For hypertrophic scars exceeding 5 mm in thickness, the recommended technique when using an Ablative Fractional CO2 Laser (AFCL) is pulse stacking, often referred to as the multiple pulse technique. This specific method involves delivering two to three consecutive laser pulses to the exact same microscopic target point to achieve necessary depth.
Core Takeaway Standard single-pass laser treatments often fail to penetrate the base of thick, fibrous tissue. Pulse stacking solves this by using the first pulse to open a channel and subsequent pulses to drill deeper, ensuring the ablative energy reaches and remodels the deep structures of the scar without widening the surface wound.
The Mechanics of Deep Scar Treatment
Overcoming Tissue Resistance
Hypertrophic scars are dense accumulations of disorganized collagen. In scars thicker than 5 mm, a single laser pulse often lacks the penetration power to reach the bottom of the lesion.
The Pulse Stacking Technique
To address this, practitioners employ a "stacking" method. By firing two to three consecutive pulses at the same location, the laser bypasses the tissue ablated by the first shot. This allows the energy to travel vertically deeper rather than spreading laterally.
The Goal: Deep Structural Remodeling
The primary objective is to reach the deep reticular dermis where the root of the scar resides. According to clinical protocols, this depth is essential to physically break down the thickened collagen bundles responsible for the scar's elevation.
How AFCL Transforms Scar Tissue
Creating Micro-Channels
The AFCL operates on the principle of Fractional Photothermolysis. It creates an array of microscopic thermal injury channels (Microthermal Treatment Zones) within the scar tissue.
Triggering the Healing Cascade
These micro-channels act as a specific injury signal to the body. The localized destruction triggers a natural repair mechanism, prompting the skin to degrade the old, rigid scar tissue.
Collagen Reorganization
As the skin heals, it synthesizes new collagen fibers. Unlike the original scar tissue, these new fibers are arranged in a more orderly fashion, which significantly improves the flatness and flexibility of the skin.
Understanding the Trade-offs
Thermal Management
While pulse stacking provides necessary depth, it significantly increases the localized thermal load. The practitioner must balance the need for deep ablation with the risk of causing excessive lateral heat damage to surrounding tissue.
The "Biological Reservoir" Necessity
The safety of this aggressive technique relies on the "fractional" nature of the laser. The healthy, untreated tissue surrounding each micro-channel acts as a biological reservoir, which is critical for rapid healing and re-epithelialization after deep stacking.
Making the Right Choice for Your Goal
When treating thick hypertrophic scars, your approach must align with specific clinical objectives.
- If your primary focus is reducing scar elevation: Prioritize pulse stacking (2-3 pulses) to ensure energy penetrates beyond the 5 mm depth of the fibrosis.
- If your primary focus is improving flexibility: Rely on the micro-ablative zones to mechanically break tension and induce collagen rearrangement.
- If your primary focus is enhancing drug delivery: Utilize the deep channels created by the laser as physical conduits to deliver therapeutic medications directly into the deep dermis.
By effectively managing the depth of ablation through pulse stacking, you can turn a rigid, raised scar into flatter, more pliable tissue.
Summary Table:
| Feature | Pulse Stacking (Multiple Pulse Technique) |
|---|---|
| Application | Hypertrophic scars exceeding 5 mm thickness |
| Mechanism | 2-3 consecutive pulses on the same target point |
| Core Goal | Deep structural remodeling of the reticular dermis |
| Tissue Effect | Breaks dense collagen without widening surface wounds |
| Safety | Utilizes fractional zones as biological reservoirs |
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References
- Artur Weremijewicz, Wojciech Dębek. Laser therapy in the treatment of post-burn scars in children. DOI: 10.15557/pimr.2020.0067
This article is also based on technical information from Belislaser Knowledge Base .
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