Treatment of hypotrophic scars

Hypotrophic scars occur as a result of deep destruction of skin tissue and subcutaneous fat. Such scars can occur after deep forms of acne, chickenpox and look stamped, approximately the same size and shape with sharp borders from healthy skin and often crater-like edges. Larger hypotrophic scars with less sharp edges appear after regression of dermatoses, where the primary element was a node. And, finally, domestic and road traffic injuries can also leave retracted single and large hypotrophic scars after healing.

With such large scars, as a rule, people turn to plastic surgeons to reduce their size and depth. In surgical practice, the technique of scar excision is used, if the tissues allow it. As a result of such surgical interventions, the appearance of the scar improves and it can become flatter, but longer. If, due to the location and size of the scar, it is not possible to excise and tighten the tissue, various reconstructive plastic surgeries are performed, in particular, with counter flaps, as a result of which the scar is flattened, but takes a zigzag shape. After the surgical stage of treatment, in order to improve the aesthetic appearance of the scar, patients should be referred by surgeons to dermatocosmetologists.

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

Patients with small hypotrophic scars are a contingent for dermatocosmetologists. However, some surgeons suggest excising each scar, as a result of which an elongated or circular normotrophic scar appears in place of the hypotrophic round scar. This work is very meticulous, is performed almost at a jewelry level, takes a lot of time, so few surgeons undertake it. Subsequent surgical polishing, done at an early stage, can practically hide traces of scars. But as has already been said, most often these patients end up in the offices of dermatocosmetologists.

What methods can dermatocosmetologists use to improve the appearance of hypotrophic scars and what can be expected from dermatocosmetology technologies?

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

1. Cryomassage.

Can be used at early stages of scar formation. Due to improved tissue trophism, the depth (-) of the tissue can become smaller. Old scars are practically not amenable to cryomassage treatment.

2. Vacuum massage.

It can only be effective on young scars.

3. Electrophoresis.

Iontophoresis of a cosmetology stand with vasoactive biostimulating, vitamin preparations, microelements (theonicol, organic silicon, ascorbic acid, aflutop, oligosol zinc, retinoic acid, etc.).

4. Phonophoresis.

With madecassol, solcoseryl ointment, mederma cream.

5. Electrophonophoresis, laser therapy, laserphoresis, microcurrent therapy, magnetic thermal therapy.

They can also be used only for the treatment of young scars. However, due to the fact that there are much more effective methods, it is inappropriate to prescribe patients procedures that require time and material costs and are of questionable effectiveness.

6. Mesotherapy.

Biologically active, vitamin-rich preparations that improve microcirculation and cell metabolism (aloe extract, placenta extract, nicotinic acid, retinoic acid, vitamin C, etc.).

Homeopathic preparations have also proven themselves to be effective (see mesotherapy for atrophic scars).

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

It is a modern and quite effective method of treating hypotrophic scars. The method is carried out either with a simple needle with the introduction of novocaine under the scar, or with an instrument such as a pointed hook, or with a special thread. Separation of the scar from the surrounding tissues leads to the fact that the aseptic inflammation resulting from the injury activates the synthetic and proliferative activity of fibroblasts. The resulting gap between the bottom of the scar and the underlying tissues begins to fill with connective tissue. As a result, there is a thickening of the tissue in the area of the bottom of the scars and, consequently, a decrease in their depth.

8. All types of therapeutic dermabrasion.

Dermabrasion is the second important stage in the treatment of hypotrophic scars. Only it allows, after "lifting" the bottom of the scars, to smooth them out as much as possible with the surrounding skin. There are quite a lot of patients who are afraid of any surgical interventions, including dermatosurgical ones. The attitude to lasers is also ambiguous, so such patients should undergo therapeutic dermabrasion, any option. The number of sessions and courses is individual, depending on the type of scars and tissue reactivity. It is better to conduct sessions actively, grinding the area around the scars almost to "blood dew". With such deep therapeutic dermabrasion, procedures are carried out no more than once a week, after complete cleansing of the surface from peeling and possible crusts.

