Scar Treatment

By Dr Carolyn Berry / 01 May 2014

Dr Carolyn Berry shares her experiences in treating caesarean scars and stretch marks

There has been an interesting evolution of ‘body awareness’ in aesthetic practice. In the past, we have been primarily concerned with rejuvenating the face, but certainly in my practice, there has evolved an increasing emphasis on improving body concerns. This is particularly noticeable at this time of year, as our patients prepare for their summer holidays. Interest in body image increases year on year and I anticipate it will continue to do so. As practitioners, we need to be appropriately skilled in order to address our patients’ concerns and provide them with the best possible results. Whilst we are seeing a growing male population in our practices, the majority is still made up of women. A large proportion of these women have children and very few women go through pregnancy without any sequelae. Stretch marks are a very common problem, particularly on the lower abdomen. The caesarean section scar itself is rarely a significant worry because it now lies very low, however the ‘overhang’ affects virtually 100% of women post caesarian section, even the very thin. This is due to the reflection of the abdominal fat of the rectus muscles of the anterior abdominal wall. 

Caesarean section overhang

Most women aspire to wearing a bikini post childbirth. It is a marker of body attractiveness because it is unforgiving and shows every bulge and imperfection, and even those without abdominal stretch marks struggle with the ‘fatty pouch’ or overhang following caesarian section. Because of this I am increasingly asked to provide correction. Many of these women are not existing patients, and are not already having aesthetic treatments. However, successful treatment of this area often leads to further interest in other aesthetic procedures.
As a doctor I have been pre-occupied with the caesarean overhang for many years, having first noted it when I worked in general practice. What fascinated me was that it did not just occur with heavier women, but also with very slim women with a flat abdomen. Even these women experienced a little bulge, tending to sit just above the bikini bottoms. Unfortunately there is very little in medical literature about this phenomenon, and it appears thus far to have been largely ignored by doctors. The overriding consensus would appear to be: baby well, mother well, scar clean and healed, job well done. One can fully understand this, and it almost seems trivial to even consider such unimportant issues as overhang and stretch marks – they are often considered our battle scars to be worn with pride.

Dr Berry uses CoolSculpting to treat caesarian section overhang
For me, treatment for the caesarian section overhang happened by accident. I had acquired a CoolSculpting machine and one of my patients requested I treat her caesarian section overhang. There was sufficient mobility of the fat to treat with CoolSculpting and the results were very encouraging. Unfortunately, many women do not realise that there is such an effective, non-invasive treatment for this fat bulge, and still believe the only treatment is invasive liposuction. However, if clinicians increasingly focus their attention on treating both striae distensae and the caesarean overhang, our patients will as a consequence feel that they don’t have to just “put up “ with the sequelae of pregnancy.

Striae distensae

Unlike the overhang, there is thankfully some helpful information on stretch marks. Striae distensae (stretch marks) are an extremely common, therapeutically challenging form of dermal scarring.1 Aetiology remains somewhat of a mystery with various possible causes cited including hormones, physical stretch and structural alterations to the integument. Genetics would also appear to be an important factor in determining susceptibility of connective tissue.2 Various treatments have been trialled over the years. However, few high-level randomised controlled trials evaluating treatments for striae distensae exist. The histology of stretch marks is that of a scar and the development likened to that of wound healing.3 In the early stages there are inflammatory changes with recent striae distensae showing superficial perivascular lymphocytic infiltrate around the venules.4 In the later stages there is thinning of the epidermis due to flattening of the rete ridges and loss of collagen and elastin.5
Many therapies have been tried over the years, including topical agents, and these have had limited success. Vitamin E creams may have some effect on prevention of stretch marks6 and Tretinoin was found to have better results in striae rubra but even this was limited.7 As our patients’ expectations have evolved they now expect significant change and good results, and are increasingly unhappy with minor improvements, which means we as practitioners are under pressure to deliver.

Treatment

With the knowledge that we are dealing with scar tissue, it is reasonable that we treat striae distensae in a similar manner to a scar. Scar tissue needs to be damaged and stimulated to initiate repair mechanisms and so the more invasive treatments will yield better results. Having researched the literature and various treatment modalities it became apparent to me that lasers presently appear to give the best results.8 Various lasers improve the appearance of striae distensae: the pulse dye improves immature striae rubra,9 and the Nd:Yag laser gave satisfactory results in treatment of striae distensae in a study of 20 patients.10

I had already observed that PRP has really revolutionised my treatment of scar tissue in general, and therefore predicted similarly positive results when treating striae distensae.

The most encouraging results to date have been with fractional but unfortunately the studies with fractional laser available are few and limited. A 2007 Brazilian clinical study showed that Fraxel improved texture and appearance of mature, white striae distensae in skin type I to IV. The study demonstrated an early new indication for stretch mark treatment with Fraxel.11 This certainly looks promising and from reviewing the literature, it would seem that fractional is the laser currently giving the best results in treating striae distensae. However mention should also be made of radiofrequency. Of note is a study evaluating the effectiveness of a radiofrequency device in combination with a pulsed dye laser, in which 89% of the patients showed good to very good overall improvement. This is of particular interest because the study population was Asian and only one developed hyperpigmentation, which then improved in three months.12

So where does this leave treatment of striae distensae? I for one want more efficiency and whilst the studies show improvement, we want reproducible and excellent results. How therefore can I improve upon the results of fractional laser, and maximise stimulation of the repair mechanisms?
The answer would appear to be with platelet rich plasma. I had already observed that PRP has really revolutionised my treatment of scar tissue in general, and therefore predicted similarly positive results when treating striae distensae. General studies encouraged this thought and good results have been achieved by adding PRP treatment to fractional radiofrequency. Objective assessment in one study showed 71.9% of participants reported “good” or “very good” overall improvement.13 A review study of PRP in plastic and reconstructive surgery showed a substantially beneficial effect of PRP for several indications, including better wound healing rate, an increased survival rate of fat grafts and an enhancement of bone graft regeneration.14 Platelets contain a number of bioactive factors that contribute to the process of wound healing, such as platelet derived growth factor and transforming growth factor.15

Technique

As previously mentioned, I apply my scar treatment to stretch marks and caesarian section scars. If the patient has loose skin, which they often have as the abdominal skin has lost elasticity due to the striae distensae, I will start them on a course of radiofrequency with weekly treatments. Not only will this tighten the skin but it also causes visible improvement in the striae distensae without further treatment. Usually after three treatments, the patient has CO2 fractional resurfacing and immediately afterwards, I inject their PRP under the treated skin, paying particular attention to the worst striae distensaes and to the caesarian scar. I mainly use a mesotherapy technique, or inject the length of the striae distensae. The settings for the CO2 laser will depend on assessment of the patient’s skin and apparent depth and severity of the lesions. The first treatment is usually milder to allow me to assess what they will tolerate and how long their healing time is. When healed, the patient will return to their radiofrequency for a further three treatments after which I will repeat the process. I only treat skin types I to IV with this method as studies have shown treatment of IV to VI can cause side effects, including hyperpigmentation.16 In darker skins I use radiofrequency and skin needling with PRP injections. 

Upgrade to become a Full Member to read all of this article.