{"id":14880,"date":"2026-07-05T19:30:09","date_gmt":"2026-07-05T11:30:09","guid":{"rendered":"https:\/\/fotonmedix.com\/"},"modified":"2026-07-05T19:30:09","modified_gmt":"2026-07-05T11:30:09","slug":"precise-energy-density-distribution-minimizes-bladder-neck-contractures-in-retrograde-prostatectomy","status":"publish","type":"post","link":"https:\/\/fotonmedix.com\/fr\/precise-energy-density-distribution-minimizes-bladder-neck-contractures-in-retrograde-prostatectomy.html","title":{"rendered":"Une r\u00e9partition pr\u00e9cise de la densit\u00e9 d'\u00e9nergie permet de r\u00e9duire au minimum les contractures du col v\u00e9sical lors d'une prostatectomie r\u00e9trograde"},"content":{"rendered":"<p class=\"wp-block-paragraph\">Le principal d\u00e9fi technique lors de la vaporisation transur\u00e9trale au laser pour le traitement de l\u2019hyperplasie b\u00e9nigne de la prostate (HBP) consiste \u00e0 limiter la formation de cicatrices tardives au niveau de l\u2019interface avec le col v\u00e9sical. Lors de l\u2019application d\u2019une \u00e9nergie thermique de forte puissance \u00e0 proximit\u00e9 du sphincter ur\u00e9tral proximal, une dispersion incontr\u00f4l\u00e9e de la chaleur par conduction entra\u00eene fr\u00e9quemment une n\u00e9crose capsulaire de l\u2019anneau fibromusculaire. Ces l\u00e9sions tissulaires profondes entra\u00eenent une inflammation chronique, une formation exub\u00e9rante de tissu de granulation, puis une contracture cicatricielle ou la formation d\u2019une st\u00e9nose, ce qui n\u00e9cessite une r\u00e9vision chirurgicale secondaire. Pour r\u00e9soudre cette complication clinique et structurelle, il faut trouver un \u00e9quilibre pr\u00e9cis entre l\u2019absorption cibl\u00e9e de la longueur d\u2019onde et la focalisation de l\u2019\u00e9nergie par micro-conduits, afin de confiner strictement les modifications thermiques au tissu ad\u00e9nomateux hyperplasique.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">R\u00e9sultats attendus de la vaporisation \u00e0 haute puissance<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Rendement d'extinction en milieu aqueux<\/strong>: Absorption d'\u00e9nergie localis\u00e9e au sein d'une couche tissulaire microscopique afin de provoquer une d\u00e9sint\u00e9gration cellulaire rapide.<\/li>\n\n\n\n<li><strong>Dynamique des fluides \u00e0 micro-ouvertures<\/strong>: Section transversale minimale de la fibre permettant d'optimiser l'apport de grande quantit\u00e9 de solution saline pour un refroidissement continu des tissus.<\/li>\n\n\n\n<li><strong>Confinement par barri\u00e8re de coagulation<\/strong>: Limiter le gradient thermique lat\u00e9ral \u00e0 une profondeur stricte de 1,0 mm afin de prot\u00e9ger les faisceaux neurovasculaires adjacents.<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">Voies de d\u00e9sint\u00e9gration cellulaire \u00e0 l'int\u00e9rieur de l'ur\u00e8tre prostatique<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Pour obtenir un soulagement rapide de l'obstruction urinaire lors des interventions chirurgicales li\u00e9es \u00e0 l'HBP, il est n\u00e9cessaire de mettre en \u0153uvre une strat\u00e9gie d'ablation syst\u00e9matique permettant de retirer efficacement les tissus tout en pr\u00e9servant les limites anatomiques du col v\u00e9sical. Le tissu prostatique se compose d\u2019une zone p\u00e9riph\u00e9rique externe et d\u2019une zone de transition interne, o\u00f9 des nodules hyperplasiques se d\u00e9veloppent et compriment l\u2019ur\u00e8tre. L\u2019objectif chirurgical du traitement au laser est de vaporiser en douceur ces nodules de la zone de transition jusqu\u2019\u00e0 la capsule chirurgicale, afin de r\u00e9tablir un canal large et d\u00e9gag\u00e9 pour l\u2019\u00e9coulement de l\u2019urine sans d\u00e9stabiliser l\u2019anneau proximal du col v\u00e9sical.