有能力的看一下，呵呵，我就不翻譯了。。。治療疤痕的希望。。。

coconall

Lasers in Medical Science

© Springer-Verlag London Ltd 2009

10.1007/s10103-009-0710-3

Original Article

Comparison of the effects of short- and long-pulse durations when using a 585-nm pulsed dye laser in the treatment of new surgical scars

Keyvan Nouri¹ , Mohamed L. Elsaie^{2, 3} , Voraphol Vejjabhinanta³, Mark Stevens⁵, Shalu S. Patel⁴, Caroline Caperton¹ and George Elgart¹

(1)	Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, 1475 NW 12th Ave, Suite 2175, Miami, FL 33136, USA

(2)	NRC, Cairo, Egypt

(3)	laceType w:st="on">UniversitylaceType> of laceName w:st="on">Miami, Miami, USA

(4)	University of Miami Miller School of Medicine, Miami, USA

(5)	Department of Oral Maxillofacial Surgery, Medical College of Georgia, Augusta, GA, USA

Keyvan Nouri (Corresponding author) Email: knouri@med.miami.edu

Mohamed L. Elsaie Email: egydoc77@yahoo.com

Received: 12 June 2009 Accepted: 29 June 2009 Published online: 7 August 2009

Abstract

More than 70 million surgical procedures are performed annually in the USA with the majority involving a skin lesion and almost all individuals in their lifetime will have one or more surgical procedures resulting in scars. Patients and physicians alike are thereby motivated to improve the cosmetic outcome of scars. Prior studies have shown that the pulsed dye laser (PDL) is effective in improving the quality and appearance of the scar when using the 585-nm PDL immediately after the removal of sutures. Most published studies used a pulse duration of 450 µs, which along with the other study parameters, has led to an overall improvement of the scars. However, a pulse duration of 1.5 ms is also available when using the pulsed dye laser and it should theoretically cause fewer side-effects. To our knowledge, there are no other studies comparing the effectiveness of different pulse durations in the treatment of surgical scars starting on the day of suture removal. The purpose of this study is to compare the effect of different pulse durations (450 µs vs. 1.5 ms) in the treatments of postsurgical linear scars immediately after suture removal when using the 585-nm pulsed dye laser (PDL). Twenty non-hospitalized male and female patients (older than 18 years of age) with skin types I?IV and with postoperative linear scars measuring at least 2.1 cm were enrolled in this prospective study. Scars were randomly divided into three equal sections. The different fields were randomly chosen to receive treatment (two out of three fields) or remain as control (one field). The two fields chosen to be treated received treatment with the 585-nm PDL using a 7-mm spot size at 4.0 J. One of the treated sections was randomly selected to receive a pulse duration of 450 µs, and the other section to receive a 1.5-ms pulse. The remaining scar section was designated as control (no treatment). The three sections were mapped and recorded. The patient received treatment immediately after the sutures were removed from the wound and then monthly for 3 months. Evaluations were performed before each treatment and 1 month after the last treatment. The short-pulse and long-pulse 585-nm PDL-treated sections demonstrated a statistically significant overall average improvement of the VSS of 92 and 89%, respectively, compared to 67% for the control site (Fig. 1). Further, for individual parameters of the Vancouver scar scale (VSS), there were significant (p < 0.05) differences between control and treatment groups for all parameters, but there were no differences between the short- and long-pulse treatment groups for any parameter. Both short-pulse and long-pulse PDL are safe and effective in improving the quality and cosmetic appearance of surgical scars in skin type’s I?IV starting on the day of suture removal with no significant difference between the two pulse durations.

Keywords Pulsed dye laser (PDL) - Surgical scars - Keloid

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Introduction

More than 70 million surgical procedures are performed annually in the USA, with the majority involving a skin incision [1]. Almost all individuals in their lifetime will have one or more surgical procedures resulting in scars. Both patients and physicians seek ways to diminish the appearance of these scars, and laser treatment may provide an alternative to the current treatment options. These current methods for reducing surgical scars include surgery/grafting, dermabrasion, cryotherapy, pressure therapy, intralesional corticosteroids, interferon, imiquimod, and intralesional 5-fluorouracil. Lasers such as the CO₂ laser, argon laser, Nd:YAG laser, non-ablative lasers, and the pulsed dye laser (PDL) have been proven effective in improving the cosmetic appearance of keloids and hypertrophic scars.

