Part II: Post-injury, post-accident and post- burn scars before and after treatment
Normotrophic scars typically do not require correction rather adequate treatment at this stage of formation. Otherwise they may transform into hypertrophic or atrophic scars without proper control and treatment (Fig.1)
Fig.1. Transformation of normotrophic scar after surgery into hypertrophic
For the treatment of normotrophic scars, the following methods are used: microdermabrasion, early repetitive rotational dermabrasion, enzymotherapy, microneedling (collagen induction therapy), scar removal creams, cosmetic procedures (moisturizing, massage, lymphatic drainage), peeling: glycolic acid, ТСА peeling, phenol, surgical excision to improve appearance.
Microdermabrasion of normotrophic scar – skin polishing of the scar localization with aluminum oxide microcrystals (Al2O3). Aluminum sand is applied onto the skin surface by means of negative pressure and, knocking the particles out of the problem zone, aluminum sand is sucked into another container. Vacuum enables to elevate the scar bottom (Fig.2). This method does not require anesthesia, the recovery period being 4-10 days. Patients retain social activity. In some countries this method is called “A weekend procedure”. To archive tangible results, 3-5 procedures are required with a 3-4 week interval.
Fig.2. Normotrophic forehead scar before and after 2 procedures of microdermabrasion
Early repetitive rotational dermabrasion gives a good result in relation to fresh normotrophic scars. In the 60 years of the lastcentury, the practice began to implement grinding mill with a speed of 20 000 – 60 000 rpm (Fig.3).
Fig.3. Early repetitive rotational dermabrasion of normotrophic scar
These devices are used to treat fresh and correction of old normotrophic scars. The application point is the papillary layer of the dermis. With respect to normotrophic scars, the cutter removes unevenness of the scar tissue and stimulates the healing process (Fig. 4).
Fig.4. Normotrophic scar after surgery before and after early rotational dermabrasion
Enzymotherapy of normotropnic scars. Various enzymes application is not only reasonable, but necessary for adequate scar treatment and wound healing. Thus, participating in phagocytosis (48-72 hours after injury) some enzymes (e.g. chymotrypsin) assume the macrophage part, reducing the inflow of leucocytes to the wound which are responsible for the size of edema and inflammation. Others (e.g. hyaluronidase) dilute extracellular matrix by means of hyaluronic acid depolimerization, facilitating free cell migration. Some (e.g. collagenase) induce the destruction of excessive collagen.
Fig.5. Post- injury scars and abrasions on the face. Enzymotherapy
Treatment of normotrophic scars with microneedling (dermaroller, dermapen, dermastamp). The application of dermaroller (Fig.6) forms hundreds of microscopic channels in the skin. Following a number of complicated consecutive reactions (hemostasis – inflammation – proliferation – remodeling), fibroblasts, special skin cells, “patch” the microscopic channels formed by dermaroller needles. Collagen islands are synthesized within the channels, which are attracted to one another, thus gradually aligning the edges of scars or striae. In this manner an elastic backing of fresh collagen tissue is created on the one hand, decreasing the width of scars/striae by retracting and elevating their bottom to the skin surface on the other hand.
Fig.6. Treatment (removal) scars with dermaroller
Fig.7. Collagen induction therapy of normotrophic scar
Scar removal creams. Different ointments, creams and gels are applied depending on the stage of scar formation, such being antibacterial, normalizing blood circulation, reducing or stimulating collagen synthesis, diluting wound environment, boosting immunity of the wound area, etc. To this end used Kelo-cote, Dermatix, Stratoderm, MedGel, Kelofibrase, Scarguard, Contractubex, Aldara, among others are applied. Each individual case surely requires a consultation with the attending physician to select the necessary cream, ointment or gel, because some products are capable of not only improving, but as well as of worsening the scar condition. Topical therapy is usually applied either in parallel to, or after mechanical treatment methods.
Cosmetic procedures for treatment of normotrophic scars. In the recent past potassium permanganate solution (KMnO4) was commonly applied onto a fresh wound. An incrustation subsequently developed under which a scar was starting to form. Nowadays there is no doubt that a callous scar is formed under incrustation. A wound should be healed in humid environment where cells freely migrate, divide and share the necessary information among each other. A number of application products are used for wound hydration, capable of retaining liquid within the area of scar formation.
Fig.8. Normotrophic scar before and after combined treatment with moisturizing
Peeling for removal of normotrophic scars. Peeling incorporates the notions “to purify”, “remove the skin” and “exfoliate”. Therefore, any exfoliation-related process of epidermis in the upper layers of derma is basically referred to as a peeling. Depending on depth of effect, all peelings are divided as follows:
- superficial – several layers of keratinized cells;
- middle – throughout keratinized layer;
- deep – throughout epidermis down to the basal layer and papilla dermis, penetrating into reticular dermis.
The TCA peeling is used for normotrophic scars. For fresh normotrophic scars, the concentration of 15% TCA peeling is sufficient. After appling the acid, the skin gets a powerful boost to regeneration. This is due to the inflow of stem cells needed for recovery. However, there is an opinion that the resource of stem cells is not infinite, and the more often peels are made, the faster their resource is exhausted. The old scars are affected only by phenol peeling.