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Les anciennes boucles de coupe ou les anciens syst\u00e8mes laser Nd:YAG d\u00e9pendent fortement de la teneur en h\u00e9moglobine des tissus pour l\u2019absorption d\u2019\u00e9nergie. La distribution des vaisseaux sanguins au sein des gros nodules prostatiques \u00e9tant tr\u00e8s impr\u00e9visible \u2014 ceux-ci \u00e9tant souvent obstru\u00e9s par des bandes stromales fibreuses denses ou des calcifications \u2014, les lasers ciblant l\u2019h\u00e9moglobine g\u00e9n\u00e8rent des profils de chauffage in\u00e9gaux et irr\u00e9guliers. Cette absorption irr\u00e9guli\u00e8re entra\u00eene une \u00ab cuisson \u00bb profonde et incontr\u00f4l\u00e9e des tissus, ce qui se traduit par une desquamation tissulaire retard\u00e9e, une dysurie postop\u00e9ratoire s\u00e9v\u00e8re et un taux nettement plus \u00e9lev\u00e9 de contractures du col v\u00e9sical.<\/p>\n\n\n\n<pre class=\"wp-block-code\"><code>[Fibre optique m\u00e9dicale de 400 \u00b5m] \u2500\u2500\u2500\u25ba Passe \u00e0 travers un cystoscope rigide\n \u2502\n \u25bc\n[Activation laser \u00e0 1 470 nm]     \u2500\u2500\u2500\u25ba Vaporisation interstitielle cibl\u00e9e de l'eau\n \u2502\n \u25bc\n[Coagulation contr\u00f4l\u00e9e de 1 mm]  \u2500\u2500\u2500\u25ba Obture instantan\u00e9ment les sinus prostatiques\n \u2502\n \u25bc\n[Pr\u00e9servation de l'anneau du col v\u00e9sical] \u2500\u2500\u2500\u25ba Pr\u00e9vient la formation de cicatrices et de st\u00e9noses\n<\/code><\/pre>\n\n\n\n<p class=\"wp-block-paragraph\">L'utilisation d'un laser \u00e0 1 470 nm permet de contourner ces limites structurelles en ciblant les mol\u00e9cules d'eau, qui sont r\u00e9parties uniform\u00e9ment tant dans l'\u00e9pith\u00e9lium glandulaire que dans le stroma fibromusculaire.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Lorsque l'\u00e9nergie laser est appliqu\u00e9e, elle interagit directement avec l'eau contenue dans les cellules, transformant instantan\u00e9ment le liquide en vapeur. Cette vaporisation rapide permet d'effectuer une incision nette et pr\u00e9cise \u00e0 travers les tissus sans provoquer d'accumulation de sang, ce qui \u00e9vite la carbonisation profonde et la d\u00e9chirure des tissus associ\u00e9es aux longueurs d'onde ciblant l'h\u00e9moglobine.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Afin de garantir une pr\u00e9cision exceptionnelle lors des man\u0153uvres au sein des lobes prostatiques \u00e9troits, le syst\u00e8me d\u2019administration doit r\u00e9duire au minimum toute obstruction structurelle. L'utilisation d'une fibre optique m\u00e9dicale de 400 \u00b5m offre un profil ultra-fin qui s'adapte facilement aux canaux de travail standard des cystoscopes. Ce petit diam\u00e8tre de c\u0153ur concentre l'\u00e9nergie laser en un point de haute densit\u00e9 \u00e0 l'extr\u00e9mit\u00e9 de la fibre, permettant une vaporisation imm\u00e9diate des tissus \u00e0 des seuils de puissance plus faibles.