Clinical effect of fractional carbon dioxide laser in the treatment of contracture scars
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摘要:
目的 探讨点阵二氧化碳激光治疗挛缩性瘢痕的临床疗效。 方法 采用回顾性自身前后对照研究方法。2016年12月—2021年4月，上海交通大学医学院附属第九人民医院收治16例伴有造成关节功能障碍的挛缩性瘢痕患者，其中男7例、女9例，年龄3~49岁。对18处关节瘢痕进行点阵二氧化碳激光治疗，每2~3个月1次，直至受累关节恢复正常活动范围或者疗效达到瓶颈。记录每例患者治疗次数；首次治疗前和末次治疗后6个月，测量每例患者受累关节活动度并计算差值，采用温哥华瘢痕量表（VSS）评估每例患者瘢痕情况；于6例患者各1处关节瘢痕的1次治疗（共6次治疗）中，记录当次治疗前、治疗后即刻及治疗后第1次随访时受累关节活动度并计算治疗后2个时间点与治疗前的差值；记录治疗区域治疗后不良反应发生情况；末次随访时，采用自制问卷调查患者治疗间隙和随访期间功能锻炼执行情况和其他瘢痕治疗手段使用情况。对数据进行Wilcoxon秩和检验。 结果 本组16例患者18处关节瘢痕接受了2（1，3）次点阵二氧化碳激光治疗；末次治疗后6个月受累关节活动度为56.5（39.0，128.8）°，明显高于首次治疗前的38.4（22.9，116.3）°（Z=-3.724，P<0.01），改善了17.4（8.0，24.1）°；末次治疗后6个月瘢痕VSS评分中的血管分布、柔软度、厚度评分及总分均明显低于首次治疗前（Z=-2.989、-3.762、-2.814、-3.739，P<0.01），其中柔软度改善最为明显。在6次治疗中，当次治疗后即刻、治疗后（2.5±0.6）个月第1次随访时受累关节活动度分别为156.2（148.0，164.2）°、160.2（156.7，166.4）°，均较治疗前的151.4（145.7，155.3）°明显增加（Z=-2.201、-2.201，P<0.05），分别改善了9.1（4.4，13.0）°、13.1（8.0，15.7）°。本组患者治疗区域治疗后均未观察到水疱、感染、增生性瘢痕形成等不良反应。多数患者在治疗间隙和随访期间进行过功能锻炼，使用过压力衣/套、硅酮药物和支具。 结论 点阵二氧化碳激光能够软化瘢痕，增加相关受累关节的活动范围，适用于轻度挛缩性瘢痕的临床治疗。 Abstract:Objective To explore the clinical effect of the fractional carbon dioxide laser in the treatment of contracture scars. Methods A retrospective before-after self-control study was conducted. From December 2016 to April 2021, 16 patients (7 males and 9 females, aged 3-49 years) with contracture scars causing impaired function of the adjacent joint were admitted to Shanghai Ninth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine. Eighteen joint scars of 16 patients were treated with fractional carbon dioxide laser every 2-3 months until the joint retained its normal range of motion or the effect plateaued. The treatment times of each patient were recorded. Before the first treatment and 6 months after the last treatment, the ranges of motion of the affected joint were measured in each patient, and the difference was calculated, meanwhile, the Vancouver Scar Scale (VSS) was used to evaluate the scar of each patient. In the treatment of 1 joint scar in each of 6 patients (totally 6 times of treatments), the ranges of motion of the affected joint before the current treatment, immediately after the treatment, and at the first follow-up after the treatment were documented, and the differences between the ranges before and immediately after the treatment as well as between the ranges before and at the first follow-up after the treatment were calculated. Adverse effects after the treatment in the treatment area were documented. At the last follow-up, a self-made questionnaire was used to collect the implementation status of the physical therapy and other scar management modalities during the treatment interval and follow-up period. Data were statistically analyzed with Wilcoxon rank sum test. Results Eighteen joint scars in 16 patients received 2 (1, 3) times of fractional carbon dioxide laser treatment. The range of motion of the affected joint of 16 patients 6 months after the last treatment was 56.5 (39.0, 128.8)°, notably higher than 38.4 (22.9, 116.3)° before the first treatment (Z=-3.724, P<0.01), showing a remarkable improvement by 17.4 (8.0, 24.1)°. The vascular distribution, softness, and thickness scores, and total score in VSS scoring of scars of 16 patients 6 months after the last