What causes lumps after eyelid surgery. How to manage blepharoplasty complications. When to seek medical attention for eyelid scarring. What are the best treatments for post-surgical eyelid lumps.

Understanding Blepharoplasty and Its Potential Complications

Blepharoplasty, commonly known as eyelid surgery, is a delicate procedure that can significantly enhance one’s appearance. However, like any surgical intervention, it comes with potential complications. One of the most common issues patients face post-surgery is the development of small lumps or bumps along the incision line.

These lumps, often no larger than a grain of rice, are typically a normal part of the healing process. They result from focal swelling or fibrosis following the surgery. Due to the thin nature of eyelid skin, these lumps can be quite noticeable, both visually and to the touch.

Why Do Lumps Form After Blepharoplasty?

The formation of lumps after blepharoplasty can be attributed to several factors:

• Retention of scar tissue
• Accumulation of lymphatic fluid
• Post-surgical inflammation
• Natural healing processes

In most cases, these lumps are a temporary phenomenon. As the healing process progresses, scar tissues typically soften and flatten out over time. However, in some instances, they may persist or even thicken, requiring additional intervention.

Essential Considerations Before Undergoing Blepharoplasty

Before deciding to undergo blepharoplasty, it’s crucial to be well-informed about the procedure and potential post-operative experiences. Here are four key points to keep in mind:

1. Temporary Eye Dryness is Common

Many patients report experiencing dry eyes immediately following blepharoplasty. This is typically a temporary condition caused by post-surgical swelling, which affects the production and distribution of tears. As the swelling subsides, normal tear production usually resumes.

2. Small Bumps May Form Along the Incision

The formation of small bumps along the incision line is a normal part of the healing process. These bumps are usually the result of scar tissue formation. In most cases, they soften and flatten over time, but some patients may require additional treatment if the bumps persist or become problematic.

3. Results Take Time to Manifest

Patience is key when it comes to blepharoplasty results. While some lucky patients may see improvements within a week of surgery, it’s more common for visible results to take several weeks or even months to fully manifest. Swelling and bruising can persist for up to two weeks post-surgery, and it takes time for the skin and underlying tissues to adjust to their new configuration.

4. Avoid Repeated Blepharoplasty

If you’re unsatisfied with the results of your initial blepharoplasty, it’s important not to rush into a second surgery. Repeated procedures can increase the risk of complications, including lower eyelid malposition. Instead, consider non-surgical alternatives like Fraxel laser treatment or dermal fillers to address any remaining concerns.

Managing Post-Blepharoplasty Complications

While complications after blepharoplasty are relatively rare, it’s important to know how to manage them if they do occur. Here are some strategies for dealing with common post-surgical issues:

Dealing with Dry Eyes

To alleviate dry eye symptoms:

• Use artificial tears as recommended by your surgeon
• Avoid environments that can exacerbate dryness, such as air-conditioned spaces
• Stay hydrated
• Consider using a humidifier in your bedroom

Managing Lumps and Bumps

If you notice persistent lumps or bumps along your incision line:

• Apply gentle massage as directed by your surgeon
• Use silicone-based scar treatments
• Consider steroid injections if recommended by your doctor

When to Seek Medical Attention

While some degree of swelling, bruising, and discomfort is normal after blepharoplasty, certain symptoms warrant immediate medical attention. These include:

• Severe pain that doesn’t respond to prescribed pain medication
• Excessive bleeding or oozing from the incision sites
• Signs of infection, such as increased redness, warmth, or pus-like discharge
• Sudden changes in vision
• Asymmetry or unusual swelling of the eyelids

If you experience any of these symptoms, contact your surgeon immediately.

Non-Surgical Alternatives for Addressing Residual Concerns

If you’re not fully satisfied with the results of your blepharoplasty, there are several non-surgical options that can help refine your appearance without the need for additional surgery:

Fraxel Laser Treatment

Fraxel laser treatment can help improve skin texture and reduce the appearance of fine lines and wrinkles around the eyes. It works by creating microscopic wounds in the skin, stimulating collagen production and promoting skin rejuvenation.

Dermal Fillers

Dermal fillers, such as Restylane or autologous fat transfer, can help address volume loss and smooth out remaining contour irregularities. These treatments can provide subtle yet noticeable improvements without the risks associated with repeated surgery.

Botox Injections

Botox can be used to address crow’s feet and other dynamic wrinkles around the eyes, complementing the results of blepharoplasty and providing a more youthful, refreshed appearance.

