Laser treatment of scars

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3. ROMANIAN JOURNAL of CLINICAL and EXPERIMENTAL DERMATOLOGY 146 Clinical and morphological classifi cation allows reasonably selecting the treatment tactic (the need of using a certain method or combining dif- ferent methods, and the order in which they are used) and predicting the correction results. The correction of immature scars always re- quires great vigilance and responsibility from the phy sician performing the correction procedure since the development of such scars is unpredicta- ble due to their high sensitivity to external infl u- ence (including laser radiation) and probable risk of relapse (appearance) of pathological scar- ring. There are more possibilities for scar correction when the degree of symptoms severity in the ini- tial clinical picture is high. On the contrary, in case of low severity of all symptoms the scar correction possibilities are limited and the external result is less obvious. This should be taken into account in determining the validity of normotrophic scar therapy and during initial consultation with the patient in order to prevent high expectations. Let's take a closer look at the laser scar corre c- tion methods, their mechanism of action, poten- tial and indications. Laser coagulation of blood vessels The main laser types used for coagulation of blood vessels are: • Nd:YAG/KTP neodymium double-frequency laser with 532 nm and 540 nm wavelength; and • PDL pulsed dye laser with 575-595 nm wave- length. Various types of hemoglobin are the main chro- mophore for this radiation type. The laser causes photothermal effect aimed at coagulation of blood vessels. The result is the removal of vascular component in the scar and its blanching. Reduced vasculari- zation helps eliminate hyperemia of hypo- and atrophic scars, which improves their appearance. In the case of immature scars, the coagulation of blood vessels accelerates maturing of scar tissue by reducing the synthetic function of fi broblasts Clinical study LASER TREATMENT OF SCARS: PRACTICAL ALGORITHMS Scar maturity degree Typical clinical signs Scar types Immature scars ● visible dynamics of clinical picture in time ● the trend towards increased scar tissue ● high sensitivity to external infl uence ● subjective sensation of varying severity in the scar area ● the presence of vascular component (from red to purple-blue) ● tissue density from normal to signifi cantly increased ● possible tissue surface tension with nacreous luster ● fresh scars less than 1 year old ● hypertrophic scars up to 2 years old and small keloids* ● large and multiple keloids Mature scars ● stable clinical picture or slight changes (minimal, very slow, barely visible externally) ● no trend towards increased scar tissue ● vascular component is missing or weakly pronounced (pale or pale-pink) ● tissue density is reduced, normal or moderately increased ● no tissue surface tension ● no subjective sensations in the scar area ● normotrophic scars ● hypo- and atrophic scars ● hypertrophic scars in regression (from two years old and older) *Hypertrophic scars (1-2 years old) and smaller keloids are gro uped together since their clinical diff erences are relative in nature. These scar types can only be reliably separated using histologi cal examination or ultrasound, which is rarely used in everyday cosmetology practice. Table 3. Clinical and morphological classifi cation of scars

2. 3/September/2017 145 Laser scar correction has been used for several decades and during that time the methods and indications have undergone signifi cant transfor- mation. However, today's laser therapy belongs to the experimental methods with insuffi cient evi- dence (1) allowing achieving compelling aesthe- tic results in practice. Despite the need for more clinical data on the use of lasers, the specifi cs of selecting the required device and the treatment options/features, the growing number of publica- tions on successful laser treatment of hypertro- phic scars increases the interest in this treatment method (1). The relevance of further study of laser scar correction methods is obvious. Laser scar therapy Laser scar correction includes several methods based on various types of laser radiation (2-4). Every type of laser radiation affects a certain chro- mophore in tissues through various photobiolo- gical effects. Each laser method obviously has its own indications and results. Laser scar correction methods include: • laser coagulation of blood vessels; • classical 3D laser ablation; • fractional photothermolysis and • laser removal of hyperpigmentation. Laser scar correction has several advantages in comparison with other methods: • the ability to perform complex scar trea t- ment by combining several types of laser impact in a single treatment program and consistently applying them to the same scar to potentiate the correction effect; • treatment of scars at any location, inclu- ding in places with large functional load (for example, in the projection of the joints), which does not require restraints and re fraining from habitual way of life, and does not cause considerable discomfort to the patient; • the exact local impact of laser radiation with the ability to control its depth and • the absence of signifi cant systemic impact on the body allowing applying the methods in pediatric practice. Still! You need to remember that laser therapy methods are aimed at reducing clinical manifesta- tions and do not have signifi cant results in redu- cing the scar area. For this reason, in some cases preference should be given to surgical correction by either refraining from laser methods com- pletely or applying them after surgery. Such cases include: • the possibility of scar excision and the cre- ation of a smaller area of defect; • repairing the scar with a skin fl ap with low risk of pathological scarring; • moving the scar from an open area to a hid- den area; • removing scar adhesions with the underlying tissues that are causing the scar to retract; and • the presence of a foreign body in the scar. Given the wide variety of clinical scars, the treat- ment for a particular patient should be tailored to his/her individual needs (1). When choosing the tactic, you must also take into account the scar age and the maturity of scar tissue that can pre- dict the result of the correction and the likelihood of relapse (2). During the initial consultation, the physician should fully assess the clinical picture to deter- mine the degree of severity of all scar signs in each case (Table 2). The clinical picture should be monitored and its dynamics should be tracked during corrective therapy. The array of all clinical signs, given their degree of severity, allows determining the scar type and its degree of maturity, which became the basis for the clinical and morphological classifi cation that is the most useful in everyday medical practice from the practical point of view (Table 3). Natalia Gennadievna Kalashnikova Sign Degree of severity Subjective sensations in the scar area ● none ● paresthesia ● itching, from recurring to continuous ● pain Vascular component ● none — pale scar ● minor — pale-pink scar ● moderate — pink scar ● pronounced — scar color from bright red to purple-blue Scar tissue turgor ● reduced — fl abbiness ● normal — close to normal skin ● increased — density above normal skin ● signifi cantly tense — tissues with cartilage-like density Relief of tissues in relation to surrounding skin ● sunken tissue ● on one level ● moderate elevation — up to 0.5 cm ● signifi cant elevation — more than 0.5 cm Pigmentation in the scar area ● de- and hypopigmentation ● normal ● hyperpigmentation Table 2. Clinical signs of scars and their degree of severity

7. ROMANIAN JOURNAL of CLINICAL and EXPERIMENTAL DERMATOLOGY 150 ness, accompanied by moderately expressed hyperemia. Completed complex serial laser cor- rection: two sessions of laser ablation using the Er:YAG 2,036 nm (“Multiline”) laser and one ses- sion of laser coagulation of blood vessels using the Nd:YAG/KTP 540 nm (“Multiline”) laser. Treat- Clinical study LASER TREATMENT OF SCARS: PRACTICAL ALGORITHMS Scar type Clinical signs Correction method Expected outcome Hypo- and atrophic scars ● relief — sunken tissue, lack of volume ● tissue tone — reduced ● congestive hyperemia ● color — hypo- and depigmentation (not subject to correction) Laser ablation Relief smoothing Fractional photothermolysis Increased tissue turgor and relief optimization Laser coagulation of blood vessels Eliminating congestive hyperemia and optimizing color Laser removal of pigment Removal of hyperpigmentation Normotrophic scars ● modifi ed tissue structure and surface — rugosity, smoothness ● dyschromia — hypo-, de-, hyperpigmentation Fractional photothermolysis Tissue structure optimization, smoothing the borders between the scar and the healthy skin Laser removal of pigment Removal of hyperpigmentation Hypertrophic