Treatment with the PDL is non-invasive, painless, and requires no anesthesia. The PDL works via selective photothermolysis that targets blood vessels with minimal collateral damage. The energy from the PDL is preferentially absorbed by hemoglobin to cause local thermal injury, which is limited by the short pulse duration. Thrombosis, vasculitis, and gradual repair follow. Although the exact mechanism by which the PDL affects scarring is unknown, it is thought that microvascular destruction leads to ischemia, which may affect collagen or collagenase release, or which may deprive a scar of nutrients to prevent scar hypertrophy. Additionally, the increase in mast cells observed after PDL treatment provides histamine that stimulates normal and keloid fibroblast growth and has both positive and negative effects on collagen synthesis.

Various prior studies have evaluated the PDL and have shown that it is effective in improving the vascularity, color, height, texture, and pliability of scars [2?4]. Manuskiatti et al. treated ten keloidal or hypertrophic median sternotomy scars with the 585-nm PDL (450 µs [5]. The scars were divided into three segments and randomly treated with fluences of 3, 5, or 7 J/cm². After PDL treatment, they found evident improvement in the factors listed above, but did not find a significant difference in the outcome of the different fluences. However, they did not find a trend of better results with the lower fluence, and suggested that multiple sessions may be needed for a greater response. McGraw et al. showed the benefit of early PDL use on surgical scars in an uncontrolled study [6]. They demonstrated improved quality of the scars (especially color), and a decreased rate of hypertrophic scarring when treated with the 585-nm PDL within the first 2 weeks after surgery. A previous study by Nouri et al. treated 12 postoperative linear scars with the PDL immediately following suture removal [7]. The scars were divided into two equal sections, one for the 585-nm PDL treatment (10-mm spot size and 3.5 J/cm²) and the other for control (no treatment). The treated halves scored better in cosmetic appearance using the cosmetic visual analog scale (CVAS) and in all scar parameters using the Vancouver scar scale (VSS). A final scar analysis by a blinded examiner revealed a significant difference between treated and untreated sites. In a subsequent study, Nouri et al. also compared the effectiveness of the 585-nm PDL vs. the 595-nm PDL for the treatment of new surgical scars [8]. A total of 19 scars were randomly divided into three equal sections. The first and third sections were randomized into treatment with either 585-nm or 595-nm PDL, and the middle section of each scar was designated as the control. After evaluating the scars using the VSS and the CVAS, it was found that the 585-nm and 595-nm treated sections demonstrated an overall average improvement of 67- and 55%, respectively, compared to 32% for the control side. There was a statistically significant difference between the treated sites and the control site, but there was no significant difference between the two treated sites (p > 0.05).

To our knowledge, there are no other studies comparing the effectiveness of different pulse durations in the treatment of surgical scars starting on suture removal day. Most published studies use a short-pulse duration of 450 µs, which along with the other study parameters, have led to an overall improvement of the scars. However, a long-pulse duration of 1.5 ms is also available when using the PDL, and it should theoretically cause less side-effects. The objective of this study is to document the effect of short- and long-pulse durations when using the 585-nm PDL and to see if one is better or both are equally effective in improving scarring conditions and outcomes.

The 585-nm pulsed dye laser has been shown to clinically improve erythematous and hypertrophic scars by 57?83% after one to two treatments in patients with a 2-year scar history. Also, this laser improved >1-year-old non-erythematous, minimally hypertrophic scars when used in combination with a CO₂ laser [2].

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Material and methods

Twenty non-hospitalized male and female patients (older than 18 years of age) with skin types I?IV and with postoperative linear scars measuring at least 2.1 cm were enrolled in this prospective study. Exclusion criteria were that the patient should not be receiving any additional systemic, topical, or intralesional treatment of the scars during the study.

Each scar was divided into three equal sections and randomly assigned to receive treatment (two out of three sections) or remain as control (one section). One treatment section received the short-pulse (450-µs) 585-nm PDL using a 7-mm spot size at 4.0 J/cm². The other treated section received the long-pulse (1.5-ms) 585-nm PDL using the same settings. The remaining scar section was designated as control (no treatment). The three sections were mapped and recorded.

