第一部分 双波长PDL／Nd:YAG激光治疗增生性瘢痕的临床疗效评价 背景 瘢痕是烧伤、创伤、擦伤或者手术后的皮肤愈合形成的，在临床中非常常见。异常的伤口愈合过程会造成增生性疤痕。增生性瘢痕(Hypertrophic Scar，HS)常见的症状是疼痛、瘙痒、发红和肿胀，较为严重的症状有神经性疼痛、僵硬、挛缩、体温调节丧失等。由于增生性瘢痕给患者带来了美容上的缺陷、不舒适感、甚至功能异常、社交障碍等，造其生活质量的下降，因此需要积极治疗。治疗的目的是为了达到功能和美学上的改善。临床上有许多方法可以预防和治疗增生性瘢痕。包括：局部加压、硅酮、药物注射(类固醇、肉毒素等)、激光治疗、浅层X线照射和手术治疗等因此需要积极治疗。近年来，激光治疗的有效性和安全性越来越被认可，因此激光治疗被广泛应用在瘢痕的治疗中。 目的 双波长PDL／Nd:YAG激光被广泛应用于血管性疾病中，疗效确切，但治疗增生性瘢痕的报道较少。本研究主要探讨了双波长PDL／Nd:YAG激光治疗增生性瘢痕的有效性和安全性。 材料与方法 共有25名增生性瘢痕的患者纳入了本研究。治疗前，患者和评估医师根据患者瘢痕评估量表(Patient Scar Assessment Scale，PSAS)和观察者瘢痕评估量表(Observer Scar Assessment Scale，OSAS)对增生性瘢痕进行评估。所有患者采用双波长PDL／Nd:YAG激光进行治疗，根据患者的瘢痕情况、肤色等调整能量大小。患者每隔4-6周接受一次治疗。每次治疗过程中的不良反应都需要记录。在治疗结束后，患者和评估者再次使用PSAS和OSAS评估瘢痕情况，同时记录患者和评估者的满意度(不满意、满意、非常满意3级)。用GraphPad Prism 7.0的统计软件来比较治疗前后的各项指标。 结果 共有25名患者纳入研究，其中女性16名，男性9名，年龄在7至35岁之间，平均年龄为23岁。经过2-11次(平均次数为5.3次)的激光治疗，增生性瘢痕在症状、颜色、质地、高度等各方面都得到了明显改善，结果具有统计学差异。本研究中没有观察到严重的不良反应。医师的满意度为88％，患者的满意度为80％，患者和医师都对治疗效果感到满意，但医师的满意度略高于患者的满意度。 结论 双波长PDL／Nd:YAG激光治疗增生性瘢痕能达到很好的疗效，并且患者接受度高，不良反应的发生率低，因此，可以认为这是一个值得在临床推广的治疗增生性瘢痕的方法。 关键词 双波长PDL／Nd:YAG激光；增生性瘢痕；患者瘢痕评估量表；观察者瘢痕评估量表 第二部分 双波长PDL／Nd:YAG激光联合聚桂醇局部注射治疗在婴幼儿血管瘤中的临床应用 背景 婴幼儿血管瘤(Infantile Hemangiomas，IHs)是儿童中最常见的良性皮肤肿瘤，在儿童中发病率为4-10％。对于那些位于危及生命位置、可能导致功能障碍、内脏受累、趋向发生或是已经发生溃疡的血管瘤，积极治疗是非常必要的。而对位于美容敏感部位的血管瘤患者，也主张积极治疗，以达到尽量减少血管瘤毁容性表现的目的。目前，口服普萘洛尔是血管瘤的一线治疗方法。但这种方法也存在着一定的局限性：如复发、全身性的不良反应(睡眠障碍、腹泻、哮喘、低血压及低血糖等)、服药后瘤体继续增长等。因此，口服普萘洛尔并不适用于每一个病人。本研究的主要研究对象是不能耐受口服普萘洛尔的血管瘤患者，或是口服普萘洛尔后血管瘤瘤体仍然持续生长的患者。对这类血管瘤，我们通过双波长脉冲染料(PDL)／钕钇铝石榴石(Nd:YAG)激光联合聚桂醇局部注射治疗，发挥他们各自的优点，来达到一个满意的临床疗效。 目的 评价双波长PDL／Nd:YAG激光联合聚桂醇局部注射治疗婴幼儿血管瘤的疗效和安全性。 病人和方法 59例在山东省立医院整形美容外科首诊的诊断为婴幼儿血管瘤的患儿被纳入本研究。根据患儿家长的主诉、结合患儿的临床查体体征、B超检查结果，明确诊断为血管瘤，且为混合型的血管瘤。治疗方法是双波长PDL／Nd:YAG激光联合聚桂醇局部注射的序贯治疗，激光治疗和局部注射治疗之间的间隔时间为2周。在治疗前后记录血管瘤的大体情况；血管瘤的B超检查结果(包括瘤体的范围、厚度、血流信号的改变等情况)；记录治疗期间所发生的不良反应。由两名未参与治疗的临床医师根据大小等级量表(Size Rating Scale，SRS)及颜色等级量表(Color Rating Scale，CRS)的评价标准来评价治疗后的效果。 结果 共有59例的患儿纳入了本研究，其中，男23例，女36例，年龄在3-12月之间，平均的年龄在4.9月。5例患者为全身多发性血管瘤，48例为局部单发血管瘤患者，6例为节段性血管瘤患者。共有69处瘤体。瘤体面积在2-55㎝²，平均面积为11.2㎝²。所有的血管瘤均为混合型的，包括表浅部分及深层部分。 研究表明，患者接受1-5次的聚桂醇局部注射治疗，平均注射次数为2.4次。根据SRS来评价注射治疗的效果：29例患者达到治愈，占49.2％；20例患者达到有效，占33.9％；10例患者显效，占16.9％。患者接受2-7次的双波长PDL／Nd:YAG激光治疗，平均治疗次数为4.3次。根据CRS来评价激光治疗效果：27例患者达到治愈，占45.8％；24例患者达到有效，占40.7％；8例患者显效，占13.6％。 在我们的研究中，共观察到4例炎症后皮肤色素沉着和2例溃疡。4例炎症后色素沉着为暂时性的，在指导患者家属进行标准防晒后均完全恢复。2例溃疡经过规范换药在2周内愈合，未见明显瘢痕形成。也未见其他的不良反应。 结论 双波长PDL／Nd:YAG激光联合聚桂醇局部注射是治疗婴幼儿血管瘤的一种有效和安全的治疗方法，是口服普萘洛尔治疗婴幼儿血管瘤的一种重要补充方法。 关键词 婴幼儿血管瘤；双波长PDL／Nd:YAG激光；聚桂醇；硬化治疗

 Part I Effective treatment for hypertrophic scar with dual-wave-length PDL and Nd:YAC laser in Chinese patients Background Abnormal wound healing as observed in bums, trauma, surgery, and abrasions usually cause hypertrophic scars. It is very common in clinic. The common symptoms of hypertrophic scars are pain, itching, red, and raised. Most patients seek treatment because of being uncomfortable with cosmetic defects. Patients with severe scarring may have functional problems. Hypertrophic scars can be treated through various methods, such as silica gel treatment, drug injections, local pressure, micro-plasma radio frequency, laser treatment, and surgical scar revision. Each method is useful, as well as comes with its own limitations. In recent years, the effectiveness and safety of laser therapy have been more and more recognized, so laser therapy is widely used in treating scars. Several physicians have reported a positive response among