Fractional CO₂ Laser (SCAR3 Scanner) for a Hypertrophic Retracting Cleft Lip Scar: A Case Report

Introduction

A hypertrophic scar is a thick, elevated scar caused by an aberrant wound-healing reaction after skin damage, burns, or surgical incisions. Scars, particularly those that are hypertrophic and retracting, are a major difficulty in dermatological and plastic surgery. These scars are distinguished by an excessive buildup of collagen, resulting in elevated, itchy, or painful lesions that can spread beyond the original wound borders. In hypertrophic scars, retraction refers to the propensity of scar tissue to contract, which can cause deformation of the surrounding tissues and functional limits [1–3]. When these scars develop in highly visible and functionally critical areas, such as the face and lips, their impact on a patient’s life can be profound and multifaceted.

Cleft lip scars result from surgical repair of a congenital lip deformity. Indeed, in the context of cleft lip and palate repair, patients often undergo multiple surgical procedures from infancy, which, while corrective, can leave complex scarring patterns that evolve over time, and retracting hypertrophic scars are a known complication following surgical interventions; this can distort lip shape, restrict movement, and negatively impact facial symmetry, speech, and appearance [4].

Effective management of these mature, intricate scars requires a nuanced approach, often necessitating a combination of therapeutic modalities.

The tension exerted by the orbicularis oris muscle after cleft lip repair is a significant contributing factor to the formation of hypertrophic scars and retraction. This implies that surgical techniques that minimize tension and postoperative interventions aimed at reducing muscle activity (eg, botulinum toxin injections) could be beneficial in preventing or mitigating scar retraction [4]. Surgery is generally considered when other treatment options have failed; its role is to remove the scar or redirect tension lines.

Historically, treatment options have included topical emollients, silicone-based products, corticosteroid injections, and various ablative and non-ablative lasers. However, achieving satisfactory outcomes for long-standing, fibrotic, and retracting scars remains a complex endeavour, often requiring advanced laser technologies for optimal results. Several non-invasive options are available for the management of retracting hypertrophic scars on the lip. Standard care for perioral scars begins with silicone gels or sheets and massage, aiming to hydrate, occlude, and reduce tension. These helps reduce scar size, redness, firmness, and itching. Consistent use for 12 to 24 hours daily over several months is required. Silicone gel is often preferred for facial scars due to easier application and better cosmetic acceptability [4].

Microneedling is a minimally invasive technique that stimulates collagen remodeling through controlled micro-injuries. Studies on cleft lip scars show improved thickness and flexibility, suggesting it can effectively complement traditional treatments with the advantages of simplicity, safety, and low cost [5].

Corticosteroid injections are commonly used to treat hypertrophic lip scars by reducing fibroblast activity, collagen production, and inflammation, which softens and flattens the scar while relieving pain and itching. However, risks like skin atrophy and hypopigmentation require careful technique. They are often combined with laser or 5-FU treatments to improve outcomes and minimize adverse effects [4,6].

Botulinum toxin injections are an interesting approach to the management of hypertrophic lip scars, acting on the underlying muscle tension that contributes to scar formation and retraction. Studies have shown promising results of botulinum toxin injections in reducing wound tension and improving the appearance of hypertrophic scars after cleft lip repair or revision. This suggests that addressing the dynamic forces acting on the healing wound could be a key strategy in preventing or treating scar retraction on the lip [4].

However, these treatments can be less effective in the dynamic perioral area due to constant movement, higher tension, and risk of functional and aesthetic compromise. A variety of laser modalities are used in the treatment of retracting hypertrophic scars on the lip [7,8]. The pulsed dye laser (PDL) targets blood vessels in the scar, reducing redness and potentially preventing scar growth; it is effective for immature erythematous scars and in reducing scar height and skin tension [9].

Fractional lasers (CO2 and erbium lasers) create microscopic holes (microthermal zones) causing small, controlled areas of heat damage in the scar. These zones trigger the body’s natural healing response, leading to collagen production and remodeling. As collagen rebuilds, the skin becomes smoother, more flexible, and firmer, which helps soften and flatten scars. Fractional lasers are potentially useful for scars that limit movement or have not responded to other methods [10,11].