scar in regression (more than 2 years old) ● relief — elevation, excess volume ● tissue tone — increased ● slight hyperemia (residual vascular component) Fractional photothermolysis Reducing tissue density and scar volume Laser ablation Removing excess scar tissue — relief smoothing Laser coagulation of blood vessels Eliminating hyperemia and optimizing color Table 4. The possibilities of using laser methods for correction of mature scars Scar type Clinical signs Correction method Expected outcome Fresh scars (less than 1 year old) ● subjective sensations hyperemia ● relief — possible roughness or scar tissue growth Laser coagulation of blood vessels Stimulating the maturity of connective tissue, eliminating subjective sensations and hyperemia Fractional photothermolysis Suppression of excessive collagen production, smoothing the borders between the scar and the healthy skin Hypertrophic scar (1-2 years old), small keloid ● subjective sensations hyperemia ● tissue tone is signifi cantly increased ● relief — elevation, excess volume Laser coagulation of blood vessels Stimulating the maturity of connective tissue, eliminating subjective sensations, decreasing erythema, reducing tissue density, reducing scar volume, preventing relapse Fractional photothermolysis Destruction of excess collagen — reducing tissue density and volume Table 5. The possibilities of using laser methods for correction of immature scars

8. 3/September/2017 151 ment course length was six months. The result is the optimization of scar color and relief; patient is satisfi ed (Fig. 9 A, B). Clinical example 10. The initial assessment of the clinical picture of a fresh scar with a tendency to hypertrophic growth allowed identifying the leading symptom — moderately expressed sub- jective sensations as paresthesia and transient itching. After one session of laser coagulation of blood vessels using the Nd:YAG/KTP 540 nm (“Multiline”) laser, the subjective sensations disap- peared completely, the severity of hyperemia re- duced to moderate, and the scar tissue density decreased slightly. The next leading symptoms were uneven surface and increased tissue tone. To correct the symptoms, we completed two ses- sion of spatially modulated ablation using the Er:YAG 2,036 nm laser with SMA module (“Multi- line”), with “destructive” energy parameters of 3.9 j/cm 2 . The result is aligning the surface, matching the scar color with that of the surrounding tissues, and removing excess tissue volume and den- sity (Fig. 10 A, B). Treatment course length was 2.5 months. The patient is satisfi ed with the result. Natalia Gennadievna Kalashnikova Laser scar correction algorithm Steps Actions Special tactics when correcting immature scars Step 1 Evaluating the clinical picture and symptom severity, det ermining the scar type Step 2 Identifying the leading symptom in the total clinical picture The presence of subjective sensations of any degree of severity is always considered the leading symptom (a marker for the risk of pathological scarring and relapse) Step 3 Selecting the method of laser impact aimed at correcting the leading symptom, and assessing the impact of the selected radiation type on other clinical symptoms In case of moderate and weakly expressed subjective sensations, the correction begins with the laser coagulation of blood vessels Pronounced subjective sensations require prior drug therapy Step 4 Performing the procedures to obtain the desired eff ect The absence of positive dynamics after two sessions or negative dynamics (subjective sensations, increased severity degree, increased scar tissue volume) is an indication for adding drug therapy to the treatment (local administration of glucocorticosteroids or enzymes) Step 5 Repeated evaluation of the dynamic clinical picture and the severity of symptoms, selecting the next leading symptom Regular dynamic inspections should take place at least once every two weeks, period which is associated with the instability of clinical picture and high sensitivity of scars to external impact factors, including laser radiation Step 6 If necessary, switching to a diff erent laser method aimed at correcting the next selected leading symptom Switching to a diff erent laser method is possible only after the complete relief of subjective sensations Repeat steps 4-6 until achieving the optimum correction result Figure 9. Atrophic scar before (A) and six months aŌ er (B) complex laser correcƟ on Figure 10. Fresh scar with a tendency towards hypertrophic growth before (A) and two months aŌ er (B) complex laser correcƟ on AB AB