Each patient received treatment immediately after the sutures were removed from the wound, and then monthly for three total sessions. Evaluations were performed before each treatment, at 1 month after the last treatment, and 6 months after the first treatment. Each scar was measured and recorded. Measurements and photographs were taken at each visit.

A blinded examiner then performed the final analysis by comparing pictures as well as evaluating the patient’s scar. The scars were evaluated using the VSS and CVAS. In order to compare histological changes achieved with treatment, biopsies of each third of the scar were performed in five randomly chosen patients. The VSS is a tool used to evaluate scars based on pigmentation, vascularity, pliability, and height (Table 1). The CVAS is a tool used by both a blinded observer and the patient to evaluate the cosmetic appearance of all three sections of the scar from a range of zero to ten. Statistical analysis of the data was achieved using McNemar’s test to determine the improvements based on the VSS (pigmentation, vascularity, pliability, and height) score of the scars in each of the three groups. Analysis of variance (ANOVA) was also used to assess the effect of treatment for the CVAS.

Table 1 Vancouver scar scale

Pigmentation	0	Normal color (close to normal skin)
	1	Hypopigmentation
	2	Hyperpigmentation
Vascularity	0	Normal color (close to normal skin)
	1	Pink (slight increase in local blood supply)
	2	Red (significant increase in local blood supply)
	3	Purple (excessive increase in local blood supply)
Pliability	0	Normal (normal pliability)
	1	Supple, flexible with minimal resistance)
	2	Yielding (giving way to pressure, offering moderate resistance but does not behave as a solid mass of scar)
	3	Firm (solid, inflexible unit, not easily moved, resistant to manual pressure)
	4	Banding (rope-like tissue that blanches with extension of scar, does not limit ROM)
	5	Contracture (permanent shortening of the scar producing deformity or distortion, limits ROM)
Height	0	Normal (flat)
	1	<2 mm
	2	<5 mm
	3	>5 mm

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Results

One month after the last treatment, final scar analysis revealed a significant difference between treated and untreated sites favoring the treated sites. The short-pulse and long-pulse 585-nm PDL-treated sections demonstrated a statistically significant overall average improvement of the VSS of 92 and 89%, respectively, compared to 67% for the control site (Fig. 1). Further, for individual parameters of the VSS, there were significant (p < 0.05) differences between control and treatment groups for all parameters, but there were no statistically significant differences between the short- and long-pulse treatment groups for any parameter (Fig. 2).

Fig. 1 Average percent improvement as measured by the Vancouver scar scale (VSS)

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Fig. 2 Average percent improvement of individual VSS parameters

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For overall cosmetic appearance, there were no baseline differences at visit #1 in between groups. At visits #2?4, both short- and long-pulse treatment groups showed a significant difference from the control. There were no significant differences between the two treatment groups (Figs. 3 and 4). Photographs taken at the first and last visit are compared in Figs. 5 and 6.

Fig. 3 Mean cosmetic visual analog scale (CVAS) results

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Fig. 4 Post-treatment cosmetic visual analog scale (CVAS)

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Fig. 5 Photographs from the first and last visit of five random patients

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Fig. 6 Photographs from the first and last visit of five random patients

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Discussion

Keloids and hypertrophic scars are sequelae of abnormal wound-healing process. They are a common reason for dermatologic consultation. A multitude of signaling molecules, including growth factors [TGF-β, PDGF, vascular endothelial growth factor (VEGF)], mitogen-activated protein (MAP) kinases, matrix metalloproteinases (MMPs), and tissue inhibitors of metalloproteinases (TIMPs), regulate this complex process of scar development on the molecular level [9]. The effector molecules that link these regulatory signals and the various phases of wound healing are incompletely understood, although it is known that a derailment in this complex wound-healing process contributes to hypertrophic scars and keloid formation [10].

Hypertrophic scars are typically raised, red or pink, and sometimes pruritic, but do not exceed the margins of the original wound, whereas keloids infiltrate into surrounding normal tissue and rarely regress. Hypertrophic scars usually subside with time, whereas keloids continue to evolve over time, without a quiescent or regressive phase. The choice of an appropriate laser for treatment is influenced by a number of factors such as the fluence, spot size, scar location and duration [11].

