FUE harvesting of grafts causes “pit” scarring small, round, and typically white scars in the patient’s donor area where the grafts have been removed. FUE scarring differs from strip harvesting in that the latter procedure produces a linear scar in the donor area where the strip of skin was removed. The pit scarring from FUE and linear scar from strip harvesting are often problematic to detect when hair in the donor area is at an average length, and a skilled surgeon performs the extraction. While the outcome of the healing process, and thus the appearance of scar tissue, depends on several variables (including the type of extraction, the skill of the surgeon, and, in strip harvesting, the method of wound closure), in both FUE and FUT short cropped hair or a shaved head will typically reveal some scarring.
Fat Transfer for severe atrophic disease in which there is the destruction of the deeper tissues, fat stays the best replacement agent, first noted in 1893, to improve scars. The word autologous means material (fat) is harvested from one area and donated to another in the same individual. Autologous fat grafting meets all the fundamental criteria of ideal augmentation materials: availability, low antigenicity, minimal donor morbidity, reproducible, predictable results, and avoids non-auto graft disease transmission or incompatibility, not likely to elicit an immune response, last reported complications, and longer survivability. Accordingly, autologous fat Transfer supplies a very appealing resource for soft tissue volume augmentation. Fat is not considered adequate for individual bound down ice pick scars. However, once the scar is freed, fat may be satisfactorily injected. Fat should be considered the best filling and volumizing agent for widespread grossly atrophic disease combined with more profound tissue destruction. Fat is an excellent deeper augmenting injectable in scars. When higher volumes are needed, fat injections can save costs for the patient. I can combine fat with other resurfacing techniques.
Any volumization should be performed first. While patients in the teens and early 20s may infrequently need volumizing, most older patients need enhanced volume. Volumizing smoothed and rounded the overall facial contour, which reduces shadowing. But the importance of overall facial volumizing is that a rounded facial contour has the same shadowing in most head positions. Issues of permanence are gradually being resolved. Fat no longer appears to be as temporary as initially considered. Accurate long-lasting autologous corrections can result. Various factors may contribute to fat cell survival: harvesting method, manipulating fat, exposure to blood or lidocaine, recipient site, donor site, centrifugation, injection method including syringes and needle size, and overcorrection. Fat should be injected deeply as a three-dimensional lattice with0.1–0.2-mL aliquots. The site is gradually built up to enhance the superficial layers in a lipo-layering technique. Injections can be on any tissue plane as determined by the subcision or within all three (intradermal, subdermal, and subcutaneous) tissue planes.
Only microdroplets are usually needed for intradermal or immediate subdermal placement. Often infusion is best accomplished as the needle is withdrawn. The endpoint is a slight overcorrection. Although microinjecting fat, intra-lesion within the scar after subsection, Prof Moawad still recommends instilling at least a small amount underneath to volumize the area. This helps to stretch or distend some scars, making them more superficial in appearance. Postoperative care usually only needs an antibiotic application to the injection sites. Postoperative pain is minimal, and oral antibiotics are not needed in the author’s experience. IT can treat significant edema with a short course of oral steroids. 50% of transplanted fat should be expected to survive. Thus, touch-up procedures at three months may be needed. Overcorrection of about 10% is usually needed. As with the lipofilling of cosmetic defects, the procedure should be considered as a multi-treatment program. Small volumes are needed even if multiple scars are infused, and as such, the use of frozen fat aliquots of single harvesting will save considerable time with future injection sessions.
Fat can be stored in disposable syringes for up to one year or more without contamination or deterioration in its ability to survive. Frozen fat is a way to improve the patient and avoid an extended first downtime gradually. It also allows the chance to “touch up” areas where the fat may have dissipated or under-corrected. The best of all is fat grafting is forgivable while the mistake of permanent filler is permanent,” Prof Moawad says. The only relative drawback of fat injection has been the resorption of some of the fat volume. However, with proper technique, 30–70% of the fat is kept, Prof Moawad says. The Disputes about longevity and the technique variation has postponed the announcement of fat as the perfect filler, added Prof. Moawad. Recent advances in fat grafting include plasma-rich platelets (PRP), adipose tissue-derived stem cells (ADCs), or collagenase digest fat showing great promise with scars treatment.