Long-Term Care and Maintenance After Blepharoplasty

To maintain the results of your blepharoplasty and promote optimal healing, consider the following long-term care strategies:

Sun Protection

Protect your delicate eyelid skin from sun damage by:

• Wearing sunglasses with UV protection
• Applying a broad-spectrum sunscreen specifically formulated for the eye area
• Wearing a wide-brimmed hat when outdoors

Skincare Routine

Develop a gentle yet effective skincare routine that includes:

• A mild, non-irritating cleanser
• A hydrating eye cream
• Antioxidant-rich serums to protect against environmental damage

Healthy Lifestyle Choices

Support your overall health and maintain your results by:

• Staying hydrated
• Eating a balanced diet rich in vitamins and antioxidants
• Getting adequate sleep
• Avoiding smoking and excessive alcohol consumption

Choosing the Right Surgeon for Your Blepharoplasty

The success of your blepharoplasty and your risk of complications largely depend on the skill and experience of your surgeon. When selecting a plastic surgeon for your eyelid surgery, consider the following factors:

Credentials and Experience

Look for a board-certified plastic surgeon with specific experience in blepharoplasty. Don’t hesitate to ask about their training, years of experience, and the number of eyelid surgeries they’ve performed.

Before and After Photos

Review the surgeon’s portfolio of before and after photos, paying particular attention to patients with similar facial features and concerns as yours.

Patient Reviews and Testimonials

Read reviews and testimonials from previous patients to get a sense of their experiences and satisfaction levels.

Communication Style

Choose a surgeon who listens to your concerns, explains the procedure clearly, and sets realistic expectations for your results.

Innovative Techniques in Blepharoplasty

As surgical techniques continue to evolve, new approaches to blepharoplasty are emerging that aim to minimize complications and improve outcomes. Some of these innovative techniques include:

Transconjunctival Blepharoplasty

This technique involves making an incision on the inside of the lower eyelid, eliminating visible external scars. It’s particularly useful for removing or repositioning fat pads without removing excess skin.

Fat Repositioning

Rather than simply removing excess fat, some surgeons now reposition fat to create a smoother, more youthful contour. This technique can help avoid the hollow-eyed look that sometimes results from overly aggressive fat removal.

Laser-Assisted Blepharoplasty

The use of laser technology in blepharoplasty can offer several advantages, including:

• More precise incisions
• Reduced bleeding during surgery
• Potentially faster healing times

These innovative approaches highlight the importance of choosing a surgeon who stays current with the latest advancements in the field.

The Psychological Impact of Blepharoplasty

While much attention is given to the physical aspects of blepharoplasty, it’s important to consider the psychological impact of the procedure as well. Eyelid surgery can have a significant effect on a person’s self-image and confidence.

Positive Outcomes

Many patients report feeling more confident and youthful after blepharoplasty. The removal of excess skin and fat can make a person appear more alert and approachable, potentially improving both personal and professional interactions.

Managing Expectations

It’s crucial to have realistic expectations about the outcomes of blepharoplasty. While the procedure can significantly improve appearance, it’s not a cure-all for all facial aging concerns. Patients should be prepared for:

• A recovery period that may involve temporary changes in appearance
• The possibility of needing additional treatments to achieve desired results
• The ongoing effects of natural aging

Body Dysmorphic Disorder

In some cases, patients seeking blepharoplasty may be struggling with body dysmorphic disorder (BDD), a condition characterized by obsessive preoccupation with perceived flaws in appearance. It’s important for surgeons to screen for BDD and refer patients for psychological support when necessary, as these individuals are unlikely to be satisfied with surgical results.

By understanding both the physical and psychological aspects of blepharoplasty, patients can make more informed decisions and approach the procedure with a balanced perspective.

The Occurrence Of Lumps After Blepharoplasty And Techniques To Treat Those Lumps 2023

Tiny lumps or bumps on the skin can be noticed after any surgery during the healing process. A sensitive surgery such as an eyelid can invite such complexities easily as you have to move your eyelids constantly. Through this blog, we will try to uncover the grey areas that cause the issue and the way to treat them. 

However, ensure that you do not self examine your condition and treat it yourself. Ask your plastic surgeon to take a look at you, in return, you will get expert advice keeping you away from harm’s way. 

If you are looking for blepharoplasty Dubai, you have landed in the right place for all kinds of advice. 

What happens exactly?

After blepharoplasty, a small grain-sized lump can sprout along the incision and it is quite normal. The focal swelling or fibrosis after surgery is the reason behind this occurrence. As the skin on the eyelids is very thin, the lumps can easily be felt or seen prominently.  

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Before exploring the depth of reason. Let us take a look at four elements that you need to know about blepharoplasty. 

4 Things you should know before blepharoplasty

These four things often cause discomfort to patients as they get confused while understanding the entire process. 

Here is an easy way, take a look-

Eyes can get dry after the surgery

Often blepharoplasty Dubai patients report dry eyes right after the surgery. Dr. Tarek Aesthetics has studied that this is temporary. The fluid that makes the eyes watery is made with water, mucus, and oil with a fluid secreted by eyelid glands.  

After the eyelid surgery, pressure is created from the swelling resulting in dry eyes. This leads to your brain getting triggered to produce tears, however, the tears created do not carry mucus or oil for keeping the eyes moist. The itchy and dry feeling will wear off as soon as the swelling reduces. 

