【醫師說】你對激光祛疤了解多少

發表時間：2019-05-02 11:40:05 文章來源：杭州美萊

　　大家好，我是劉明章，是杭州美萊美容(rong)皮膚科(ke)副主任(ren)，我(wo)的人生格言(yan)是(shi)：“博學之(zhi)(zhi)(zhi)，審問之(zhi)(zhi)(zhi)，慎(shen)思之(zhi)(zhi)(zhi)，明辨之(zhi)(zhi)(zhi)，篤行之(zhi)(zhi)(zhi)”。十(shi)余年(nian)匠(jiang)心，只(zhi)為溫暖每一位患(huan)者(zhe)，精(jing)益求精(jing)，力求不斷超(chao)越自我(wo)。

　　今天，我們一起來聊(liao)聊(liao)關(guan)于激光祛疤的相關(guan)知識。

　　激光祛疤的原理

　　這里(li)的激(ji)光(guang)泛(fan)指各種光(guang)電，有激(ji)光(guang)、光(guang)子、射頻等。激(ji)光(guang)祛疤(ba)，通過早期局灶性(xing)選(xuan)擇性(xing)熱作用(yong)，可以刺激(ji)皮(pi)膚原位再(zai)生修復，以達(da)到(dao)修復疤(ba)痕目的。

　　選擇性熱作用

　　激(ji)光(guang)(guang)(guang)治療疤痕(hen)的(de)基本(ben)原理就是(shi)選(xuan)擇性熱(re)(re)作用，皮膚(fu)組織內(nei)的(de)主(zhu)要色(se)基血(xue)(xue)紅蛋白、黑色(se)素(su)(su)、水分(fen)子(zi)。針(zhen)對血(xue)(xue)紅蛋白的(de)有脈(mo)沖(chong)燃料激(ji)光(guang)(guang)(guang)、光(guang)(guang)(guang)子(zi)、532nm-1064nmNd-YAG激(ji)光(guang)(guang)(guang)，可以封閉早期增(zeng)生的(de)毛細血(xue)(xue)管(guan)，抑制疤痕(hen)增(zeng)生。針(zhen)對黑色(se)素(su)(su)的(de)激(ji)光(guang)(guang)(guang)主(zhu)要是(shi)調Q激(ji)光(guang)(guang)(guang)，如Nd-YAG激(ji)光(guang)(guang)(guang)、紅寶石(shi)激(ji)光(guang)(guang)(guang)和綠(lv)寶石(shi)激(ji)光(guang)(guang)(guang)，對于(yu)色(se)沉或粉塵沉積(ji)有良好治療效果。針(zhen)對水分(fen)子(zi)的(de)比較多如CO2激(ji)光(guang)(guang)(guang)、鉺(er)激(ji)光(guang)(guang)(guang)、紅外激(ji)光(guang)(guang)(guang)等，以及超聲、射頻、等離子(zi)等，這類光(guang)(guang)(guang)電主(zhu)要是(shi)產生合(he)適的(de)熱(re)(re)損傷，激(ji)發組織的(de)再生修復。

