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Stria tedavisinde lazer

Stria tedavisinde lazer. Dr. Sedat Akdeniz Dicle Üniversitesi Tıp Fakültesi, Diyarbakır. Stria tedavisinde kullanılabilen lazerler. Pulsed-Dye Laser (PDL) Excimer Laser Copper-Bromide Laser 1,450-nm Diode Laser 1,064-nm Nd:YAG Laser Fractional Photothermolysis.

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Stria tedavisinde lazer

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  1. Stria tedavisinde lazer Dr. Sedat Akdeniz Dicle Üniversitesi Tıp Fakültesi, Diyarbakır

  2. Stria tedavisinde kullanılabilen lazerler • Pulsed-Dye Laser (PDL) • Excimer Laser • Copper-Bromide Laser • 1,450-nm Diode Laser • 1,064-nm Nd:YAG Laser • Fractional Photothermolysis

  3. Stria tedavisinde lazer kullanımı • Son yılların popüler tedavi seçeneği • PDL en sık kullanımı bildirilen lazer • CO2 (Carbon dioxide) ve erbium-substituted yttrium aluminium garnet (YAG) gibi ablatif lazerlerin kullanılması kısa süreli heyecan oluşturmuş • Uzamış yara iyileşmesi ve özellikle esmerlerde pigmentasyon değişikliği kullanımını sınırladı

  4. Lazer kollajen üretimi • Kullanılan lazerlerin dalga boyu ve enerji düzeyine bağlı olarak kollajen ve elastin üretimi etkilenir • Uygun enerji düzeyleri ile fibroblast ve endotel hücreleri stimüle olurken, yüksek enerji düzeyleri kullanıldığında bu hücrelerin proliferasyon, üretim ve fonksiyonlarının inhibe olduğu gözlenmiştir • Bosatra M, Jucci A, Olliaro P, et al: Invitrofibroblastanddermisfibroblastactivationbylaserirradiation at lowenergy. Dermatolgica 168:157–162, 1984 • Boulton M, Marshall J: He-Ne laserstimulation of humanfibroblastproliferationandattachment in vitro. Laser Life Sci 1:125–134, 1986 • Castor DJ, Abergel RP, Keeker C, et al: Effects of theNd: YAG laser on DNA synthesisandcollagenproduction in human skin fibroblastcultures. AnnPlastSurg 11:214–221, 1983 • Colver GB, Priestley GC: Failure of a helium-neon lasertoaffectcomponents of woundhealing in vitro.Br J Dermatol 121:179–186, 1989

  5. Yeni kollejen oluşumu - lazer • Kullanılan lazerin enerji düzeyinin iyi bilinmesi gerekiyor • Birden fazla lazerin yeni kollajen oluşumunu uyardığı bildirilmiştir • Michel JL. ED2000s: 585nm collagenremodellingpulseddyelaser. J CosmetLaserTher 2003;5:201–3. • Fournier N, Dahan S, Barneon G, et al. Nonablativeremodeling: clinical, histologic, ultrasound, imaging, andprofilometricevaluation of a 1,540 nm Er:Glasslaser. DermatolSurg 2001;27: 799–806. • Prieto VG, Diwan AH, Shea CR, et al. Effects of intensepulsedlightandthe 1,064 nmNd:YAG laser on sun-damagedhuman skin: histologicandimmunohistochemicalanalysis. DermatolSurg 2005;31:522–5. • Papadavid E, Katsambas A. Lasersforfacialrejuvenation: a review. Int J Dermatol 2003;42:480–7.

  6. Pulsed Dye Laser • Striaların erken evresinde dilate kan damarlarının belirgin olması tedavide PDL uygulaması için iyi bir durum oluşturmaktadır • McDaniel ve ark, Alsterimmatürstria (rubra), tedavisinde 585-nmflashlampPDL’in etkili olduğunu bildirmişler • Karsai S, Roos S, Hammes S, et al. Pulseddyelaser: what’snew in non-vascularlesions. JEADV 2007;21:877–90. • McDaniel DH, Ash K, Zukowoski M. Treatment of stretch Marks withthe 585 nmflashlamppumpedpulseddyelaser. DermatolSurg 1996;22:332–7. • Alster TS. Lasertreatmentifhypertrophicscars, keloidsandstriaerubra. DermatolClin 1997;15:419–29.