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Cette diffusion concentr\u00e9e garantit que l'\u00e9nergie reste focalis\u00e9e pr\u00e9cis\u00e9ment \u00e0 l'endroit o\u00f9 la pointe de la fibre entre en contact avec la prostate, ce qui permet au chirurgien de r\u00e9s\u00e9quer les nodules obstructifs situ\u00e9s pr\u00e8s du col v\u00e9sical avec une s\u00e9curit\u00e9 et un contr\u00f4le exceptionnels.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Protection de la capsule prostatique par modulation de largeur d'impulsion<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Il est essentiel de contr\u00f4ler la propagation de la chaleur vers l\u2019ext\u00e9rieur afin de prot\u00e9ger la fine capsule prostatique externe et les nerfs pelviens d\u00e9licats qui longent ses bords lat\u00e9raux. La profondeur de cette conduction thermique est d\u00e9termin\u00e9e par le temps de relaxation thermique de la matrice prostatique, riche en eau. Si le laser est utilis\u00e9 en onde continue, la chaleur s'accumule rapidement au sein du tissu et se propage vers l'ext\u00e9rieur au-del\u00e0 du bord de l'ad\u00e9nome, ce qui pr\u00e9sente un risque de perforation de la capsule, d'incontinence urinaire temporaire ou de dysfonction \u00e9rectile.<\/p>\n\n\n\n<pre class=\"wp-block-code\"><code>\u00c9mission en onde continue :\n\u00c9mission laser ===============================================&gt; Propagation thermique en profondeur vers la capsule prostatique\n\nStrat\u00e9gie en mode puls\u00e9 :\n\u00c9mission laser =====&gt; =====&gt; =====&gt; Chaleur confin\u00e9e \u00e0 la zone d\u2019ablation\nPhase de refroidissement    [P\u00e9riode de repos] [P\u00e9riode de repos]     [P\u00e9riode de repos]\n<\/code><\/pre>\n\n\n\n<p class=\"wp-block-paragraph\">La mise en \u0153uvre d'un cycle d'\u00e9mission puls\u00e9e introduit une br\u00e8ve phase de refroidissement int\u00e9gr\u00e9e entre les salves d'apport d'\u00e9nergie. Le r\u00e9glage du laser sur des impulsions br\u00e8ves, de l'ordre de la milliseconde, permet \u00e0 la couche cellulaire cibl\u00e9e d'atteindre les temp\u00e9ratures \u00e9lev\u00e9es n\u00e9cessaires \u00e0 une vaporisation efficace, tout en laissant au tissu environnant le temps de dissiper la chaleur.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Cette gestion thermique pr\u00e9cise maintient la temp\u00e9rature \u00e0 la surface de la capsule chirurgicale bien en dessous du seuil de l\u00e9sion cellulaire. Cette configuration permet de cr\u00e9er une couche h\u00e9mostatique fiable de 1,0 mm d\u2019\u00e9paisseur derri\u00e8re l\u2019incision \u2014 suffisamment \u00e9paisse pour obturer instantan\u00e9ment les sinus veineux prostatiques sous-jacents, mais suffisamment fine pour \u00e9viter les br\u00fblures profondes de la capsule, garantissant ainsi une intervention plus s\u00fbre et plus pr\u00e9visible.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Registre des cas cliniques : vaporisation sous-capsulaire dans le cadre d'une hyperplasie glandulaire s\u00e9v\u00e8re<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Les donn\u00e9es cliniques ci-dessous illustrent une intervention chirurgicale transur\u00e9trale pour le traitement de l'hypertrophie b\u00e9nigne de la prostate (HBP) r\u00e9alis\u00e9e avec succ\u00e8s \u00e0 l'aide de la plateforme FotonMedix LaserMedix 3000U5. Elles d\u00e9montrent une ablation efficace des tissus et un contr\u00f4le pr\u00e9cis de l'\u00e9nergie dans le cas d'une prostate pr\u00e9sentant une obstruction s\u00e9v\u00e8re.