Small bumps can form on the incision

After the blepharoplasty, a few patients have complained about slight bumps during the healing. Normally, when the incision heals, scar tissues build resulting in a bulge. However, with time the tissues get softer in most cases, while it gets thicker for some. In case of this, recommend Dr. Tarek Aesthetics for minimum amounts of steroids to treat the tissues. 

The results after surgery will not show in just a week 

It is common to have swelling or bruising after blepharoplasty. Some patients luckily see results right after the switches are removed after six to seven days. However, different patients have different healing rates.  

Few may be doing well in three to four days, while some might be dealing with bruising and swelling for as long as two weeks. So, consider all these circumstances before you judge your new look. Give time to your body for healing and the underlying tissues and skin to adjust to the surgery after the swelling and bruising. 

Don’t go for another blepharoplasty

After undergoing eyelid surgery, if you still feel that the skin around your eyelids is still loose, do not jump into another surgery immediately. If you repeat blepharoplasty Dubai patients can increase the risks for complications.

You can also notice the lower eyelid is pulling down or out in case of repeated surgery. If you want to take another treatment, then consult your plastic surgeon about Fraxel laser, or filling it with Autologous or Restylane Fat. This will help in treating the area without the risk of pulling down the lower eyelid. 

Blepharoplasty is indeed a complicated surgery. Those who choose to undergo this procedure should know everything that will help them through the surgery. These points sum up most of the areas that a patient should keep in mind. 

Additionally, if you have undergone filling, or any other surgeries near your eyelid recently refrain from getting this surgery if you have not healed completely. Consult a surgeon before you undergo the surgery after you have healed.

Now let us find out why lumps occur and how they can be dealt with after blepharoplasty.

Reasons for a lump to show up

The common cause for lumps might be caused because of the retention of scar tissues or lymphatic fluid. Post-blepharoplasty the scar tissues get firm and slightly raised. Most of the eyelid surgery or blepharoplasty Dubai patients’ scars get worse then heals slowly. 

It takes over 3 to 4 months for the scar to mature resulting in softening. Generally, without any intervention, the scars respond well to routine scar treatment such as silicone gel or moisturizing creams. If needed, a small dosage of cortisone can be injected into the scar in case the hard lumps need to be broken down into smaller ones. 

The granuloma or lump might be the result of a reaction caused due to the sutures used in the surgery. When the body builds a scarred wall around the stitches mostly around the knot it is a suture reaction. The lumps can be easily felt due to the thin skin around the eyelid. A lump is formed when deep stitches are used to hold the eyelid tissues to the periosteum (bone).

This is a result of lower eyelid surgery. In a transconjunctival blepharoplasty, the incision is inside the eyelid. The lump could also be a reaction from ointment used during the surgery, leading to building foreign bodies. The treatment is easy with surgical excision, which can be done right in the office and with minimum pain.

How are these lumps classified?

There are different kinds of lumps that can occur after surgery. Let us discuss some of them.

• Blood clotting (hematoma) or a cyst filled with fluid (seroma): This is healed with time.
• Stye or chalazion: This develops after undergoing eyelid surgery. This can be treated by an ophthalmologist by removing the stye easily. 
• Nodule of fat: Occurs when you had injected fat during the surgery. 
• Bacterial infections: Scarcely found in patients, a painful, unresolved, and reddish lump. It can be a local infection or an abscess on the incision. The treatment for this is antibiotics and warm soaks. If the issue doesn’t get resolved, then the scar might need to be opened again for draining the area and resolving the problem. 

Apart from these tips on different kinds of lumps, it is necessary to keep in touch with your blepharoplasty Dubai surgeon.

Follow up with the plastic surgeon for guidance and treatment

The various reasons cause various issues, hence it is important for you to be in touch with your plastic surgeon after the blepharoplasty. The surgeon will be able to diagnose you and determine which kind of a lump you have grown and what will be the best treatment. Steady communication with your surgeon will help in answering questions that may come to your mind during the healing process. 

The right time to get a blepharoplasty is now!

Modern and advanced technologies and techniques have made eyelid surgery easier, effective, and safer. Being said that modern surgery is more capable of delivering the best results that you desire and with minimum pain, downtime, and discomfort. An experienced plastic surgeon equipped with advanced technology can offer better results that are long-lasting. The anesthesia specialist will ensure that you are comfortable and safe in a modern clinic. 

Consult an expert before the procedure

Before you go through the procedure ensure that you consult a professional who will be able to guide you thoroughly in addressing your concerns. As the autonomy and ability to heal are unique for each one of us, a detailed evaluation by an expert plastic surgeon can help you. Through this, you will be able to explore different options, and finally, choose the one that suits you best.  

How will you find the best blepharoplasty Dubai surgeon?

There are certain things that you need to keep in mind, while you look for a surgeon.

1. What is their overall experience and how many successful surgeries they have completed?
2. What do their clients say about the services?
3. Do they have the right certifications for conducting medical cosmetic procedures?

