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Intralesional Therapy
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111
area. The mechanically emulsied autologous fat
referred to as nanofat contains no vivid adipocytes. It retains its regenerative potential because
the stromal vascular fraction (SVF) that survives
the emulsication process contains broblasts,
endothelial cells, pre-adipocytes, vascular smooth
muscle cells, lymphocytes, monocytes, and
ADSCs [20] that are responsible for the proliferative, and subsequent lling effects of nanofat [22].
It has shown remarkable effects in skin regeneration after injection [23] (Figs.6, 7, and 8).
Adverse effects: Donor site hematoma and
irregularities. Oil cysts and calcications.
Variable retention rate and unpredictability of
effect.
Therapeutic application: Use tumescent anesthesia with standard aseptic precaution. The fat
harvesting can be done with one-way harvesting
cannulas or a triport Colemans cannula with Luer
Lock syringes. Leave the aspirate undisturbed in
a vertical position for 15min. Discard the tumescent uid separating on the bottom of the syringe.
The aspirated fat can now be emulsied using a
Luer Lock single or 3-way connector passing
between two syringes 30 times (microfat) or 60
times (nanofat). Sieve the emulsion through a
two-layered moist saline surgical gauze to
remove all solid elements to ensure free ow
through a 27 G needle.
Fig. 6 Deep dermal burn injury at day 7 after mishandled
laser rejuvenation therapy of the face
Fig. 8 Post-therapeutic result after 1cycle of nanofat 1.5. year after the initial injury. Improved quality of the skin and
reversed hyperpigmentation
Fig. 7 Hyperpigmentation and scarring of the skin in this
patient as a residuum of the burn injury 6months after the
trauma
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C. Tschumi and J. A. Plock
Inject intralesionally into the scar using a 27 G
needle. Yellowish blanching of the scar marks the
end point of injection [17].
Clinical Tip
Use nanofat grafting with PRPs in combination with needling or other resurfacing
procedures to achieve best outcomes.
Platelet-Rich Plasma (PRP)
andRelated Treatments
PRP consists of plasma that is enriched with a
high concentration of platelets. The effect of PRP
on scars, atrophic scars in particular, is understood through the release of growth factors.
Furthermore, PRP generates hyaluronic acid,
which is also a promotor of cell proliferation and
extracellular matrix formation in addition to the
known effect of drawing water into the matrix,
causing swelling, volume, and skin turgor. PRP
has been studied mostly as adjunctive therapy to
other treatment modalities like micro-needling
and fractional ablative laser [16].
Conclusion
Intralesional therapy is an established key component in the treatment of abnormal scarring with
proven good results. It can be used in a prophylactic setting or in active hypertrophic scars. In
keloids, a combination of several intralesional
treatments or a multimodal approach can lead to
better results. Always reassess therapeutic success and consider a change or addition to the
treatment in the absence of satisfactory results.
In non-hypertrophic and atrophic scars, autologous intralesional therapy plays an important
and effective role in the correction of contour and
improvement of scar quality and pigmentation.
References
1. 013- 030l_S2k_Therapie- pathologischer- Narben-
hypertrophe- Narben- Keloide_2020- 11.pdf (awmf.
org).
2. Mustoe TA, Cooter RD, Gold MH, etal. International
clinical recommendations on scar management. Plast
Reconstr Surg. 2002;110(2):560–71. https://doi.
org/10.1097/00006534- 200208000- 00031.
3. Schäffer MR, Efron PA, Thornton FJ, Klingel K,
Gross SS, Barbul A.Nitric oxide, an autocrine regulator of wound broblast synthetic function. J Immunol.
1997;158(5):2375–81.
4. Danielsen PL, Rea SM, Wood FM, et al. Verapamil
is less effective than triamcinolone for prevention of
keloid scar recurrence after excision in a randomized
controlled trial. Acta Derm Venereol. 2016;96(6):774–
8. https://doi.org/10.2340/00015555- 2384.