9. Peelings.

Peels are an alternative to dermabrasion. Medium AHA and glycolic peels (50-70%) are preferred. The negative factor of using these technologies is that peels cannot be done many times, due to the possibility of developing an allergic reaction or increased skin sensitivity.

In case of hypotrophic scars, deep phenol peels are more indicated than medium AHA peels. However, to implement these technologies, an operating room, a resuscitation team and a hospital are necessary. Such conditions are available 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. Surgical 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 with a Schumann cutter, carbon dioxide or erbium laser that it is possible to optimally improve the appearance of scars, the previous treatment of which by 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 the crusts fall off, that is, 2-4 weeks after the first.

11. Contour plastic surgery.

Contour plastic surgery is a technique that can be used to make the relief of hypotrophic scars more even by introducing special preparations under the bottom of the scar. Contour plastic surgery is used as a final procedure after surgical or therapeutic dermabrasion, in the case of remaining elements of (-) tissue. This is due to the fact that it is often not possible to completely eliminate deep hypertrophic scars even with the above-mentioned therapeutic measures. In this regard, it becomes necessary to raise the bottom of the scar, which can be achieved with the help of contour plastic surgery. And surgical and even therapeutic dermabrasion accelerate the degradation of biological preparations for contour plastic surgery.

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

1. Materials with limited shelf life, biodegradable (biological).

Biodegradable drugs are divided into single-phase and two-phase.

Single-phase or homogeneous preparations consist of one substance: collagen, hyaluronic acid, etc. Recently, due to the prevalence of the mad cow disease virus, there has been a cooling of interest in collagen preparations, so hyaluronic acid preparations currently predominate on the market.

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

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

As an example of contour plastic preparations that are successfully used to correct scars and stretch marks, we will cite SURGIDERM preparations, manufactured by Corneal (France). This is a series of the latest generation of preparations based on hyaluronic acid. The preparations are a transparent gel of hyaluronic acid of non-biological origin, highly purified, meeting all European and international quality and safety standards (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. This is butanediol diglycidyl ether (BDDE). The concentration of hyaluronic acid in the preparations is up to 24 mg / p

The SURGIDERM series of products have international and Russian certificates.

It is known that in order to increase the stability (resistance) of hyaluronic acid in tissues, it must have intermolecular cross-links. Corneal has developed and patented a new method for the formation of 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 ensuring increased resistance to thermal destruction and the effects of free radicals.

The SURGIDERM series consists of 6 products: Surgiderm 18, Surgiderm 30, Surgiderm 24 XP, Surgiderm 30 XP, Surgiderm, Surgiderm Plus. All products in this series are single-phase, therefore, free of microparticles and absolutely homogeneous. It should be noted that Surgiderm 30 XP has the highest degree of reticulation, and Surgiderm 18 has the lowest. The higher the degree of hyaluronic acid reticulation, the more prolonged the duration of action of the product. Thus, Surgiderm 30 XP remains in tissues for up to 18 months.

As a means for correcting hypotrophic scars, it is most advisable to use Surgiderm 30 XP and Surgiderm 24 XP, since these preparations are not only easily introduced into the tissues, but are also 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 the resorption of the preparation, there will be an aftereffect. For the correction of atrophic scars, it is more advisable to use Surgiderm 18 to begin working with scars, and after its resorption, 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 for 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.
• Inflammation, pyoderma, viral diseases in the injection area.
• Allergic reaction to chicken protein, hyaluronic acid, polyvalent allergy.

Note.

• It is forbidden to inject Surgiderm series preparations and all preparations for contour plastic surgery immediately after surgical dermabrasion, chemical peels and in cases of acute inflammatory reactions. This will accelerate the absorption of the preparations and may lead to complications.

Contour plastic surgery of scars and stretch marks is recommended at the end of the course of treatment using other technologies, since after the introduction of fillers, all other treatment measures will lead to accelerated absorption of the drugs.

Biphasic or heterogeneous preparations are often of greater interest to doctors involved in scar correction. They are implants with a prolonged effect and consist of inert synthetic particles suspended in a biological substance - collagen or hyaluronic acid. They are absorbed within 18-24 months. However, it should be remembered that it is precisely these preparations that most often cause the appearance of a fibromatous reaction in the form of granulomas, which sometimes even occur away from the injection site.