If you keep these simple things in mind, then you will be able to find the best blepharoplasty Dubai surgeon. 

Conclusion

We hope that this blog was enough for you to understand the reasons for lumps occurring after blepharoplasty. Please let us know how helpful this article was to you, and if you like it, share it with your friends. If you have any comments on this article, drop your valuable feedback for us in the comment section.

If you want to get such surgery, ensure that you go through the right processes and follow what the surgeon advises you. Dr. Tarek Aesthetics offers you a number of aesthetic solutions, along with blepharoplasty Dubai. We have experience in offering the right treatment with minimum or no complications. 

Our patients have proudly recommended us to their close ones, for critical cosmetic surgeries. If you want to get more details give us a call at +971 56 960 5146 or email us at [email protected].

Revision Blepharoplasty Minneapolis | Revisional Eyelid Surgery St. Paul

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Revision Blepharoplasty Surgery

The upper eyelids and our eyes are the focal points of our faces. When we look at others, we focus directly on this part of the face, and our eyes can easily pick up on asymmetries or differences in the eyelids. Eyelid surgery is a nuanced, unforgiving subspecialty of plastic surgery and it can go wrong in many ways. Dr. Dewan’s entire professional career has been devoted to eyelid surgery and he has significant experience in revision surgery. The best way to avoid revision surgery is to see a surgeon who specializes in eyelid surgery.

What makes revision surgery difficult?

Whenever we have eyelid surgery, our bodies take up to 6 months to heal. Part of this healing is to form scar tissue internally. As scar tissue forms, it is made of thick, firm material, as well as small blood vessels. This scar tissue fundamentally changes the anatomy of wherever it forms. When a patient requires revision surgery, it is up to the surgeon to navigate through this scar tissue in order to accomplish the surgical goals. Scar tissue makes this more challenging by having increased bleeding, and making it more difficult to find the normal anatomical landmarks that surgeons use to safely perform surgery. Additionally, the presence of scar tissue changes how the normal skin and fat lie after surgery. This means that revision surgery is always more unpredictable compared to a first-time operation.

How much improvement can you make with revision surgery?

The most important aspect of revision surgery is your consultation. During your consultation, Dr. Dewan will discuss your surgical history, aftercare, and your current goals. He will also perform a thorough exam and then provide you with recommendations to improve your eyelids. Revision surgery is challenging and Dr. Dewan will provide realistic goals and outcomes. Ultimately, scar tissue and prior surgeries may limit your final results, but the goal is always to move toward improvement, and generally make your eyes more symmetric.

Can I have other procedures performed at the same time?

There are many procedures that can be performed at the same time to enhance the overall effect of the revision surgery.  These include:

• Lower eyelid blepharoplasty:In many cases, performed a rejuvenating procedure to reduce the tired, lower eyelid “bag” can help your overall appearance and also “hide” any asymmetry from the upper eyelid revision.
• Ptosis repair:Occasionally, upper eyelids are left hanging too low over the eye. When a revision is performed, it may include lifting the eyelid to achieve a more symmetric look.
• Brow elevation: Elevating the brows can provide a more “open” appearance and hide extra folds or asymmetries from revision surgery.
• Eyelid lesion removal:In many cases, small growths or eyelid bumps are present along incision lines from prior surgery. During a revision, removing these scar cysts is necessary to achieve the best results.

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Is there scarring seen in the eyelid after surgery?

Revision blepharoplasty most commonly uses the same blepharoplasty incision you had made in your previous surgery.

• Generally, Dr. Dewan’s approach is to hide this incision by creating a new eyelid crease for you at the site of this incision.
• During surgery, Dr. Dewan also tries to remove as much previous scar tissue as is safe, hopefully limiting any visible thick scars in the eyelids.
• Because the incision line is usually the location of your new eyelid crease, Dr. Dewan will also place special stitches to re-form the crease, which helps give a more defined and symmetric appearance to the lids.

What is the recovery like?

Most patients describe recovery from revision blepharoplasty as similar to the recovery from their initial surgery. That said, because of the previous scar tissue, most patients have more swelling and bruising with the revision. This swelling is treated with lots of ice packs. Post-operative pain is mild, with pain medicine such as Tylenol all that is necessary to treat it. When you are comfortable, you are free to do most of your routine daily activities. Showering is possible the morning after surgery, and other than exercise, most activities can be performed as you would normally. Dr. Dewan prefers to use dissolving stitches and they will go away on their own in about 10 days. He will also schedule a post-operative visit for you 1 week following surgery.

Before and After

Our before and after photos are from right before the surgery to about 5-10 days after. All our photos are unretouched. You can expect additional improvements for several weeks after surgery, and most patients are so happy with their surgeries that they don’t come in after the immediate post-operative visit (though we always are happy to see them).