PRP is used to improve the healing of ablative fractional resurfacing wounds. Autologous Platelet Rich Plasma uses platelets prepared from the patient’s blood to support and accelerate hard and soft tissue regeneration. As vehicles for controlling the delivery of growth factors, platelets are injected into the dermis. They induce the proliferation of fibroblasts, promote the production of new collagen and other extracellular matrix components, stimulate stem cell migration proliferation and differentiation, and improve differentiation micro-vascularization.
Volume change, correction includes focal dermal filling of individual scars and volume fillers (e.g., fat transfer, off-the-shelf fillers such as hyaluronic acid (HA), polylactic acid, and hydroxyapatite. Potential superficial skin products may include collagen or hyaluronic acid, and deep skin products include fat, synthetics, silicone, implants, and permanents. An ideal filler material would be physiologic (incorporated into the body’s tissues), simple to place(injection), permanent (no degradation), and risk-free (no complications or side effects). Most of these apply to depressed scars such as the atrophic rolling variant or sometimes others.
Elevess is approved for injection into the mid to deep dermis to correct moderate to severe facial wrinkles and folds, such as nasolabial folds. ELevess is approved in the EU to correct soft tissue contour deficiencies, such as wrinkles, folds, and scars, and enhance lips’ appearance. ELEVESS is approved in Canada to correct soft tissue contour deficiencies of the face, such as wrinkles, folds, and scars. Poly-L-lactic acid (PLLA) is a biodegradable, non-toxic, synthetic, inactive material derived from corn starch. It has been used in suture material, stents, and other biomedical implants. Due to the extensive bio-stimulatory effects of this product, it is considered a semi-permanent filler. The clinical effects can be seen for up to 2 years. The FDA approved Sculptra in 2004 for human immunodeficiency virus (HIV)- related facial lipoatrophy. It has PLLA microspheres in a powdered form. A common finding with this product is palpable but usually invisible subcutaneous “micronodules.”
More recent studies of PLLA using a diluted suspension of the product have resulted in a dramatically decreased rate of micronodule formation. Many practitioners use six ccs of sterile water for reconstitution, and in areas such as the hands and chest, even larger dilutions are used. Longer reconstitution times are also recommended, with the reconstitution occurring at least 8 hours before the injection of the product. It would be best if you took care to inject the product in the superficial fat and not in the mid-dermis, and the clinician should be careful not to inject the sediment at the end of the syringe.
Radiesse or Calcium hydroxylapatite (CaHA) is the mineral part of the bone; therefore, it should not stimulate an immune response, making it biocompatible. This material has been used previously in dental, orthopedic, urologic, and vocal cord applications. It acts as a scaffold for collagen ingrowth. The FDA approved Radiesse in 2006 for the correction of facial wrinkles and folds and HIV-associated facial lipoatrophy. In 2009, it received FDA approval for cosmetic use in non-HIV patients as well. Administration of CaHA supplies immediate 1: 1 correction and does not expand beyond what was injected. Over time, the carrier gel is absorbed, and new collagen is formed around the microspheres. The result is a longer-lasting implant with characteristics close to natural tissue. The longevity of correction ranges from 10 to 18months. Most commonly, Radiesse is used to correct nasolabial folds, atrophic cheeks, and temporal wasting. The clinical results may last for 12 months or longer, although the carrier gel lasts no longer than six months, thus often resulting in a slight decrease in correction at that time. I must take extreme care to avoid injection while withdrawing the needle out of the skin, which will result in the deposition of material into the dermis.
Liquid injectable silicone (Silikon 1000, Adatosil 5000, Bioplastique) Readily fulfills most of the criteria for an ideal filling substance. It is a clear, odorless, tasteless, colorless, and stable substance. Liquid injectable silicone does not harden or soften, still is unaltered within the range of human body temperature, and is chemically unchanged by exposure to air, most chemicals, and sunlight. It can be stored for long periods at room temperature and does not allow for the growth of microorganisms. Although not entirely biologically inert, liquid injectable silicone has been shown to have the least physiologic reactivity of most foreign materials. Additionally, it lacks mutagenic, carcinogenic, and teratogenic effects; no true allergies to silicone have been documented. Although the technique is dependent, the advantages of liquid injectable silicone over other liquid injectable filler substances are its precision and permanence.