9. ROMANIAN JOURNAL of CLINICAL and EXPERIMENTAL DERMATOLOGY 152 When to start the correction of fresh scars? There is still no consensus on this issue among professionals. Some believe that the sooner you start interfering with the scar forming process the better aesthetic effect can be achieved as a cor- rection result in order to prevent scar growth (17). Opponents argue that until the scar is stable, you cannot say what type of scarring it will follow — physiological or pathological — and that is why early intervention is risky and unwarranted. We agree with the effectiveness of early correc- tion and get good results. Clinical example 11. Early postoperative scar correction on the 30th day after upper blepharo- plasty — 1 session of spatially modulated ablation using the Er:YAG 2,036 nm laser with SMA module (“Multiline”), with “destructive” energy settings of 3.2 j/cm 2 . Obtained a good result (Fig. 11 A, B). Clinical example 12. Early correction of post- traumatic scar on the 28th day after trauma (Fig. 12 A, B). Completed 1 session of spatially modulated ablation using the Er:YAG 2,036 nm laser with SMA module (“Multiline”), with “de- structive” energy settings of 3.2 j/cm 2 . The result is positive. Clinical example 13. Early postoperative scar correction on the 28th day after laparotomy (Fig. 13 A, B). Completed 1 session of spatially modulated ablation using the Er:YAG 2,036 nm laser with SMA module (“Multiline”), with “stimu- lating” energy settings of 2.21 j/cm 2 . Negative dynamics recorded after the proce- dure. The result is subjective sensations in the form of itching in the scar area, increased hyper- emia, and increased width and volume of scar tis- sue. The reasons for the negative dynamics after the laser therapy: • incorrect energy settings that increase the functional activity of fi broblasts; • late examination of the patient (more than one month after treatment); and • belated therapy correction. You need to remember that when correcting immature scars (including fresh scars), you need to use the utmost caution when evaluating all the risks and know how to minimize them, be reaso- nable when selecting the treatment tactic, timely and adequately monitor the dynamics and adjust therapy as needed. Immature scars should be treated by specialists with extensive experience. Integrated approach to scar correction Despite the broad potential and high effi ciency of laser scar correction methods as monotherapy and combination of methods, there are several clinical situations when you need to add other methods: • Intrascar corticosteroid injections — must pre- cede laser therapy in cases of pronounced sub- jective sensations (intense itching, pain), pro- gressive scar growth and large volume of scar tissue. Treatment can also be complemented by the administration of bleomycin, 5-fl uorouracil and/or verapamil (optional) (10-12). • Medicines for external use (silicone plaster, enzymatic gels) — can be used between ses- sions of laser therapy if the scar is in a constant Clinical study LASER TREATMENT OF SCARS: PRACTICAL ALGORITHMS Figure 11. Fresh postoperaƟ ve scar before (A) and two weeks aŌ er (B) early laser correcƟ on Figure 12. Fresh posƩ raumaƟ c scar before (A) and two weeks aŌ er (B) early laser correcƟ on Figure 13. Fresh postoperaƟ ve scar before (A) and fi ve weeks aŌ er (B) early laser correcƟ on (negaƟ ve dynamics) AB AB A B

5. ROMANIAN JOURNAL of CLINICAL and EXPERIMENTAL DERMATOLOGY 148 yielded a positive result by reducing the scar depth (Fig. 3 A, B). Clinical example 4. One session of laser abla- tion using the Er:YAG 2,036 nm (“Multiline”) laser as a monotherapy for hypertrophic scar in regres- sion resulted in a signifi cant improvement in scar appearance by removing excess volume and le- veling the relief (Fig. 4 A, B). Fractional photothermolysis The principle of fractional photothermolysis is the alternation of microdamage zones with intact tissue areas in the impact zone, thus reducing the invasiveness of the procedure and ensuring its ef- fectiveness. This is the most extensive group of methods that is notable for diverse types of laser radiation used and the characteristics of devices imple- menting this method. All lasers in this group can be divided into two groups depending on the extent of the photo- thermal effect: 1. None-ablative lasers, whose photothermal effect causes coagulation of tissues in micro- damage zones: • ND:YAG neodymium laser with 1,320 nm wavelength; • diode laser with 1,450 nm wavelength; • Er:Glass erbium glass laser with 1,540 nm wavelength; and • Thulium-fi ber (1,927 nm). 