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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_198_библиотеки_им_акад_М_И_Перельмана
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https://t.me/med1917
Case 4 Hypertrophic Scar of the Upper Lip
See Fig. 8a, b.
H. Cartier et al.
ba
Fig. 8 (a) Hypertrophic scar after cleft palate repair. (b)
Result 1 year after 2 PDL treatments, 6weeks apart (6J/
cm2, 1.5ms), associated with 10days of corticoids cream
and silicone tape xed during the night for 3 months.
Courtesy of Hugues Cartier
Lasers andEnergy-Based Devices inScar Therapy: APractical Use
https://t.me/med1917
Comments
– The pulsed dye laser is the gold standard of
vascular lasers. Initially used for angiomas
from birth, it can be equally useful for vascular or inammatory scars with a minimal risk
of burning.
– For skin of color type (SOC), patients have
more melanin in their epidermis. This melanin
can act as a competing target chromophore
for hemoglobin, causing an increased risk of
adverse effects. Higher uence may be necessary to produce the expected clinical
endpoint.
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For a diffuse redness in SOC, a non-purpuric
approach (e.g., 5J/cm2, 12mm spot size, 0.45ms,
DCD 40ms before/20ms post cooling cryogenic
system) is recommended for an immediate vessel
disappearance without purpura.
For large vessel in SOC: large spot, 10/15J/
cm2, 10ms, DCD 40/20 ms for a same clinical
endpoint.
KTP 532nm
The KTP 532 laser is the competitor of the pulsed
dye laser. The short wave penetrates only slightly
less than the pulsed dye laser. It has an afnity for
both the vascular network and the pigment. It is
therefore necessary to be careful when using it on
tanned skin or on skin with a phototype above III
on the Fitzpatrick scale. The new generations of
this type of laser also allow photocoagulation and
photothermolysis modes.
Yellow Laser 577nm and589nm
These two wavelengths are those best absorbed
by hemoglobin. They are therefore an intermediate between the KTP laser and the pulsed dye
laser. And even if there are few publications for
the treatment of scars, there is no reason to
believe that they cannot reduce vascular redness.
However, they do not cause purpura.
Fig. 9 Laser beam of a Nd-YAG 1064 nm, classic settings to treat active acne scar or inammatory scar: 0.3–
0.5ms, 3–5 J/cm2, fast motion of a laser beam scanning
procedure to obtain a thermal effect close from 52 °C.
Courtesy of Hugues Cartier
Nd: YAG 1064nm Long Pulse andNd: YAG
1319nm
These two lasers do not emit the same wavelengths but are still in the infrared range.
Nevertheless, their indications are in the same
range. They aim to remodel scar tissue, even if it
is more than 3–4mm thick, and have a signicant
thermal effect. The Nd-YAG laser, however, has
the characteristic of being able to photocoagulate
large vessels beyond the millimeter. It can be
used point by point or in scanning mode to accumulate this thermal effect to promote red scar or
remodeling to give for exibility. For Nd: YAG, a
low uence less than 5 J/cm2 and an emission
time between 0.3 and 0.5ms are recommended
for skin tightening (Fig. 9). Devices have a thermal sensor that continuously calculates the skin
surface temperature, which should be stable at
around 52°C, but it is difcult to know for how
long you should maintain this thermal level.
A more classic setting is also possible but
variable according to the publications by example for hypertrophic and red scars: spot diameter
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H. Cartier et al.
5–10mm, time per pulse 25–60ms, energy density between 10 and 75 J/cm2 and two to three
passes every 2–4–6weeks between each session
until an efcacy [4, 5].
The decision between the two modes is empirical but it is important to avoid accumulating too
much energy which will cause immediate whitening, signaled by a thermal burn.
Q-Switched Nanosecond andPicosecond
Laser
Several wavelengths are available: 532, 755,
585–650–694, and 1064 nm. The characteristic
of these lasers is that they emit phenomenal pho-
toacoustic energy in an extremely short time, 300
picoseconds to 50 ns depending on the device.
Initially used for tattoo removal, they are also an
indication for pigmented scars, to a certain extent
post-inammatory or post- inammatory pigmentation (PIH), collagen remodeling in scanning
mode or a fractional MLA mode as the LIOB
procedure (laser-induced optical breakdown),
and of course for tattooed scars from traumatic
exogenous pigments (Fig. 10a–d).