<\/p>\n\n\n\n<figure class=\"wp-block-table\"><table class=\"has-fixed-layout\"><thead><tr><td><strong>Param\u00e8tre clinique<\/strong><\/td><td><strong>Sp\u00e9cifications relatives \u00e0 l'admission des patients<\/strong><\/td><\/tr><\/thead><tbody><tr><td><strong>Profil du patient<\/strong><\/td><td>Homme de 73 ans<\/td><\/tr><tr><td><strong>R\u00e9f\u00e9rence pathologique<\/strong><\/td><td>R\u00e9tention urinaire r\u00e9cidivante associ\u00e9e \u00e0 des calculs v\u00e9sicaux secondaires (score IPSS : 31)<\/td><\/tr><tr><td><strong>\u00c9valuation du volume de la prostate<\/strong><\/td><td>92 grammes de volume total avec une importante compression bilat\u00e9rale des lobes lat\u00e9raux<\/td><\/tr><tr><td><strong>Choix de la longueur d'onde du laser<\/strong><\/td><td>Longueur d'onde de 1 470 nm uniquement<\/td><\/tr><tr><td><strong>Dimensions du c\u0153ur de la fibre<\/strong><\/td><td>Fibre optique m\u00e9dicale en silice de haute puret\u00e9 \u00e0 c\u0153ur de 400 \u00b5m<\/td><\/tr><tr><td><strong>Puissance de sortie<\/strong><\/td><td>100 watts<\/td><\/tr><tr><td><strong>Configuration de l'intervalle entre les impulsions<\/strong><\/td><td>Mode puls\u00e9 (configuration du rapport cyclique 60%)<\/td><\/tr><tr><td><strong>Dur\u00e9e totale de l'ablation<\/strong><\/td><td>S\u00e9ance continue de 48 minutes<\/td><\/tr><tr><td><strong>\u00c9nergie cumul\u00e9e administr\u00e9e<\/strong><\/td><td>172 800 joules au total pour la s\u00e9ance<\/td><\/tr><\/tbody><\/table><\/figure>\n\n\n\n<h3 class=\"wp-block-heading\">Calendrier de l'\u00e9valuation postop\u00e9ratoire<\/h3>\n\n\n\n<ul class=\"wp-block-list\">\n<li><strong>Jour 1 apr\u00e8s l'op\u00e9ration<\/strong>: L'irrigation v\u00e9sicale a \u00e9t\u00e9 interrompue pr\u00e9matur\u00e9ment en raison de l'absence totale d'h\u00e9maturie visible ; le patient a pu uriner normalement apr\u00e8s le retrait du cath\u00e9ter, avec un r\u00e9sidu post-mictionnel inf\u00e9rieur \u00e0 20 ml.<\/li>\n\n\n\n<li><strong>4e semaine apr\u00e8s l'op\u00e9ration<\/strong>: Le d\u00e9bit maximal ($Q_{max}$) a atteint 19,2 ml\/s ; l'examen cystoscopique confirme la pr\u00e9sence d'un ur\u00e8tre prostatique large et lisse, sans signe de desquamation tissulaire ni de st\u00e9nose.<\/li>\n\n\n\n<li><strong>Sixi\u00e8me mois apr\u00e8s l'op\u00e9ration<\/strong>: L'\u00e9chographie de contr\u00f4le confirme un volume prostatique r\u00e9siduel de 26 grammes ; cicatrisation compl\u00e8te au niveau du col v\u00e9sical, sans aucun signe de contracture ; le score IPSS reste stable \u00e0 6, ce qui confirme un r\u00e9tablissement complet.<\/li>\n<\/ul>\n\n\n\n<h2 class=\"wp-block-heading\">Contr\u00f4le de l'ablation tissulaire gr\u00e2ce \u00e0 une dynamique de d\u00e9collement contr\u00f4l\u00e9e<\/h2>\n\n\n\n<p class=\"wp-block-paragraph\">Pour obtenir un canal urinaire parfaitement lisse et d\u00e9gag\u00e9 \u00e0 travers la prostate, il est n\u00e9cessaire d\u2019associer la puissance de sortie du laser \u00e0 une technique de d\u00e9placement manuel syst\u00e9matique au niveau de la surface tissulaire. \u00c0 l\u2019aide du syst\u00e8me SurgMedix de FotonMedix, l\u2019op\u00e9rateur fait progresser le cystoscope dans l\u2019ur\u00e8tre prostatique et positionne l\u2019embout de la fibre de 400 \u00b5m au niveau de la commissure ant\u00e9rieure, en d\u00e9pla\u00e7ant le laser selon un mouvement de d\u00e9capage contr\u00f4l\u00e9, du col v\u00e9sical vers le bas jusqu\u2019au verumontanum.