This patient is 50 years old and hated her eyes. She had an Asian blepharoplasty many years before seeing Dr. Dewan. She said that she didn’t feel as confident and didn’t even look like herself after the surgery. She hated the asymmetry and “unusual” appearance of the lids. Her goal was to look “more normal” and “more like herself.” Dr. Dewan performed a revision Asian blepharoplasty and crease definition on both sides. Her post-operative picture is from 12 days after surgery. Despite having a lot of healing left, she was thrilled with the outcome and felt she could be confident again!This patient is 60 years old and wanted her eyes to look more even. She had a previous blepharoplasty and didn’t like the way her right eyelid looked. She thought she had more skin and bulk on the right eye, and she liked the way her left eyelid looked. During her examination, Dr. Dewan found that she had a much lower eyelid crease in the right eye and a higher eyelid position compared to the left eye. Dr. Dewan performed a revision blepharoplasty and raised her eyelid crease, and also slightly lowered the eyelid to match the left side. This was performed in our office. The after photo is 7 days after the surgery, so there is a lot of healing still to go, but her eyes are much more symmetric and she was thrilled!

Will insurance pay for this?

Revision blepharoplasty is only covered by insurance if your eyelids are covering your eye and blocking your vision. During your consultation, Dr. Dewan will measure your eyelid position perform a visual field to determine to what extent your vision is being blocked. These measurements will then be sent to your insurer, and if you meet their criteria, your insurance will cover the revision blepharoplasty. In most cases, however, revision blepharoplasty is meant to restore the cosmetic appearance of your eyelids and is, therefore, not covered by insurance. Dr. Dewan will provide a quote for surgical fees during your consultation.

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Prevention and treatment of pathological scars in surgical practice | Chernyakov A.V.

The article is devoted to the prevention and treatment of pathological scars. The role of drugs with a multicomponent composition, affecting different parts of the process of scar formation, is considered. Described preventive measures aimed at preventing keloid scars, including the use of peeling, dermabrasion, and mesotherapy.

Introduction

The process of rehabilitation of patients in the postoperative period is closely related to wound healing and the formation of a postoperative scar. In most patients with extensive injuries of various etiologies, pathological scars form at the site of the lesion, leading to dysfunction of the limbs, deformities of the body and face, and an increase in the level of disability.
One of the ways to reduce the trauma of the operations performed is to reduce the volume of the surgical wound through the introduction of minimally invasive (endoscopic, laparoscopic, thoracoscopic, etc.) operations and the use of sparing wound closure methods (including intradermal absorbable suture) (Fig. 1).

Morphological process of scar formation

Currently, there is no clear separation of the terms “scar” and “scar tissue” [1]. At its core, a scar is a connective tissue formation that is formed in the process of wound healing, and scar tissue occurs in the last phase of the wound process – the phase of epithelization. The process of scar formation includes external (volume, localization, type of wound healing) and internal factors (reactivity of the body, structural features of the connective tissue, etc. ). The severity of the cicatricial process depends on the amount of damage: it is greater in case of deep damage with damage to the sweat and sebaceous glands, hair follicles [2].
In the process of wound healing, several phases are conditionally distinguished, replacing and often overlapping each other: the exudation and inflammation phase, the proliferation phase, and the reorganization phase [3].
In the 1st phase (exudation and inflammation), the blood coagulation system is activated and a platelet-fibrin clot is formed at the site of injury, which leads to bleeding arrest and the creation of a temporary matrix consisting of glycoproteins (collagen), proteoglycans and hyaluronic acid, which serves as the basis for connective tissue synthesis. Subsequently, against the background of fibrinolysis and destruction of platelets, numerous growth factors (transforming growth factor β, epidermal growth factor, insulin-like growth factor, platelet growth factor, etc.) are released and neutrophils are attracted, phagocytizing foreign particles and activating keratinocytes and macrophages.
In the 2nd phase (proliferation), the formation of young connective tissue, rich in blood vessels and cells, and the synthesis of collagen by fibroblasts occur. A feature of this phase is the predominance of embryonic collagen (type III) in the tissues of the postoperative scar, which is thin fibers and is characterized by elasticity and good extensibility. Subsequently, type III collagen is replaced by less elastic type I collagen. At the same time, myofibroblasts synthesize proteins actin and desmin, which improve the convergence of wound edges.
In the 3rd phase of wound healing (phase of reorganization), contractile proteins and various components of the extracellular matrix are synthesized by fibroblasts. Fibroblasts, mast cells and macrophages synthesize matrix metalloproteinases, which destroy the components of the extracellular matrix. Thus, in the reorganization phase, the balance between collagen synthesis and destruction is maintained, which leads to the formation of a normal scar.

