Treatment of hypotrophic scars

Hypotrophic scars arise as a result of deep destruction of skin tissues and subcutaneous fat. Such scars can occur after deep forms of acne, chicken pox and look stamped, of approximately the same size and shape with sharp boundaries from healthy skin and often cratered edges. Larger with less sharp edges, hypotrophic scars appear after regression of dermatoses, where the primary element was the node. And, finally, household and traffic injuries can also leave after the healing involved single and large area of hypotrophic scars.

With such scars of a large area, as a rule, they turn to plastic surgeons to reduce their size and depth. In surgical practice the technique of excision of scars is used, if tissues are allowed. As a result of such surgical interventions, the appearance of the scar improves and it can become more flat, but longer. If, because of the location and size of the scar, it is not possible to excise and tighten the tissue, various reconstructive plastic operations are done, in particular by counter flaps, as a result of which the scar is flattened, but takes a zigzag shape. After the surgical stage of treatment, to improve the aesthetic appearance of the scar, patients should be directed by surgeons to dermatocosmetologists.

Continuity in working with patients with any scars is a prerequisite for good results of treatment!

Patients with small hypotrophic scars - a contingent for dermatocosmetologists. However, some surgeons propose to excise each scar, as a result of which an elongated or circular normotrophic appears on the site of the hypotrophic rounded scar. This work is very scrupulous, performed almost at the jewelry level, takes a lot of time, so few of the surgeons are taken for it. The subsequent operative grinding, made in the early terms, can practically hide the traces of scars. But as already said, most often these patients find themselves in the offices of dermatocosmetologists.

By what methods can dermatocosmetologists improve the appearance of hypotrophic scars and what can be expected from dermatocosmetological technologies?

The efforts of dermatocosmetologists are primarily aimed at raising the bottom of the scars. After this task is accomplished to the maximum, manipulations and procedures aimed at smoothing the scars with surrounding tissues are carried out.

1. Cryomassage.

It can be used early in the appearance of scars. By improving the trophism of tissues, the depth (-) of the tissue may become smaller. Old scars practically do not give in to cryomassage treatment.

2. Vacuum massage.

The effect of it can only be on young scars.

3. Electrophoresis.

Ionophoresis of cosmetology rack with vasoactive biostimulating, vitamin preparations, microelements (theonikol organic silicon, ascorbic acid, aflutop, oligosol zinc, retinoic acid, etc.).

4. Phonophoresis.

With madecasol, solcoseryl ointment, cream mederma.

5. Electrophorophoresis, laser therapy, laser phoresis, microcurrent therapy, magneto-thermal therapy.

Can also be used only to treat young scars. However, due to the fact that there are much more effective methods, it is impractical to prescribe to patients procedures that require time and material costs and are questionably effective.

6. Mesotherapy.

Biologically active, vitamin, improves microcirculation, metabolism of cells with drugs (aloe extract, placenta extract, nicotinic acid, retinoic acid, vitamin C, etc.).

Homeopathic remedies have also proved useful (see mesotherapy of atrophic scars).

7. Skinbiogeting or separation of the bottom of the rumen from the underlying tissues.

It is a modern and effective technique for the treatment of hypotrophic scars. The technique is carried out either with a simple needle with the introduction of novocaine under the scar, or with a tool such as a pointed hook, or with a special thread. Separation of the scar from surrounding tissues. Leads to the fact that the aseptic inflammation that has arisen as a result of trauma activates the synthetic and proliferative activity of fibroblasts. The resulting gap between the rumen bottom and underlying tissues begins to be filled with a connective tissue. As a result, there is a thickening of the tissue in the region of the bottom of the scars and, consequently, a decrease in their depth.

8. All variants of therapeutic dermabrasion.

Dermabrasion is the second important stage in the treatment of hypotrophic scars. Only it allows, after "raising" the bottom of the scars as much as possible to smooth them with the surrounding skin. There are quite a few patients who are afraid of any surgical interventions and dermatosurgical ones as well. To lasers also the ratio is not unambiguous, so such patients should undergo therapeutic dermabrasion, by any option. The number of sessions and courses - individually, depends on the type of scars and tissue reactivity. It is better to conduct the sessions actively, polishing the area around the scars practically to the "bloody dew". With such a deep therapeutic dermabrasion, the procedures are performed no more often than 1 time per week, after complete cleansing of the surface from peeling and possible crusts.

9. Peelings.

Peelings are an alternative to dermabrasion. Median AHA and glycol peels (50-70%) are preferred. A negative factor in the use of these technologies is that many times peelings can not be done, because of the possibility of developing an allergic reaction or increased sensitivity of the skin.

With hypotrophic scars, more than the median AHA peels, deep phenol peels are shown. However, these technologies require the following: an operating room, a resuscitation team and a hospital. Such conditions exist only in large hospitals and clinics. In addition, this technology is fraught with a number of serious complications, so its use is very limited.