<\/p>\n\n\n\n<pre class=\"wp-block-code\"><code>                    [Position de l'embout de la fibre de 400 \u00b5m]\n \u2502\n \u25bc\n [Mouvement de d\u00e9capage vers le bas]    \u2500\u2500\u2500\u25ba \u00c9limine les nodules obstructifs couche par couche\n \u2502\n \u25bc\n [Champ de vapeur localis\u00e9 \u00e0 1 470 nm] \u2500\u2500\u2500\u25ba Obture instantan\u00e9ment les sinus prostatiques\n \u2502\n \u25bc\n [Canal ur\u00e9tral lisse] \u2500\u2500\u2500\u25ba \u00c9limine les sympt\u00f4mes mictionnels irritatifs\n<\/code><\/pre>\n\n\n\n<p class=\"wp-block-paragraph\">Un mouvement r\u00e9gulier de l'embout de la fibre vers le bas, selon un mouvement de d\u00e9capage, garantit que l'\u00e9nergie \u00e0 1 470 nm sectionne le tissu ad\u00e9nomateux de mani\u00e8re uniforme, sans cr\u00e9er de cr\u00eates profondes et irr\u00e9guli\u00e8res dans la paroi ur\u00e9trale. Lorsque le laser interagit avec les cellules riches en eau, il vaporise le tissu proprement, tandis que les courtes pauses entre chaque passage permettent au liquide d'irrigation salin d'\u00e9liminer les petits d\u00e9bris tissulaires et de maintenir une visualisation claire.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Cette approche syst\u00e9matique emp\u00eache le sang de s'accumuler ou d'obstruer le champ de vision du chirurgien, ce qui permet un suivi pr\u00e9cis des limites de la capsule chirurgicale. L'\u00e9nergie thermique restant confin\u00e9e dans une zone \u00e9troite de 1,0 mm, les r\u00e9seaux nerveux sensibles situ\u00e9s \u00e0 l'ext\u00e9rieur de la capsule prostatique sont prot\u00e9g\u00e9s contre les l\u00e9sions thermiques. Ce contr\u00f4le \u00e9limine les douleurs postop\u00e9ratoires intenses et les sensations de br\u00fblure couramment associ\u00e9es aux m\u00e9thodes de coupe traditionnelles, offrant ainsi aux \u00e9quipes d\u2019approvisionnement m\u00e9dical B2B une solution hautement fiable et rentable qui r\u00e9duit la dur\u00e9e des s\u00e9jours hospitaliers et \u00e9tablit une norme plus \u00e9lev\u00e9e en mati\u00e8re de s\u00e9curit\u00e9 des patients.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Foire aux questions sur les aspects techniques et les march\u00e9s publics<\/h2>\n\n\n\n<h3 class=\"wp-block-heading\">Pourquoi pr\u00e9f\u00e8re-t-on une fibre \u00e0 c\u0153ur de 400 \u00b5m \u00e0 une fibre de 600 \u00b5m pour la vaporisation de la prostate \u00e0 haute puissance ?<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">La sonde \u00e0 fibre optique m\u00e9dicale de 400 \u00b5m offre une flexibilit\u00e9 sup\u00e9rieure, permettant au cystoscope de se faufiler \u00e0 travers des cols v\u00e9sicaux \u00e9troits ou sur\u00e9lev\u00e9s sans exercer de contrainte sur les c\u00e2bles de guidage internes de l\u2019instrument. Son diam\u00e8tre de c\u0153ur plus petit concentre l\u2019\u00e9nergie \u00e0 1 470 nm en un point plus petit et de plus haute densit\u00e9 au niveau de la surface tissulaire. Cette focalisation pr\u00e9cise permet une coupe plus nette et une vaporisation plus rapide \u00e0 des puissances totales plus faibles, ce qui contribue \u00e0 \u00e9viter une propagation thermique \u00e9tendue vers les couches profondes de la capsule.