  7. Pulsed Dye lazer • Extraselülar matrixte kollajen miktarını artırmaktadır • Jiminez ve ark’ları (deri tipi I –IV) 585 nm flashlamp PDL’in stria rubra ve alba tiplerinin tedavisinde etkili olduğunu bildirmişler • Koyu tenli kişilerde (tip VI-VI) pigmentasyon değişikliklerinden dolayı dikkatli kullanılmalıdır • Jiminez GP, Flores F, Berman B, et al. Treatment of striae rubra and stria alba with the 585-nm pulsed-dye laser. Dermatol Surg 2003;29:362–4. • Nouri K, Romagosa R, Chartier T, et al. comparison of the 585 nm pulse dye laser and the short pulsed co2 laser in the treatment of striae distensae in skin types IV and VI. Dermatol Surg 1999;25:368–70.

  8. A) Skin biopsy of normal appearing skin adjacent to striae (elastin, X40). B) An untreated abdominal striae adjacent to the normal skin shown in a (elastin, X4O). C) Biopsy of the same abdominal striae shown in B, 8 weeks after treatment with the 585-nm flashlamp-pumped pulsed dye laser at a fluence of 2.0 f/cm- and a spot size of 7 mm. McDaniel DH, Ash K, Zukowski M: Treatment of stretch marks with the 585-nm flashlamp-pumped pulsed dye laser. Dermatol Surg 22:332–337, 1996

  9. Hematoxylin and eosin stain of mouse skin taken at 4 weeks after the four laser treatment modalities. Collagen fibers in the irradiated sites showed a marked increase in the amount and a significant improvement in the organization with the high affinity for the stain; (A) the 595-nm pulsed dye laser (PDL), (B) 1,320-nm neodymium–yttrium–aluminum garnet (Nd:YAG) laser, (C) 1,064-nm long-pulsed Nd:YAG lasers, (D) 1,064-nm Q-switched laser; A0, B0, C0, and D0 were their respective controls. Elsaie ML, Baumann LS, Elsaie LT. Striae distensae (stretch marks) and different modalities of therapy: an update. Dermatol Surg 2009;35(4):563-573.

  10. Stria tedavisinde 585-nm PDL Treatment of stretch marks with the 585-nm flashlamp-pumped pulsed dye laser.McDaniel DH, Ash K, Zukowski M. Dermatol Surg. 1996 Apr;22(4):332-7.

  11. 39 stria 4 farklı protokole göre bir kere tedavi edilmiş • Tedavi edilen strialar aynı hastanın tedavi edilmeyen striaları ile karşılaştırılmış • Striaların yaşı: ort: 14 yı( 8 ay- 32 yıl) • Tedavi yanıtı klinik, fotoğraf, deri biopsileri ile değerlendirilmiş

  12. Tüm protokollerle klinik yanıt alınmasına rağmen en belirgin iyileşme 3.0 J/cm2 ile elde edilmiş • Tedaviden 8 hafta sonra biopside dermal elastin artışı saptanmış

  13. Stria tedavisinde 585-nm PDL kullanımı 2 uygulama 3 J/cm2, 10 mm spot size 20 hasta Striaların yaşı: ort: 6 ay- 20 yıl Tedavi etkili, koyu tenlilerde pigmentasyon önemli yan etki Jimenez GP, Flores F, Berman B, Gunja-Smith Z. Treatment of striae rubra and striae alba with the 585-nm pulsed-dye laser. Dermatol Surg 2003;29(4):362-365.

  14. Excimer Laser • Fokal olarak uygulanabilen UVB’ye yakın dalga boyu • Vitiligo tedavisinde etkilidir • Matür strialarda etkili olduğunu bildiren çalışmalar var • Shen Z, Gao TW, Chen L, et al. Optimal frequency of treatment with the 308-nm excimer laser for vitiligo on the face and neck.Photomed Laser Surg 2007;25:418–27.

