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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1072_Библиотеки_им_академика_М_И_Перельмана
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H. Cartier et al.
vening as quickly as possible, what is gained in
thickness will eventually be gained in less
width.
– Vascular lasers can also be of interest. A recent
study compared the effectiveness of pulsed
dye laser vs pulsed dye laser combined with
ultrapulse fractional CO2 laser in the treatment
of immature red hypertrophic scars [24] (Figs.
22 and 23a, b).
“Fifty-six patients (56 sites) were randomly
divided into a treatment group and control group.
The control group was treated with the 595nm
PDL at a uence of 7–15J/cm2 and pulse widths
of 1.5–3ms, 7mm spot size. The treatment group
was treated with a fractional CO2 laser
(UltraPulse CO2: Deep FX, Energy: 30–50mJ,
Frequency: 300Hz, Density 5%, Scan Shape, and
Spot Size were decided by shape and area of
scar) after utilizing the 595nm adjustable pulse
width PDL (Fluence: 7–15 J/cm2, Pulse:
1.5–3ms, Spot size: 7mm). MEBT/MEBO, previously described as a post-treatment wound ointment, was used after laser treatment. The scars of
the treatment group and the control group were
evaluated for changes in pigment, height, vascularity, and pliability using the Vancouver Scar
Scale (VSS) after two laser treatments.”
Finally, the total VSS score, as well as the
score for melanin, height, vascularity, and pliability in both groups, showed an obvious
decrease following the treatments. There were
statistically signicant differences between
before treatment and after treatment (P<0.05);
however, the total score of the VSS, and score of
the melanin, height, vascularity, and pliability in
the control group decreased more than that of
treatment group, and there was a statistically signicant difference (P<0.05).
The 595nm adjustable pulse width PDL combined with the fractional CO2 laser appears to
have a benecial clinical effect on fresh red
hypertrophic scars, with no severe adverse reactions seen.
Vascular IPL or KTP 532 nm therapy also
offers a safe and effective means of hypertrophic
scar treatment [25, 26]. The settings vary depending on the device.
Fig. 22 Immature hypertrophic scar: combined treatment
with PDL and Laser (AFLCO2) Assisted Drug Delivery
(LADD). Courtesy of Hugues Cartier
Fig. 23 (a) Mixed hypertrophic and keloid scar after an
upper lip resurfacing with Er: YAG laser. (b) Result after
3 sessions of pulsed dye laser (595nm, 6 J/cm2, 1.5ms,
Case 16 Hypertrophic Scar After Wrinkles
Resurfacing on the Upper Lip
See Fig. 23a, b.
spot size 7 mm) and intralesional injection of diluted
injectable corticosteroids, follow-up 18months. Courtesy
of Hugues Cartier
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Keloids
This subject alone could be an entire chapter. The
genetic and topographical context makes its management complex with medical and surgical
advice. Either the scar is surgically removed,
generally intralesionally, or by reducing tension
forces with aps, and the treatment is started
from scratch with rigorous follow-up, which
requires compression and corticosteroid injections for several months (Fig. 24).
Typically, a needle can be used to inject the
scar. However, depending on the scar’s thickness or the difculty of injecting into it, techniques can be used to facilitate the delivery of
corticosteroids. The LADD procedure involves
using a fractional ablative laser, MRF, or simple mechanical micro-needling that creates
deep wells in the skin (laser-assisted drug delivery). The dedicated devices like the mechanical
Dermojet© or the pneumatic needle-less liquid
jet technology injection as Enerjet© are options
to deliver drugs into the skin. The jet disperses
therapeutic substance in the dermis with less
pain (velocity 150 ms) vertically (controlled
depth penetration up to 6 mm) and laterally
(10mm). This technique is used for hypertrophic keloids with injection of drugs as 5FU and
corticoids (Figs. 5a, b and 26a–c).
For atrophic scars, an effect of de-anchoring
the scar base can be achieved by injecting substances like hyaluronic acid, which elevates and
provides support for the scar which has been
raised.