treatment were significantly lower than those before the first treatment (Z=-2.989, -3.762, -2.814, -3.739, P<0.01), with the most obvious improvement in softness. In 6 times of treatments, the range of motion of the affected joint immediately after treatment and at the first follow-up of (2.5±0.6) months after treatment were 156.2 (148.0, 164.2)° and 160.2 (156.7, 166.4)°, both notably higher than 151.4 (145.7, 155.3)° before treatment (Z=-2.201, -2.201, P<0.05), showing a remarkable improvement by 9.1 (4.4, 13.0)° and 13.1 (8.0, 15.7)°, respectively. No adverse effects such as blisters, infection, or hypertrophic scar formation were observed in the treatment area of 16 patients after treatment. Most patients adopted physical therapy, compression, silicone gel or sheets, and braces during the treatment interval and follow-up period. Conclusions The fractional carbon dioxide laser can soften the scar and increase the range of motion of the affected joint, which is suitable for the clinical treatment of mild contracture scars. -
Key words:
- Cicatrix /
- Laser therapy /
- Comparative effectiveness research
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参考文献
(38) [1] KhansaI,HarrisonB,JanisJE.Evidence-based scar management: how to improve results with technique and technology[J].Plast Reconstr Surg,2016,138(3 Suppl):S165-178.DOI: 10.1097/PRS.0000000000002647. [2] KafkaM,CollinsV,KamolzLP,et al.Evidence of invasive and noninvasive treatment modalities for hypertrophic scars: a systematic review[J].Wound Repair Regen,2017,25(1):139-144.DOI: 10.1111/wrr.12507. [3] RobsonMC,BarnettRA,LeitchIO,et al.Prevention and treatment of postburn scars and contracture[J].World J Surg,1992,16(1):87-96.DOI: 10.1007/BF02067119. [4] ThorneCH. Grabb and Smith's plastic surgery[M].7th ed. Philadelphia:Lippincott Williams & Wilkins, 2013. [5] MathesSJ, NahaiF. Clinical atlas of muscle and musculocutaneous flaps[M]. St. Louis: Mosby, 1979. [6] MaxeyL, MagnussonJ. Rehabilitation for the postsurgical orthopedic patient[M].3rd ed. St.Louis: Elsevier Health Sciences,2013. [7] Issler-FisherAC,WaibelJS,DonelanMB.Laser modulation of hypertrophic scars: technique and practice[J].Clin Plast Surg,2017,44(4):757-766.DOI: 10.1016/j.cps.2017.05.007. [8] PoetschkeJ,DornseiferU,ClementoniMT,et al.Ultrapulsed fractional ablative carbon dioxide laser treatment of hypertrophic burn scars: evaluation of an in-patient controlled, standardized treatment approach[J].Lasers Med Sci,2017,32(5):1031-1040.DOI: 10.1007/s10103-017-2204-z. [9] ZuccaroJ,MuserI,SinghM,et al.Laser therapy for pediatric burn scars: focusing on a combined treatment approach[J].J Burn Care Res,2018,39(3):457-462.DOI: 10.1093/jbcr/irx008. [10] OuyangHW,LiGF,LeiY,et al.Comparison of the effectiveness of pulsed dye laser vs pulsed dye laser combined with ultrapulse fractional CO2 laser in the treatment of immature red hypertrophic scars[J].J Cosmet Dermatol,2018,17(1):54-60.DOI: 10.1111/jocd.12487. [11] ŻądkowskiT,NachulewiczP,MazgajM,et al.A new CO2 laser technique for the treatment of pediatric hypertrophic burn scars: an observational study[J].Medicine (Baltimore),2016,95(42):e5168.DOI: 10.1097/MD.0000000000005168. [12] HultmanCS,FriedstatJS,EdkinsRE,et al.Laser resurfacing and remodeling of hypertrophic burn scars: the results of