The Nd: YAG laser is used for the treatment of hypertrophic scars and keloids; this laser allows selective photothermolysis of blood vessels and collagen remodeling [12].

Laser therapy offers a versatile approach to managing hypertrophic lip scars, addressing various aspects of scar tissue, such as vascularity, collagen structure, and surface texture. The choice of laser modality should be tailored to the specific characteristics of the scar. The variety of lasers mentioned (PDL, fractional CO2, Nd: YAG, erbium) and their different mechanisms of action (targeting blood vessels, collagen remodeling, ablation) indicate that laser therapy is not a one-size-fits-all solution; thorough assessment of the scar’s color, thickness, texture, and stage of maturation is crucial to select the most appropriate laser and treatment parameters for optimal outcomes. However, laser therapy risks include redness, swelling, temporary darkening (PIH), or infection, especially if aftercare is not followed properly [7,8].

There is limited high-quality evidence specifically on cleft lip scar treatments, with most data coming from case reports and small case series. Indeed, despite advancements in surgical and laser-based interventions, there remains a paucity of data addressing the management of long-standing cleft scars. Most published studies focused on early postoperative scar modulation or short-term aesthetic outcomes, whereas evidence regarding the efficacy of various treatment modalities in mature, fibrotic cleft scars is limited. Additionally, standardized assessment tools and long-term follow-up data are lacking, making it difficult to establish evidence-based guidelines for optimal therapeutic strategies in these patients. Larger, controlled studies are needed to better understand the effectiveness and safety of different therapies for these scars [7,13]. In light of these considerations, a fractional CO2 laser equipped with a scanner named SCAR3 was developed; this scanner was designed for deep scar repair, as it uses a smaller spot size to enhance laser penetration, thus decreasing the energy emitted by the laser and minimizing the risk of hyper- or hypopigmentation. By enabling CO2 laser energy to reach dermal depths exceeding 1 mm [14], it promotes regeneration of ablated tissue and surrounding thermal zones, supporting neocollagenesis and effective scar remodeling even in thicker scars.

The purpose of this case report is to describe the use of the aforementioned fractional CO2 laser equipped with the SCAR3 scanner for improving a complex hypertrophic cleft lip scar, highlighting clinical outcomes (aesthetic enhancement, psychological well-being, and social reintegration) and treatment considerations.

Case Report

PATIENT INFORMATION:

A 43-year-old woman who underwent 5 operations performed with maxillofacial and plastic surgery from the age of 2 to 12 years old, presented a significant hypertrophic and retracting scar on the left upper-lip, extending from the nasal base to the vermilion border. Scar dimensions were measured with a ruler; the scar measured approximately 30 mm in length and 5 mm in width, with a raised height estimated around 2 to 3 mm, a direct consequence of multiple surgical repairs for a congenital cleft lip and palate. The scar was 17 years old. The scar tissue was hypopigmented and firm to palpation, demonstrating contracture that mildly distorted the normal lip contour (Figure 1A, 1B). Despite previous attempts at scar management (topical emollients and silicone-based products), including unspecified laser treatments approximately 10 years earlier, her scars continued to cause considerable emotional, social, and esthetic discomfort. The patient was a smoker and she appeared to be in good health. Her Fitzpatrick skin type was III, indicating a moderate risk for post-inflammatory hyperpigmentation, which is important to consider when planning treatment. Functionally, she had some restriction in upper-lip mobility and slight difficulty with oral competence; lip mobility was moderately affected in some limited functions (eg, drinking, smoking, and whistling), although she did not report any speech impairment, pain, or itching. The combination of these factors significantly impacts both the esthetic appearance and functional dynamics of the perioral region.

PREPARATION PRIOR TO LASER THERAPY: No systemic antiviral pre-treatment was deemed necessary or administered. No topical anaesthetic was applied prior to the laser treatment with CO2 system equipped with SCAR3 scanner (DEKA M.E.L.A., Florence, Italy). This SCAR3 scanner reduces patient pain and the risk of hyperpigmentation (PIH) while allowing for deeper ablation depths and less energy delivery [15].