– Pulsed Dye Laser is probably the easiest to
use (Fig. 25a, b). The settings are variable,
with an emission time of 0.45–40ms and an
energy of 6–10J/cm2. Manuskiatti etal. com-
pare these two extreme emission times and
conclude that the volume of keloidal or hyper-
trophic median sternotomy scar segments
treated with 0.45 and 40ms pulses decreases
signicantly after two treatments. Segments
treated with 0.45-ms pulse widths showed sig-
nicantly greater improvement than those
treated with 40-ms pulses after three treat-
ments. The elasticity of the 0.45-ms segments
was notably higher than that of the 40-ms seg-
ments after two treatments. The pulse width
had no signicant effect on the improvement
of scar erythema. Additionally, PDL at 595nm
was safe even in dark-skinned patients [27].
Fig. 24 Keloids: combined PDL and LADD treatment
with triamcinolone acetate under occlusive tape. Courtesy
of Hugues Cartier
Case 17 Chest Keloids
See Fig. 25a, b.
Fig. 25 (a) Just after PDL on keloids setting 595nm, handpiece 10mm 6ms 7J/cm2. (b) No recurrence of keloids 6
years after 3 sessions of combination PDL and TAC injection inside in same sessions. Courtesy of Hugues Cartier
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Comments
For a limited and young keloid, use in a combined treatment with pulsed dye laser and corticosteroids is indicated. The use of pulsed intense
offer them for fear of the risk of radiodermatitis
and its long-term consequences. Focused radiotherapy is now available, and some dermatological centers are authorized to use it.
lights was also documented in these indications.
A ash of external radiotherapy or endocurie
therapy in the immediate postoperative period
can also be very effective but few French teams
Case 18 Classic Abdominal Keloid After
Surgery
See Fig. 26a–e.
cd e
Fig. 26 (a) Classic keloid after abdominal suture in a
patient with a genetic predisposition to keloids. (b) Result
after 4 sessions of ablative fractional Laser in combination
with steroid injection and application under tape every
6 weeks (LADD procedure). (c) Just after ablative CO2
fractional laser. (d) Result after 6 sessions of LADD
(laser-assisted drugs delivery) and 15months follow-up.
(e) The LADD procedure has reduced the thickness and
pruritus and given the patient comfort with a more exible
scar. Courtesy of Hugues Cartier
a
b
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Comments
If the keloid is xed, less inammatory, and
brous, the use of fractionated ablative lasers or
conventional methods to atten or surgically cut
the keloid is possible but the associated use of
corticosteroids will be essential anyway. Some
colleagues combine the injection of corticosteroids (10–40 mg/cc TAC/triamcinolone) and 5
Fluorouracil (50mg/cc) with a dedicated needle
or device to facilitate injection. Other lasers are
tion forces. The high-penetration fractional CO2
laser is a way to gain a few degrees of exibility.
The principle is based on dilaceration of the scar
tissue to make it more exible, but it will not
have the elasticity of normal skin. Some colleagues recommend the combined use of the
fractional CO2 laser and the pulsed dye laser
after surgery for long-lasting results such as ear
keloids after resection [28] (Figs. 27a–c, 28a, b,
29a, b).
useless as their thermal and penetration properties are limited and may even sustain inammation. In another context, wound healing often
responds to surgical intervention to reduce trac-
Case 19 Lobe Keloid in Phototype V,
AfricanType
See Fig. 27a–c.
Fig. 27 (a) Auricular’s keloid, genetic predisposition for
skin phototype V or VI. (b) Debulking of keloids after a
combination of AFL on the basement of the scar, corti-
c
coids, and maintenance by PDL to avoid recurrence. (c)
Result at 9 months without recurrence. Courtesy of
Hugues Cartier
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Comments
For thick or more mature limited keloids:
topical application of TAC is also another
possibility.
excision- basement treatment with CO2 laser
and then prevention of the recurrences by sessions of AFL CO2/PDL followed at once by the
Fig. 28 (a) Treatment combining compression, intra-lesional corticoids, and pulsed dye laser 6.5 days/3 ms then
6days/1.5ms pam 7. (b) Result after 5 sessions and 15months of follow-up. Courtesy of Hugues Cartier
Case 20 Brest Keloid After Mastopexy
See Fig. 28a, b.