5. Hietanen KE, Järvinen TA, Huhtala H, Tolonen
TT, Kuokkanen HO, Kaartinen IS. Treatment of
keloid scars with intralesional triamcinolone and
5- uorouracil injections—a randomized controlled
trial. J Plast Reconstr Aesthet Surg. 2019;72(1):4–11.
https://doi.org/10.1016/j.bjps.2018.05.052.
6. Kim WI, Kim S, Cho SW, Cho MK. The efcacy
of bleomycin for treating keloid and hypertrophic scar: a systematic review and meta-analysis. J
Cosmet Dermatol. 2020;19(12):3357–66. https://doi.
org/10.1111/jocd.13390.
7. Trisliana Perdanasari A, Lazzeri D, Su W, etal. Recent
developments in the use of intralesional injections
keloid treatment. Arch Plast Surg. 2014;41(6):620–9.
https://doi.org/10.5999/aps.2014.41.6.620.
8. Gupta S, Kalra A. Efcacy and safety of intralesional 5-uorouracil in the treatment of keloids.
Dermatology. 2002;204(2):130–2. https://doi.
org/10.1159/000051830.
9. Zouboulis CC, Blume U, Büttner P, Orfanos
CE.Outcomes of cryosurgery in keloids and hypertrophic scars. A prospective consecutive trial of case
series. Arch Dermatol. 1993;129(9):1146–51.
10. Zouboulis CC. Principles of cutaneous cryosurgery:
an update. Dermatology. 1999;198(2):111–7. https://
doi.org/10.1159/000018084.
11. Gupta S, Kumar B. Intralesional cryosurgery
using lumbar puncture and/or hypodermic needles for large, bulky, recalcitrant keloids. Int
J Dermatol. 2001;40(5):349–53. https://doi.
org/10.1046/j.1365- 4362.2001.01117.x.
12. Har-Shai Y, Amar M, Sabo E. Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids. Plast Reconstr Surg.
2003;111(6):1841–52. https://doi.org/10.1097/01.
PRS.0000056868.42679.05.
Intralesional Therapy
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13. Har-Shai Y, Brown W, Labbé D, et al. Intralesional
cryosurgery for the treatment of hypertrophic scars
and keloids following aesthetic surgery: the results
of a prospective observational study. Int J Low
Extrem Wounds. 2008;7(3):169–75. https://doi.
org/10.1177/1534734608322813.
14. Hoffmann NE, Bischof JC.Cryosurgery of normal and
tumor tissue in the dorsal skin ap chamber: part II—
injury response. J Biomech Eng. 2001;123(4):310–6.
https://doi.org/10.1115/1.1385839.
15. van Leeuwen MC, Bulstra AE, Ket JC, Ritt MJ,
van Leeuwen PA, Niessen FB. Intralesional cryotherapy for the treatment of keloid scars: evaluating effectiveness. Plast Reconstr Surg Glob
Open. 2015;3(6):e437. https://doi.org/10.1097/
GOX.0000000000000348.
16. Gupta A, Kaur M, Patra S, Khunger N, Gupta
S. Evidence-based surgical management of postacne scarring in skin of color. J Cutan Aesthet Surg.
2020;13(2):124–41. https://doi.org/10.4103/JCAS.
JCAS_154_19.
17. Bhooshan LS, Devi MG, Aniraj R, Binod P, Lekshmi
M. Autologous emulsied fat injection for rejuvenation of scars: a prospective observational study.
Indian J Plast Surg. 2018;51(1):77–83. https://doi.
org/10.4103/ijps.IJPS_86_17.
18. Sardesai MG, Moore CC.Quantitative and qualitative
dermal change with microfat grafting of facial scars.
Otolaryngol Head Neck Surg. 2007;137(6):868–72.
https://doi.org/10.1016/j.otohns.2007.08.008.
19. Zuk PA, Zhu M, Mizuno H, etal. Multilineage cells
from human adipose tissue: implications for cellbased therapies. Tissue Eng. 2001;7(2):211–28.
https://doi.org/10.1089/107632701300062859.