With depressed, broad-based scar, the 1,000-centistoke viscosity liquid silicone is used exclusively with a 27-gauge 1/2-inch needle. Despite concerns about its long-term safety and adverse inflammatory reactions, the long-term experience of physicians skilled in administering liquid injectable silicone has shown it to be safe and efficacious for soft tissue augmentation. The microdroplet, multiple-injection approach, provides a small amount of silicone injected at the correct depth in the tissue at monthly intervals, usually needing only a few treatments. Allowing about a month between treatment sessions enables the scar to stretch, reconfigure, or accommodate the presence of the liquid silicone. Concerns about its long-term safety and adverse tissue reactivity have been raised in many articles. Silicone has been implicated in a variety of local and systemic adverse inflammatory reactions. Treatment-site reactions, including redness, pain, tissue hardness, discoloration, ecchymosis, excessive tissue elevation, and migration of the injected material to local and distant areas, have been reported — more severe complications, including subcutaneous bumps, lumps, ulceration, and local lymph node enlargement. Following large amounts of silicone injections, physicians have reported tissue destruction and scarring, lung and liver inflammation. None of those mentioned above reports have associated such side effects or complications with silicone for acne treatment. Only tiny volumes of the material are employed.
Polymethylmethacrylate (PMMA) is an acrylic plastic that has been used in many medical applications for years, including bone cement, lenses, dental work, and pacemakers. PMMA supplies support for human collagen deposition. If PMMA is placed too superficially, It will lead to lumps formation. Most practitioners prefer a threading injection technique. Unlike the other dermal fillers, this dermal filler should be considered a permanent dermal filler. This dermal filler is shown to correct the nasolabial folds, although used for scar and forehead furrows. Because results are permanent, it is often best not to achieve full correction in one session but to carry out the desired result over several treatment sessions. Bellafill (previously known as Artefill) has been marketed and sold in the United States as a permanent dermal filler to correct nasolabial folds since 2007 and received FDA approval for acne scarring in December 2014. With this new sign, Bellafill is currently the only “on-label” dermal filler approved by the FDA to treat moderate to severe, atrophic, distensible facial scars on the cheeks of patients older than 21.
Scarring occasionally occurs in areas that are subject to recurrent movement. This may be less obvious when one is young and the tissues more able to resist the movement through the flexibility and springiness of the dermis and the subcutaneous volume overlying the muscle action. However, aging develops a combination of events such as photodamage, recurrent facial habits (smoking, elocution), and loss of volume that combine to make tissues naturally unable to resist the underlying muscular forces. This allows static wrinkles and lines to develop. Suppose one is scared, mainly if this scarring is atrophic or mildly hypertrophic. In that case, normal muscle movement may have an exaggerated effect because of volume loss from past acne activity and loss of dermal flexibility with scarring. This is particularly true of grade 3 rolling atrophic scarring. In such areas, botulinum toxin may be used. Although botulinum toxin has a role in treating scars in the upper face, especially when scars are present in the glabella or forehead regions, this is important in the lower face, where the marionette lines and chin are the two most commonly affected areas. Botulinum toxin may be combined with fillers, although the fillers are usually administered later once the effect of the botulinum is proved. The use of dermal fillers and botulinum are synergistic in many cases. Most studies have focused on treatment rather than the prevention of post-surgical and traumatic scars. Early management of surgical patients is more likely to yield better cosmetic outcomes and need fewer treatments and less time and expense in the long run. Standard precautions such as maintaining moisturization and decreasing tension or movement should be strongly encouraged. Botulinum toxin has been proven effective in minimizing post-surgical scars because of its ability to decrease movement and stress around a healing wound.