  15. Excimer Laser- striaSkar dokusunda melanosit var mı? • Melanosit veya prekürsorleinin saptanması için mel-5, c-kit and NKI/beteb kullanılmış • Skar dokusu ve çevresindeki normal dokudaki melanosit sayısı eşit olarak saptanmış • Skar dokusunun açık renkte görünmesinin nedeni vasküler yapıların azalması ve optik yanılgı (kollajen fibrillerinin paralel dağılımından kaynaklanmaktadır) • Why are Scars Pale? An Immunohistochemical Study Indicating Preservation of Melanocyte Number and Function in Surgical Scars SHIREEN S. VELANGI1 and JONATHAN L. REES2 Acta Derm Venereol 2001; 81: 326–328.

  16. Hipopigmente strialarda excimer laser’in etkinliği araştırılmış • 75 hasta, total 615 tedavi • Tüm hastalarda ortalama 8.4 tedaviden sonra strialarda pigmentasyon gözlenmiş • Klinik olarak %80 iyileşme • Matür striaların tedavisinde etkili bulunmuş • Deri atrofisinde düzelme gözlenmemiş • 308-nm Excimer laser treatment of mature hypopigmented striae.Goldberg DJ, Sarradet D, Hussain M. Dermatol Surg. 2003 Jun;29(6):596-8.

  17. Skar ve Stria pigment bozukluğunu düzeltmek için excimerlaser • Yüz, gövde ve extremitelerinde hipopigmente skarları bulunan 31 hasta • 50 J/cm2 • Lezyonlara %50 ve %75 pigmentasyon gelişene kadar (kalorimetrik), 2 hafta aralıklarla aynı doz tekrarlanmış (maksimum 10 tedavi) • Tüm hastalarda %60-70 klinik iyileşme gözlenmiş • The safety and efficacy of the 308-nm excimer laser for pigment correction of hypopigmented scars and striae alba. Alexiades-Armenakas MR, Bernstein LJ, Friedman PM, Geronemus RG. Arch Dermatol. 2004 Aug;140(8):955-60.

  18. Hypopigmented scars treated with the 308-nm excimer laser. Prominent hypopigmented facial scars present at baseline (A) demonstrated excellent pigment correction following 5 treatments (B). The visual pigment levels began to decline at the 2-month follow-up (C) and returned to near baseline levels at the 6-month follow-up (D)

  19. Striae alba treated with the 308-nm excimer laser. Striae alba on the hip are shown at baseline (A) and following 5 treatments (B), with excellent pigment correction. The cosmetic benefit was maintained to the 2-month follow-up (C). Striae alba in a dark-skinned patient treated with the 308-nm excimer laser. Striae alba on the abdomen are shown at baseline (A) and following 9 treatments (B), with excellent pigment correction. The cosmetic benefit was well maintained to the 1-month follow-up (C).

  20. Copper-Bromide Laser • Tek çalışma • SD’lı 15 hasta CuBr laser (577-511 nm) ile tedavi edilip 2 yıl takip ediliyor • Etkili olduğu bildirilmiş • Two-year follow-up results of copper bromide laser treatment of striae. Longo L, Postiglione MG, Marangoni O, Melato M. J Clin Laser Med Surg. 2003 Jun;21(3):157-60.

  21. 1,450-nm Diode Laser • Non-ablative 1,450-nmdiodelaser’inatrofikskarın tedavisinde etkili olduğu bildirilmiş • 11 hasta, striarubra ve alba • 4, 8, veya 12 J/cm2, 6 hafta arayla toplam 3 kere • Hiçbir hastada iyileşme gözlenmemiş • %64 hastada hiperpigmentasyon gelişmiş • Lasers in SurgeryandMedicine 38:196–199 (2006) Non-Ablative 1,450-nmDiodeLaserTreatment of StriaeDistensaeYong-Kwang Tay, MD,* ColinKwok, MD, andEileen Tan, MD