2. Ablative lasers, whose photothermal effect causes tissue ablation in microdamage zones: • Er:YAG erbium laser with 2,940 nm wave- length; and • CO 2 laser with 10,600 nm wavelength. Water is the chromophore in both cases. The leading mechanism is photothermal. By itself, the concept of “fractional photother- molysis” does not say anything about the poten- tial of this method. The result is determined by the type of laser radiation used and the basic parameters of its delivery to the impact zone that depends on the characteristics of a specifi c de- vice. The end result of fractional photothermolysis varies widely and depends on the choice and ca- pabilities of a specifi c device. The result of scar correction using fractional photothermolysis is determined by a number of physical parameters: • the wavelength of radiation used, and, there- fore, the nature of impact that is released in the damage microzone; • the diameter of the damage microzone; • the density of damage microzones at 1 cm 2 ; • the percentage of total area coverage and so on. The main effect is the reorganization of the scar tissue. Depending on energy parameters, this method allows achieving two goals: • stimulation of collagen production; and • destruction of excess collagen. The impact on scar surface is realized indirectly by changing the tissue tone, which also helps im- prove the scar color and smooth its borders with normal skin. The indications for using fractional photother- molysis vary just as the achieved effects and can be defi ned by the capabilities of a specifi c de- vice. Some methods allow working with all kinds of scars. Clinical example 5. Spatially modulated abla- tion using the Er:YAG 2,036 nm laser with SMA module (“Multiline”), energy density of 2,21 j/cm 2 , for hypotrophic scar correction had a stimulating effect on neocollagenesis, which clinically mani- fested in timproved scar tissue tone and surface, and scar appearance in general (Fig. 5 A, B). Spatially modulated ablation (SMA method) is a special kind of impact that cannot even be com- pletely identifi ed with fractional methods. A laser emission was spatially modulated with the help of a developed SMA module. As a result, the emission hits the tissue surface not in the form of a continuous wide spot, but as an ordered set of micro-spots 50 microns in diameter. The dis- tance between micro-spots was also 50 microns. Unlike fractional methods, the leading mecha- nism that produces the effect of tissue remode- Clinical study LASER TREATMENT OF SCARS: PRACTICAL ALGORITHMS Figure 4. Hypertrophic scar in regression before (A) and three months aŌ er (B) one session of laser ablaƟ on Figure 5. Hypotrophic scar before (A) and two months aŌ er (B) one session of spaƟ ally modulated ablaƟ on AB AB

6. 3/September/2017 149 ling is photomechanical, and not photothermal. When exposed to high-energy short laser pulse in zones with a high degree of damage, microa- blation areas start forming on the surface. These areas in turn are the source of mechanical waves’ generation due to the rapid explosive expansion of tissues at their instant evaporation. Acoustic waves penetrate into deep layers where they in- terfere with waves coming from the neighboring microablation areas. The wave’s amplitude grows and becomes suffi cient for causing local mechani- cal microtraumas of cells and fi brous structures and launching the processes for restructuring connective tissue. Clinical example 6. Spatially modulated a blation using the Er:YAG 2,036 nm laser with SMA module (“Multiline”) and energy density of 2.21 j/cm 2 for the correction of a normotrophic scar. The result is the smoothing of scar borders (Fig. 6 A, B). Clinical example 7. One session of spatially modulated ablation using the Er:YAG 2,036 nm laser with SMA module (“Multiline”) and energy density of 3.9 j/cm 2 for the correction of a hyper- trophic scar proved effective. The destructive ef- fect on excess collagen clinically manifested in the decreased tone of the scar tissue, reducing excess scar and optimizing its surface and color (Fig. 7 A, B). These examples demonstrate the wide poten- tial of the method described above when using different parameters. Laser removal of hyperpigmentation Laser removal of pigment is used for hyperpig- mentation