Case 5 Acne Scars, Ice Pick Scars, and
Dilated Pores
See Fig. 10a–d.
dc
Fig. 10 (a) Acne scar and ice pick scar. (b) Petechial and
erytheme jaust the use of the Q-switched laser 1064nm in
a stacking mode (8 J/cm2; spots size 3 mm, 5 ns). (c)
Result after three sessions 1 month apart. (d) Permanent
result 4years after. Courtesy of Hugues Cartier
Lasers andEnergy-Based Devices inScar Therapy: APractical Use
https://t.me/med1917
Pulsed Polychromatic Light
Pulsed polychromatic light, ash lamp, or
intense pulsed light (IPL) has the main characteristic of emitting photons of multiple wavelengths (Fig. 11). The spectral band is therefore
wide, from 400 to 1200nm, but the use of lters
allows a contingent of photons to be ltered. The
Intense Pulsed Light is indicated for acne, vascular, inammatory, and pigmented scars [6] (Fig.
12a–d). It can be combined in the same session
with photoacoustic or non-ablative lasers.
Fig. 11 Sample of IPL handpieces with the choice of the
ltering system and the contact spot size. Courtesy of
Hugues Cartier
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Case 6 Acne Conglobata
See Fig. 12a–d.
H. Cartier et al.
Fig. 12 a) Case 6 Fulminant acne treated by a combina-
tion of steroids, isotretinoin 5 then 10mg/day + macrolides + metronidazole and emptying of abscess cysts. (b)
Drying of cystic lesions but scarring may develop
2months after. (c) After 4 months of the beginning of the
treatment, 10 IPL sessions will be programmed over
15months: 515 and 550nm, 10J/cm2, double pulse 5ms
interpulse 10ms. (d) Stabilised result at 30months, the
patient has received 9months of isotretinoin at an average
dose of 10 mg per day while being treated by IPL.
Courtesy of Hugues Cartier
ab
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Light-Emitting Diodes (LEDs)
The use of LEDs can also respond to the management of a healing process [7]. It also responds to
eterious effect except in the blue-violet (<450nm)
range. This spectral band can in fact prolong postinammatory pigmentation (Fig. 13a, b).
the choice of wavelength. In most publications,
for inammatory or recent scars, 630 nm is the
rst choice with infrared 850nm. However, their
benet is the subject of debate. They have no del-
Fig. 13 (a) Fresh forehead traumatic scar. (b) Dramatical improvement after 3months and 15 sessions of red 633nm
and infrared 850nm LEDs: 20J/cm2, 15min each. Courtesy of Hugues Cartier
Case 7 Recent Traumatic Scar After
Corrective Surgery
See Fig. 13a, b..
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Comments
The patient was hospitalized for a month, and we
took advantage of this to offer her mixed LEDs
every 2 days, always in combination with the
classic postoperative healing procedure. We were
surprised by the result and the textural quality of
the scar. The choice of parameters and the number of sessions were empirical but there were no
side effects.
Radiofrequency
Radiofrequency delivers only a thermal effect,
unlike lasers.
Contact Radiofrequency
Contact radiofrequency by regular scanning
allows mechanical remodeling while delivering
heat, which we try to stabilize at around 50°C
thanks to thermal sensors. This is the same principle of infrared heat accumulation as the
Nd-YAG 1064 laser.
Fractional Radiofrequency
This involves dozen electrodes applied in contact
with the skin to cause surface thermocoagulation
to regenerate it. It acts on less than 1mm of skin
thickness.
Radiofrequency withMicro-Needles
(MRF)
This is like fractional ablative lasers. Physically,
these are polarized needles that penetrate between
0.5m and 4mm deep to create thermal columns
to fragment and remodel brosed or atrophic skin
tissue (Fig. 14a–c).
There is a choice between insulated and unprotected needles. In the rst case, only the tip will be
able to deliver its full thermal energy. Depending on
the thickness of the scar tissue, it will be necessary
to make several passes to treat the entire scar volume. In the second case, the whole needle delivers
this energy. This is also a source of discussion as to
the possible choice. Note that needles can become
damaged and blunt more quickly if the scars are
very dense, unlike fractional ablative lasers.
Lasers andEnergy-Based Devices inScar Therapy: APractical Use
https://t.me/med1917
Case 8 Fibrous Neck Acne Scar
See Fig. 14a–c.