  22. 1,064-nm Nd:YAG Laser • Dermal kollajende artış yapıyor • İmmatür strialarda dilate venüller ve içerisindeki oksihemoglaobin hedefidir • Vasküler yapılara iyi penetrasyon gösterir • Bundan dolayı immatür striaların tedavisinde etkili olarak kullanılabilir • Trelles MA, A ´ lvarez X, Martı´n-Va´squez MJ, et al. Assessment of the efficacy of nonablative long-pulsed 1,064 nm Nd:YAG laser treatment of wrinkles compared at 2,4, and 6 months. Facial Plast Surg 2005;21:145–53. • Sadick NS. Laser treatment with a 1,064 nm laser for lower extremity class I-III veins employing variable spots and pulse width parameters. Dermatol Surg 2003;29:916–9

  23. 1,064 nm Nd: YAG laser • 20 hasta • İmmatürstria tedavisinde • Belirgin etki bildirilmiş • Komplikasyonlar nadirdir, esmerlerde bile yan etkiler azdır • Goldman A, Rossato F, Pratti C. Stretchmarks: treatmentusingthe 1,064 nmNd:YAG laser. DermatolSurg 2008;34:1–7.

  24. TreatmentUsingthe 1,064-nmlong-pulsedNd:YAG Laser • 20 hasta • İmmatürstria, 26 tedavi (10 breast, 5 abdominal, 2 chest, 4 buttock, 2 flank, 3 thighs) • Tip II-IV • 3-6 hafta arayla 3-4 tedavi • 1,064-nmlong-pulsedNd:YAG laser, spot size 2.5-mm, fluences 80-100 J/cm2 • Stretch Marks: TreatmentUsingthe 1,064-nmNd:YAG Laser ALBERTO GOLDMAN, MD, FLA´VIA ROSSATO, MD, AND CLARISSA PRATI, DermatolSurg 2008;34:686–692

  25. (A) 19-year-old patient with recent striae of the breast. (B) Result after four sessions Stretch Marks: Treatment Using the 1,064-nm Nd:YAG Laser ALBERTO GOLDMAN, MD, FLA´VIA ROSSATO, MD, AND CLARISSA PRATI, MDDermatol Surg 2008;34:686–692

  26. (A) Striae gravidarum of the abdomen. (B) Result after three sessions.

  27. Fractional nonablative laser- stria • Fractional nonablative 1550-nm erbium-doped laser’in stria tedavisinde kullanımı ile ilgili farklı oranlarda etkili olduğu bildirilmiş • Kim BJ, Lee DH, Kim MN, et al. Fractional photothermolysis for the treatment of striae distensae in Asian skin. Am J Clin Dermatol 2008;9(1):33-37. • Stotland M, Chapas AM, Brightman L, et al. The safety and efficacy of fractional photothermolysis for the correction of striae distensae. J Drugs Dermatol 2008;7(9):857- 861. • Katz TM, Goldberg LH, Friedman PM. Nonablative fractional photothermolysis for the treatment of striae rubra. Dermatol Surg 2009;35(9):1430-1433. • Bak H, Kim BJ, Lee WJ, et al. Treatment of striae distensae with fractional photothermolysis. Dermatol Surg 2009;35(8):1215-1220

  28. Fractional Photothermolysis • Epidermistendermise uzanan kolon şeklinde (MTZ) mikroskobik doku hasarları oluşturur • Sonrasında kontrollü yara iyileşmesi • Sağlam epidermalkeratinositler hızlı bir şekilde (24 h) reepitelize olarak yara iyileşmesini hızlandırır • Stratumkorneum korunur • Geronemus RG. Fractionalphotothermolysis: currentandfutureapplications. LasersSurgMed2006;38(3):169-176.

  29. Lasers in Surgery and Medicine 38:142–149 (2006)Skin Responses to Fractional PhotothermolysisHans-Joachim Laubach, MD,* Zeina Tannous, MD, R. Rox Anderson, MD, and Dieter Manstein, MD A) Hour 1 after FP (200 H&E). Microthermal zones (MTZ, black outline) with columns of altered collagen (black arrow) can be distinguished. The entire stratum corneum remains intact even above the epidermal MTZs. There is no inflammatory infiltrate around the dermalMTZsyet. B) Hour 1 after FP (200 H&E) vessels in the MTZs are thermally destroyed (white arrows).