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Case 21 Keloid and Hypertrophic Scar of the
Wrist
See Fig. 29a, b.
147
Fig. 29 (a) Fixed old scar of the wrist. (b) Result at
15 months after a combination of fractional CO2 laser
(spot size 120 microns, 1ms time emission, density 5%,
90–130mJ) with in same time 5 corticosteroid procedures
every 2months to ameliorate thickness, roughness, pliability. Courtesy of Hugues Cartier
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Comments
– The role of the CO2 laser is to fragment the
scar brosis. Corticosteroids reduce any
inammatory process resulting from the thermal shock of the laser and cause atrophoderma of the xed scar tissue generating the
mobilization of the wrist movement.
– The alternative of micro-needling with radio-
frequency or fractional Er: YAG is, respectively, limited by the difculty of penetrating
strong brous scar tissue and less laser beam
generation compared to a CO2 laser.
Vascular Scars
The vascular network that appears at the edge of
the scar may be the consequence of repeated use
of corticosteroids but may also appear spontaneously, neoangiogenesis being part of any scarring
process. Neoangiogenesis is often seen after
facelift or reconstructive surgery of the nose.
These vessels are often ne and supercial and
are easily treated with all vascular lasers (Fig.
30a, b).
Case 22 Telangiectatic Network on Both Sides
of the Scar
See Fig. 30a, b.
Fig. 30 (a) Development of telangiectasias on both sides of the frontal surgical scar. (b) Result after a single session
of pulsed dye laser. Courtesy of Francois Will
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Case 23 Chalazodermic Scar
See Fig. 31a, b.
ab
Fig. 31 (a) Old face hemangioma looks like as a chalazodermic scar. (b) Before and after a single session of classic
resurfacing by CO2 laser. Courtesy of Thierry Fusade
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Hyperpigmented Scars [29]
The genesis of hyperpigmentation following a
cutaneous trauma, whether spontaneous, postsurgical, or after an aesthetic procedure, more often
laser or peel, seems to respond to the same physiology: post-inammatory hyperpigmentation
(PIH) and/or lack of sun protection.
In the case of prolonged inammation, a
mechanism of photo-protection with the production of melanin and then the export of melanosomes to neighboring keratinocytes is put in
place. In the case of hyperpigmentation, the melanin can be found in the horny layer but also in
the dermis where it is distributed in extracellular
or intra- macrophagic (melanophagic) lumps: this
is known as pigment incontinence. Pigment
incontinence occurs very frequently in PIH
because there is an alteration of the basement
membrane. However, this varies according to the
initial inammatory process (e.g., lichen where it
is major because the inammatory inltrate nibbles at the membrane).
From a therapeutic point of view, corticosteroids are still the basis of treatment as early as
possible for subjects at risk. Their effectiveness is
explained by their anti-prostaglandin action,
which is involved in the physiological process.
If we can hope for a reduction of a simple
post-inammatory pigmentation spontaneously
in 1 year, it is much more difcult to do so for a
hyperpigmented scar.
As a preventive measure, as demonstrated by
Passeron etal., it is obvious that the scarring area
should be kept away from sunlight and even from
ambient light. It is even more important to avoid
placing patients under LEDs in the blue-violet
spectrum during the healing phase, which would
promote prolonged pigmentation just as much as
UV light and for even longer.
To regulate xed pigmentation, anti- tyrosinase
depigmenting topicals are initially recommended,
with hydroquinone at different concentrations in
classic formulations such as Kligman’s trio. If
hydroquinone, which already has a proinammatory power, is combined with active
ingredients that accelerate cell turnover such as
AHAs or topical retinoids, then care must be
taken not to perpetuate the inammation. It is
therefore necessary to limit their use over time
and adapt their concentration or add corticoids or
alternate with other bleaching ingredients as
kojic acid and azelaic acid with lower risk of
denitive hypochromia.