since hypopigmentation and depig- mentation cannot be corrected using the existing laser methods. The following is used to eliminate hyperpig- mentation in the scar projection: • Nd:YAG/KTP neodymium double-frequency laser with 532 nm and 540 nm wavelength; • CVL copper vapor laser with 510 nm wave- length; • Ruby/Qsw q-switched ruby laser with 694 nm wavelength; • Alex/Qsw q-switched alexandrite laser with 755 nm wavelength. Melanin is the main chromophore for these ra- diation types. The laser causes photomechanical or photothermal destruction of excess melanin, removes hyperpigmentation in the scar projec- tion and aligns its color with that of the surroun- ding skin. Indications: mature scars with hyperpigmenta- tion. Clinical example 8. Completed 1 session of pigment removal in the postoperative scar area using the Alex/Qsw laser with 755 nm wavelength (“Multiline”). Correction result is the alignment of the scar color with that of the surrounding skin (Fig. 8 A, B). The possibilities of using different laser therapy methods depending on the scar type are presen- ted in Tables 4 and 5. A unifi ed scar correction tactic does not exist. That is why the development of the fundamental principles governing the treatment strategy is of great practical importance. Based on our extensive clinical experience, we have developed the steps for performing laser scar correction, which we are successfully using in practice (2-4, 8, 9). Clinical examples of using the algorithm in practice: Clinical example 9. The initial assessment of the clinical picture of the atrophic scar allowed identifying the leading symptom — surface rough- Natalia Gennadievna Kalashnikova Figure 6. Normotrophic scar before (A) and six months aŌ er (B) one session of spaƟ ally modulated ablaƟ on Figure 7. Hypertrophic scar before (A) and two months aŌ er (B) one session of spaƟ ally modulated ablaƟ on Figure 8. Normotrophic scar before (A) and one month aŌ er (B) one session of laser pigment removal AB AB AB

1. ROMANIAN JOURNAL of CLINICAL and EXPERIMENTAL DERMATOLOGY 144 LASER TREATMENT OF SCARS: PRACTICAL ALGORITHMS Keywords: scar, laser treatment of scar, algorithm. Abstract This article aims to present the main laser scar correction methods and their potential: how to choose the right laser scar correction method and the optimal combination of various methods for a certain kind of scar deformity?; can all scars be treated using laser correction?; treatment start dates; when there is a risk of pathological scarring recurrence and how to avoid it; when you should choose surgical correction; practical algorithms to help the physician performing laser scar correction. Natalia Gennadievna Kalashnikova ”Linline” network of clinics, Laser Medicine, Moscow, Russian Federation Corresponding author: Natalia Gennadievna Kalashnikova Udalsova St.85-2, Moscow, Russian Federation Phone: +7-906-79-42-757 Email: kalashnikovaline@mail.ru Clinical study Cite this article : Natalia Gennadievna Kalashnikova. Laser treatment of scars: practical algorithms. RoJCED 2017;3(4):144-153 LASER TREATMENT OF SCARS: PRACTICAL ALGORITHMS Introduction A scar is a newly formed connective tissue that develops in place of deep skin defects involving the destruction of the dermis. Depending on the etiology, there are posttraumatic, postoperative and postinfl ammatory scars. A patient seeking help of aesthetic medicine specialists always sees scar deformation as a de- fect that he/she wants to get rid of. A scar affects not only the appearance but also the psychologi- cal status of the patient, his/her social adaptation, the more so if it is located in the facial or any other visible area. Of course, our patients expect us to do wonders. We always ask them what we can do to help. We want them to understand that remo- ving scar deformation completely is not possible at this time. Aesthetic correction only helps to reduce the severity of clinical symptoms of scar deformities allowing discomfort elimination and making the scar less noticeable. There are many invasive and non-invasive scar correction methods (Table 1). Non-invasive methods Invasive methods Well-known, scientifi cally sound and recommended methods Pressure/compression therapy Intralesional administration of glucocorticosteroids Silicone dressings and gels Surgical scar correction Experimental methods and methods with insuffi cient evidence Oils, lotions and creams Laser therapy Massage Radiation therapy Static and dynamic splints Cryosurgery Psychological counseling Intralesional administration of other drugs Antihistamine drugs Table 1. Overview of non-invasive and invasive scar treatment methods (1) Open Access Article https://doi.org/10.26574/rojced.2017.4.3.144 https://doi.org/10.26574/rojced.2017.4.3.144 https://doi.org/10.26574/rojced.2017.4.3.144