hypertrophic scar patients treated with various forms of phototherapy, such as exposure to Pulsed Dye Laser (PDL), Intense Pulsed Laser (IPL), and fractional laser. For example, PDL and IPL can accelerate mutation of scar, whereas non-ablative and ablative fractional laser can improve scar’s texture. Objective The sequential combined PDL/Nd:YAG laser treatment that combines 585/1064 nm lasers has been found to be useful in improving acne vulgaris and leg veins; however, it is less reported for hypertrophic scar treatment. In our study, we have evaluated the effectiveness and safety of dual-wave-length laser in the management of hypertrophic scars. Materials and methods Twenty-five Chinese patients who clinically diagnosed as having hypertrophic scars participated in this study. Before laser treatment, all patient scars were evaluated using the Patient Scar Assessment Scale (PSAS). It contains six items that are scored numerically (1-10 for each item). The patients scored the characteristics of scar color, pliability, thickness, relief, itching, and pain. Two observers, who were plastic surgeons but did not participate in the research, scored patients’ scars by using the Observer Scar Assessment Scale (OSAS) which contains five items: vascularization, pigmentation, pliability, thickness, and relief. The treatment was terminated, when the color and thickness of the scar were obviously improved or patient achieved satisfactory results. All patients were treated with combined PDL/Nd:YAG laser at 4-6 weeks intervals. The patients and observers evaluated scars again by using the Patient and Observer Scar Assessment Scales. A 3-grade scale (poor, good, and excellent) was used to evaluate patient and observer satisfaction, at the end of laser treatment. We compared the changes in the various parameters before and after treatment. Statistical analyses were performed using GraphPad Prism 7.0. Results Sixteen female and nine male subjects, aged 7-35 years, were enrolled in our study, with a median age of 23 years. The total number of treatment sessions was determined by the response and satisfaction of the patient. The mean number of treatments was 5.3 (range: 2-11). We used pair t-test to compare the changes in each index before and after final treatment. The results showed that hypertrophic scar was significantly improved after several laser treatments. No severe adverse effects were observed. Most of patients and observers were satisfied. The observers’ satisfaction was slightly higher than that of the patients. Conclusions The hypertrophic scar was significantly improved after several laser treatments and severe adverse effects were not observed. Considering the safety and satisfactory effects of dual-wave-length laser treatment, it can be regarded as a good method for treating hypertrophic scars. This study clearly demonstrates that combined PDL/Nd:YAG laser treatment is an effective, safe and well-tolerated treatment option for hypertrophic scars. Key words combined PDL/Nd: YAG laser; hypertrophic scars; Patient Scar Assessment Scale (PSAS); Observer Scar Assessment Scale (OSAS) Part II Combination of sclerotherapy and dual-wavelength laser in the management of infantile hemangiomas in Chinese infants Background Infantile hemangiomas (IHs) are the most common benign vascular tumor, occurring in 4% to 10% of all children. Some cases of IH have