　　局灶性熱作用

　　主要以水分子為(wei)(wei)色(se)基的激(ji)光(guang)(guang)(guang)，光(guang)(guang)(guang)斑(ban)大(da)，熱(re)損(sun)傷(shang)(shang)(shang)范圍(wei)(wei)就比(bi)(bi)較(jiao)大(da)，恢復慢、炎(yan)癥(zheng)反應、重不(bu)良反應明(ming)顯。局(ju)(ju)灶(zao)性光(guang)(guang)(guang)熱(re)作用(yong)(yong)(yong)(yong)的原(yuan)(yuan)理(li)(li)(li)(li)(li)就是將一(yi)(yi)個較(jiao)大(da)的激(ji)光(guang)(guang)(guang)光(guang)(guang)(guang)斑(ban)分割成數十(shi)個直(zhi)徑(jing)(jing)數百(bai)微(wei)米、甚至更細(xi)小(xiao)的光(guang)(guang)(guang)束，經表皮透進入仿(fang)真(zhen)，在皮膚(fu)(fu)上形成小(xiao)的孔(kong)徑(jing)(jing)，這樣就會(hui)產(chan)生柱狀的凝(ning)固(gu)帶(dai)和(he)(he)熱(re)損(sun)傷(shang)(shang)(shang)帶(dai)，啟動皮膚(fu)(fu)的修復程序(xu)，較(jiao)終(zhong)引起表皮和(he)(he)仿(fang)真(zhen)重塑和(he)(he)重建，達到治療目的。依據這個原(yuan)(yuan)理(li)(li)(li)(li)(li)設(she)(she)計的激(ji)光(guang)(guang)(guang)稱為(wei)(wei)點(dian)(dian)(dian)(dian)(dian)陣(zhen)(zhen)(zhen)(zhen)(zhen)激(ji)光(guang)(guang)(guang)，皮膚(fu)(fu)表面有孔(kong)徑(jing)(jing)的稱為(wei)(wei)剝脫型(xing)點(dian)(dian)(dian)(dian)(dian)陣(zhen)(zhen)(zhen)(zhen)(zhen)激(ji)光(guang)(guang)(guang)，如(ru)CO2點(dian)(dian)(dian)(dian)(dian)陣(zhen)(zhen)(zhen)(zhen)(zhen)激(ji)光(guang)(guang)(guang)；皮膚(fu)(fu)表面沒有真(zhen)正(zheng)孔(kong)徑(jing)(jing)，僅僅引起一(yi)(yi)個柱狀的熱(re)變性區域，屬于非剝脫型(xing)點(dian)(dian)(dian)(dian)(dian)陣(zhen)(zhen)(zhen)(zhen)(zhen)激(ji)光(guang)(guang)(guang)，如(ru)1540nm和(he)(he)1565nm紅外光(guang)(guang)(guang)纖點(dian)(dian)(dian)(dian)(dian)陣(zhen)(zhen)(zhen)(zhen)(zhen)激(ji)光(guang)(guang)(guang)。依據此原(yuan)(yuan)理(li)(li)(li)(li)(li)，設(she)(she)計了(le)點(dian)(dian)(dian)(dian)(dian)陣(zhen)(zhen)(zhen)(zhen)(zhen)射頻，減少熱(re)損(sun)傷(shang)(shang)(shang)，等(deng)離子也(ye)是點(dian)(dian)(dian)(dian)(dian)陣(zhen)(zhen)(zhen)(zhen)(zhen)分布的熱(re)損(sun)傷(shang)(shang)(shang)柱。聚焦超(chao)聲在做妊娠(shen)紋、深層疤痕或面部提升時，也(ye)要合理(li)(li)(li)(li)(li)應用(yong)(yong)(yong)(yong)局(ju)(ju)灶(zao)性熱(re)作用(yong)(yong)(yong)(yong)的原(yuan)(yuan)理(li)(li)(li)(li)(li)，合理(li)(li)(li)(li)(li)布局(ju)(ju)深層熱(re)損(sun)傷(shang)(shang)(shang)灶(zao)，避免過度損(sun)傷(shang)(shang)(shang)。由于設(she)(she)備自帶(dai)點(dian)(dian)(dian)(dian)(dian)陣(zhen)(zhen)(zhen)(zhen)(zhen)模式，熱(re)損(sun)傷(shang)(shang)(shang)深度和(he)(he)范圍(wei)(wei)不(bu)足(zu)，所以有醫師對局(ju)(ju)灶(zao)性熱(re)作用(yong)(yong)(yong)(yong)做了(le)擴展，用(yong)(yong)(yong)(yong)CO2激(ji)光(guang)(guang)(guang)的超(chao)脈沖模式定點(dian)(dian)(dian)(dian)(dian)氣(qi)化(hua)，呈矩陣(zhen)(zhen)(zhen)(zhen)(zhen)排(pai)列，稱“人工點(dian)(dian)(dian)(dian)(dian)陣(zhen)(zhen)(zhen)(zhen)(zhen)”。筆者的一(yi)(yi)個同事(shi)針對點(dian)(dian)(dian)(dian)(dian)陣(zhen)(zhen)(zhen)(zhen)(zhen)激(ji)光(guang)(guang)(guang)治療毛(mao)孔(kong)粗大(da)時，光(guang)(guang)(guang)束可能沒有對準毛(mao)孔(kong)，提出用(yong)(yong)(yong)(yong)CO2激(ji)光(guang)(guang)(guang)的超(chao)脈沖模式對準毛(mao)孔(kong)定向氣(qi)化(hua)，同事(shi)和(he)(he)筆者在實(shi)踐(jian)中發現，這種(zhong)方法做毛(mao)孔(kong)，效果(guo)比(bi)(bi)較(jiao)好(hao)，客人比(bi)(bi)較(jiao)滿(man)意，擅(shan)自定義為(wei)(wei)“毛(mao)孔(kong)點(dian)(dian)(dian)(dian)(dian)陣(zhen)(zhen)(zhen)(zhen)(zhen)”。