a large, prospective, before-after cohort study, with long-term follow-up[J].Ann Surg,2014,260(3):519-529; discussion 529-532.DOI: 10.1097/SLA.0000000000000893. [13] HultmanCS,EdkinsRE,LeeCN,et al.Shine on: review of laser- and light-based therapies for the treatment of burn scars[J].Dermatol Res Pract,2012,2012:243651.DOI: 10.1155/2012/243651. [14] KrakowskiAC,GoldenbergA,EichenfieldLF,et al.Ablative fractional laser resurfacing helps treat restrictive pediatric scar contractures[J].Pediatrics,2014,134(6):e1700-1705.DOI: 10.1542/peds.2014-1586. [15] SeagoM,ShumakerPR,SpringLK,et al.Laser treatment of traumatic scars and contractures: 2020 international consensus recommendations[J].Lasers Surg Med,2020,52(2):96-116.DOI: 10.1002/lsm.23201. [16] WaibelJS,GianatasioC,A.RandomizedRudnick, controlled early intervention of dynamic mode fractional ablative CO2 laser on acute burn injuries for prevention of pathological scarring[J].Lasers Surg Med,2020,52(2):117-124.DOI: 10.1002/lsm.23170. [17] KauvarA,KubickiSL,SuggsAK,et al.Laser therapy of traumatic and surgical scars and an algorithm for their treatment[J].Lasers Surg Med,2020,52(2):125-136.DOI: 10.1002/lsm.23171. [18] LeviB,IbrahimA,MathewsK,et al.The use of CO2 fractional photothermolysis for the treatment of burn scars[J].J Burn Care Res,2016,37(2):106-114.DOI: 10.1097/BCR.0000000000000285. [19] HaedersdalM.Fractional ablative CO2 laser resurfacing improves a thermal burn scar[J].J Eur Acad Dermatol Venereol,2009,23(11):1340-1341.DOI: 10.1111/j.1468-3083.2009.03215.x. [20] HurlimanE,ZelicksonB,KenkelJ.In-vivo histological analysis of a fractional CO2 laser system intended for treatment of soft tissue[J].J Drugs Dermatol,2017,16(11):1085-1090. [21] HantashBM,BediVP,KapadiaB,et al.In vivo histological evaluation of a novel ablative fractional resurfacing device[J].Lasers Surg Med,2007,39(2):96-107.DOI: 10.1002/lsm.20468. [22] MansteinD,HerronGS,SinkRK,et al.Fractional photothermolysis: a new concept for cutaneous remodeling using microscopic patterns of thermal injury[J].Lasers Surg Med,2004,34(5):426-438.DOI: 10.1002/lsm.20048. [23] ZhangZ,ChenJ,HuangJ,et al.Experimental study of 5-fluorouracil encapsulated ethosomes combined with CO2 fractional laser to treat hypertrophic scar[J].Nanoscale Res Lett,2018,13(1):26.DOI: 10.1186/s11671-017-2425-x. [24] DeBrulerDM,BlackstoneBN,BaumannME,et al.Inflammatory responses, matrix remodeling, and re-epithelialization after fractional CO2 laser treatment of scars[J].Lasers Surg Med,2017,49(7):675-685.DOI: 10.1002/lsm.22666. [25] OzogDM,LiuA,ChaffinsML,et al.Evaluation of clinical results, histological architecture, and collagen expression following treatment of mature burn scars with a fractional carbon dioxide laser[J].JAMA Dermatol,2013,149(1):50-57.DOI: 10.1001/2013.jamadermatol.668. [26] QuL,LiuA,ZhouL,et al.Clinical and molecular effects on mature burn scars after treatment with a fractional CO2 laser[J].Lasers Surg Med,2012,44(7):517-524.DOI: 10.1002/lsm.22055. [27] MakboulM,MakboulR,AbdelhafezAH,et al.Evaluation of the effect of fractional CO2 laser on histopathological picture and TGF-β1 expression in hypertrophic scar[J].J Cosmet Dermatol,2014,13(3):169-179.DOI: 10.1111/jocd.12099. [28] LeeSJ,SuhDH,LeeJM,et al.Dermal remodeling of burn scar by fractional CO2 