When treating scars by excision, neurotoxins may be used in a prophylactic method of scar minimization to aid in the best healing. Neurotoxins such as botulinum toxin A may be used at this level of scarring, often as an adjunct to surgery for acne scarring, such as cyst, scar, or sinus tract excision. Botulinum toxin may be helpful to decrease tension produced by muscular forces surrounding the scar. In addition to the botulinum toxin’s direct effect on reducing muscular activity, there also appears to be an inhibitory effect of botulinum toxin itself on fibroblasts, offering another potential mechanism for producing a more satisfactory outcome for problematic scar revision and lesion removal. Other treatment modalities around the time of surgery, such as LASH, PDL, nonablative, and ablative lasers, also appear to contribute to better healing responses. Laser therapy may improve the appearance of wounded skin by promoting better collagen organization in healing wounds.
Energy Dependent Scars Treatment
Nonablative Laser therapies include multiple wavelength lasers, pulsed light, and other forms of energy delivery. Because these modalities are less aggressive, they are more useful for atrophic, rolling, or hypertrophic scars than icepicks, boxcar, or keloid scars. The morphology of the scar is more predictive of results than the extent or amount. In addition, these therapies are more often used with darker skin types because ablative management tends to have a higher risk of pigmentary alterations. There is selective thermal stimulation of dermal collagen to increase local proliferation while the epidermis is spared, although cooling must ensure superficial protection. The first to mention is the 532-nm KTP laser, which is safe and effective for improving acne (more so than scar treatment), thus preventing acne sequelae such as scarring. The best nonablative laser to use for hypertrophic scars or keloids is the 585-nm pulsed dye laser (PDL). Best results and most minor side effects are obtained on Fitzpatrick skin types I or II because of less competition with melanin. This laser focuses on erythema and vascularity, so incidental scar improvement is possible because of decreasing vascularity (the scars are hyperemic because of angiogenesis) and associated secondary effects in the local field or other cellular alterations specifically about collagen. Improvement after use can be seen for up to a year.
Furthermore, it has a role in the treatment of minor atrophic scarring. As mentioned under vascular lasers in Grade 1 scarring above, other wavelengths such as the 1,064-nm long-pulsed and quality-switched laser have been successful in the nonablative treatment of acne scarring. The 1064-nm Nd: YAG laser proves a common pigment effect with a higher vascular effect, causing hemostasis and resultant infections within the vessels. It could have an effect like those just discussed for PDLs used on hypertrophic scars or keloids. However, repeated treatments are needed.
A minimal melanin absorption spectrum and deep papillary and mid reticular dermal treatment are achieved with the 1320-nm Nd: YAG laser. Those with a predominance of atrophic scars, defined as greater than 90% of the present, improved with mixed scars next. Another laser variant is the 1450-nm diode. Water’s efficient absorption is seen but minimally by melanin when using the 1540 Er: glass laser. The primary depth is within the papillary dermis, where collagen tightening and neocollagenesis are achieved — progressive improvement and long-term benefit after treatment with this modality. It says that outcomes are often gradual, with increased dermal collagen seen in 6 months after four successive treatments, and continued improvement occurs several months after the session. These lasers use conducted heat from the chromophore to produce a diffuse dermal injury, heating to >50°C and inducing collagen remodeling.
The following few therapies are not accurate lasers but rely more on different energy forms to achieve their effect. The first is intense pulsed light (IPL). These machines emit a wide range of wavelengths from their source that can be precisely narrowed using wavelength filters. Other parameters, such as pulse length, pulse delay, and joules, can also be adjusted. All these options, in combination, allow for tailoring therapy to a defined goal. “IPL offers a therapeutic alternative to the gold standard PDL [for the treatment of hypertrophic scars. The Ellipse IPL treatment directs well-controlled pulses of light into the upper skin layer. This works by attacking the vascularization of the scar. One treatment approach involves pre-treating the first keloid elements with a corticosteroid, followed by a course of short IPL emissions. A typical regimen includes up to four treatments spaced four weeks apart. This approach reduces the redness of the scar and stimulates collagen reorganization, thus reducing its size.