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a
b
c
Fig. 14 (a) Fixed acne scar with brous tissue. (b) MRF
(microneedle radiofrequency). Between 8 and 64 needles
can penetrate simultaneously the skin depending on the
device with a depth between 0.5 and 4 mm. (c)
Improvement with a structure and texture modication
after three sessions 2months apart. Courtesy of Hugues
Cartier
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Other Waves
Shock Waves
Focused Ultrasound
These waves are focused according to the transducers used to create skin fusion points at more
than 70°C instantaneously: 1.5, 3.5, and 4.5mm
deep. High-intensity focused ultrasound (HIFU)
is indicated for skin tightening and slackening.
With the skin relaxation due to aging, the visualization of a scar is reaccentuated, and HIFU
could help to reduce scar.
Mechanical Devices andOther
Sources ofHeat
Micro-Needling, Mechanical Subcision,
andScar Raising withPunch Biopsy
This is outside the scope of lasers and other
waves, but mechanical techniques still can be
used in the management of deep scarring, atrophic and mature scars (Fig. 15a–d).
They are not associated with a thermal effect
and can be used without risk for scars on all phototypes [8].
Case 9 Acne Scar and Micro-Needling
See Fig. 15a–d.
Fig. 15 (a) Atrophic acne scar, phototype VI. (b)
Bleeding effect just after micro-needling. (c) Result after
two sessions of micro-needling and llers injection with
hyaluronic acid. (d) Result 2 years after the last session
with the re-appearance of scars. Courtesy of Hugues
Cartier
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Cryotherapy andRadiotherapy [9–10]
These two techniques are indicated for xed
keloid scars or after surgical removal of a keloid
to avoid recurrence. Depending on the country,
endocuritherapy is preferred by introducing an
iridium thread into the keloid or now there is a
focused cutaneous radiotherapy device that
avoids the need for treatment in a leaded room in
a radiotherapy center, which is normally the only
one authorized to provide this type of radiation.
The only system is SRT-100™ (Sensus
Healthcare, Boca Raton, Florida) using a biologically effective dose (BED) of 30Gy with irradiation scheme of three 6Gy SRT treatments on
Days 1, 2, and 3 following surgeries.
Cryosurgery without and with intralesional
corticosteroids is effective and safe on young and
small keloids not only as a destructive physical
procedure but also by inducing biochemical and
immunological scar rejuvenation.
Lasers in Surgical Scars
There is increasing evidence of the effectiveness
of lasers, light-based devices, and others energybased devices (EBD) in the postsurgical healing
process. These different treatments occur at various times before or after surgery [11].
The Day Before Surgery withNonablative Fractional Laser
The concept of being able to treat a scar increasingly quickly stems from the work of Haedersdal
etal. A single NAFL treatment at low to medium
uence performed 1 day prior, or in the early
phases of wound healing, may have the potential
to optimize scar formation in full wounds without
side effects including dyschromia. It was a randomized, controlled, intra-individual trial with
Erbium-glass 1540 nm NAFL versus no laser
treatment on 16 subjects receiving 10 standardized
full-thickness punch biopsy wounds. A single
NAFL exposure has been assessed 1day before
the biopsy, immediately after, and 2weeks after.
Three uence levels provided deep and supercial
energy depositions (range 30–70mJ/microbeam).
The results show that biopsy scars are invisible if the area is laser treated the day before the
biopsy [12]. In clinical practice, treatment 24h
before the operation may be of interest [13].
Laser asanEarly Procedure During
Surgery
Automated Laser Diode 1210nm [14]
The Laser-Assisted Skin Healing treatment
induces a controlled heat stress that promotes tissue regeneration. This comparative trial is the
rst to evaluate the performance of a new automated 1210-nm laser system, compatible with all
Fitzpatrick scale phototypes. The horizontal
sutured incision of one breast was treated with
the portable 1210-nm laser while in the operating
theater. The other breast was used as the study
control. Finally, at 24weeks, the treated side had
a 36% (p<0.038) reduction in scar volume compared to the control group. At 52weeks, there
was a 29% (p=0.004) reduction in volume, an
11% (p = 0.017) reduction in scar area, and a
17% (p=0.002) improvement in the smoothness
(roughness) of the scar compared to the control
group. This procedure in facial skin surgery must
benet from more practical applications, but it is
used for long scars of the body (Fig. 16a–d).
Result: Taking action at the end of the intervention is a promising way forward with limited
risk. Courtesy of Francois Will
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