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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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162
https://t.me/med1917
H. Cartier et al.
Comments
While treatment of active acne with lasers has
been successful, many studies are limited by the
lack of control populations and comparison to
standard therapies for active acne. Laser thera-
pies are increasingly becoming part of or an
adjunct to the medical treatment of active acne
and are a useful treatment modality.
For Fixed Acne Scars
Changes in the skin’s micro-relief for acne scars.
These are the most frequent scarring manifestation: the skin grain becomes coarser, irregular,
and takes on a dull appearance. These irregularities are made up of dilated pores induced by the
progressive dilation of the sebaceous ostia by
hyper-seborrhea.
Alterations totheSkin’s Micro-Relief
Fractional lasers are of great interest here. Their
use in ablative, non-ablative, or mixed mode
makes it possible to obtain in three to four sessions spaced at least 2 months apart (to benet
from the early remodeling phase of the previous
session) a regularization of the skin surface
allowing a visible softening of the skin texture
(Fig. 38a–d).
– Fractional lasers remain the rst-line treat-
ment for ostial dilatation. They reduce the
diameter of the pores by contraction and dermal densication and regularize surface irregularities by their tensor effect.
ab
Lasers andEnergy-Based Devices inScar Therapy: APractical Use
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Case 30 Acne Scars with Ice Pick and
Enlarged Pores
See Fig. 38a–d.
163
c d
Fig. 38 a) Dilated pores, atrophic and ice pick acne
scars. (b) Result after four sessions at 6weeks apart. (c)
NAFL 1550nm laser treatment: 50 mJ, 3ms. (d) NAFL
linear beam mode: 50 mJ, 3ms, 25% density, 3 passes.
Courtesy of Hugues Cartier
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H. Cartier et al.
Comments
The use of non-ablative fractional lasers includ-
ing phototypes IV, V, and VI is possible with a
much lower risk of triggering post-inammatory
pigmentation than with fractional ablative lasers.
Wherever possible, they should be recommended
as a rst option.
– Depressed scars require a more complex two-
stage sequence. Scar raising is the rst essential step prior to laser abrasion when the
depressions are deep; it is performed under
local anesthesia. The isolated fragment is
placed slightly above the surface of the adjacent skin using a punch with a diameter
greater than the scar to be raised. Subcision
and dermal graft can be combined.
Coagulation will maintain the lift in its new
position. Fatty plasters are changed daily for
the rst 4 days following the operation, after
which the lifts are left in the open air. In the
time interval between this procedure and the
laser abrasion, the appearance is reminiscent
of a papular acne are-up. Laser abrasion is
performed at least 1 month after the rst procedure (Fig. 39a–d).
Anatomical unit performs laser dermabrasion, depending on the skin’s laxity and therefore
often depending on the age of the patients concerned. In young patients, abrasion with a low
thermal effect is done with the Erbium: YAG
laser. The demand for scar correction in older
people requires the use of the CO2 laser which
leads to a real re-draping by dermal contraction
in addition to leveling. Postoperative erythema is
prolonged (2–3months versus 4–6months) [34,
35].
Lasers andEnergy-Based Devices inScar Therapy: APractical Use
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Case 31 Ablative and Resurfacing Procedure
with CO2 Laser
See Fig. 39a–d.
165
a
b
c
d
Fig. 39 (a) Mixed acne scars: pox scars, chicken pox
scars, atrophic and ice pick scars. (b) Healing time after
acne scar raising and before resurfacing of the area by
CO2 laser. (c) Final result after one session of ablative CO2
laser. Courtesy of Thierry Fusade. (d) Acne scar raising
with punch biopsy adapted to the size of the scar. Courtesy
of Hugues Cartier
166
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H. Cartier et al.
Case 32 Ice Pick Scars of the Nose
See Fig. 40a–d.
Fig. 40 (a) Ice pick scar or dilated pore treated by the
phenol cross technique in one session. (b) The solution is
slid on with a sharpened wooden stick. (c) Healing time
with crusty dermal (d) Scar tissue elevation can be
obtained by injecting a small amount of hyaluronic acid.
Courtesy of Hugues Cartier
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167
Comments
– Ice pick scars will benet rstly from surgical
removal with punch and secondary suture when
possible. The chemical technique TCA or
Phenol Cross is an alternative but sometimes it
can open up ice pick scars even more (Fig.
40a–d). In some cases, the use of the TCA/
Phenol cross may open up the enlarged pores
further. It is preferable to remove surgically and
then smooth the scar surface with a CO2 or
Erbium: YAG ablative laser.
– In the situation where depressed scars are pre-
dominant and the after effects appear too burdensome for patients to manage, ablative
fractional lasers can also be used.
– With AFL, the depth of treatment must be
favored over density and thermal diffusion
appears to be a determining factor. Thus,
whatever the type of fractional laser used, the
power, energy, and/or time of the unit pulses
(dwelling) will be chosen to be high, while the
density of the thermal cones (MTZ) or ablation will be medium or low. The session can be
repeated.
– With the same parameters, the greatest
improvements are obtained during the rst
sessions.