20. Frese L, Dijkman PE, Hoerstrup SP.Adipose tissuederived stem cells in regenerative medicine. Transfus
Med Hemother. 2016;43(4):268–74. https://doi.
org/10.1159/000448180.
21. Coleman SR, Katzel EB.Fat grafting for facial lling
and regeneration. Clin Plast Surg. 2015;42(3):289–
97. https://doi.org/10.1016/j.cps.2015.04.001.
22. Rigotti G, Marchi A, Galiè M, etal. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by
adipose-derived adult stem cells. Plast Reconstr Surg.
2007;119(5):1409–22. https://doi.org/10.1097/01.
prs.0000256047.47909.71.
23. Tonnard P, Verpaele A, Peeters G, Hamdi M,
Cornelissen M, Declercq H. Nanofat grafting: basic
research and clinical applications. Plast Reconstr
Surg. 2013;132(4):1017–26. https://doi.org/10.1097/
PRS.0b013e31829fe1b0.
Further Reading
Ren Y, Zhou X, Wei Z, Lin W, Fan B, Feng S.Efcacy
and safety of triamcinolone acetonide alone and in
combination with 5-uorouracil for treating hypertrophic scars and keloids: a systematic review and metaanalysis. Int Wound J. 2017;14(3):480–7. https://doi.
org/10.1111/iwj.12629.
Tonnard P, Verpaele A, Peeters G, Hamdi M, Cornelissen
M, Declercq H. Nanofat grafting: basic research
and clinical applications. Plast Reconstr Surg.
2013;132(4):1017–26. https://doi.org/10.1097/
PRS.0b013e31829fe1b0.
Wong TS, Li JZ, Chen S, Chan JY, Gao W.The efcacy of
triamcinolone acetonide in keloid treatment: a systematic review and meta-analysis. Front Med (Lausanne).
2016;3:71. https://doi.org/10.3389/fmed.2016.00071.
Lasers andEnergy-Based Devices
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inScar Therapy: APractical Use
HuguesCartier , FrancoisWill, ThierryFusade,
andHans-JoachimLaubach
Abbreviations
2940nm, Er:YAG Erbium:YAG (yttrium-alu-
minum-garnet) laser
AFL Ablative fractional laser
BED Biologically effective dose
DCD Dynamic cooling device
EBD Energy-based devices (EBD)
HIFU High-intensity focused
ultrasound
IPL Intense pulsed light
Ktp Crystal titanyl phosphate de
potassium
LADD Laser-assisted drug delivery
LEDs Light-emitting diodes
LIOB Laser-induced optical
breakdown
MMPs Collagenase-type
metalloproteinases
MMPs Metalloproteinases
MRN, MRF Radiofrequency micro
needling
MTZ Microthermal zone
NAFL Non-ablative fractional laser
H. Cartier (*)
Arras, France
F. Will
Brumath, France
T. Fusade
Paris, France
H.-J. Laubach
Strasbourg, France
Nm Nanometer
Ns, nano Nanosecond
PDL=LCP Pulsed dye laser (p135,
PIH Post-inammatory
Ps, pico Picosecond
QS Q-switched
RF Radiofrequency
SOC Skin of color type
TAC Acetate of triamcinolone
tca Trichloroacetic acid
UV Ultraviolet
VSSS Vancouver scar scale score
Introduction
Each scar is unique; it is this diversity that makes
the issue so complex and so simple to manage! In
most cases, the evolution of a process is normal,
and it is necessary to explain to the patient that it
takes time, generally from 6 to 18months.
form and evolution, its mode of occurrence, its
topography and on whom it forms, and much
more like the habits of sporting life are so much
data to be considered as a challenge for the laserist doctor.
one way to improve a scar. But they are part of a
switch LCP French wording
for PDL)
pigmentation
The analysis of the scar prole according to its
Lasers and all other available devices are only
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
S. P. Nischwitz et al. (eds.), Scars, https://doi.org/10.1007/978-3-031-24137-6_11
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H. Cartier et al.
combination with the other techniques developed
in the other chapters.