　　原位再生修復

　　激(ji)(ji)光(guang)(guang)治療(liao)疤痕不(bu)單(dan)單(dan)是(shi)(shi)(shi)熱損傷后(hou)(hou)再(zai)(zai)(zai)修(xiu)復，而(er)是(shi)(shi)(shi)可以原(yuan)(yuan)位(wei)(wei)(wei)再(zai)(zai)(zai)生(sheng)(sheng)(sheng)(sheng)修(xiu)復。皮(pi)膚原(yuan)(yuan)位(wei)(wei)(wei)再(zai)(zai)(zai)生(sheng)(sheng)(sheng)(sheng)修(xiu)復的(de)(de)細(xi)(xi)胞(bao)(bao)學基礎有(you)兩方面：一是(shi)(shi)(shi)皮(pi)膚附屬器如(ru)大(da)汗腺、小汗腺、皮(pi)脂腺及毛囊等(deng)；二是(shi)(shi)(shi)表(biao)皮(pi)的(de)(de)細(xi)(xi)胞(bao)(bao)，在表(biao)皮(pi)的(de)(de)基底層大(da)約(yue)有(you)10%的(de)(de)表(biao)皮(pi)細(xi)(xi)胞(bao)(bao)，另(ling)外(wai)毛囊的(de)(de)隆突部也富含(han)表(biao)皮(pi)細(xi)(xi)胞(bao)(bao)。激(ji)(ji)光(guang)(guang)刺(ci)激(ji)(ji)組織后(hou)(hou)，會釋(shi)放出各種細(xi)(xi)胞(bao)(bao)生(sheng)(sheng)(sheng)(sheng)長因(yin)子(zi)(zi)，這些生(sheng)(sheng)(sheng)(sheng)長因(yin)子(zi)(zi)刺(ci)激(ji)(ji)細(xi)(xi)胞(bao)(bao)的(de)(de)不(bu)對稱分化(hua)，有(you)利于(yu)表(biao)皮(pi)的(de)(de)生(sheng)(sheng)(sheng)(sheng)長。術后(hou)(hou)給(gei)予(yu)外(wai)源性(xing)生(sheng)(sheng)(sheng)(sheng)長因(yin)子(zi)(zi)、CGF、PRP、脂肪細(xi)(xi)胞(bao)(bao)、外(wai)周血(xue)細(xi)(xi)胞(bao)(bao)等(deng)也是(shi)(shi)(shi)為了更(geng)好的(de)(de)皮(pi)膚原(yuan)(yuan)位(wei)(wei)(wei)再(zai)(zai)(zai)生(sheng)(sheng)(sheng)(sheng)修(xiu)復。另(ling)外(wai)細(xi)(xi)胞(bao)(bao)的(de)(de)活性(xing)需要很好的(de)(de)濕性(xing)環(huan)境，所以術后(hou)(hou)涂抹美寶(bao)濕潤燒(shao)傷膏有(you)助(zhu)于(yu)原(yuan)(yuan)位(wei)(wei)(wei)再(zai)(zai)(zai)生(sheng)(sheng)(sheng)(sheng)修(xiu)復。