Pathogenesis

Reliable reasons for the development of hypertrophic and keloid scars have not yet been identified. The formation of such scars is based on violations of the processes of collagen synthesis and degradation at various stages of scar formation, violations are due to the following reasons [4, 5]:
1) intensification of the synthesis of collagen fibers in the postoperative wound for a long time
time;
2) the influence of various growth factors (transforming growth factor β) on the development of hypertrophic scars by stimulating angiogenesis, collagen synthesis, fibroblast proliferation, inhibition of cytoplasmic matrix degradation [6];
3) increased activity of inhibitors of metalloproteinases, leading to the formation of excess collagen and fibronectin;
4) violations of the processes of apoptosis of fibroblasts of the postoperative wound against the background of suppression of the p53 protein, which is a regulator of the cell cycle.
Pathological scars can appear at any age, but most often they occur in young patients. This is due to the peculiarities of their skin – elasticity and extensibility due to the synthesis of a large amount of collagen, while in older patients the skin is more rigid.

Scar classification

Currently, the following classification of scars is accepted [2].
I. Physiological (normotrophic) scars.
II. Pathological scars:
1. Atrophic scars:
• stab,
• rectangular,
• rounded,
• striae.
2. Hypertrophic scars.
3. Keloid scars:
A. By etiology:
• true keloid scars,
• false keloid scars.
B. By morphology:
• fibroblastic (active),
• fibrotic (stable).
Normotrophic scars develop as a result of the physiological process of wound healing.
The development of atrophic scars occurs at the site of ulcerative defects, pyogenic infiltrates, infectious granulomas, in foci of chronic inflammation. The main difference between atrophic scars is the absence of cells and blood vessels, dermal atrophy, and severe fibrosis [7]. Stretch marks are also characterized by rupture of elastic fibers along with a deficiency of collagen and elastin.
Hypertrophic scars are characterized by a fairly dense texture, they rise above the surface of the skin, but do not go beyond the damage. Histological examination reveals the growth of collagen fibers, an increase in the number of fibroblasts, and the presence of a developed vascular network [8].
A keloid scar is a neoplasm of immature connective tissue that extends beyond the damage zone and is characterized by the presence of a large number of fibroblasts and obliterated vessels, bundles of collagen fibers forming nodal structures [9].
Currently, the division of keloid scars into true (occurring spontaneously) and false (arising at the site of microtrauma) has undergone some changes, since it has been proven that true keloid scars also occur against the background of microtraumatization of the postoperative wound.

Treatment

The problem of treating patients with keloid and hypertrophic scars has not been completely solved [10]. This is due to the fact that there is no single effective method of managing such patients. Rational tactics for dealing with pathological scars include therapeutic, physiotherapeutic, radiological, surgical and cosmetic methods [11].

