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Surgery and Cosmetics

Bogdana Victoria Kadunc

Treatment of Acne Scars: Surgical or Fractional-based Laser Approach?

Bogdana Victoria Kadunc

Friday, April 12, 2013

Acne scarring results from the damage that occurs in and around the pilosebaceous unit during the acne process, leading to an increase or lack of tissue formation. It can be disfiguring and devastating, and can often negatively affect the patient's psychological, professional and social lives.

Acne sequelae present with heterogeneous morphology and have several degrees of severity; therefore, treatment is considered to be challenging. In order to treat patients with acne scarring, it is fundamental to classify the scars according to morphological features and the degree of severity. This would allow a more precise treatment indication, based on the pattern of each scar, and enable the dermatologist to provide a perspective of the possible improvement to the patient.

Kadunc Fig 1

Jacob et al.1 described three types of atrophic acne scars: rolling, boxcar and ice-pick. Additionally, Kadunc and Almeida2 carried out a comprehensive classification, dividing them into three types and 11 subtypes (Table 1). In 2006, Goodman and Baron3 outlined a grading system defining four grades based on the severity of scars: macular, mild, moderate and severe. That grading system was based on the color, number and visibility of scars.

Treatments for acne scars were first described in the literature from 1950 and comprised deep chemical peels, dermabrasion procedures, punch techniques and silicone injections.4 Publications about laser resurfacing,5 non-ablative lasers,6 and subcision7 treatments emerged in the 1990s, whereas the more recently published techniques describe the chemical reconstruction of skin scars (CROSS),8 the percutaneous collagen induction (PCI),9 the use of fractional ablative and nonablative lasers,10 and the injection of non-permanent fillers11 in the management of acne scars

Kadunc Fig 2


Types Of Acne Scars And Treatment Techniques

After learning the patients' expectations and possibilities (many prefer office-based procedures with short recovery times), the first step is to carry out a macro and a more detailed assessment of the shape, color, depth, size, consistency and number of scars, as well as considering the patient's skintexture and phototype. The various types of acne scars are described in Table 1, according to their morphologic classification3 and respective treatments.

Table 1. Acne Scar Types and Respective Treatment

Type of Acne Scars Treatment
Elevated hypertrophic Tangential excision + intralesional injections of corticosteroids
Elevated keloidal Subtotal tangential excision + intralesional injections of corticosteroid or bleomycin or 5-fluorouracil (Figure 1)
Elevated papular Electrosurgery (Figure 2)
Elevated bridges Tangential excision
Dystrophic Elliptical excision along relaxed tension lines + sutures
Depressed distensible retractile Subcision
Depressed distensible undulated Subcision + fat or calcium hydroxyapatite or poly-l-lactic acid or hyaluronic acid of varying viscosities injections, depending on the depth of the defect (Figure 3)
Depressed non-distensible superficial Dermabrasion, or ablative laser resurfacing  (CO2 or Er:YAG) (Figure 4)
Depressed non-distensible medium Punch elevation or electrosurgery based leveling of the borders or CROSS
Depressed non-distensible deep (ice-pick) 1-2mm diameter Post, infra- or pre-auricular punch grafting(Figure 5)or CROSS
Depressed non-distensible deep (ice-pick) 2.5-4mm diameter Punch excision and suturing along relaxed tension lines (Figure 6)


Kadunc Fig 3

 

The action of non-ablative (1,450 nm diode, 1,540 nm erbium glass, 1,320 nm and 1,064 nm Nd:YAG), fractional non-ablative (1,440 nm Nd:YAG, 1,540 nm erbium, 1,550 nm erbium) and fractional ablative (10,600 nm CO2, 2,790 nm YSGG, 2,940 erbium YAG) lasers, and radiofrequency in acne scarring is non-specific; it results in a controlled thermal injury that gradually stimulates the production of collagen, which moderately improves any type of depressed scar. Likewise, PCI promotes general collagen deposition as a result of bleeding, which leads to the release of several growth factors.

Understanding acne scar histopathologic findings and relating them to the treatment is crucial. Those findings consist of an increase in tissue formation, demonstrated in hypertrophic (elevated) scars/keloids, and tissue loss or damage, observed in atrophic (dystrophic and depressed) scars.

Kadunc Fig 4

In 2001, Lee12 conducted a study aimed at relating microscopic findings to diverse procedures for treating acne scars, examining 18 serial sections of 31 atrophic scars. In the epidermis, it was possible to observe keratin plugging in hair follicle orifices and multi-channeled tracts. The main features found in the dermis included a decrease in dermal thickness (with insufficient dense collagen fiber deposition), and loss of pilosebaceous units. Those microscopic features confirmed the indication of ablative methods to improve the cutaneous relief, and the use of fillers for the precise correction of the loss of volume in the dermis.

With the same objective of providing evidence of efficacy and safety in non-ablative fractional photothermolysis for acne scars, Bencini et al.13 used the in-vivo reflectance confocal microscopy to determine the consequences of six treatments with 1,540 nm erbium glass-fiber-delivered laser (Lux 1,540TM, PalomarMedical Technologies, Burlington, MA, USA), in patients presenting scarring grades 2 or 3, according to Goodman and Baron's classification.3 Six months following the last treatment, replacement of the old collagen with new collagen was observed. In contrast to the old and coarse collagen, this new collagen had thin and reticulate fibers and was particularly evident around the hair follicles, mirroring that seen in healthy skin.

