck cases. A square spot size of 10 mm was used so that 5 mm of each side of the approximated wound was treated. The other half of the wound was not laser treated. The entire wound was then closed with absorbable 5.0 fast-absorbing gut sutures followed by Mastisol (Ferndale Laboratories, Ferndale, Michigan) and Steri-Strips (3M Health Care, St Paul, Minnesota).

Patients were seen at 1 week and again 2 to 3 months after treatment by the same physician (D.M.O.). At the final 2- to 3-month postoperative visit, photographs were taken, and each subject completed a questionnaire rating the appearance and improvement of their scar. Patients were then offered the option of having the control side treated with the fractional carbon dioxide laser.

Photographs were reviewed by 3 blinded, board-certified dermatologists (R.L.M., Lisa K. Chipps, MD, and Edgar Fincher, MD, PhD) (Figure). Physicians compared both ends of each scar and rated them as equal or determined that one was cosmetically superior to the other.

Ten patients with 10 scars completed the treatment protocol and follow-up (5 men and 5 women). The average age was 67.5 years (range, 44-82 years). The average length of repair was 5.3 cm, resulting in an average treatment length of 2.7 cm. Seven lesions were on the head and neck, while 3 were on extremities (Table 1).

No significant adverse events occurred. All patients experienced expected transient erythema and crusting at the treated site, which resolved in 1 week. One patient had 2 suture abscesses develop on the control side. Ninety percent of the subjects (9 of 10) felt that the laser-treated side was cosmetically superior to the control side (P  =  .003) (Table 2). Patients also compared the 2 sides for elevation, discoloration, and erythema (Table 2). The χ² test for specified proportions was performed on these variables, and results indicated that statistical significance was reached for each (P  =  .003 for elevation, P  =  .014 for discoloration, and P  =  .008 for erythema). Physician consensus rating (2 of 3 physician agreement) of scar photographs (9 evaluated) was 100% (P  =  .003) (Table 3).

Our study demonstrated that fractional carbon dioxide laser treatment of wound edges at the time of the procedure significantly improves the appearance and texture of scars in the setting of Mohs complex closures 2 to 3 months after surgery. To our knowledge, this is the first time that this has been demonstrated with a fractional ablative laser or in a prospective study. It is also the first time that this has been demonstrated on nonfacial sites, as shown in the Figure.

Nine of the 10 subjects elected to have treatment of the control side with the laser at follow-up. It is a limitation that both sides of the scar were ultimately treated, which prevents longer-term evaluation.

We have used this method to achieve minimal scarring on face-lift incision lines with excellent results. This work could potentially change the current approach in all surgical disciplines if these results can be validated with a long-term (6-12 months) multicenter study.

Correspondence: Dr Ozog, Division of Mohs and Dermatological Surgery, Department of Dermatology, Henry Ford Hospital, 3031 W Grand Blvd, Ste 800, Detroit, MI (dozog1@hfhs.org).

Accepted for Publication: March 18, 2011.

Author Contributions:Study concept and design: Ozog and Moy. Acquisition of data: Ozog. Analysis and interpretation of data: Ozog. Drafting of the manuscript: Ozog. Critical revision of the manuscript for important intellectual content: Ozog and Moy. Study supervision: Ozog and Moy.

Previous Presentations: Preliminary data from this study was presented at the American Academy of Cosmetic Surgery meeting; January 31, 2010; Orlando, Florida; and at the American Society for Dermatological Surgery meeting; October 22, 2010; Chicago, Illinois.

Additional Contributions: Lisa K. Chipps, MD, and Edgar Fincher, MD, PhD, evaluated and rated the patient posttreatment photographs. Gordon Jacobsen, MS, provided statistical analysis.