  30. Day1 after FP (200H&E).MTZsare outlined in black. Microscopic epidermal necrotic debris (MENDs; black arrows) represents the elimination of thermally damaged keratinocytes. MENDs are loaded with melanin. Subepidermal clefting is evident from 1 hour after FP and lasts up to 5 days (stars). The dermal part of the MTZs appears unchanged from day 1, and shows thermally altered collagen and a lack of nuclear staining. Subtle perivascular inflammatory infiltrate begins to form in the dermis (white arrow).

  31. Day 7 after FP (200—Elastica von Gieson). Theregular candelabra arrangement of elastic fibers persists at alltimes after FP (white arrow). MTZs are outlined in black

  32. 51 hasta • 1540-nmfractionalnonablative Er:Glasslaser • 10 mm optik başlık ile 35-55 mJ/mb veya 15 mm optik başlık, 12-14 mJ /mb • 6-8 hafta arayla 2-4 tedavi • Klinik iyileşme 3 doktor tarafından değerlendirilmiş • Histolojik değerlendirme hemotoxylin, eosin ve orcein-giemsa • Son tedaviden 6 ay sonra olguların tümünde %50’den fazla iyileşme • AesteheticSurgeryJournal 31(4) 411-419 2011, FractionalNonablative 1540-nmLaserTreatment of StriaeDistensae in Fitzpatrick Skin Types II to IV: ClinicalandHistologicalResultsrancesca de Angelis, MD; Larissa Kolesnikova, MD; FrancoRenato, MD; andGiuseppinaLiguori, PhD

  33. Epidermis ve dermiste gelişen mikrotermal hasar kontrollü yara iyileşmesini uyararak dermal kollajen artışını sağlar Fractional nonablative lasers

  34. Neocollagenesis in thereticulardermisresultingfromthe 1540-nmtreatment. (A) Untreatedstriaeshow an atrophiedepidermiswithdegeneratedandfragmentedcollagenfibers. (B) Onemonthafterthelast of threetreatmentswiththe 1540-nmerbium:glasslaser, significantneocollagenesis is demonstrated.

  35. Increasedamounts of elasticfibersfollowingthe 1540-nmtreatment. (A) Beforetreatment, elasticfibers (darkpurplestain) in thereticulardermisappearfragmentedandsparse in number. (B) Onemonthafterthelast of threetreatmentswiththe 1540-nmerbium:glasslaser, theelasticfibersappearuniformlyincreased in number.

  36. (A) This 40-year-oldwomanpresentedwithwidespread, 12-year-old, pregnancy-relatedverticalstriaealbaacross her lower abdomen. Thispatient had a Fitzpatrick III skin type. (B) Threemonthsafterthelast of fourtreatmentswiththe 10-mm tip of the 1540-nmerbium:glasslaser at energysettingsrangingfrom 45 to 55 mJ/μband a 15-mspulsewidth, thehypopigmentationandtexturalirregularitiesweresignificantlyreducedandthepatient’s skin appeareduniformlysmoothAnothernotablefeature of thispatient’sclinicaloutcomewasthemarkeddecrease in pretreatmenthypopigmentation; takentogether, theseimprovements in pigment andtexturecontributedto an overallsofteningandsmoothing of thestriation-likeappearance of thetreatedregion

  37. (A) This 30-year-oldwomanpresentedwithone-year-oldstriaerubraspanning her breasts as a result of pubertalgrowth. Thispatient had a Fitzpatrick III skin type. (B) Fourmonthsafterthelast of threetreatmentswiththe 10 mm-tip of the 1540-nmerbium:glasslaser at 40 mJ/μband a 15-mspulsewidth, thepinkish-reddiscoloration of thestriaeappearedmarkedlyreduced.

  38. Lazer - stria • Birden fazla etkili lazer var • Striaların erken dönemde tedavi edilmesi önemlidir • Koyu tenli kişilerde pigmentasyon değişikliklerine dikkat etmek gerekir • Uzun süreli iyileşmeler için yeni uygulamalar gerekebilir • Fractional nonablatif lazer daha etkili gibi görünmektedir

  39. Teşekkür ederim

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