Treatment of Trapdoor Deformity Using Erbium-doped Yttrium Aluminum Garnet Laser

Trapdoor deformity, a phenomenon of outward bulge of tissue centrally due to concentric retraction of a curved scar peripherally, may occur after surgery and present a therapeutic challenge.¹ Trapdoor deformities located on cosmetically sensitive areas like the face can often negatively impact patients’ psychosocially wellbeing and quality of life. Numerous surgical and nonsurgical approaches—such as corticosteroid injections, subcision, surgical debulking, peripheral undermining, and reorientation—have been utilized with variable results and recurrence may occur.^1,2 Although surgical correction can be definitive, patients prefer rapid treatment without the need for additional surgery and lengthening of scars.² Here, we report a simple, nonsurgical treatment using a 2,940-nm, non-fractionated, Erbium-doped Yttrium Aluminum Garnet (Erbium:YAG) laser to rapidly improve postsurgical trapdoor deformities.

Facial trapdoor deformities were treated with Erbium:YAG laser (BURANE XL, Alma Lasers, Buffalo Grove, IL at settings of 3.0 mm and 13 J/cm² or Joule, Sciton Inc, Palo Alto, CA at settings of 2–4 mm and 10 μm/pass) without thermal coagulation to ablate into the superficial dermis and flatten the protruded area until it is no longer elevated compared with the surrounding tissue. The curved depressed scar was additionally treated to better blend the borders of the scar with surrounding normal skin. Anesthesia was achieved with local infiltration using 1% lidocaine with epinephrine. The treatments were performed in a clinic setting and can be completed in under 5 minutes with patients tolerating the procedure well. Postprocedural wound care involved cleansing the treated area with mild soap and water, gently patting the area dry, application of petrolatum-based ointment, and covering with nonstick gauze twice daily until complete reepithelization of the treatment area, which takes ~5–7 days.

The majority of patients experience significant and durable improvement of the trapdoor deformity after 1 treatment with high satisfaction without recurrence or significant side effects (Fig. 1). Some patients may require an additional laser treatment 1–2 months later to further correct any contour irregularities. Patients typically experience minimal to no pain and mild oozing for ~12 hours afterwards. Postprocedural erythema may last several weeks after reepithelization but can be easily covered with makeup or treated with vascular lasers.

Fig. 1.: A patient with trapdoor deformity on the nose before (A) and 6 weeks after (B) one Erbium: YAG laser treatment.

Erbium:YAG laser resurfacing has been effectively utilized to treat both depressed and elevated surgical, acne, and traumatic scars. This technique to treat trapdoor deformities have been safely and successfully used in our practice for many years with high patient satisfaction. Advantages of this technique include that it can be completed in minutes under local anesthesia in an office-based setting and its unique ability to simultaneously address elevated and depressed contour irregularities in addition to texture and color mismatch. The procedure can be repeated as needed to achieve the desire cosmetic outcome, which is long-lasting once achieved. In summary, Erbium:YAG laser ablation represents an effective, nonsurgical treatment option for correcting trapdoor deformities that is well tolerated by patients with minimal recovery in a single treatment. However, as with any surgical technique, the ultimate outcome from the treatment depends on the operator’s experience and training in the procedure.