a tendency toward regression, with treatment only required for complicated cases and IHs located in facial and other cosmetic positions. Since 2008, oral propranolol has become a first-line treatment for IH. But some patients respond poorly to oral therapy. There are also some complications with oral propranolol, such as sleep disturbance, diarrhea, bronchiolitis, hypoglycemia, and hypotension, etc. Oral propranolol therapy is not suitable for every patient. Combining dual-wavelength laser treatment and sclerotherapy of IH allows the different components of the treatment to play to their individual strengths, complementing each other so that a satisfactory result can be achieved. Objective To evaluate the efficacy and safety of combination therapy with sclerotherapy and dual wavelength pulsed dye laser (PDL) & Nd:YAG for infantile hemangiomas (IHs). Patients and methods Fifty-nine patients with IH were recruited from the plastic surgery department of Shandong Provincial Hospital Affiliated to Shandong University. All IHs which were diagnosed as mixed hemangioma had both superficial and deep components. All patients with IH received treatment with sclerotherapy and dual wavelength PDL & Nd:YAG treatment at 4-week intervals. The general situations of hemangioma before and after treatment were recorded. B-ultrasound examination results of hemangioma before and after treatment (changes in tumor thickness and blood flow signal) were recorded. Adverse reactions occurred during treatment were recorded. Observers assessed the size and color of IH using a size rating scale and color rating scale before and after treatments. Results Twenty-three male and 36 female subjects, aged between 3 and 12 months, were enrolled in the study, with a median age of 4.9 months. There were 5 cases of multifocal IH, 48 cases of focal IH, and 6 of segmental IH, representing 69 lesions in the 59 patients. Surface areas of the lesions ranged from 2 to 55 ㎝², with a mean of 11.2 ㎝². All IHs had both superficial and deep components. The study showed that IH improved significantly after several sessions of treatment. Sclerotherapy reduced the size of IH, whereas dual-wavelength laser lightened the color of IH. Size of IHs evidently improved after 1 to 5 treatment sessions, with a mean of 2.4 sessions, Infantile hemangioma color was clearly less intense after 2 to 7 treatment sessions, with a mean of 4.3 sessions. The data were also normally distributed. Estimates using the SRS indicated that sclerotherapy completely resolved the IHs in close to half (49.2%, 29) of the patients, mostly resolved in 33.9% (20), and a moderate decrease in size in 16.9% (10). Evaluation of the effect of the dual-wavelength laser treatment on the IHs using the CRS indicated that 45.8% (27) of patients experienced complete reduction in coloration, 40.7% (24) with color mostly resolved, and 13.6% (8) with an intermediate change. Four cases of transient hyperpigmentation and 2 cases of ulceration were observed in our study. The ulcerations healed in about 2 weeks using standard wound dressings. No other adverse effects occurred. Conclusion Combined sclerotherapy and dual-wavelength laser treatment is an effective and safe option for IH. It is an important supplement to oral propranolol in the treatment of infantile hemangioma. Key words Infantile hemangioma; dual-wavelength laser; sclerotherapy