Depigmenting peels are only the most aggressive version of the use of topicals; it should be
kept in mind that they can themselves induce
reactive pigmentation. Their use should be considered in the light of the pros and cons.
The use of tranexamic acid seems, according
to publications, to be less useful in recent hyperpigmented scars. It is identical to postinammatory pigmentations according to the
experience of some authors, unlike melasma for
which it is increasingly prescribed. It will be necessary to investigate its topical use once the right
formula has been found, as in this form it carries
far fewer risks of side effects.
In the context of lasers, there are very few
publications on the subject because it is necessary to empty the melanosomes without causing
inammation, which would induce an infernal
cycle through a feed-back effect. This is also the
reason why a test area and the very early use of
corticoids are recommended after any kind of
laser, including ablative ones, all the more so as
the phototype is high.
– Few cases of laser-related PIH of the face
were successfully treated by combined ther-
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151
apy with 578-/511-nm copper bromide laser
and light-emitting diodes (LEDs) [30].
– The effect of the different Q-switched lasers
on normal or hyperpigmented skin is comparable; only the depth of penetration varies
according to the equipment used. Because of
the principle of selective photothermolysis,
the damage caused to the melanosomes is
followed by cellular destruction of the melanocytes and keratinocytes loaded with pigments. Histological studies after triggered
laser treatment on normal skin show a correlation between the extent of epidermal
damage and the uences delivered and the
initial level of pigmentation. The anomalies
usually encountered after exposure to triggered pigment lasers are ballooning of melanocytes and keratinocytes. These same
studies have made it possible to determine a
threshold uence. Below this uence, the
destruction of melanosomes is not associated with a joint destruction of melanocytes
and a reactive paradoxical hyperpigmentation may result. Interaction with factors
inhibiting melanogenesis would cause an
increase in tyrosinase activity resulting in an
effect equivalent to that seen in postinammatory hyperpigmentation.
If, however, hyperpigmentation occurs, and
one wishes to propose laser treatment
• Most authors on the subject recommend either
low uence with nano or picosecond triggered
lasers, emitting either at 532 or 694–670nm
(rather in fractionated mode) or at 755nm and
with caution, the one that is most recommended remains 1064 nm, still like the one
with melasma but with a superior benet in
terms of long-term result it seems (Fig. 32a–
e). It is however difcult to give a threshold
uence. Based on data from Asian publications, they are low, often less than 1.5J with a
1064nm nanosecond laser.
– The other range of laser recommended is
based on fractionated non-ablative lasers, also
with low uence, of the order of 15–35mJ/
MTZ for emission durations of less than 3ms,
but with caution and a test area.
– The outsider is the ash lamp or pulsed poly-
chromatic light with a modulation of the spectral band, the number of pulses and interpulses,
and a low uence to avoid any rebound of the
hyperpigmentation. The number of passes
required for improvement can be in the order of
3–5.
– Fractional ablative and non-ablative lasers
also improve the hyperchromy of burn scars
by homogenizing them. Combinations are
also possible, such as a combination of nonablative fractional laser and pulsed light, pigment laser, or pulsed light and peeling.
– Moreover, treatment of laser-induced PIH
remains a challenge. To prevent PIH, especially for skin of color, with AFL prefers a low
density of 1–5% MTZ while keeping the
energy high and the pulse duration time short,
less than 1 ms. Do not forget to use topical
corticosteroids, if necessary, immediately
after the session and for a few days. There is
no longer any risk of causing an infection. The
use of topical or oral tranexamic acid is not
relevant.
– In conclusion, hyperpigmented scars and post-
inammatory pigmentation are treated in the
same way, but with more hope for the latter:
sun protection is always essential, and dermocorticoids should be used at an early stage for
subjects at risk or with a high phototype. The
later we intervene, the more complex the treatment becomes.
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