　　早期干預的理論基礎

　　創傷(shang)愈合分為三個階段：急性炎(yan)癥(zheng)期(qi)、細(xi)(xi)(xi)胞(bao)(bao)(bao)增(zeng)生(sheng)期(qi)、瘢(ban)(ban)痕(hen)(hen)形(xing)(xing)成(cheng)(cheng)期(qi)。創傷(shang)發生(sheng)后(hou)，就進入炎(yan)癥(zheng)階段，伴(ban)血(xue)栓形(xing)(xing)成(cheng)(cheng)及(ji)補體反應(ying)。傷(shang)口(kou)的(de)早期(qi)變(bian)化傷(shang)口(kou)局部(bu)(bu)有不同程(cheng)度(du)的(de)組(zu)(zu)織(zhi)(zhi)(zhi)壞死(si)和(he)血(xue)管(guan)斷裂出(chu)血(xue)，數小(xiao)時內便出(chu)現(xian)炎(yan)癥(zheng)反應(ying)，表現(xian)為充血(xue)、漿液(ye)滲(shen)出(chu)及(ji)白細(xi)(xi)(xi)胞(bao)(bao)(bao)游離，故局部(bu)(bu)紅腫。白細(xi)(xi)(xi)胞(bao)(bao)(bao)早期(qi)以(yi)中性粒細(xi)(xi)(xi)胞(bao)(bao)(bao)為主，3天后(hou)轉為以(yi)巨(ju)噬(shi)細(xi)(xi)(xi)胞(bao)(bao)(bao)為主，巨(ju)噬(shi)細(xi)(xi)(xi)胞(bao)(bao)(bao)釋放(fang)各種細(xi)(xi)(xi)胞(bao)(bao)(bao)因子和(he)生(sheng)長因子。細(xi)(xi)(xi)胞(bao)(bao)(bao)增(zeng)生(sheng)期(qi)：傷(shang)口(kou)收縮(suo)(suo) 2~3天后(hou)傷(shang)口(kou)邊(bian)緣的(de)整層皮膚(fu)及(ji)皮下組(zu)(zu)織(zhi)(zhi)(zhi)向中心移動(dong)，于(yu)是(shi)傷(shang)口(kou)迅速縮(suo)(suo)小(xiao)，直到14天左右停止。傷(shang)口(kou)收縮(suo)(suo)的(de)意義(yi)在于(yu)縮(suo)(suo)小(xiao)創面。實驗證明，傷(shang)口(kou)甚至可(ke)縮(suo)(suo)小(xiao)80%。瘢(ban)(ban)痕(hen)(hen)形(xing)(xing)成(cheng)(cheng)期(qi)：肉芽組(zu)(zu)織(zhi)(zhi)(zhi)增(zeng)生(sheng)和(he)瘢(ban)(ban)痕(hen)(hen)形(xing)(xing)成(cheng)(cheng) 大(da)約從第3天開始從傷(shang)口(kou)底部(bu)(bu)及(ji)邊(bian)緣長出(chu)肉芽組(zu)(zu)織(zhi)(zhi)(zhi)，填平傷(shang)口(kou)。毛(mao)細(xi)(xi)(xi)血(xue)管(guan)大(da)約以(yi)每日(ri)延長0.1~0.6mm的(de)速度(du)增(zeng)長，其方(fang)向大(da)都(dou)垂直于(yu)創面，并呈袢狀彎曲。第5~6天起纖(xian)維(wei)母細(xi)(xi)(xi)胞(bao)(bao)(bao)產生(sheng)膠(jiao)原(yuan)纖(xian)維(wei)，其后(hou)一周膠(jiao)原(yuan)纖(xian)維(wei)形(xing)(xing)成(cheng)(cheng)甚為活躍，以(yi)后(hou)逐(zhu)漸緩(huan)慢(man)下來。隨著膠(jiao)原(yuan)纖(xian)維(wei)越來越多，出(chu)現(xian)瘢(ban)(ban)痕(hen)(hen)形(xing)(xing)成(cheng)(cheng)過(guo)(guo)程(cheng)，大(da)約在傷(shang)后(hou)一個月瘢(ban)(ban)痕(hen)(hen)完全形(xing)(xing)成(cheng)(cheng)。對(dui)于(yu)疤痕(hen)(hen)修復，早期(qi)給予(yu)激(ji)光干預，封閉毛(mao)細(xi)(xi)(xi)血(xue)管(guan)，減少炎(yan)癥(zheng)反應(ying)，避免疤痕(hen)(hen)組(zu)(zu)織(zhi)(zhi)(zhi)過(guo)(guo)度(du)形(xing)(xing)成(cheng)(cheng)，如增(zeng)生(sheng)或變(bian)寬。

　　總之，激光祛疤的原理就是早期局灶性選擇性熱作用促進皮膚原位再生修復。