LASER TREATMENT: Laser treatment was applied using power 10 W, dwell time 1500 μs, a D-pulse mode (DP), spacing 500 μm, stack 1, and double pass. Two sessions were carried out, spaced 56 days apart: day 0 (session 1) and day 56 (session 2). A follow-up evaluation was conducted 2 months after the second session, corresponding to day 116. Laser setting parameters and protocol are shown in Tables 1 and 2. No complications or adverse effects were observed at either session.

POST-TREATMENT CARE:

After the laser treatment, the patient was instructed to apply an antibiotic ointment twice daily for the first 7 days. Subsequently, she was advised to maintain extreme sun protection during daylight hours and apply a topical silicone product each evening until her next scheduled treatment session.

OUTCOME AND CLINICAL OBSERVATIONS:

During the procedure, the patient reported a perceived pain level of 3 on a scale of 1 to 5, indicating a moderate and tolerable level of discomfort.

Images were captured using a digital camera (SONY Model DSCRX10M3, Japan) before and after the second treatment (Figure 1); photographs were standardized using identical cameras and shooting settings, using the same flash and ambient light.

After the last session, the patient’s level of improvement was assessed using a Modified Vancouver Scar Scale (mVSS) [16,17]. The mVSS was assigned by 1 blinded treating physician.

The mVSS evaluates the scar’s vascularity, pigmentation, pliability, height, pain, and pruritus at baseline and after 2 laser treatments; each parameter was scored from 0 to 3 (higher scores=more severe scarring). To get the final VSS score, the scores from each parameter are added together; the mVSS chart indicates an overall improvement in scar characteristics, especially in pliability, vascularity, and pigmentation, with minimal changes in height; pain, and pruritus levels remained the same as before therapy (Table 3, Figure 2).

After laser treatment, lip mobility improved from “moderately limited” to “not limited”.

Although a topical silicone gel was applied nightly between sessions as part of standard post-laser aftercare, the overall clinical improvement – particularly in scar pliability, vascularity, and pigmentation – is more consistent with the known effects of fractional CO₂ laser therapy. Silicone was used for a short time and was not continued after the final session, reducing the likelihood that it played a significant long-term role in the remodeling process. Furthermore, the relatively rapid onset of changes observed after each laser session aligns with the laser’s mechanism of inducing controlled dermal injury and collagen remodeling. While the contribution of silicone cannot be completely excluded, it is reasonable to attribute most of the observed improvement to the laser treatment itself.

A 5-point satisfaction scale (1: Extremely dissatisfied; 2: Dissatisfied; 3: Neutral; 4: Satisfied; 5: Extremely satisfied) was used. After treatments, the patient was extremely satisfied, with a scale score of 5, and she reported noticeable improvement in scar flexibility and esthetic appearance after treatment with the CO₂ laser and SCAR3 scanner.

No significant adverse effects were observed. Mild erythema and crusting occurred after the procedure, resolving within 5 to 7 days. No edema or post-inflammatory hyperpigmentation (PIH) was noted. She reported having reduced daily activity for about 1 week after each session, with normal activities resumed shortly thereafter.

Discussion

STUDY LIMITATIONS:

The main limitations of the current study include the lack of a long-term follow-up, the absence of standardized outcome measures, and a relatively small sample size. This topic clearly needs further rigorous research, such as larger samples, standardized outcome measurements, and long-term follow-up, to provide specialists with high-quality information to support their treatment decisions. Rigorous and well-designed trials are required to conclusively prove its efficacy in comparison to other treatments, as well as to find ideal protocols in conjunction with other therapies for hypertrophic lip scar retraction.

FUTURE DIRECTIONS:

Further sequential/combined protocols with the use of CO₂, which improves texture and contraction, and pulse dye laser (PDL), which targets and reduce vascularity and erythema, may produce additive or synergistic benefits in scar management.

Conclusions

This case highlights the effectiveness of CO2 laser treatment in managing complex hypertrophic and retracting scars, significantly improving both the physical appearance of the scar and the patient’s emotional well-being. Furthermore, there are no age restrictions for the use of this laser technology for traumatic scar management.