4. 3/September/2017 147 (5, 6), which is clinically expressed not only in the removal of vascular component and tissue blanching but also in the disappearance of sub- jective sensations, the decrease of scar density and the reduction of its excess volume. The exact mechanism of immature scarring im- provement has not yet been determined. There are several theories, one of which involves local tissue ischemization with reduced nutrition, which reduces the functional activity of cells and the number of immature collagen matrix (5). Another theory, on the contrary, implies that the cause of the fi broblasts dysfunction is not a quantitative in- crease of vessels in an immature scar but rather their incapacity, which leads to tissue hypoxia. Normalization of microcirculation in the lesion supports stimulation of connective tissue matura- tion (6). In addition, this type of radiation increa- ses the production of matrix metalloproteinases, including collagenases (15), which promotes the destruction of excess collagen. The indications for using laser coagulation of blood vessels can be divided into two groups: 1. Immature scars: • fresh scars with pronounced vascular compo- nent, tendency to hypertrophic growth, and the presence of subjective sensations (16); • hypertrophic scars up to two years old and small keloids; and • large and multiple keloids (in the complex therapy with other correction methods). 2. Mature scars with injected vessels and con- gestive vascular events. Clinical example 1. Four sessions of laser co- agulation of blood vessels using the ND:YAG/KTP 540 nm (“Multiline”) laser as a hypertrophic scar monotherapy resulted in reduced hyperemia, density and volume of scar tissue (Fig. 1 A, B). Clinical example 2. Completed three ses- sions of laser coagulation of blood vessels using the Nd:YAG/KTP 540 nm (“Multiline”) laser as a monotherapy. The correction result is the opti- mization of color and external manifestations of scarring in general (Fig. 2 A, B). Laser ablation The classical total laser ablation is performed using two lasers: • Er:YAG erbium laser with 2,940 nm wave- length; and • CO 2 laser with 10,600 nm wavelength. Water is the main chromophore for middle and far infrared range radiation. The impact of such laser radiation causes the photothermal effect of ablation ( i.e. , evaporation of tissue surface layers) due to the high rate of its absorption by water. This method is considered traumatic since it causes the formation of wound surface. The depth of ablation depends on the type of laser used, energy settings and the number of applica- tions on the same site; it is selected individually and may vary in the treatment area with a view of targeted formation of surface relief. The result is the smoothing of uneven relief be- tween scar tissue and surrounding skin and the mild remodeling effect on connective tissue. The indications for using laser ablation: mature scars: • hypo- and atrophic scars; and • hypertrophic scars in regression (more than two years old). Laser ablation is not used for immature scars due to the high risk of recurring pathological scarring. Clinical example 3. One session of laser abla- tion using the Er:YAG 2,036 nm (“Multiline”) laser as a monotherapy for atrophic post-acne scars Natalia Gennadievna Kalashnikova Figure 1. Hypertrophic scar before (A) and fi ve months aŌ er (B) four sessions of laser coagulaƟ on of blood vessels Figure 2. Atrophic post-acne scars with congesƟ ve vascular component before (A) and two months aŌ er (B) three sessions of laser coagulaƟ on of blood vessels Figure 3. Atrophic post-acne scars before (A) and three months aŌ er (B) one session of laser ablaƟ on A A B B AB