Radiofrequency devices use electrical energy to transfer heat energy to the dermis at low temperatures. These devices are intended to resurface the skin but induce thermal damage to dermal collagen while sparing the epidermis. Resistance and the resultant degree of thermal damage are determined by the depth and composition of the treated tissue. When applied over a period, thermal energy contracts and thickens collagen fibers disrupts hydrogen bonds, and alters the conformation of the collagen triple helix. It also induces a more prolonged wound-healing effect associated with sustained remodeling, reorientation, and formation of new collagen bundles over later months, resulting in effective skin tightening with minimal recovery time.
The collagen-based fibrous septa that separate fat lobules in the subcutaneous tissue are also preferentially heated, leading to further collagen denaturation and contraction of the subcutaneous tissue and accounting for the immediate tightening and lifting effect on the skin. Because RF energy uses an electrical current rather than a light source, it does not affect epidermal melanin; therefore, patients of all skin types, including darker skin types and those predisposed to develop post-inflammatory hyperpigmentation, may be treated with RF. Everybody is a good candidate for RF, but it is of particular significance to those who do not like invasive surgical intervention and are still young for surgery. Contraindications include implantable medical devices such as pacemakers and defibrillators and active dermatologic conditions like collagen vascular disease.
Monopolar systems deliver current using one electrode that contacts the skin and another that acts as a grounding pad. The electrode contacting the skin delivers the electric current to the skin. The epidermis is spared by applying a cooling while the dermis is heated uniformly and volumetrically. Aside from rhytides reduction, successful treatment of moderate to severe cystic acne, acne scarring, and cellulite has been reported. The use of more extensive, faster tips, lower energy levels, and multiple passes have diminished associated pain but not cut it. The low-level multiple-pass approach needs 4-6 sessions every one to two weeks. The procedure can be repeated everyone year as needed to keep the results.
The main difference between bipolar and monopolar RF is the configuration. The bipolar configuration consists of two active electrodes placed a short distance apart, overlying the intended treatment area. The monopolar RF devices have one active electrode placed on the skin and a grounding electrode. The current flows between the two electrodes. The depth of penetration is half the distance between the two electrodes. The significant limitations of the bipolar RF devices are the depth of penetration. The mechanism of action for simple bipolar RF devices is like that of monopolar RF devices.
A combination of light devices has been used to overcome this limitation. Bipolar RF devices are often combined with light-based technologies, termed electro-optical synergy (ELOS). The ELOS system uses the synergistic effects of light and RF-based devices. The light energy preheats the target tissue through photothermolysis, which lowers the tissue’s impedance. The lower impedance makes the tissue more susceptible to the RF part so that it is selectively targeted. Therefore, lower energy levels of the light and RF parts are needed to produce the desired effect with fewer side effects. The optical part also targets fibroblasts, blood vessels, and dyschromia.
The most widely used ELOS systems use intense pulsed light (IPL), a diode laser, or infrared light. RF devises the Polaris™, and ReFirme™ from Syneron™ uses bipolar RF at the ends of laser systems (780–910nm diode for the Polaris and 700–2000nm infrared light for the ReFirme™. It is another system used with the bipolar device that uses a vacuum to maximize and control the penetration of the electric current. The vacuum is used to fold the skin to a predetermined depth, which allows for closer alignment and deeper penetration with the RF energy than with traditional monopolar and bipolar devices. However, a significant drawback of this therapy is that it needs many treatments at 2- to3-week intervals, which may achieve only mild to moderate improvement.
FACES-based devices are composed of an RF generator, a handpiece, and a tip with two parallel electrodes. The volume of treated tissue is limited to that found between the electrodes at the special vacuum tip, so lower energy levels can be used to meet the energy density needed to reach and affect the chosen skin layers, leading to greater efficacy, less pain, and lower incidence of side effects. Although the combination systems are better tolerated than the monopolar RF systems, I may use topical anesthetic creams to alleviate any associated pain at the physician’s discretion. Modest results have been reported about the efficacy of the ELOS systems for and face in facial laxity, acne, scars, vascular and pigmented lesions, hair removal, and cellulite.