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">En quoi le laser \u00e0 1 470 nm permet-il de r\u00e9duire les d\u00e9lais de r\u00e9cup\u00e9ration postop\u00e9ratoires par rapport \u00e0 la RTUP traditionnelle ?<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Les interventions traditionnelles de RTUP consistent \u00e0 exciser des tissus \u00e0 l'aide d'une boucle \u00e9lectrique \u00e0 haute fr\u00e9quence, ce qui laisse de vastes zones \u00e0 vif \u00e0 l'int\u00e9rieur de la prostate qui mettent des semaines \u00e0 cicatriser et provoquent souvent des saignements abondants lorsque la cro\u00fbte se d\u00e9tache.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Le laser \u00e0 1 470 nm vaporise les tissus de mani\u00e8re nette tout en obturant instantan\u00e9ment les vaisseaux sanguins sous-jacents, ce qui permet d'obtenir un canal lisse et sans saignement, facilitant ainsi le retrait rapide du cath\u00e9ter et r\u00e9duisant consid\u00e9rablement la dur\u00e9e d'hospitalisation du patient.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Quelles sont les consignes de stockage et de manipulation que le personnel clinique doit respecter pour pr\u00e9server les fibres proctologiques \u00e0 fort grossissement ?<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">Les fibres haute puissance \u00e9tant dot\u00e9es d\u2019un c\u0153ur fin en verre de silice, elles ne doivent en aucun cas \u00eatre pli\u00e9es de mani\u00e8re trop serr\u00e9e ni enroul\u00e9es au-del\u00e0 de leur rayon de courbure minimal de 60 mm, que ce soit lors du stockage ou de la mise en place. Avant d\u2019activer le laser, l\u2019op\u00e9rateur doit v\u00e9rifier que l\u2019extr\u00e9mit\u00e9 de la fibre d\u00e9passe d\u2019au moins 5 mm l\u2019extr\u00e9mit\u00e9 du canal du cystoscope afin d\u2019\u00e9viter tout dommage thermique accidentel \u00e0 la lentille de l\u2019endoscope. Enfin, le connecteur laser SMA-905 doit \u00eatre maintenu parfaitement propre et exempt d\u2019humidit\u00e9 \u00e0 l\u2019aide de lingettes optiques afin d\u2019\u00e9viter toute r\u00e9flexion d\u2019\u00e9nergie susceptible d\u2019endommager les ports de sortie du syst\u00e8me laser.<\/p>","protected":false},"excerpt":{"rendered":"<p>The paramount technical challenge during transurethral laser vaporization for benign prostatic hyperplasia (BPH) is the mitigation of delayed cicatricial scarring at the bladder neck interface. When delivering high-power thermal energy near the proximal urethral sphincter, unmanaged conductive heat dispersion frequently causes denrans-capsular necrosis of the fibromuscular ring. This deep tissue damage leads to chronic inflammation, [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"themepark_post_bcolor":"#f5f5f5","themepark_post_width":"1022px","themepark_post_img":"","themepark_post_img_po":"left","themepark_post_img_re":false,"themepark_post_img_cover":false,"themepark_post_img_fixed":false,"themepark_post_hide_title":false,"themepark_post_main_b":"","themepark_post_main_p":100,"themepark_paddingblock":false,"slim_seo":{"title":"Precise Energy Density Distribution Minimizes Bladder Neck Contractures in Retrograde Prostatectomy - FotonMedix","description":"The paramount technical challenge during transurethral laser vaporization for benign prostatic hyperplasia (BPH) is the mitigation of delayed cicatricial 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