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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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Case 24 Hyperpigmented Scars of the Nose
See Fig. 32a–e.
a
H. Cartier et al.
c
d
e
Fig. 32 (a) Old and ded hyperpigmented traumatic scar
of the nose. (b) Just after the rst session of Q-switched
laser 532: 0.8J/cm2, 5ns. (c) Disappointing results after
the rst session of Q-switched 532 laser. (d) Just after
with higher energy 3 J/cm2 than the previous settings,
5ns, spot 4mm plus betamethasone cream twice a day
10days. (e) Dramatical improvement after 3 sessions after
Q-switched 532nm laser. Courtesy of Hugues Cartier
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Hypopigmented Scars
After a suture or a deep burn, it is usual to observe
a denitive achromy due to the lack of hair follicles present in the depths, reservoirs of
melanocyte stem cells, which allow pigmentary
resurgence. But if there are still some stem cells
capable of differentiating into melanocytes, they
retain the ability to form melanin when they
a
migrate to the hair bulbs or to the epidermis,
which still allows repigmentation. Although there
are no more melanocytes in black skin than in
white skin, the melanosomes are larger and more
numerous, and more mature, i.e., more “reactive”
(Fig. 33a–c).
Case 25 Forehead Traumatic Scar
See Fig. 33a–c.
b
c
Fig. 33 (a) Hypochromic forehead scar. (b) Three weeks after Erbium: YAG dermabrasion. (c) Results 5 years after a
single session with almost complete recovery of the hypochromy. Courtesy of Hugues Cartier
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H. Cartier et al.
Thus, when faced with a so-called mature scar
made up of xed tissue, as the achromy appears
well after 3 months, it is extremely difcult to
recolor naturally.
There are nevertheless several strategies if we
think that there may be a few melanocytes or
stem cells left in “disarray” capable of differentiating into melanocytes, particularly in burn scars,
and we can try to stimulate them.
- Moderate sun exposure (like vitiligo, these
areas are more “sensitive” to UV rays) and the
use of localized phototherapy by laser or 310nm
excimer lamp can be effective, but patience is
required and at least 6 months are necessary
before any results are obtained, which must be
maintained at least at the beginning.
Techniques are often combined for better
results
• Ablative lasers, particularly fractionated or
micro-needling, have their place. It has been
shown that these ablative techniques can stimulate cell differentiation pathways and lead to
the reappearance of hair and/or sweat appendages in old scars.
After failure of these techniques or if it is
thought that there are no cells that can be stimulated, always in association with phototherapy or
natural heliotherapy, attempts at melanocyte selfgrafting should be made. The laser group of the
French dermatology society had conducted a prospective study proposing, in hypopigmented
scars, the combination of an ablative laser and
autografting by spraying a melanocyte suspension obtained with the Viticell© kit from
Genevrier. The results were very inconsistent
because the grafting of these particularly fragile
cells was not obvious on scar tissue and brous,
not very conducive to cell migration unlike vitiligo where this technique is effective (Fig.
34a–g).
Medical dermopigmentation is a risk-free
indication that satises numerous patients, particularly in the reconstruction and pigmentation
of the areola.
a
b
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Case 26 Hypochromic Scar, Fibrous Tissue
Forearm
See Fig. 34a–g.
155
c
d
e
f
g
Fig. 34 (a) Melanocytic grafts after scarring of the fore-
arm. (b) Result 7months after the transplant, slight reduction in pigmented areas. (c) Skin grafting before chemical
separation to recover suspended melanocytes by the
Viticell© process. (d) The grafted area is rst prepared by
gentle abrasion with a CO2 or Erbium: YAG ablative laser.
(e) The grafted area is rst prepared by supercial abrasion
with a CO2 or an Erbium: YAG laser. (f) The objective is
simply to prepare the area to be grafted by removing the
epidermal layer and the supercial dermis. If the abrasion is
too deep, the melanocytes will not be viable. (g) Deposition
of the melanocyte suspension on the area to be grafted,
which has been previously abraded. This deposit will be
maintained in place by an occlusive dressing for 5days. (a)
Melanocytic grafts after scarring of the forearm. (b) Result
7months after the transplant, slight reduction in pigmented
areas. (c) Skin grafting before chemical separation to
recover suspended melanocytes by the Viticell© process.
(d) The grafted area is rst prepared by gentle abrasion with
a CO2 or Erbium: YAG ablative laser. (e) The grafted area is
rst prepared by supercial abrasion with a CO2 or an
Erbium: YAG laser. (f) The objective is simply to prepare
the area to be grafted by removing the epidermal layer and
the supercial dermis. If the abrasion is too deep, the melanocytes will not be viable. (g) Deposition of the melanocyte
suspension on the area to be grafted, which has been previously abraded. This deposit will be maintained in place by
an occlusive dressing for 5days
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Comments
– Fo r acne scars and small hypopigmented
scars, some of us recommend NAFL, AFL, or
MRF, topical application of bimatoprost plus
topical application of 0.25% retinoids to stimulate dormant stem cells or melanocytes to
“wake them up.”
– In our experience, the melanocyte grafting
procedure works better for vitiligo than for
scars with a brous tissue that is probably not
hospitable to fragile melanocytes.
Mature, Fixed Scars withRelief
Alterations
Thick Scars
Provided that there are no signs of hypertrophic
scarring or keloids, all raised scars can be treated
with a pulse laser.