The psychological experience of a scar must
also be considered, especially as the “miracle of
the laser” can sometimes disappoint the patient.
Therefore, “Primum non nocere,” not all scars
should be treated by laser.
We wish to be as synthetic and practical as
possible in the development of this chapter with a
certain bias that may be subject to discussion.
Thus, we will review the available devices and
the therapeutic proposals for scars of less than
100days and more than 100 days and of course
acne scars. Why 100days or around 3months is
a bias but also a clinical observation beyond
which a healing is on the right way or not and
when patients usually wish to intervene because
the scar does not disappear as they would like. Of
course, it is possible to intervene at other times in
the life of a scar because in most cases, everything happens according to the normal evolution
of a healing process.
Laser andOther Electromagnetic
Devices
A distinction is made between photonic devices
and other devices that deliver a direct heat source
without targeting a particular tissue.
A LASER is dened by its wavelength, which
is monochromatic photon emission (Light
Amplication by Stimulated Emission of
Radiation). The laser emits light that is absorbed
by three essential skin targets: pigment, vascular,
i.e., everything that is red, and water. The beam
of photons emitted by the laser, like all other
electromagnetic sources, is converted into heat or
thermal effect by the target. Nevertheless, there
are radiation effects: photocoagulation, photo
thermolysis, photoacoustic, and photoablation.
It is important to remember that the thermal
energy released will alter the skin tissue and
induce its remodeling and structural modication. In this respect, the ratio of delivered energy,
wave penetration, and duration of the thermal
effect is also important to obtain the desired
result.
It should also be kept in mind that a laser or
other sources penetrate deeply into the skin. This
is an essential element to consider because if you
have a thick scar and the photons remain on the
surface, there will be a minor impact in the long
term. But this penetrance must be correlated to its
absorption in the tissues that stop and absorb the
waves. This is the anisotropy that is very variable
according to the nature of the scar tissue and the
color of the skin.
Laser
Ablative Laser, Ablative Fractional
Laser (AFL)
There are two possible wavelengths CO2
(10,600 nm Fig. 1) and Erbium:YAG laser
(2940nm, Er:YAG=yttrium-aluminum-garnet).
These two lasers have the function of vaporizing,
coagulating, and remodeling skin tissue.
Depending on their mode of operation, they can
abrade a surface for a classic mode-locked mode
for a resurfacing or in a fractional mode but with
a variable density of MTZ (microthermal zone)
to create thermal columns whose density, size of
the points, and depth of penetration are function
of each indication: retractile or mature scar, drug
delivery (laser-assisted drug delivery=LADD).
The difference between these two wavelengths
and their use is a matter of debate for the respec-
Fig. 1 CO2 handpieces: continuous wave with 3 spot
sizes and scanner system (spot size 120 microns, density
3–5–10%, energy 10–150 mJ, variable emission time).
Courtesy of Hugues Cartier
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tive users. Simply put, the CO2 laser induces
greater and more penetrating thermal damage
while the Er: YAG laser induces a gentler and
more precise dermabrasion.
In fractional mode, the dots or spot size of a
CO2 laser can vary in diameter from 120 microns
(max depth 3.5 mm) to 1.3 mm (max depth
0.3mm). You can use both for a remodeling and
a resurfacing combination in the same session but
with a higher risk of side effects (Fig.2).
The Er: YAG laser is not very coagulant, even
though its emission time can be modulated to
Fig. 2 Fractional emission for a laser CO2 with micro-
beams spot size 180 microns, and 0.4mm between each
MTZ. Courtesy of Hugues Cartier
1500 μs. It is also possible to stack the shots with
variable uence or time emission to combine
thermal and penetrating effects (max depth
1.5–2mm).
These two lasers abrade or reshape scars pro-
le by breaking the collagen bers. The resurfacing mode with these two lasers is also possible,
which leaves no space in the healthy skin and is
particularly effective, but with variable effects in
terms of healing, from 5 to 10days.
