Authors:
Kristina Novak – otorhinolaryngologist, plastic surgeon, specialist in contour plastics, postgraduate student of the Department of Otorhinolaryngology, National Medical University. O.A. Bogomolets

Kristina Filevich - Intern Surgeon of KNP "1 TMO in Lviv, OP "Hospital of St. Luke", editor of Pro Cosmetology Bhub

War - trauma visible and invisible

Military injuries received by fighters and civilians affect all components of health. Injuries resulting from the combined effect of adverse war factors often cause life-threatening physical conditions and also provoke a significant deterioration in the mental health of the victims [ 1 ].
Scarring is one of the most common physical defects resulting from combat injuries.

Scars that victims receive during hostilities often become reasons for dissatisfaction with their appearance, a decrease in self-esteem. Also, scarring is a direct association with a traumatic experience, serving as a trigger for the onset or exacerbation of symptoms of post-traumatic, depressive disorders, neuroses, in particular, dysmorphophobia [ 2 , 3 ].

Difficult in aspects of rehabilitation and treatment are the physical complications of the scarring process. A volumetric tissue defect that occurs as a result of hypertrophic scars, and a violation of regenerative processes in the body, cause the development of contractures - limitation of joint movements associated with the recovery of the skin by a scar. This complication significantly reduces the patient's quality of life, reducing working capacity, and also has many concomitant pathological conditions, such as trophic disturbance, innervation of the affected area, lymphostasis, and progressive immobilization of a body part [ 4 , 5 ].

Post-traumatic hypertrophic scars

Hypertrophic scars are formed at the site of relatively large and deep soft tissue lesions. The process of scarring is accompanied by hyperproduction of connective tissue elements that replace and separate the skin defect. A large amount of newly formed dense scar tissue explains the direct correlation between the size of hypertrophic scars and the risk of contractures and impaired neurotrophicity of the affected area [ 6 ].

Among the approaches to the treatment and prevention of complications of post-traumatic scars, the occurrence of which was preceded by a combat injury, there are surgical and non-surgical ones.

Surgical treatments

Today, surgical methods of treatment are more often used. They involve the plasticity of the defect, sometimes using autotransplantation techniques. However, this method is quite traumatic, has a long rehabilitation period, many contraindications and high risks of complications. Among them, in this context, it is necessary to single out possible cases of an individual tendency to form keloid scars, which are often difficult to differentiate from hypertrophic ones [ 7,8 ], and the issue of treating such scars requires additional research, taking into account the not fully understood mechanisms of their development. Also, after surgical correction, there is always a risk of repeated postoperative scarring [ 9 ].

Non-surgical treatments

In our practice, it is also advisable to consider non-surgical methods of treatment of victims in combat operations with hypertrophic cicatricial processes.

Laser correction of scars and contractures

Laser therapy using fractional ablation technology is the most effective for eliminating cosmetic defects and contractures caused by hypertrophic scars after combat injuries [ 10 , 11 ]. Under the action of focused laser energy, thermal destruction of scar tissue occurs, as well as stimulation of collagenogenesis due to photothermolysis in the deep layers of the dermis. Laser correction of scars allows you to speed up the process of rehabilitation of the victim and prevent complications. According to recent studies, erbium lasers are the most effective in the treatment of scars and contractures [ 12 , 13 ].

Injection treatment with drugs based on hyaluronic acid and glucocorticosteroids

The effectiveness of this method of therapy for hypertrophic scars is explained by the synergistic effect of hyaluronic acid with non-crosslinked chains and cortisone. Recent in vivo and in vitro studies have clarified the mechanism of action of this treatment method: steroids, depending on the dose, reduce fibroblast proliferation, and hyaluronic acid, acting on prostaglandin secretion, reduces inflammation, and the presence of non-crosslinked chains improves regenerative properties. CD-44 receptors stimulate the release of cell proliferation factors [ 14 , 15 ].

Injection treatment with drugs containing polydeoxyribonucleotides

A new direction in the field of scar treatment is the injection of polydeoxyribonucleotides (PDRN). These substances are a combination of purine and phosphodiester bonds that form a pyrimidine nucleotide monomer capable of binding to adenosine A2 receptors, stimulating the release of vascular endothelial growth factor. The enhancement of neoangiogenesis improves the trophism of the dermal layers, which explains the effect of biorevitalization of polydeoxyribonucleotides [ 16 , 17 ].

Topical use of silicone-based gels

Silicone-based topicals, applied superficially to the scarring site, are a non-invasive treatment method. The anti-scar properties of silicone are explained by its polymeric structure, which provides long-term hydration of the stratum corneum of the dermis, as a result of which the production of fibroblasts is regulated, elastogenesis is stimulated and collagenogenesis is reduced. The regenerative properties of drugs are mediated by modulation of fibroblast growth factor (FGF) and tumor growth factor (TGF) [ 18 ]. Also, a layer of a silicone-containing preparation protects the skin from infection, the negative effects of UV irradiation, and the prevention of the development of pathological scar tissue [ 19 ].

The above methods for the treatment of post-traumatic hypertrophic scars, depending on the clinical situation, can be used as an alternative to surgical treatment or as part of a complex therapy consisting of invasive and non-invasive techniques.

conclusions

• Wound healing is a complex process and requires treatment, prevention of secondary infection, and care as soon as possible to minimize the risk of complications. Given the possibilities of medicine on the battlefield and the rules of medical triage, wounded military personnel and civilians do not always receive sufficient medical care, and therefore often face pathological scarring of wounds.
• The most common among post-traumatic scars are hypertrophic. The consequences of this type of scarring limit the physical properties of the body, leading to contracture and immobilization of body parts, and also reduce the quality of life of the victim, creating aesthetic discomfort, which can be a trigger for mental health disorders.
• Treatment of scars requires the compilation of unified protocols for the provision of medical care at different levels using the most effective methods of treatment. In addition to ensuring rational treatment, this will help increase public confidence in national medicine, as well as protect the rights of the attending physician to be able to use the latest treatment regimens with proven effectiveness.
• The management of patients with scarring problems requires an individual approach, so the best solution is a combination of various surgical and non-surgical treatment tactics.

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