Before considering a dermabrasion, scars subjected to repeated tensional efforts should be
screened, especially in the nasolabial fold or the
upper white lip. In these two situations, the great
mobility induced by the opening of the mouth
does not allow a satisfactory leveling, the permanent tensional efforts (elocution, mastication)
inducing a new inammatory hypertrophic process by a mechanical stretching effect.
For other scars, the abrasion will be progressive, so controlling the depth of treatment and
remaining particularly cautious on scarred areas
without annexes (deep burns) is important. It
should always be kept in mind that a second treatment is always preferable to a too deep abrasion.
Atrophic Scars
Depressed scars must rst be surgically revised
when possible: the principle is to resect all or
parts of the most damaged areas. This surgery is
only possible if the scar orientation is good and if
the tension on the edges is sufciently limited not
to cause secondary enlargement. Certain large
scars can sometimes benet from lifting, such as
chicken pox or wide scars. Otherwise, laser
dermabrasion will focus on the scar margins,
softening steep slopes to make the depression
less visible by blurring shadows in natural light
(Fig. 35a–i).
Chalazodermic Scars
A typical example of a chalazodermic scar is
the aftermath of a blowing hemangioma. The
skin appears very thin, the dermis no longer
ensuring its support function and leaving the
underlying hypodermis to appear like a hernia
or, on the contrary, drawing a depression
linked to this thinning. This type of scar is one
of the best indications for fractional lasers;
however, in certain situations partial results
may indicate the use of a pulsed CO2 laser
(Fig. 31a, b).
ab
cd
ef
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Case 27 Atrophic and Dehiscent Scar After
Corrective Surgery
See Fig. 35a–i.
157
Fig. 35 (a) Old and mature facial post-traumatic scar
(dog bite).(b) Resurfacing of the scar base and its edges
and then passing more widely beyond the scar in fractional mode to avoid edge effects. (c) Seven days after the
laser procedure and injection of hyaluronic acid below
and inside the scar. (d) Result at 1 month after the combination laser and llers injection. (e) Result at for 4months
after the combination laser and llers injection. (f)
Stability of the scar over 3years without any other modality since. (g) Chalazodermic scar in smiling. (h) Structural
modication, pliability-elasticity-roughness at 4months.
(i) Maintenance of this structural and textural change at
3 years after a mix of ablative laser and AH llers.
Courtesy of Hugues Cartier
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H. Cartier et al.
gh
i
Fig. 35 (continued)
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Acne Scar
Acne scars occur consequent to abnormal wound
healing following sebaceous follicular inammation in acne.
Various types of acne scars are ice pick, rolling, pox scar, hypertrophic, and keloidal.
Different modalities of treatment include subcision, dermaroller, radio frequency therapy, punch
excision, chemical peeling, and lasers.
After ensuring that there are no progressive
acne lesions during the interview, it is the analysis of the scars during the preliminary consultation that will enable the therapeutic attitude to be
specied. We will thus separate spontaneously
regressive sequelae and permanent sequelae and
determine the nature of the latter [31].
Active Acne withInammation, Why
Wait?
Acne, also known as acne vulgaris within the
medical community, is a chronic inflammatory
skin condition. Acne can grow everywhere,
but the more common spots for breakouts are
the face (particularly the cheeks and forehead), back, chest, and shoulders. It can be
improved with over-the-counter treatments,
but more severe forms of the condition would
require medical intervention. There are several
types of acne, from blackheads to conglobata.
But although we have a medical arsenal to
treat this acne, the use of lasers and BEDs can
be helpful. Indeed, the risk of scarring must be
considered, and its early management is
debated [32].
For inammatory acne, we can propose
photo- biomodulation with LEDs alone or optimize it with dynamic phototherapy. Without
going back over the photo-chemical mechanism, the results are quite interesting (Fig. 36a–
c). Encapsulated gold particles activated by
Nd-YAG laser shots are also another therapeutic option (Sebacia ©) while waiting for the
new wavelengths dedicated to acne which are
currently being researched. To target P. acnes
and its secretion, it is necessary to damage the
sebaceous glands to stop or minimize sebum
production. Optically, at 1726 nm, fat and
sebum absorb twice as much as compared to
H2O.
Pulsed dye laser, Nd-YAG 1064nm, and nonfractional and non-ablative such as Nd-YAP
1340 nm are other options to eliminate active
acne, but they are often a temporary effect. For
mature women, laser therapy may nevertheless
be an alternative to conventional drugs and topical ointments in treatment impasse [33] (Fig.
37a–d).
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Case 28 Active Acne with High Risk of Scars
Treated by Photo-Dynamic Therapy
See Fig. 36a–c.
H. Cartier et al.
a
b
c
Fig. 36 (a) Active acne in a patient who refuses all sys-
temic treatment for a desire to become pregnant. (b)
Inammatory reaction with moderate desquamation after
a session of dynamic phototherapy with 5-ALA cream
20%. (c) Complete reduction of active acne after 3 sessions of PDT and persistence of acne scars to be treated
later. Courtesy of Hugues Cartier
ab
cd
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Case 29 Active Acne Scars with Inammation
and High Risk of Atrophic and Ice Pick Scars
See Fig. 37a–d.
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Fig. 37 a) Inammate acne scars. (b) Pulse dye laser to
reduce inammation settings 6ms, 10 J/cm2, 10mm spot
size. (c) Nd: YAP 1340 nm to reduce scars in progress,
setting: 100 MTZ/cm2, 110 mJ/MTZ, 5 ms. (d)
Stabilization of acne scar in progress by an alternating
treatment between PDL and Nd: YAP, 4 sessions in
5months. Courtesy of Hugues Cartier
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