Valley Scars in Visual Studio .NET

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Valley Scars
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Valley scars result from a defect in volume in the area of the scar This loss of volume may be at the level of the dermis or of the subcutaneous tissue Correction of this volume loss can be achieved in two ways: fillers may be injected into the area of volume loss or a reaction may be induced in the patient that will result in collagen remodeling
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FIGURE 26-6 Shallow atrophic scars before (left) and after (right) treatment with the Obagi TCA blue peel (Photograph courtesy of Dr Zein E Obagi)
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Valley-shaped scars
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approved for use in the United States has undergone changes so that the PMMA beads are of a more uniform size and therefore do not undergo phagocytosis Subcision
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Subcision
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Subcutaneous incision, or subcision, for the treatment of depressed scars was first described in 199550 After outlining, anesthetizing, and sterilizing the affected areas, a 22-gauge needle or a tribeveled 18-gauge hypodermic needle (Nokor, Becton Dickinson, Franklin Lakes, NJ) is inserted into the superficial fat with the bevel up just adjacent to the scarred area The needle is turned so that the bevel is perpendicular to the skin surface, and the needle is moved back and forth in a fanning motion to break up the fibrous tissue that is depressing the scar Audible rasping and popping is observed as the underside of the dermis is released from its subcutaneous attachment51 Following the procedure, patients can expect bruising for up to 1 week The exact mechanism of action of subcision is not fully understood Orentreich and Orentreich described two mechanisms including release of tethers that bind down the scar and reactive formation of new connective tissue50 Alam et al studied the effectiveness of subcision on acne scarring in 40 patients and noted that the investigators as well as the patients found that subcision improved the appearance of rolling acne scars51
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CoolTouch (nonablative)
Fractionated laser
Laser resufacing/ dermabrasion
FIGURE 26-7 Treatment algorithm for valley-shaped scars
CHAPTER 26 FACIAL SCAR REVISION
Synthetic Fillers
HYALURONIC ACID Hyaluronic acid consists of alternating residues of Dglucuronic acid and N-acetyl-Dglycosamine that can bind up to 10,000 times its weight in water It is found throughout the body in connective tissue as well as in synovial tissue and fluid Hyaluronic acid is marketed as Restylane , Restylane Fine Lines , and Perlane (Medicis Aesthetics, Scottsdale, AZ), Hylaform , and Juv derm Ultra Plus (Allergan, Irvine, CA), all of which have been approved by the FDA for superficial rhytides All these formulations are composed of stabilized hyaluronic acid at 20 mg/mL but have varying sizes of injected particles Hyaluronic acid is popular because of its ease of injection, excellent safety profile, low rate of hypersensitivity reactions (1 in 2000), and superior longevity when compared with collagen Complications include mild bruising, edema, arterial embolization, and visible papules2 POLY-L-LACTIC ACID Poly-L-lactic acid (Sculptra, Dermik Laboratories, Bridgewater, NJ) belongs to the alpha hydroxy acid family and Sculptra is composed of crystalline, irregularly sized microparticles of poly-L-lactic acid that are 40 to 60 m in diameter This synthetic polymer has been approved for HIV-related facial lipoatrophy by the FDA Sculptra is packaged as a sterile freeze-dried preparation that is reconstituted with sterile water 48 hours before injection After injection of the poly-Llactic acid, a foreign body reaction occurs over several weeks to months, presenting as a volumetric expansion45 It is important to note that there is no visual endpoint at the time of injection, and a waiting period of at least 4 to 6 weeks after initial product placement is recommended before subsequent injections
Complications of poly-L-lactic acid include nodules (typically arising several weeks after injection) and granulomas (emerging months to years after injection); incidence rates range from 6% to 52%46 Early nodules may be broken up with needle fragmentation or further diluted with sterile saline Late nodules and granulomas typically require treatment with excision; steroid injections may also be effective Metabolism occurs via bioabsorption and gradual degradation CALCIUM HYDROXYLAPATITE Calcium hydroxylapatite (CaHA) (Radiesse , Bioform Medical, San Mateo, CA) is a synthetic filler that typically lasts 12 to 18 months before subsequent injections are needed47 Radiesse was recently approved by the FDA for the correction of moderate to severe facial folds, such as nasolabial folds, as well as treatment of HIV lipoatrophy There is no need for a skin test prior to use, and the correction that is obtained is close to 1:1, meaning that no expansion of the implant will occur after injection CaHA has been used for superficial depressed scars48 and acne scars49 Side effects are generally mild; occasionally, nodules may form following treatment This is especially more common when CaHA is used in the lips Additionally, CaHA is radiopaque, so patients should be aware that it may appear on X-ray films or other imaging ARTEFILL Polymethylmethacrylate (PMMA) (ArteFill , Artes Medical, San Diego, CA) is a permanent dermal filler that has been recently approved by the FDA for the correction of nasolabial folds To our knowledge, there are no studies examining the effectiveness of ArteFill in treating facial scarring The concern with this filler agent is the risk of nodule formation The formulation
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