Fractional laser treatment is a non-invasive treatment that uses a device to deliver a laser beam divided into thousands of microscopic treatment zones that target a fraction of the skin at a time. This is analogous to a photographic image being enhanced or altered pixel by pixel. Fractional laser treatment has bridged the ablative and nonablative laser techniques used to treat sun-damaged and aging skin. While ablative laser treatments work mainly on the epidermis (surface skin cells) and nonablative treatments work solely on dermal collagen (mid-layer of skin) only, fractional laser treatment works at both the epidermal and dermal layers of the skin FT were developed as a way for laser surgeons to get closer to ablative laser resurfacing clinical outcomes with less patient downtime and fewer overall adverse events.
The laser beam is divided into thousands of tiny but deep columns of energy into the skin. These are called microthermal treatment zones (MTZs). Within each MTZ, old epidermal pigmented cells are expelled, and penetration of collagen in the dermis causes a reaction that leads to collagen remodeling and new collagen formation. MTZs, the laser targets and treats intensively within the zone while surrounding healthy tissue remains intact and unaffected. These MTZs vary from device to device. Some are nonablative dermal injuries only; because others are associated with ablative changes in the skin, causing both epidermal and dermal injury patterns. MTZs also vary significantly in their diameter of effect and the degree of depth they make to create the injury. Once injured, the skin begins a very rapid process of repair. After a 48- to 72-hour phase of acute thermal damage, a phase of skin healing and repair starts, mediated by the adjacent skipped areas of intact tissue. In this 30-day phase, the areas of thermally ablated tissue are invaded by fibroblast cells and the epidermal stem cell to produce new collagen. reproduction
Fractional thermolysis (FT) can be divided into several classifications. The easiest has been to classify FT devices into nonablative and ablative FT laser systems. This classification was “easy” at the beginning when only several devices were available. It is now a little more complex, especially between the ablative laser systems. This new terminology seems prudent now. Ablative FT laser systems originally were divided into classifications based on laser type: CO2, Er: YAG, or (YSGG, 2790nm). What has changed is that different ablative FT laser systems emit light differently, with penetration depths that may be considered “superficial” and others that may be considered “deep.”
Thus, a new classification system seems practical at this point. Ablative FT lasers have been classified into “micro-ablative FT laser systems,” which would include those lasers that produce epidermal and dermal damage to a depth less than 750 microns, and “deep dermal ablative FT laser systems,” which would include those lasers that produce damage beyond 750 microns in the skin. The repair mechanisms seen in fractional occur through the trans-epidermal delivery of treated necrotic skin into the stratum corneum, where it is exfoliated away in a short time. This fractional treatment results in a faster healing process than if all tissues in the treatment area were exposed to the laser. This process is known as microscopic epidermal necrotic debris (MENDs). MENDs or another term that appears unique to fractional technology. With the formation of MENDs, selective extrusion of melanin pigmentation after the thermal injury during Fractional laser, resulting in significant improvement in cutaneous pigmentation, a milestone that had yet to be achieved with the earlier generations of nonablative lasers After a 48- to 72-hour phase of acute thermal damage, a phase of healing and repair starts, which is mediated by the adjacent columns of intact tissue. In this 30-day phase, the areas of thermally ablated tissue are invaded by fibroblast-derived neocollagenesis and epidermal stem cell reproduction.
Furthermore, the rapid recovery times seen with fractionated CO2 laser marks a significant improvement over traditional CO2 and Er: YAG laser resurfacing because of the differences in wound healing mechanisms. Traditional ablative laser wounds heal by the migration of stem cells from hair follicles. In contrast, with fractional ablative resurfacing, re-epithelialization occurs more rapidly because of the migration of neighboring cutaneous stem cells.
Ablative FT laser systems originally were divided into classifications based on laser type: CO2, Er: YAG, or YSGG, 2790nm. What has changed is that different ablative FT laser systems emit light differently, with penetration depths that may be considered “superficial” and others that may be considered “deep.” Thus, a new classification system seems prudent at this point. Ablative FT lasers have been classified into “micro-ablative FT laser systems,” which would include those lasers that produce epidermal and dermal damage to a depth less than 750 microns, and “deep dermal ablative FT laser systems,” which would include those lasers that produce damage beyond 750 microns in the skin. Indications for nonablative FL include mild to moderate acne scarring, dyschromia, hypopigmented scars, fine wrinkling, and texture changes associated with photoaging on the face, chest, neck, and hands. The nonablative FP systems include; Fraxel restore 1550nm, Fraxel refines 1410nm, Affirm 1440nm, StarLux 1540, Matisse 1540 Dermablate1540nm, Mosaic 1550nm, and Sellas 1550nm. The nonablative devices produce minimal patient discomfort. Some patients may need a topical anesthetic before the procedure and/or forced fantastic air cooling during the procedure.