The pulsed dye laser has become the popular treatment for remodeling post-operative scars. Both types of scars are abnormal wound responses in predisposed individuals and represent a connective tissue response to trauma, inflammation, surgery, or burns [12]. The first challenge to scar therapy begins with the simple identification and diagnosis of the problematic abnormal wound healing [13].

During the mid-1980s, the introduction of the theory of Selective Photothermolysis by Anderson and Parrish, led to the birth of the pulsed dye laser. Pulsed dye lasers are unique in that they can deliver very high peak powers of energy over short periods of time. These high peak power pulses cause a selective thermal injury to targeted structures in the skin with minimal collateral injury to surrounding tissue. The first commercialized pulsed dye laser was designed to deliver 450-µs pulses at a wavelength of 585 nm. This parameter set was the closest technical specification to the ideal parameters per Anderson and Parrish’s description of Selective Photothermolysis. The trend for scar treatment had always been towards the 585-nm wavelength and the short duration at 450 µs.

The PDL is considered to be the standard treatment of vascular lesions, such as port wine stains, initial hemangiomas, and facial telangiectasias. Additionally, this laser type is often successfully used for non-vascular indications, such as keloids or hypertrophic scars [14]. Currently, the PDL wavelengths of 585 and 595 nm are most frequently used for therapeutic purposes. Alster reported an average improvement of 57% after the first treatment and 83% after the second treatment with PDL for hypertrophic surgical and traumatic scars. In addition to a reduction in erythema, flattening, a clear reduction in itching and pain, and optimization of the skin texture have been observed [15]. The entire scar in each patient was exposed to PDL at a wavelength of 585 nm, a pulse duration of 0.45 ms, and a fluence of 6.5 to 7.25 J/cm². Recent biochemical studies suggest that 585-nm PDL treatment alters signaling pathways to favor collagen degradation and fibroblast apoptosis [16]. In contrast to the above-cited results, Chan and colleagues failed to show any clinical improvement using PDL for hypertrophic scars. In 27 hypertrophic scars, one side of each of which was treated (585 nm, 7?8 J/cm², 2.5 ms, 5 mm), the authors documented no superiority of the treated half after three to six treatments regarding thickness and elasticity, although pain and touch sensitivity were far better on the treated side [17]. Currently, there is no consensus on the mechanism by which the PDL achieves such clinical outcome. Hypotheses have included selective destruction of microvasculature and regulation cellular activity, such as inhibition of growth factors TGF- β and PDGF, and stimulation of MMP and IL-6 for matrix degradation. The short duration at 450 μs may more selectively eliminate the small vascular supply of the scar. The long duration at 1.5 ms may generate heat more slowly and results in less side-effects. Both short-pulse and long-pulse 585-nm PDL resulted in scar improvement, but there was no difference between the two pulse durations.

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Conclusions

The PDL is safe and effective in improving the quality and cosmetic appearance of surgical scars in skin types I?IV starting on the day of suture removal. Both short- and long-pulse 585-nm PDL resulted in scar improvement, but there was no difference between the two pulse durations. Laser therapy for improvement in the parameters of postoperative scarring continues to merit further studies to refine the laser settings that will lead to the best cosmetic outcome in patients. Both short-pulse and long-pulse PDL are safe and effective in improving the quality and cosmetic appearance of surgical scars in skin types I?IV starting on the day of suture removal with no significant difference between the two pulse durations

Acknowledgments We would like to thank the Hugoton Foundation for their grant and support of this project.