10. 3/September/2017 153 trauma zone and therefore poorly amenable to correction. • Hyaluronic acid injections and PRP therapy al- low achieving more pronounced results when combined with laser methods for correcting deep defects with signifi cant relief depression. The treatment of patients with large and mul- tiple keloids requires a comprehensive approach. To be fair, it should be noted that such scars must be mainly treated by the surgeons in specialized clinics. If beauticians start treating such category of patients, they need to remember that such pa- thology involves the disturbance of the immuno- logical and endocrine status (3, 14). That is why the patients must fi rst undergo clinical laboratory examination and consultation with related profes- sionals. Complex therapy should be used in case of any identifi ed deviations. Large and multiple keloids should be corrected in stages — on small areas (up to about 10 cm 2 ). After achieving a positive result in one area, you should start correcting the next area. Conclusion You always have to remember that laser therapy is administered in courses, the end results of cor- rection are evaluated only after several months, and the effect build-up lasts up to a year. The opti- mal choice of therapeutic tactics ensures effi cien- cy and minimizes risks. The more pronounced a degree of clinical changes of scar deformities is before treatment, the more possibilities for cor- rection there are and the visual result from it is more signifi cant. The less pronounced clinical symptoms are in the beginning, the less visible the changes are after the correction, and the vi- sual result is less signifi cant. Naturally, this may dissatisfy the patient. That is why such situation requires detailed discussion during the initial consultation with an explanation of therapy pos- sibilities and an agreement on its necessity. Financial disclosure: none declared. Confl icts of interest: none declared. Patients’ consent obtained. Natalia Gennadievna Kalashnikova This work is licensed under a Creative Commons Attribution 4 .0 Unported License. The images or other third party material in this article are included in the article’s Creative Commons license, unless indicated otherwise in the credit line; if the material is not included under the Creative Commons license, users will need to obtain permission from the license holder to reproduce the material. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc/4.0/ 1. Stan Monstrey, Esther Middelkoop, Jan Jeroen Vranckx, Franco Bassetto, Ulrich E. Ziegler, Sylvie Meaume, Luc Teot. Updated scar management practical guidelines: Non-invasive and invasive measures 2014 . British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. 2. Kalashnikova NG, Timofeeva EV. Laser correction of scars: clinical experience. Kosmetik International 2014;2:27-37. 3. Kalashnikova NG Combined laser treatment of keloid scars. Apparatus cosmetology 2014;3:82-76. 4. Igoshina AV, Ronzina VL New possibilities of medicine in the treatment of scars of various etiology. Aesthetic medicine 2014;4:663-670. 5. Cepkolenko VA. Laser technologies in aesthetic medicine. Kiev: «Company «Estet» 2009. 6. Laser and lights. Edited by David J. Goldberg, Elsevier, 2010. 7. Kluchareva SV, Nechaeva OS, Kurganskay IG Pathological scars in the practice of dermatologist – new possibilities of drug therapy of “Egallohit”. Bulletin of aesthetic medicine 2009;2. 8. Kalashnikova NG Possibilities of laser therapy in scar correction. Bulletin of postgraduate medical education 2014;1:53. 9. Igoshina AV, Kalashnikova NG. Laser correction of scar: the result of applying the space-modulated ablation. Apparatus cosmetology 2015;4:82-85. 10. Middelkoop E, Monstrey S, Teot L, Vranckx JJ, eds. Scar Management Practical Guidelines . Maca-Cloetens. 2011, pp. 1-109. 11. Aggarwal H, Saxena A, Lubana PS, Mathur RK, Jain DK. Treatment of keloids and hypertrophic scars using bleomycin. J Cosmet Dermatol 2008;7:43-49. 12. Fitzpatrick RE. Treatment of infl amed hypertrophic scars using intralesional 5-FU. Dermatol Surg 1999;25:224-232. 13. Kobec MV, Vasileva VS. The dependence of the result of the laser treatment of hypertrophic scarring from the initial reactivity of the organism. Bulletin VSNC RAMN 2016;6:60-65. 14. Shafranov VV Keloid scars. New treatment technologies . P. 2. M: RAEN 2009. 15. Kuo YR, Wu WS, Jeng SF, et al. Suppressed TGF-beta1 expression is correlated with up-regulation of matrix metalloproteinase-13 in keloid regression after fl ashlamp pulsed-dye laser treatment. Lasers Surg Med 2005;36:38-342. 16. Nast A, Eming S, Fluhr J, et al. German S2k guidelines for the therapy of pathological scars (hypertrophic scars and keloids). J Dtsch Dermatol Ges 2012;10:747-762. 17. Ahmed Samir Edriss, V. Smrcka. Therapy of keloid and hypertrophic scars: a review. European Journal of Plastic Surgery 2011;6:425-436. Bibliography

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