After treatment most, patients notice erythema and some edema, which can last for up to 48 hours following the treatment, followed by skin desquamation for several more days. With all nonablative fractional devices, there is usually a need for multiple treatments to achieve the result. Most contend that 4 to 6 treatments must reach the given desired outcome for most clinical indications. Fractional radiofrequency is a newer nonablative approach. There are two ways to deliver fractional RF. Whereas some “Matrix RF” devices use electrodes, others use an array of microneedles arranged in pairs between which bipolar RF energy is delivered ePrime system. Another system Miratone FRF system using a microneedle electrode array. The fractionally delivered energy creates zones of affected skin next to unaffected areas. The treated areas result in thermal damage in the deep dermal collagen, stimulating wound healing, dermal remodeling, and new collagen, elastin, and hyaluronic acid formation. The unaffected areas found in between affected areas initially keep skin integrity but, in the long term, serve as a reservoir of cells that promote and accelerate wound healing.
A new device has been developed that combines fractionated optical energy with a 915-nm diode with a fractionated bipolar RF. This integrated system targets the epidermis and superficial dermis. Using the RF part synergistically, less energy is used to heat the collagen in the deep dermis and stimulate new collagen formation and contraction Matrix Laser. This device has been associated with significant improvement in acne scarring, texture, and pigmentation. Small papular scars that may appear on the nose and chin respond well to fine wire diathermy, not a new technique, but recently described for this subgroup. If there are few scars, their augmentation by temporary or longer-term autologous or external agents may be proper. Combinations of subcision, blood transfer, nonablative or vascular laser, and skin needling may be helpful for more significant scarring.
During the late 1990s and early 2000s, the gold standard for the treatment of facial lines and wrinkles as well as acne and traumatic scars was, at least from a laser point of view, the carbon dioxide (CO2) laser system. Carbon dioxide laser was first used for post-acne scarring, replacing dermabrasion and intense chemical peeling. The CO2 laser emits a 10.600nm wavelength, which is strongly absorbed by tissue water. The penetration depth is dependent upon water content and independent of either melanin or hemoglobulin. This treatment is more aggressive and more profound than a chemical peel but stays at 20 to 30 um specific depths with thermal damage of 50 to 150 um. It is usually bloodless but still achieves total ablation of the epidermis and a part of the dermis. In addition to the destructive nature, there may also be stimulation of collagen by the procedure. The usefulness is primarily for hypertrophic scars, boxcar scars (preferably shallow), and, less effectively, keloids. Some achieve quick results, visible as soon as two weeks, but improvement because of the wound-healing phases continues for at least 18months. Downtime with the CO2 laser typically lasted about one week or more. Depending on the device and the aggressiveness of the clinician utilizing the device, potential adverse effects became more significant. Although traditional ablative laser resurfacing was able to achieve results for skin tightening, which rivaled surgical correction, the potential adverse effects included pain, edema, persistent erythema, infections, post-inflammatory hyperpigmentation, and the most problematic of all, hypopigmentation following the ablative procedure, seen in some patients two years following the laser surgery significantly limited the application of this technology.
To counter these potential adverse events, the Er: YAG laser was introduced. It emits a wavelength of 2940 nm in the infrared range, which is close to the absorption peak of water and yields an absorption coefficient 16 times that of the CO2 laser. This provides a more precise skin ablation with minimal thermal damage to the surrounding tissue minimal thermal damage, resulting in less severe side effects and faster overall healing times. Downtime still may be from 5 to 7 days, depending on the power used. Er: YAG lasers still can occur as well as other problems like those of the CO2 laser. Again, this may be of benefit for hypertrophic scars, rarely keloids, and shallower boxcar scars.