Therapeutic methods

Drugs used to treat patients with pathological scars belong to different pharmacological groups and have application points at each stage of scar development [7].
A. Corticosteroid preparations
Corticosteroid drugs are the mainstay in the treatment of patients with keloid scars. Their action is based on the inhibition of the synthesis of inflammatory mediators and fibroblast proliferation, which leads to a decrease in the level of glycosaminoglycans and collagen in the wound [7]. The drugs in this group include:
• Hydrocortisone , used by injection and topically [12];
• Triamcinolone acetate , injected into the affected area at intervals of 4-6 weeks;
• Betamethasone dipropionate is used as a topical formulation. A feature of the action of this drug is a decrease in the relief of scar tissue due to changes in the kinetics of fibroblasts and resorption of connective tissue [12].
When using corticosteroid drugs, complications such as skin atrophy, telangiectasia, and pigmentation disorders may develop.
B. Enzyme preparations
Enzyme preparations used in the treatment of patients with pathological scars include collagenases and hyaluronidases, which hydrolyze collagen and glycosaminoglycans in scar tissue with further restoration of the normal composition and structure of the extracellular matrix [7].
The specific substrate of hyaluronidase are glycosaminoglycans – “cementing” substance of the connective tissue. As a result of hydrolysis, the viscosity of glycosaminoglycans decreases, the ability to bind water and metal ions. As a result, the permeability of tissues increases, their trophism improves, edema decreases, and the elasticity of scar-modified areas increases. The effect is most pronounced in the initial stages of the pathological process. A problem with many enzyme preparations is their inactivation upon administration. The indicated disadvantage is deprived of the drug Longidase ^® , which is a conjugate of hyaluronidase with a high molecular weight carrier, due to which the clinical effect of the drug is higher than that of the native enzyme. Conjugation increases the resistance of hyaluronidase to the action of temperature and inhibitors, increases efficiency, leads to prolongation of action, while maintaining the pharmacological properties of the carrier, which has chelating, antioxidant, anti-inflammatory activity. Due to its polytropic properties, Longidase ^® suppresses the reverse reaction aimed at the synthesis of connective tissue components, has an antifibrotic effect, and reduces the severity of the inflammatory reaction. It is well tolerated by patients [7, 13].
To prevent the formation of a hypertrophic scar after surgical operations or in the case of an already formed hypertrophic scar, Longidase is administered intra-scar or subcutaneously near the site of the lesion 1 time in 3 days, with a course of up to 15 injections at a dosage of 3000-4500 IU. Depending on the size and duration of scar formation, it is possible to alternate subcutaneous and intramuscular administration of the drug once every 5 days at a dosage of 3000 IU, with a course of up to 20 injections [13].
Conducted clinical studies demonstrate a significant effect of the drug, which consists in reducing the density of the scar and restoring skin elasticity, in patients with hypertrophic and keloid cicatricial changes with different localization and duration of the pathological process [14, 15].
Currently, a cream containing a stabilized hyaluronidase, Imoferase ^® , has appeared, which can be used by patients themselves at home to continue treatment or care [16]. The cream is applied 2 times a day (preliminary preparation of the skin is not required), it is easily absorbed and does not leave marks on clothes. The clinical efficacy of the drug has been demonstrated by the team of authors of the MGMSU named after M.V. Evdokimov. 1622 patients were examined in 46 Russian medical centers aged 18 to 45 years, with post-traumatic (698 people, 43. 03%), post-burn (98 people, 6.04%) and iatrogenic (826 people, 50.93%) scars. In 372 (22.93%) people, normotrophic types of cicatricial changes in the skin were recorded, in 1250 (77.07%) – hypertrophic ones. As a result of the use of Imoferase ^® cream for 8 weeks. there were statistically significant reductions in the intensity of dyspigmentation by 56.05%, the intensity of blood filling of scar tissue by 38.86%; scar height by 68.47%. Adverse events requiring the abolition or reduction of the frequency of application of the cream were not recorded [17].
In a study conducted in 2016 at the Scientific and Practical Center for Expert Evaluation of the Quality and Safety of Food and Cosmetics “CosmoProdTest”, with the participation of 35 volunteers with hypertrophic scars, the following results were obtained: the thickness of the scar decreased (by 2.1 times) and uncomfortable subjective sensations in the area of ​​the scar (according to the POSAS scale, the symptom “pain” decreased by 1. 9 times, “itching” – by 1.5 times).
Researchers from the Khanty-Mansiysk Clinical Dermatovenerologic Dispensary concluded that Imoferase 9 cream0222 ® is highly effective in topical application, by photophoresis, ultraphonophoresis in patients with hypertrophic scars of various etiologies (30 people took part in the study).
In 2016 at the GKB im. F.I. Inozemtseva (Moscow) were treated in the early stages after injury (up to 3 months) of 30 patients who suffered burns of the II–III degree. Thanks to the use of Imoferase ^® cream, 80% of patients did not develop pathological post-burn scars, and with formed post-burn scars, scar tissue regressed by 1.7 points on the VSS scale.
As for the tolerability of the drug, within the framework of the study in CosmoProdTest, the use of the cream in 25 people with reactive (sensitive) skin did not have an irritating, allergenic and sensitizing effect.
B. Immunomodulators
The use of immunomodulators is a relatively new method of treating patients with pathological scars.
• Interferon -α2b, injected into the suture line after excision of a pathological scar, prevents its recurrence by inhibiting the synthesis of collagen types Ι and ΙΙΙ, which are the main structural components of scar tissue [18];
• Meglumine acridone acetate is an interferon inducer and affects the T-cell link of immunity [7]. The drug has an inhibitory effect on the synthesis of pro-inflammatory cytokines and reduces the level of chronic inflammation in the scar, which stimulates the growth of keloid tissue [7].
D. Vitamin therapy
The use of vitamins locally or by intradermal injection is a new direction in the treatment of patients with pathological scars.
• Retinol ( vitamin A ), accelerates wound healing, inhibits the growth of pathological scar tissue, increases the proliferation of epidermal cells and inhibits the proliferation of fibroblasts. The use of vitamin A leads to inhibition of the growth of keloid fibroblasts and reduces the level of collagen [19];
• Tocopherol ( vitamin E ), an active antioxidant that inhibits lipid peroxidation, stabilizes lysosomal membranes of endotheliocytes, which reduces the degree of endothelial dysfunction [20].
D. Flavonoid Compounds
This group of drugs includes various phytoextracts (quercetin , kaempferol, protocatechin , etc.), which are applied topically as part of various dressings. The effect of flavonoid compounds on the development of scar tissue is explained by their antioxidant properties, the ability to inhibit the process of lipid peroxidation and lipid peroxidation of membrane phospholipids, which affects the activity of endotheliocyte membranes [21]. Inhibition of the production of collagen and fibronectin is also noted due to the inhibition of specific genes involved in the work of some growth factors [11].
E. Amino acids
Currently, the effectiveness of glycine in the treatment of patients with pathological postoperative scars has been most studied. This amino acid is involved in the formation of new cells, has a hydrating ability. The use of glycine locally allows you to maintain the protective function of the epidermis, and its penetration into the dermis improves microcirculation, slows down the degradation of connective tissue. Studies have shown that its use in high doses allows for the prevention of keloid formation due to the endothelioprotective effect of the drug [19].
G. Combined preparations for the treatment of patients with pathological scars
Multicomponent preparations for the treatment of patients with pathological scars are more effective than monocomponent preparations, since they affect different parts of the scar formation process.