In fractional mode, as a creation of spaced
skin wells, healing is faster than in resurfacing
mode (Fig. 3). This often requires several sessions to obtain a result, but they also allow the
penetration of active ingredients such as corticoids, which are particularly useful for highly
inammatory, hypertrophic, or even keloid scars.
The procedure is called laser-assisted drug delivery (LADD) [1].
The optimal depth is difcult to determine
because studies report that drug deposition
depends on both the anisotropy of the scars and
skin areas, the laser sequences, the type of AFL
and the drugs. The increasing laser uence and
irradiation time will increase cellular uptake of
large molecules through the skin in a dosedependent manner, but it is not that simple. If the
barrier of the thermal columns is too coagulated,
or if the drug applied is too late after the session,
the drugs will not be able to penetrate. Similarly,
drugs diffusion is also variable depending on
their intrinsic nature.
Fig. 3 Microbeams of
AFL irradiation induce
MTZ rankings from
classically 100 to
300μm but until
1.25mm diameter.
Holes can extend down
to the deep reticular
dermis. Courtesy of
Hugues Cartier
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H. Cartier et al.
The parameters of these devices vary, and
we can only advise you to follow the settings of
the laboratories or those of the publications
which refer to them. To reshape a scar, it is necessary to penetrate to an estimated depth of
50–75% into the thickness of the scar 4a, b and
5a–d.
There are no standardized settings but Matteo
Clementoni recommends to keep the following
in mind:
– The thicker the lesion, the higher the energy
will be.
– The higher the energy is, the lower the density
will be.
– In a thick retractive bundle, consider different
directions of the shots.
– Consider multiple passes instead of increasing
the density of the shots.
Case 1 Post Hemangioma Scar of the UpperLip
See Fig. 4a, b.
– A pinpoint bleeding is a good endpoint (if the
time emission of a CO2 is less than 1 ms).
– For a collagen remodeling and to avoid a sur-
rounding burn to the scar, reduce energy if you
see a skin contraction.
– Consider a supercial fractional ablation to
improve the aesthetic appearance.
– With a supercial handpiece use very low
energy and high frequency to sculpt the supercial irregularities or prefer the use of Er:
YAG to CO2.
When applicable, the combined-mode Er:
YAG + CO2 can offer synergistic benet of ablative and coagulation effect. However, it is difcult to determine superiority between modalities
due to the clinical heterogeneity, settings, combination, and lack of comparative study design.
Fig. 4 (a) CO2 resurfacing of hemangioma sequelae in a single session. (b) Outcome maintained 3 years after.
Courtesy of Thierry Fusade
cd
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Case 2 Atrophic and Pox Scars with Large
Pores
See Fig.v.
119
a
b
Fig. 5 (a) Acne scars with large pores. (b) Just after a rst
session ablative Er:YAG 10J/cm2, 1000μs. The epidermis
and dermis are completely removed down to the base of
the scars. Of course, it is necessary to evaluate this depth
visually in order not to obey the healing process. Bleeding
is a sign that the papillary dermis has been touched. (c) Just
after the fractional CO2: 150 mJ-200Hz-density 5/9-spot
size 1.25 mm. Although this is a fractional mode, the
impacts are wider (1.25mm) and not as deep (120μm estimated depth) as the classic fractional mode with small
MTZ mode (120–300μm). In this case, the skin debris is
not wiped off, but left as is by applying a protective healing
ointment such as Vaseline. (d) Final result 4years after 3
sessions of ablative fractional and two non-fractional laser
(CO2+Er:YAG). Courtesy of Hugues Cartier
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Comments
There were clear improvements in the textural differences but it needed numerous sessions to
reduce scars and dilated pores. The risk of permanent hypochromia must also be taken into account.