10. Operative dermabrasion

Operative dermabrasion, as well as therapeutic and peeling, is the key and final procedure in the treatment of hypotrophic scars. It is with the help of operative dermabrasion by Schuman's milling cutter, carbon dioxide or erbium laser that it is possible to optimally improve the appearance of scars, whose previous treatment for reducing their depth was quite effective. Good results are achieved by repeated sessions of operative dermabrasion with a short interval. Repeated dermabrasion is done immediately after crusting, that is, 2-4 weeks after the first.

11. Contour plastic.

Contour plastic is a technique by which it is possible to make the relief of hypotrophic scars more smooth, introducing special preparations under the rumen. The contour plastic is used as the final procedure after operative or therapeutic dermabrasion, in the case of the remaining elements (-) of the tissue. This is due to the fact that it is often not possible to completely eliminate deep hypertrophic scars even by the above-mentioned therapeutic measures. In this regard, there is a need to raise the bottom of the rumen, which can be achieved through contour plasty. And operative and even therapeutic dermabrasion speed up the degradation of biological preparations for contour plasty.

Injection microimplants can be divided into 2 groups: materials with a limited period of validity and permanent implants.

1. Materials with a limited period of validity, biodegradable (biological).

Biodegradable drugs are divided into single-phase and biphasic.

Single-phase or homogeneous preparations consist of one substance: collagen, hyaluronic acid, etc. Recently, due to the prevalence of the cow's rabies virus, collagen preparations have cooled, so hyaluronic acid preparations are currently dominating the market.

Preparations of hyaluronic acid have been used for the second decade to correct dermatocosmetological deficiencies of the skin and scars. This is due to the biocompatibility of hyaluronic acid with human tissues, lack of species specificity, hydrophilicity, ease of application, softness and elasticity of its preparations.

Hyaluronic acid preparations include: Juviderm, Rofilan hylan, Hylaform, Sergiderm, Restylane, Theosial, etc. These temporary implants and the period of their stay in the tissues are limited to a period of 3 to 18 months.

As an example of contour plastic preparations, which are successfully used for the correction of scars and striae, we will cite preparations SURGIDERM, manufactured by Corneal, (France). This is a series of drugs of the latest generation based on hyaluronic acid. The preparations are a transparent gel of hyaluronic acid of non-biological origin, high degree of purification, meeting all European and alternative quality standards of safety (biocompatibility, sterility, transparency, protein content, bacterial endotoxin content, etc.). The reticulating agent used to form cross-links is recognized as the least toxic of all known. It is butandiol diglycidyl ether (BDDE). Concentration of hyaluronic acid in preparations up to 24 mg / p

Preparations of the SURGIDERM series have international and Russian certificates.

It is known that to increase the stability (stability) of hyaluronic acid in tissues, it must have intermolecular cross-links. Corneal has developed and patented a new method of forming intermolecular cross-links, which results in the formation of a strong and branched 3D matrix (three-dimensional) structure of hyaluronic acid. Such a multidimensional structure of hyaluronic acid limits the action of hyaluronidase, preventing its diffusion into the internal structures of the molecule, as well as surface degradation, thereby increasing the resistance to thermal destruction and the action of free radicals.

The SURGIDERM series consists of 6 preparations: Surgiderm 18, Surgiderm 30, Surgiderm 24 XP, Surgiderm 30 XP, Surgiderm, Surgiderm Plus. All preparations of this series are single-phase, therefore, are free of microparticles and completely homogeneous. It should be noted that the highest degree of reticulation is Surgiderm 30 XP, and the lowest Surgiderm 18. The higher the degree of reagentation of hyaluronic acid - the more prolonged the drug has. So Surgiderm 30 XP is stored in tissues up to 18 months.

As a means for correcting the hypotrophic scars, Surgiderm 30 XP and Surgiderm 24 XP are most expedient, as these preparations are not only easily introduced into tissues, but evenly distributed in them due to the high degree of plasticity of the preparations. In addition, hyaluronic acid has a stimulating effect on fibroblasts, so that even after resorption, the aftereffect will occur. For the correction of atrophic scars, it is more expedient to use Surgiderm 18 to start working with scars, and after resolving it, to switch to more viscous preparations Surgiderm 30 XP or Surgiderm 24 XP with a longer period of action. Exactly the same system of work is proposed with striae. These recommendations are related to the fact that it is easier to work with less viscous preparations and, accordingly, it is easier to achieve the desired aesthetic effect.

Contraindications for the use of hyaluronic acid preparations:

• Autoimmune diseases.
• Diseases, accompanied by a decrease in local and general immunity.
• Inflammations, pyoderma, viral diseases in the field of injections.
• Allergic reaction to chicken protein, hyaluronic acid, polyvalent allergy.

Note.

• Do not inject Surgiderm and all preparations for contouring immediately after operative dermabrasion, chemical peelings and in cases of acute inflammatory reactions. This will speed up the resorption of drugs and can lead to complications.

Contour plastic scars and striae is recommended at the end of the course of treatment with the help of other technologies, since after the introduction of fillers all other medical measures will lead to an accelerated resorption of the drugs.