– Dermal grafting, injection of polylactic acid,
calcium hydroxyapatite, and hyaluronic acid
are now very common for scar lifting, reduc-
tion of pox scar, depression, or rolling scars,
alone and especially in combination with
laser remodeling, especially AFL and NAFL
or MRF.
– To trim the shoulders of depressed, chicken-
pox scar, pox scar, or rolling scars and to
reduce the difference in height at the surface
of the skin, you can use a drilling method with
a donut-shaped design of the laser scanner or
use a handpiece with a spot size of less than
1mm in pulse or continuous mode to reduce
the border edge (Fig. 41a–j, 42a–e, and 43a,b).
Case 33 Ablative Fractional Laser for
Atrophic Acne Scars To
See Fig. 41a–j.
Fig. 41 (a) Mature acne scar. (b) Fractional CO2: spot
1.25 11, 150 mJ/175 Hz, density 5/10. (c) Incomplete
result with persistent scars of the upper cheek area. (d)
Healing time during 1 week with crusts treated by
Vaseline. (e) Second procedure with fractional CO2 (150
mJ/175 Hz, density 5) then a second pass after rubbing
with a damp compress (150/150, density 4). (f) The healing time is longer after rubbing, up to 10 days, always
with Vaseline as a protective ointment. (g) Inammation
and redness treated by a short pulse of bethametasone
cream during 5days to avoid a higher risk of post-inammation-hyperpigmentation (PIH). (h) Slight PIH, to be
managed with time and sunscreen. (i) Result after two
ablative procedures 8months after. (j) Final result after
two ablative procedures 6years after. Courtesy of Hugues
Cartier
168
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H. Cartier et al.
c
d
f
e
Fig. 41 (continued)
Lasers andEnergy-Based Devices inScar Therapy: APractical Use
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Case 34 Complex Acne Scars and Combined
Procedure Er: YAG Plus CO
2
See Fig. 42a–e.
169
a
b
c
d
e
Fig. 42 (a) Acne scars: pox scar, rolling, pathomimics,
failure TCA cross-session. (b) Just after ablative laser:
rst pass with Er: YAG (10J/cm2, 1500μs) and then second pass with fractional (CO2 150mJ, 150Hz, 1.25mm
spot size, density 6). (c) Wound healing with application
of mimosa powder, usually used after a phenol peel to
avoid scratching by the patient. (d) Detachment of the
mimosa crust on the eighth day. (e) Dramatical improvment 3 months after one session of Er: YAG + CO2.
Courtesy of Hugues Cartier
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H. Cartier et al.
Comments
– Rolling scars caused by underlying fat melting
are too deep to be improved by laser. It is illusory to expect treatments with fractional pulsed
lasers or laser resurfacing on this type of lesion
to have a tensor effect that lasts more than a
few months. Their correction is obtained by lling with an injection of hyaluronic acid. The
choice of cross-linking depends on the depth of
the lesions to be treated. Lipo-structure is only
exceptionally proposed for the most severe
lesions. Slow resorption occurs in sites that are
not much mobilized by facial expressions, and
the results often persist for 18–24months (Fig.
43a, b).
Case 35 Rolling and Atrophic Scars and
Hyaluronic Acid
See Fig. 43a, b.
Fig. 43 (a) Mature acne scar. (b) Expected result at 9months after 2 sessions, 1 month apart, of hyaluronic acid injec-
tion below and inside scars (medium G′) without any laser or EBD. Courtesy of Thierry Fusade
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171
Comments
– Ice pick scars need to be raised at rst.
– Rolling scar can be reduced by injecting llers
alone. Hyaluronic acid raises scar tissue and
stimulates neocollagenesis.
– The durability of HA is variable but in brous
tissue, it can be stable for years. Other injectables as inductors can be used as PLLA (polylactic acid) or CaHA (hydroxyapatite of
calcium) (Figs. 44a–h).
– Complex bridge scars and xed retractile
depressions benet from surgical removal.
The subcision is proposed for a long time to
break the brous bridges, but it can sometimes be disappointing because the scar may
reform a brous ange after a few weeks
unless a resorbable material (Hyaluronic
a
Acid) is used. At the time of surgical revision,
to avoid secondary scar enlargement, par-
ticular attention must be paid to the suture in
2 or 3 planes with perfect confrontation of
the deep plane.
– For residual erythema and post-inammatory
hyperpigmentation on dark skins, we are usu-
ally content to wait for regression, as these
marks are always involutivity within few
months. However, we can also suggest laser
treatment as Nd:YAG long pulse in fast motion
mode, non-ablative fractional and vascular
laser as pulsed dye laser.
Case 36 Mixed and Complex Acne Scars
See Fig. 44a–h.
b
c
Fig. 44 (a) Acne scar with deep ice pick, atrophic and
chicken pox scars. (b) One year of combined treatment.
(c) After a second year of a combined treatment. (d) Final
result after 2 sessions of MRF, 1 Er:YAG, 5 sessions of
fractional CO2, 2 sessions of PLLA. (e) Abrasion with Er:
d
YAG + fractional CO2. (f) Abrasion with CO2 then fractionated CO2 in second and third passes. (g) MRF
(microneedle radiofrequency) combined with subcision
and diluted subdermal poly-lactic acid injection. (h)
Fractional CO2 laser. Courtesy of Hugues Cartier
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