Physiotherapeutic methods

These treatments are based on various physical effects on the pathological scar and include:
A. Products containing silicone (plates, patches, gels) [7]
The effect of silicone plates and patches on keloids is due to their uniform pressure on the scar, which leads to a decrease in the volume of the extracellular matrix and to the correct, ordered arrangement of collagen fibers in the wound. The use of silicone plates allows you to constantly keep the surface of the scar moist, protect it from drying out and traumatization. Constant hydration of the scar tissue helps to restore the water balance of the epidermis and normalize the activity of fibroblasts, which prevents excessive growth of the connective tissue, and exposure to a negatively charged static electric field of silicone can lead to regression of the keloid process [12].
B. X-ray therapy
The use of X-ray therapy is due to the effect of ionizing radiation on the connective tissue, which leads to edema and destruction of both fibroblasts and collagen fibers [22]. A feature of the method is that irradiation affects only the epidermis and superficial layers of the dermis (including the scar), while the load on the underlying tissues is minimal. Contraindications for prescribing X-ray therapy include:
• kidney disease,
• decompensation of circulatory disorders,
• the presence of dermatitis.
The total radiation dose is 15–20 Gy. To prevent the development of a keloid scar, it is possible to irradiate the wound once on the day the sutures are removed.
B. Exposure to low temperatures (cryolysis)
Cryotherapy on a pathological scar (with liquid nitrogen) leads to damage to the vessels of the microvasculature and cell death as a result of the formation of microcrystals inside the cells. The disadvantage of the method is pain and frequent development of hypo- and depigmentations, which in some cases may be irreversible [1].
D. Laser therapy
The use of laser therapy in patients with pathological scars is based on the ability of collagen to contract against the background of local heating (when using a carbon dioxide laser) or to be destroyed during photothermolysis (when using pulsed dye lasers) [1]. The use of lasers leads to a decrease in the size of the scar and its softening. However, when using only laser exposure to a pathological scar, a fairly high percentage of relapses is noted. Therefore, the photophoresis method is of interest, when a drug is first applied to the scar, and then laser irradiation is performed using a contact-stable, quasi-scanning, or contact-labile method. Use low-energy infrared laser radiation (pulse power is 2-8 W / pulse) with a pulse repetition rate of 80 or 1500 Hz. It should be noted that Longidase 9 preparations0222 ® and Imopherase ^® can be used for photophoresis. Longidase is dissolved in water for injection, procedures are carried out daily or every other day with a course of up to 15 procedures. Repeated courses are shown after 2 months. This physiotherapeutic method is most effective for fresh scars from 2 weeks to 2 months ago [15].
E. The use of ultrasonic vibrations in the framework of the method of ultraphonophoresis
The technique is carried out using the combined use of a drug (for example, Longidase or Imoferase) and ultrasonic vibrations in continuous or pulsed mode with a frequency of 880 kHz – 1 MHz. Before use, Longidase is diluted in 1 ml of liquid (sodium chloride solution 0.9%, water for injection, novocaine solution, etc.) and applied to the scar, then, without a time interval, ultrasound is applied using the contact method, the intensity is 0. 2 W / cm2 when the process is localized on the face, and 0 when localized on other parts of the body. .4–0.8 W/cm2. The total duration of the procedure does not exceed 15 minutes, the procedures are carried out daily or every other day with a course of up to 20 procedures. A second course of ultraphonophoresis is allowed no earlier than after 3 months. It is important to note that this method, in combination with intra-cicatrical and subcutaneous (near the site of the lesion) administration of Longidaza, is effective for the treatment of cicatricial changes even more than 1 year old [15].
It should be noted that the effectiveness of the use of therapeutic and physiotherapeutic agents depends on the period of scar formation – the older it is, the less effective the treatment. This is due to the predominance of scar tissue and a decrease in the number of vessels in the connective tissue formation, which disrupts its trophism.

Surgical treatment

Surgical excision of keloid scars is used extremely rarely, because a traumatic effect on the scar almost always leads to a recurrence of the keloid. The method is based on the removal of scar tissue and the creation of optimal conditions for healing by primary intention: comparison of homogeneous tissues and wound edges, cleansing the wound, suturing the wound with an atraumatic absorbable thread. Surgical treatment must necessarily be accompanied by other methods of prevention and treatment of pathological scars [1].

Corrective cosmetic procedures

Currently used cosmetic procedures (peels, mesotherapy, dermabrasion) perform aesthetic correction of small scars, but do not have any therapeutic effect [1]. At the same time, cosmetic methods can be used only in the 3rd phase of scar organization. To obtain satisfactory results, cosmetic procedures must be combined with therapeutic methods.

Prevention of pathological scarring

The healing process of a postoperative wound depends on the amount of damage and the characteristics of the patient’s body. Preventive measures aimed at preventing keloid scars include the use of minimally invasive techniques that reduce trauma to the skin, and the use of various therapeutic and physiotherapeutic agents that prevent the formation of keloid tissue [11].