An example of such preparations is Philoderm BeautySphere, which is a natural branched hyaluronic acid of non-animal origin, mixed with Dextran microspheres. The gel is viscoelastic, transparent and sterile.

After injection of Philoderm BeautySphere, Dextran microspheres interact with the skin, stimulating the formation of new collagen fibers. Hyaluronic acid regulates the degree of tissue hydration, returning their 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 under the bottom of the scar. The preparation should be injected with a minimum 27 G needle (3 needles are included in the kit). After the injection, massage the treated area with your fingertips. To achieve a good and long-lasting result, the procedure should be repeated after 2-3 weeks.

Reviderm - dextran microspheres in hyaluronic acid are absorbed within 2 years. The injection technology is similar to the previous one.

2. Long-acting materials that degrade slowly (polymeric).

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

The use of “non-absorbable” preparations for contour plastic surgery after preliminary surgical resurfacing allows for a significant improvement in the cosmetic outcome of treatment for patients with hypotrophic scars and is the method of choice for them.

• Pharmacrylic gel, made in Russia.

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

Pharmacrylic and biopolymer gels are the means of choice for the treatment of hypotrophic scars. This is explained by their cost-effectiveness and the possibility of correcting defects for an infinitely long time. In addition, they practically do not give allergic reactions. If the doctor has used a number of technologies and has not achieved clinical results in reducing the depth of scars, contour plastic surgery is the last resort for him, allowing him to level the relief of the scar in relation to the surrounding skin. This technology can be used only after the inflammatory reaction accompanying the previous procedure has been removed. As a rule, this technology is used after therapeutic or surgical dermabrasion. It is always better to start contour plastic surgery with monophase or two-phase biodegradable materials. Achieving a satisfactory effect after the introduction of such drugs will be a guide to the doctor's actions in the future, after their absorption. And then the last and final stage will be the introduction of a non-absorbable drug, for example, a biopolymer gel.

Biopotimer 350 S.R. (Spain).

It consists of solid dimethylpolysiloxane particles. It is a mixture of linear siloxane polymers. completely methylated, balanced by trimethylsiloxane units that block the edges of the molecules, and silicon dioxide. The size of the microparticles is from 200 to 400 nanomicrons. The transport gel - suspension D 1 - propanediol (solvent) and an aqueous medium - are sterile and apyrogenic. The transport gel does not belong to the silicone group and after injection is absorbed within 30 days. It is replaced by fibrin and collagen, which surround the microimplant and prevent the migration of microparticles.

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

• does not have hemolytic, toxic, mutagenic (teratogenic), allergenic or carcinogenic effects;
• sterilely packaged in 5.0 and 10.0 ml vials;
• is biocompatible;
• does not migrate, stimulates the synthesis of collagen fibers by fibroblasts.

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

1. Treat the injection site with an antiseptic.
2. Draw the preparation from the bottle into a 2.0-5.0 ml syringe, then fill the insulin syringe with a non-removable needle with gel and inject under the scar. The needle used for this is 27G.
3. It is not recommended to administer a volume exceeding 3-5 ml at a time.
4. Additional correction is possible 2 weeks after the first procedure.
5. In case of an inflammatory reaction, use wet-drying dressings, lotions, sprays (oxycort, panthenol), ointments with antibiotics.
6. Edema and erythema accompanying the administration of the drug can be relieved with ice.
7. Avoid injecting the drug into the subepidermal layers when removing the needle;

During the first 24 hours, inflammation may occur in the implantation area.

12. Surgical dermabrasion of scars, followed by filling of scar depressions with a “dermal equivalent”.

The optimal methods for treating hypotrophic scars are:

• mesotherapy with drugs that stimulate fibrogenesis (including fibroblast culture);
• vacuum massage;
• surgical or therapeutic dermabrasion;
• contour plastic surgery or intradermal stimulation of the scar;
• home care with medications: mederma, capilar, madekasol.