Biphasic or heterogeneous drugs are often of more interest for physicians involved in scar correction. They are implants with a prolonged effect and consist of inert synthetic particles in the suspended matter of a biological substance - collagen or hyaluronic acid. They dissolve within 18-24 months. However, it must be remembered that these drugs most often cause the appearance of a fibromatous reaction in the form of granulomas, which sometimes even appear away from the site of administration.

An example of such drugs is Philoderm BeautySphere, which is a natural branched hyaluronic acid of non-animal origin, mixed with Dextran microspheres. The gel is visco-elastic, clear and sterile.

After the injection of the Philoderm BeautySphere preparation, dextran microspheres interact with the skin, stimulating the formation of new collagen fibers. Hyaluronic acid regulates the degree of moistening of tissues, returning them volume and elasticity.

1 ml Philoderm BeautySphere contains:

• hyaluronic acid - 20 mg
• sodium chloride 9 mg
• Dextran microspheres - 25 mg
• magnesium phosphate - 1 mg

Philoderm Beauty Sphere is injected deep beneath the bottom of the rumen. The drug should be injected with a minimum of 27 G needle (3 needles included). After the injection, massage the treated area with your fingertips. To achieve a good and lasting result, the procedure should be repeated after 2-3 weeks.

Reviderm - microspheres of dextran in hyaluronic acid resolves within 2 years. The technology of introduction is similar to the previous one.

2. Long-acting materials, slowly degraded. (Polymer).

• Based on polyacrylamide gel - PAGE (Pharmacryl, Outline, Evolution, etc.)
• Based on polydimethylsiloxane. Biopolymer gel.

The use of "non-absorbable" preparations for contour plasty after preliminary operative grinding allows to significantly improve the cosmetic result of treatment of patients with hypotrophic scars and is for them a method of choice.

• Farmakrilovy gel, production Russia.

Is a synthetic, non-absorbable drug. The negative quality of the drug is its very high viscosity and great difficulty in introducing even a 21 G needle.

Pharmacil and biopolymer gels are a means of choice for the treatment of hypotrophic scars. This is explained by their cost-effectiveness and the possibility of correction of defects for infinitely long time. In addition, they practically do not give allergic reactions. If the doctor, used a number of technologies and did not achieve clinical results to reduce the depth of the scars, contour plastic is for him the last means to level the relief of the rumen in relation to the surrounding skin. To start this technology is possible only after the removal of the inflammatory reaction accompanying the previous procedure. Typically, this technology is used after therapeutic or operative dermabrasion. Starting contour plastics is always better with monophasic or biphasic biodegradable materials. Achieving a satisfactory effect after the introduction of such drugs will become a guide to the doctor's action for the future, after they are resorbed. And then the last and final stage will be the introduction of a non-absorbent preparation, for example a biopolymer gel.

Biopotimer 350 (Spain).

It consists of solid particles of dimethylpolysiloxane. This is a mixture of linear polymers of siloxane. Completely methylated, trimethylsiloxane units that block the edges of the molecules, and silicium dioxide. The size of the microparticles is from 200 to 400 nanomycrons. Transporting gel-suspension D 1-propandiol (solvent) and aqueous medium-are sterile and are pyrogen-free. The transport gel is not part of the silicone group, and after the injection it dissolves within 30 days. It is replaced by fibrin and collagen, which surround the microimplant and prevent the migration of microparticles.

The drug does not need special storage conditions (temperature, humidity, light);

• does not have hemolytic, toxic, mutagenic (teratogenic), allergic and endogenic effects;
• sterile packaged in vials of 5.0 and 10.0 ml;
• is biocompatible;
• It does not migrate, it stimulates the synthesis of collagen fibers by fibroblasts.

Recommendations for the use of the gel for the correction of hypotrophic scars:

1. Place the place of treatment with an antiseptic.
2. Collect the drug from the vial in a 2.0-5.0 ml syringe, then fill the insulin syringe with a non-removable gel needle and insert under the scar. The needle that is used is 27G.
3. It is not recommended to administer a volume exceeding 3-5 ml at the same time.
4. Correction is possible in 2 weeks after the first procedure.
5. In case of occurrence of inflammatory reaction - application of wet-drying bandages, lotions, sprays (oxycorte, panthenol), ointments with antibiotics.
6. Edema and erythema accompanying the introduction of the drug can be doped with ice.
7. Avoid getting the drug into the subepidermal layers when removing the needle;

During the first 24 hours, inflammation can occur in the implantation zone.

12. Operative dermabrasion of scars, with the subsequent filling of cicatricial indentations with "dermal equivalent".

The optimal methods for treating hypotrophic scars are:

• mesotherapy with drugs that stimulate fibrogenesis (including fibroblast culture);
• vacuum massage;
• operative or therapeutic dermabrasion;
• contour plastic or intradermal stimulation of the rumen;
• home care preparations: mederma, capillar, madecasol.