And too high a uence, too long a shooting time,
and too high a density can induce this secondary
Fig. 6 Laser beam emission by a scanning procedure of a
NAFL, Er:glass 1565nm with variable settings (uence
70 mJ maximum, time of emission variable function of
the spot density, density 100–500 MTZ/cm2). A slight
swelling is already visible. Courtesy of Hugues Cartier
effect. The debate is open to consider that one or
two aggressive sessions are better than several
accumulated sessions. It is a balance between the
variable healing effects of thermal aggression and
the risk of causing hypochromic scars.
Non-ablative Lasers
Non-ablative Fractional Laser (NAFL)
The modeling of NAFLs is described in the
Princeps Publication [2].
There are two main types of laser: the
erbium- glass, 1540–1550–1565 nm, and the
Nd: YAP laser, 1340nm. They act in a fractionated mode with a variable pulse time, density,
and size of points. Due to the thermal columns
they induce, the photons penetrate between 1
and 2 mm, allowing scar remodeling without
creating skin vaporization. Unlike ablative
lasers, there is therefore no scar desiccation
phase (Fig. 6). There is no crust, and the healing time is short, less than 48–72h with slight
skin swelling and redness for a few days (Fig.
7a, b).
Case 3 Mature Hypertrophic Acne Scars
See Fig. 7a, b.
Fig. 7 (a) Hypertrophic mature acne scars of the chin. (b)
After three sessions, 6weeks apart, of NAFL, Nd: YAP
1340nm (100 MTZ/cm2, 130 mJ, 3–5ms). Reduction of
skin surface with low downtime, no crust. Courtesy of
Hugues Cartier
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Comments
Non-ablative fractional lasers have the advantage of minimal postoperative effects with light
swelling and redness for a few days. There is no
crusting and the risk of infection is minimal.
They are increasingly proposed before ablative
lasers even if the result is much more progressive and sometimes in plateau after a few sessions. New device combines AFL and NAFL in
the same session, by example CO2 plus 1570nm
and ultrasound but we need more data to
conclude.
Non-ablative, Non-fractional Laser
The 1210nm diode laser is the main one. To our
knowledge, it is the only one in its category
developed and used immediately after a surgical
suture. Its particularity is its portability (750g),
and the complete automation of its settings to
heat a skin surface of 2cm2 per shot always at the
same temperature (maximum 53 °C) automatically matching the skin heat in contact with the
handpiece.
The wavelength allows us to treat all skin colors. It is advisable to use only colorless threads
under the skin (external threads are not, however,
contraindicated) so as not to concentrate the photons on colored threads, particularly black ones.
Indeed, this can create heat points that are harmful to a fresh scar.
Vascular Lasers
The so-called vascular lasers focus on the vascular network. Apart from a hypochromic and atrophic scar, these lasers are useful alone or
combined to reduce an inammatory process or a
scar that remains red, the result of a dilated vascular network.
Pulsed Dye Laser 595nm (PDL)
The rst pulsed dye laser emitted at 585nm, systematically inducing purpura, i.e., photothermolysis of the vascular network. The latest
generations emit 595nm for a higher penetration
(estimated 1–2 mm) and can vary the emission
time in photothermolysis or photocoagulation. In
the rst case, the privileged target remains the
vascular pattern. The purpura is caused by damaged vascular walls. The settings range is in
between 0.5 and 6ms: 6 and 10J/cm2, with variable spot size 5–10mm, considered as an intermediate sub-purpuric mode.
In the second case, as the emission time is
longer (beyond 6ms), there is no or very little
purpura but a thermal effect which can be interesting also in a scarring process in progress or
for vessels of diameter greater than 1mm (Fig.
8a, b).
It is necessary to integrate the adjustment of
the delivered energy which varies the target effect,
the thermal effect, and the penetrance of the photons. The aim of vascular lasers and particularly
the pulsed dye laser is to destroy capillary destruction, generate hypoxemia, and reduce collagen
production. In fact, it is not so simple because
these lasers promote the production of neocollagenesis, break brous bridges by the intrinsic
photonic effect, and release collagenase- type
metalloproteinases (MMPs). What is paradoxical
is that eventually, despite the inammatory cascade that it provokes, the scar does not suffer from
a laser burn [3].
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