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References

1.	FastStats (2002) National Center for Health Statistics. Centers for Disease Control and Prevention, Atlanta, GA, USA
2.	Alster TS (1994) Improvement of erythematous and hypertrophic scars by the 585-nm flashlamp pumped pulsed dye laser. Ann Plast Surg 32(2):186?90
3.	Alster TS, Williams CM (1995) Treatment of keloid stemotoy scars with 585-nm flashlamp pumped pulsed dye laser. Lancet 345:1998?200
4.	Alster TS (1997) Laser treatment of hypertrophic scars, keloids and striae. Dermatol Clin 15(3):419?29
5.	Manuskiatti W, Fitzpatrick R, Goldman M (2001) Energy density and numbers of treatment affect response of keloidal and hypertrophic sternotomy scars to the 58 nm PDL. J Am Acad Dermatol 45:557?565
6.	McGraw JB, McGraw JA, McMellin A et al (1999) Prevention of unfavorable scars using early pulsed dye laser treatments: a preliminary report. Ann Plast Surg 42:7?14
7.	Nouri Jimenez GP, Harrison-Balestra C, Elgart GW (2003) 585-nm PDL in the treatment of surgical scars starting on suture removal day. Dermatol Surg 29:65?73
8.	Nouri K, Rivas M, Stevens M et al. Comparison of the effectiveness of the pulsed dye laser 585-nm vs. 595-nm in the treatment of new surgical scars. Accepted for publication in Lasers Med Sci
9.	Bock O, Yu H, Zitron S et al (2005) Studies of transforming growth factors beta 1?3 and their receptors I and II in fibroblast of keloids and hypertrophic scars. Acta Dermatol Venereol 85:216?20
10.	Stamenkovic I (2003) Extracellular matrix remodelling: the role of matrix metalloproteinases. J Pathol 200:448?64
11.	Bouzari N, Davis SC, Nouri K (2007) Laser treatment of keloids and hypertrophic scars. Int J Dermatol 46:80?88
12.	English RS, Shenefelt PD (1999) Keloids and hypertrophic scars. Dermatol Surg 25:631?8
13.	Slemp AE, Kirschner RE (2006) Keloids and scars: a review of keloids and scars, their pathogenesis, risk factors, and management. Curr Opin Pediatr 18:396?402
14.	Karsai S, Roos S, Hammes S, Raulin C (2007) Pulsed dye laser: what's new in non-vascular lesions. J Eur Acad Dermatol Venereol 21:877?890 (Review)

coconall

這是從國外的學術期刊中獲得的資料，從現在看來，疤痕是無法完全消除的，但是可以治療到最佳的狀態(tài)。。。。

如今國內的技術達不到圖片上的要求。。。

我得出的結果是，治療疤痕。。。還是到國外去好點。。。。哎。。。。

有一張圖沒發(fā)上來。。。因為每天只可以發(fā)5張。。。。

腿上疤

有能力的還是翻譯一下吧....

疤痕快消失

講的是鐳射，也就是現在的點陣激光之類的吧。

針對的也是新疤痕

jackey5418

還是激光，希望有用！

小小魚

原文
　　
　　的影響比較短的時間??而long-pulse當使用一個585-nm脈沖染料激光治療新的手術疤痕
　　
　　穆罕默德?l . Elsaie2 Nouri1,Keyvan、3、Voraphol Vejjabhinanta3,馬克Stevens5臨近夏魯寺s . Patel4,卡羅琳,Elgart1 Caperton1和喬治
(1)
　　部門與皮膚的手術后,皮膚病學邁阿密。米勒大學醫(yī)學院,滇西北、套房12大街1475 2175 33136,佛羅里達州邁阿密,美國
　　(2)
　　埃及,開羅描述,
　　(3)
　　邁阿密大學,邁阿密,美國
　　(4)
　　邁阿密。米勒大學醫(yī)學院,邁阿密,美國
　　(5)
　　口腔頜面外科部門,醫(yī)學院的喬治亞州,奧古斯塔、遺傳算法、美國等國家
　　Keyvan努里?卡邁勒?(通訊作者)
　　電子郵件:knouri@med。