Ablative Plasma skin resurfacing. A device for performing ablative resurfacing has been developed, which works by passing radiofrequency into nitrogen gas. The “nitrogen plasma” causes rapid skin heating with limited tissue ablation and minimal collateral thermal damage. The results are like gentle CO2 and Air: YAG laser resurfacing. The more aggressive the treatment, the higher the fluence, the more impressive the results. Laser skin resurfacing has been employed to treat many skin conditions, but photoaging and scarring are the two most common indications.
Pre-conditioning Treatment Program of the skin with Vitamin A and/or lactic acid with or without bleaching cream or lotion (Hydroquinone, arbutin, licorice Kojic acid, and Azelaic acid) has become a standard protocol at MSI and is especially important in darkly pigmented skin treated with ablative resurfacing techniques. IT treated the skin for several weeks before the procedure. Pre-conditioning programs are essential to tighten the skin, reduce wound healing, and decrease the chance of dyspigmentation. In the first 2-3 weeks, the skin goes through an accommodation phase and is often red and irritated. In conjunction with ablative/nonablative treatment and laser therapies, well-chosen MSI skincare products will result in enhanced results and maintenance of the improvement seen. You can apply topical healing ointment under a semi-occlusive dressing for the first few postoperative days to protect the skin. It would be best if you gently cleaned treated areas daily with water and hydrating cleanser. Postoperative redness typically lasts several (4–6) weeks after laser treatment and can receive help from Red Out cream with vitamin K to hasten redness resolution. Strict sun avoidance and photoprotection should be advocated until complete healing to reduce the risk of pigment alteration. Skin darkening is transient and will fade out using our advanced whitening formula with a unique combination of bleaching agents such as Hydroquinone, arbutin, licorice Kojic acid, and Azelaic acid. Another treatment modality used that focuses on hypertrophic scars, and to a lesser degree, the keloid is silicone dressing. There is variable support to the silicone itself, with results more likely attributable to occlusion or hydration. The pressure-supported mechanism and other rationales include temperature, increased oxygen tension, electrostatic properties, or immunologic effects. Although the mechanism of action of silicone elastomer sheeting has not been completely elucidated, it is an effective means of treating and preventing hypertrophic and keloid scars. If the moderate hypertrophic disease is apparent, the treatments that have been described over the past decade have included intralesional corticosteroids, vascular laser, and fluorouracil (and other cytotoxic) injections.
Intralesional corticosteroid injections have become a mainstay in treating hypertrophic scar and keloids, alone or in combination with other therapeutic procedures. Corticosteroid application can soften and flatten keloids but cannot narrow hypertrophic scars or cut keloids. We recommend beginning with direct serial intralesional corticosteroid injections in an already developing keloid or hypertrophic scar. The most commonly used drug for steroid injection is triamcinolone acetonide (TA) at a dose of 5 to 10 mg/mL, which should be injected with a 25- to 27-gauge needle into the upper dermis of a developing hypertrophic scar every 3 to 6 weeks. Injections are discontinued when the scar is stable, surgical intervention is indispensable, or side effects such as tissue atrophy, hypopigmentation, or telangiectasia. The treatment of preexisting keloids should begin with three monthly, intralesional injections of TA at a dose of 40 mg/mL mixed with equal parts of 2% lidocaine. Some authors also recommend the addition of hyaluronidase, which helps to disperse the injection. Because tissue absorption through intact or sutured skin is poor, the use of topical steroids is shown only for superficial lesions, such as those occurring from dermabrasion. More recently, intralesional verapamil at a concentration of 2.5 mg/mL (0.5–2mLinjected volume depending on the size of the scar) or topical imiquimod has been suggested as postoperative adjunctive treatment to surgical excision of keloidal. Intralesional cytotoxic, including fluorouracil, bleomycin, and mitomycin, are used for hypertrophic and keloidal scars. Fluorouracil can be used at a 50 mg/mL concentration and has been mixed 80:20 with low-strength intralesional steroids. However, it may also be used alone, with approximately 1 mL used in each scar.
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