Burn scar rejuvenation
Achieving improvement in burn scars can be tricky, however Dr Matthias Aust describes how medical needling can offer a solution
There are many non-invasive and surgical procedures to treat scars. Many patients don’t want to go through surgery again, especially after burns, because they are concerned about long hospitalisation and questionable outcome. Therefore minimally invasive procedures such as dermabrasion, deep chemical peels and laser therapy have become more important.
All of these procedures though are ablative. Dermabrasion ablates the skin down to the basal membrane and a CO2 laser creates a wound, destroying the cells up to the basal membrane, leading to a thinner epidermis than before. Also by removing the epidermis and cells—especially the melanocytes—you run the risk of dyspigmentation.
An ablative laser brings us more skin tightening than needling, because a tiny scar is created underneath the basal membrane in the papillary dermis, and a scar always contracts causing skin tightening. However underneath, in ideal circumstances, you would want scar free healing and the stimulation of the body’s own growth factors.
One way to achieve stimulation of the body’s own growth factors is by skin needling. For burn scars, we do what is termed a “severe” needing and afterward the patient will look bruised and swollen. The needles puncture through the epidermis and set up bleeding underneath the basal membrane and even deeper. The needle then goes out of the epidermis again and the cells close. The epidermis remains intact with just puncture channels.
The reason for dyspigmentation involves the melanocyte as well as the keratinocyte. The melanocyte sits on the basal membrane and is a dendritic cell. If you perform an ablative procedure you remove some of these cells so you could end up with too few and create hypopigmentation, or the cells might overreact and produce too much leading to hyperpigmentation. With a needle this risk is lessened by just bringing the cells out, and when the needle goes back, the cells go back together.
Postoperative treatment is simple because you don’t create an open wound, so no dressing is required. Importantly though, it doesn’t matter how long the needles are—avoid crusts. If you have crusts, underneath you can have bacteria and bacteria can lead to secondary wound healing which can end up scarring.
You can treat any part of the body, because it works so simply and is nothing more than simple wound healing.
You need a bleeding, and the reason you get long-lasting results with “severe” needling I believe, is because you have the bleeding. If you don’t have the bleeding it’s needle therapy, which will not bring long-lasting results but does avoid the downtime.
When I was a young doctor I was trained not to touch a scar for one year after injury, let it heal. I now totally disagree. I have achieved good results from needling scars two months after injury. The scar would have improved by itself as it was an active scar, however you don’t have to send a patient away with active scarring—you can help improve the healing.
I was also taught to avoid keloid scars, however, I now also disagree. After treating almost 1,000 people with hypertrophic scarring we decided to try needling with keloid scars. Results have shown in some instances an improvement in elasticity—it can definitely help. You don’t get a result, but you certainly don’t make it worse. I would never promise my patients results when needling keloid scars, but I certainly recommend it is worth trying.
We’ve seen very few complications in terms of infections or long-lasting bruising and we have not seen any scarring, dyspigmentation, or photosensitivity.
You can get hyperpigmentation after needling, if the needle gets blunt with multiple usage and tears the skin, so you must be careful.
We have carried out research using rats. Histologies showed that eight weeks after needling, the epidermis increased in thickness. Also with needling, our research showed you have an increase of EGF, FGF and VGF, which are the body’s own growth factors for the epidermis, the fibroblasts and for new blood vessels.
We also examined the theory that needling promotes scar free healing. 24 hours postoperatively there was no damage shown in the epidermis, just completely intact skin. The same with the connective tissue, it remained completely intact with no signs of damage, plus TGF-beta 3 was up-regulated in all control groups.
While you can improve scar with needling, unfortunately we didn’t see any improvement in big areas of hypopigmentation.
We can combine needling with another operation method, ReCell, a “skin in a spray”. You take a small skin sample and make a solution, which you spray onto a wound bed. This optimises wound healing and improves cosmetic and functional results. It heals very quickly, and you can spray all living cell type—Langerhans cells, fibroblasts, melanocytes and keratinocytes.
The problem with ReCell is you need a wound bed, an open wound to spray the cells onto. I initially found this difficult to understand, because if you remove cells first with ablation, just to spray the cells on again, you take one step back, to go two steps further. This might not be a problem in healthy skin, but it is a problem in burn scars as the epidermis is thinner, so there is a risk of ablating too deeply. So we thought, maybe the puncture channels that we have after needling with a 3mm roller would be enough to get the cells in.
We have an ongoing study with 20 patients, with a one year follow-up for 10 of the patients. We measured scar areas bigger than 10 square centimetres and scars at least 12 months or older, which were hypopigmented. We evaluated them by pictures and questionnaire for the patient as well as for the doctor, and we evaluated the amount of melanin with a tool called a maxometre.
We needled the scars and then used ReCell and the results are showing improvement, we are looking to publish the results soon
Dr Matthias Aust is a specialist in medical needling and is chief consultant for the Department of Aesthetic and Plastic Surgery at the Malteser Hospital in Bonn, Germany