小小魚

2009年6月12日收到:接受:6月29日2009年8月7日發(fā)表在線:2009年
　　
　　文摘
　　
　　外科手術70多萬,每年在美國進行的大部分事故是一個皮膚損害,幾乎所有的個體,在他們的一生中會有一個或多個手術導致的傷疤。病人和醫(yī)生都是有動力去提高從而化妝品的結果的傷疤。在此之前的研究表明,脈沖激光的客運專線)是有效的(提高質量).據我們所知,還沒有其他的研究比較不同脈沖時間的有效性的外科疤痕治療開始前的最后一天縫合去除。本研究的目的在于比較不同時間的影響(450μs脈沖和1.5 ms)在治療上的postsurgical縫合后立即移除線性疤痕當使用的585-nm脈沖染料激光器(客運專線)。20 non-hospitalized男性和女性患者(年齡大于18歲)與皮膚類型I-IV而用.疤痕患者隨機分為三等分。不同的領域中隨機挑選的接收治療(三分之二的領域)或繼續(xù)作為控制(一場)。上述兩個領域的公司被選為585-nm接受過治療的治療使用7-mm斑大小的客運專線在4.0 j .的一個部分是治療隨機選取一個脈沖持續(xù)時間來接受,共450μs,另一部分人能得到一1.5-ms脈搏。剩下的疤節(jié)被指定為控制(沒有治療)。3個部分被映射和記錄。病人接受治療后,立即被清除出縫合傷口,然后每月為3個月。每一種治療方式的評價進行了較深入的研究和1個月前最后一次治療后。short-pulse 585-nm PDL-treated和long-pulse的部分展示了一個統(tǒng)計上的顯著性總體平均的改進和89%的92 VSS分別比為控制工地67%(圖1)。進一步的,因為個別參數的溫哥華疤痕規(guī)模(VSS),有顯著差異(p < 0.05),治療組之間的所有控制參數,但沒有差異,治療組long-pulse短,對于任何參數。short-pulse和long-pulse都是安全、有效的客運專線在提高服務質量、外觀的手術疤痕的皮膚類型出發(fā)了,一天的I-IV縫合切除無顯著差異,而這兩個人之間的脈搏
.

小小魚

介紹
　　
　　外科手術70多萬,每年在美國進行,多數是涉及一種皮膚切口[1]。幾乎所有的個人,在他們的一生中會有一個或多個手術導致的傷疤。病人和醫(yī)生都尋求減少這些傷疤的外形和激光治療可能會提供另一個當前的治療方案。這些電流方法為減少手術疤痕包括手術/嫁接,dermabrasion,冷凍治療,
治療的客運專線是非侵入性的,免費,并且不需要麻醉。經選擇性photothermolysis客運專線的工程目標血管與最小的附加的傷害。從客運專線的能量吸收是優(yōu)先血紅蛋白引起局部熱損傷,這是有限的,由短脈沖持續(xù)時間。血栓形成、血管和漸進的修理跟隨。雖然確切的機制,通過這種機制的客運專線是未知的,影響瘢痕微血管破壞被認為是導致局部缺血,可能影響膠原蛋白或膠原酶釋放或可能剝奪了傷疤的營養(yǎng),以防止疤痕肥厚。此外,增加治療后癥狀的客運專線肥大細胞提供刺激正常和蟹足腫組胺和成纖維細胞生長有正面和負面的影響膠原蛋白的合成
.先前的研究評價了各種各樣的客運專線,表明這是有效提高vascularity、顏色、身高,質地,和柔軟度的傷疤[2 - 4]。Manuskiatti等十keloidal高慶宇治療或肥厚性疤痕與585-nm中顯現的客運專線(450μs[5]。疤痕的被分成三個環(huán)節(jié)和隨機治療的fluences 3、5、或7 J /平方厘米。
治療后,他們發(fā)現明顯的客運專線改善上述因素,但沒有找到一個顯著差異,而在不同的fluences的結果。然而,他們沒有找到一個趨勢與較低的能量密度更好的結果,表明每個會話可能需要更大的反應。
麥克格勞等早期的利益高慶宇顯示在外科手術的疤痕的客運專線使用不受控制的研究[6]。他們舉行示威質量得以改善的疤痕(特別是顏色),和降低了肥厚性瘢痕形成率目標值時585-nm治療的頭兩周內手術后。此前的一項研究由努里?卡邁勒?蘇達權等治療術后線性傷疤的12去除后立即進行縫合的客運專線[7]。
疤痕的被分成二等分,一個是為585-nm治療(10-mm斑大小的客運專線和3.5 J /平方厘米),另一個用于控制(沒有治療)。在處理過的半場得分較高,外觀使用化妝品直觀類比標度(CVAS),和在所有疤痕參數選用溫哥華疤痕量表(VSS)。
最后分析了由單盲的傷疤考官透露有顯著區(qū)別對待以及未經處理的地點。在后續(xù)的研究中,努里?卡邁勒?蘇達權等的有效性也進行了比較與585-nm的客運專線?？瓦\專線的595-nm治療新的手術疤痕[8]。

小小魚

實在太多了，太多高級詞匯。等有時間再來，我去上課了