laser[J].Aesthetic Plast Surg,2016,40(5):761-768.DOI: 10.1007/s00266-016-0686-x. [29] El-HoshyK,Abdel-HalimMRE,DorghamD,et al.Efficacy of fractional carbon dioxide laser in the treatment of mature burn scars: a clinical, histopathological, and histochemical study[J].J Clin Aesthet Dermatol,2017,10(12):36-43. [30] NaouriM,AtlanM,PerrodeauE,et al.High-resolution ultrasound imaging to demonstrate and predict efficacy of carbon dioxide fractional resurfacing laser treatment[J].Dermatol Surg,2011,37(5):596-603.DOI: 10.1111/j.1524-4725.2011.01943.x. [31] BaryzaMJ,BaryzaGA.The Vancouver Scar Scale: an administration tool and its interrater reliability[J].J Burn Care Rehabil,1995,16(5):535-538.DOI: 10.1097/00004630-199509000-00013. [32] ZuccaroJ,ZiolkowskiN,FishJ.A systematic review of the effectiveness of laser therapy for hypertrophic burn scars[J].Clin Plast Surg,2017,44(4):767-779.DOI: 10.1016/j.cps.2017.05.008. [33] KarmisholtKE,HaerskjoldA,KarlsmarkT,et al.Early laser intervention to reduce scar formation-a systematic review[J].J Eur Acad Dermatol Venereol,2018,32(7):1099-1110.DOI: 10.1111/jdv.14856. [34] WillowsBM,IlyasM,SharmaA.Laser in the management of burn scars[J]. Burns,2017,43(7):1379-1389. DOI: 10.1016/j.burns.2017.07.001. [35] GiordanoCN,OzogD.Microstructural and molecular considerations in the treatment of scars with ablative fractional lasers[J].Semin Cutan Med Surg,2015,34(1):7-12.DOI: 10.12788/j.sder.2015.0124. [36] AndersonRR,DonelanMB,HivnorC,et al.Laser treatment of traumatic scars with an emphasis on ablative fractional laser resurfacing: consensus report[J].JAMA Dermatol,2014,150(2):187-193.DOI: 10.1001/jamadermatol.2013.7761. [37] Issler-FisherAC,FisherOM,HaertschP,et al.Ablative fractional resurfacing with laser-facilitated steroid delivery for burn scar management: does the depth of laser penetration matter?[J].Lasers Surg Med,2020,52(2):149-158.DOI: 10.1002/lsm.23166. [38] LvKY,XiaZF, Chinese consensus panel on the prevention and treatment of scars. Chinese expert consensus on clinical prevention and treatment of scar[J/OL].Burns Trauma,2018,6:27[2021-06-24]. https://pubmed.ncbi.nlm.nih.gov/30263894/.DOI: 10.1186/s41038-018-0129-9. -
1 点阵二氧化碳激光治疗例1患者右前臂深Ⅱ度烧伤行皮片移植后1年腕关节挛缩性瘢痕。1A.首次治疗前，腕关节屈曲功能受限；1B.点阵二氧化碳激光治疗3次后6个月，前臂瘢痕较前改善，腕关节屈曲活动度增加
2 点阵二氧化碳激光治疗例2患者跑步机压伤右手中指换药至愈合后6个月余指间关节挛缩性瘢痕。2A.首次治疗前，瘢痕挛缩致指间关节伸直受限；2B.点阵二氧化碳激光治疗1次后6个月，指腹瘢痕较前改善，手指活动范围改善
表 1 2种点阵二氧化碳激光治疗仪参数选择与对应穿透深度
仪器名称 模式 能量（mJ） 覆盖率（%） 穿透深度（μm） Ultrapulse Encore型点阵二氧化碳激光治疗仪 Deep FX 10 5 300 Deep FX 20 5 600 Deep FX 30 5 900 Deep FX 40 5 1 200 Deep FX 50 5 1 500 SCAAR FX 60 3 1 800 SCAAR FX 80 3 2 300 SCAAR FX 100 3 2 750 SCAAR FX 130 3 3 150 SCAAR FX 150 3 3 500 CO2RE型酷逸点阵二氧化碳激光治疗仪 Deep 80 5 900 注：数据来源为美国科医人医疗激光公司和文献[20] 
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表2 16例挛缩性瘢痕患者18处关节瘢痕点阵二氧化碳激光治疗前后温哥华瘢痕量表评分[分，M（P25，P75）]
项目与总分 首次治疗前 末次治疗后6个月 Z值 P值 色泽 2.0（1.0，2.0） 1.5（1.0，2.0） -1.342 0.180 血管分布 3.0（2.0，4.0） 1.0（0.3，2.0） -2.989 0.003 柔软度 4.0（4.0，5.0） 1.0（0，2.0） -3.762 <0.001 厚度 3.0（2.0，3.0） 2.0（1.3，2.0） -2.814 0.005 总分 11.5（10.0，13.0） 5.0（4.3，6.0） -3.739 <0.001
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表3 16例挛缩性瘢痕患者点阵二氧化碳激光治疗间隙和随访期间功能锻炼及其他瘢痕治疗手段的使用情况（例）
项目 持续 大部分时间 少于一半时间 从未 功能锻炼 9 1 5 1 硅酮药物 10 2 4 0 压力衣/套 5 1 8 2 支具 2 1 4 9
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