Pulse stacking is a precision capability found in advanced Fractional CO2 Laser systems that allows the device to deliver multiple consecutive energy pulses into a single microscopic channel (DOT) without moving the scanner. By treating the same specific point repeatedly in rapid succession, practitioners can drive laser energy deeper into the dermis to break down thick scar tissue while bypassing the severe thermal damage associated with high-power single pulses.
By accumulating energy vertically rather than spreading it horizontally, pulse stacking enables the safe treatment of dense, fibrous tissue found in hypertrophic scars and keloids, ensuring deep therapeutic impact with minimal risk to surrounding healthy skin.
The Mechanics of Pulse Stacking
Controlled Depth Penetration
The primary function of pulse stacking is to achieve greater ablation depth through energy accumulation. Rather than relying on a single high-energy blast to penetrate tissue, the system "drills" down incrementally.
This allows the laser to breach the thickened barriers of hypertrophic scars and keloids. It effectively reaches the deep dermis where pathological collagen resides, a depth often unattainable with standard single-pulse modes without causing excessive surface damage.
Decoupling Depth from Peak Power
In traditional laser settings, achieving depth requires increasing the peak energy of the pulse, which inevitably widens the zone of thermal injury. Pulse stacking creates a workaround for this limitation.
By delivering sequential pulses, the system accumulates thermal energy in deeper tissue layers without raising the peak energy of any individual pulse. This "Smart Stack" approach ensures the necessary thermal stimulation occurs deep within the scar without overwhelming the surface tissue.
Clinical Advantages for Scar Tissue
Breaking Down Dense Fibrosis
Hypertrophic scars and keloids are characterized by dense, chaotic bundles of excess collagen. The pulse stacking feature is specifically designed to cut through this tough fibrous tissue.
For dense keloids, increasing the stack number extends the treatment depth significantly. This physical ablation creates space within the scar structure, facilitating the rearrangement of collagen fibers and reducing scar volume.
Addressing Uneven Tissue Thickness
Scar tissue, particularly from burns, is rarely uniform in depth or density. A static setting may under-treat thick areas or over-treat thin ones.
Pulse stacking allows for dynamic customization. Practitioners can adjust the number of stacks to match the specific thickness of the fibrosis at different scanning points, ensuring effective remodeling across uneven scar topography.
Minimizing Peripheral Thermal Damage
A major risk in treating keloids is triggering further inflammation through excessive heat, which can worsen the scarring. Pulse stacking mitigates this risk by controlling the scope of thermal damage.
Because the energy is focused vertically, less heat dissipates laterally into the surrounding healthy tissue. This creates a controlled wound healing response that stimulates Type III collagen production and improved texture without causing unnecessary trauma to the adjacent skin.
Understanding the Trade-offs
While pulse stacking offers superior depth control, it requires precise calibration to avoid adverse effects.
The accumulation of thermal energy, if miscalculated, can lead to excessive heat buildup deep within the dermis. This "deep heating" is beneficial for remodeling but must be balanced carefully against the patient's skin type and the scar's vascularity to prevent prolonged healing times or post-inflammatory hyperpigmentation. Furthermore, as the laser penetrates deeper, the potential for pain and downtime may increase compared to superficial resurfacing.
Making the Right Choice for Your Goal
To maximize the efficacy of pulse stacking, tailor the setting to the specific pathology of the scar:
- If your primary focus is treating dense Keloids: Utilize higher stack counts to maximize ablation depth and physically disrupt the deep, excess collagen bundles.
- If your primary focus is Burn Scars with uneven texture: Actively adjust the stack number based on palpable tissue thickness to treat fibrosis without damaging thinner, adjacent skin.
- If your primary focus is Safety in high-risk skin: Use moderate stacking to achieve necessary therapeutic depth while keeping peak pulse energy lower to limit lateral heat spread.
Pulse stacking transforms the CO2 laser from a surface resurfacing tool into a deep-tissue remodeling instrument, essential for managing complex scar pathology.
Summary Table:
| Feature | Single Pulse Mode | Pulse Stacking (Smart Stack) |
|---|---|---|
| Energy Delivery | One high-energy blast | Multiple consecutive pulses |
| Ablation Depth | Limited by peak power | Deep, incremental penetration |
| Thermal Damage | Higher lateral heat spread | Controlled vertical energy focus |
| Primary Use | Surface resurfacing | Dense fibrosis & thick keloids |
| Patient Safety | Risk of surface burns at high energy | Safer for deep dermal remodeling |
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References
- Omar Abu-Azzam, Marwa S. El‐Mesidy. Treatment of hypertrophic scars and keloids by fractional carbon dioxide laser: a clinical, histological, and immunohistochemical study. DOI: 10.1007/s10103-015-1824-4
This article is also based on technical information from Belislaser Knowledge Base .
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