Kadunc Fig 5


Acne Scars: Procedural Pearls

  • Chemabrasion consists of a trichloroacetic acid (35% TCA) full-face, medium chemical peel followed by motor or manual dermabrasion in the most affected cosmetic units. It is very useful as it facilitates mechanical exfoliation and helps to blend dermabraded and non-dermabraded regions, reducing demarcation lines
  • Punch techniques promote very precise corrections. When removing or elevating scars, it is important to choose the appropriate punch size (one that totally encircles the lesion). The ideal donor areas for punch grafting ice-picks are the pre- and infra-auricular regions, which produce grafts that fit perfectly in other facial areas
  • Low-energy electrosurgery can be used to vaporize papular scars (especially in the chin region) or to sculpt medium-depth, non-distensible scars on the shoulders
  • When performing CROSS with 50-100% TCA to stimulate neocollagenesis in the base of the scar, it is important to maintain the wooden applicator strictly inside the scar in order to avoid TCA diffusion, necrosis and atrophy in the surrounding skin14
  • Relaxation of the facial expression muscles with neurotoxins is useful before carrying out the correction of scars, particularly in the superior third of the face and in the chin region
  • PCI for acne scars is performed with a plastic cylinder with numerous (1.5-2.5 mm) needles protruding from its surface. When rolling the device over the skin in all directions, it is important to obtain high density and uniformity of micropunctures through the epidermis into the papillary dermis
  • Fractional lasers and PCI do not remove the epidermis, leading to a short recovery time and reducing the risk of post-inflammatory hyperpigmentation in phototypes IV, V and VI, compared to ablative techniques. All fractional techniques need repeated sessions aimed at the gradual deposition of new collagen fibers. In general, the initial results can be seen in 6 months after the first session

Kadunc Fig 6


Recent Literature

The CROSS technique was compared with the PCI15 and the subcision16 in two different prospective studies. The PCI and the subcision demonstrated superior results to that of TCA for treating distensible undulated/rolling scars in both studies. The improvements were measured by grading scales.

Ong and Bashir10 recently reviewed 26 published papers on the treatment of acne scars with fractional ablative and non-ablative lasers, having found that fractional ablative lasers had a rate of improvement of 26-83%, whereas fractional non-ablative lasers had 26-50% improvement.

A recent publication17described treatments for acne scars according to their level of scientific evidence (this comprised of two grading systems: Type of evidence [level I to VI] and Grade of evidence [A,B or C]):
I/B: CO2 laser resurfacing
II/A: 585 nm dye, 1,450 nm diode, 532 Nd:YAG and 1,320 nm Nd:YAG lasers
II/B: 1,064 nm Nd:YAG laser
III/B: Intense pulsed light , calcium hydroxyapatite
IV/B: CROSS, 1,540 nm erbium: glass, fractional CO2 and erbium lasers
V/B: Autologous fat, silicone
VI/C: Hyaluronic acid, poli-l-lactic acid, dermabrasion, microdermabrasion

Some important procedures, such as subcision, punch techniques and percutaneous collagen induction, were not rated, due to the lack of number and quality of published articles.

Unfortunately, only a small number of publications on procedures for acne scars describe objective methods for measuring improvement, meaning that there is a paucity of higher levels of scientific evidence regarding this subject.

Kadunc Fig 7

Conclusion

The ultimate goal of any intervention in acne scarring is not total cure or perfection; rather, it is making scars less visible. Multiple sessions of fractional lasers or PCI can be used in less severe cases or, as a complement to subcision, punch techniques and dermabrasion or CO2 ablative resurfacing in more severe cases (Figure 7).

References

1. Jacob CI, Dover JS, Kaminer MS. Acne scarring: a classification system and review of treatment options. J Am Acad Dermatol. 2001;45:109-17
2. Kadunc BV, Almeida ART. Surgical treatment of facial acne scars based on morphologic classification: a Brazilian experience. Dermatol Surg. 2003;29:1200-9
3. Goodman GJ, Baron JA. Post acne scarring - a qualitative global scarring grading system. Dermatol Surg. 2006;32:1458-66
4. Rivera AE. Acne scarring: a review and current treatments modalities. J Am Acad Dermatol. 2008;59:659-76
5. Jordan R, Cummins C, Burls A. Laser resurfacing of the skin for the improvement of facial acne scarring: a systematic review of the evidence. Br J Dermatol. 2000;142:413-23
6. Alster TS, West TB. Treatment of acne scars: a review. Ann Plast Surg. 1997;39:418-32
7. Orentreich DS. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg. 1995;21:543-9
8. Lee JB, Chung WG, Kwahck H, Lee KH. Focal treatment os acne scars with trichloroacetic acid: chemical reconstruction of skin scars method. Dermatol Surg. 2002;28:1017-21
9. Imran I. Microneedling therapy in atrophic facial acne scars:an objective assessment. J Cutan Aesthet Surg. 2009;2:26-30
10. Ong MWS, Bashir SJ. Fractional laser resurfacing for acne scars: a review. Br J Dermatol. 2012;166:1160-69
11. Beer K. A single-center, open-label study on the use of injectable poly-l-lactic acid for the treatment of moderate to severe scarring from acne or varicella. Dermatol Surg. 2007;33:S159-S167
12. Lee WJ, Jung HJ, Lim HJ, et al. Serial sections of atrophic acne scars help in the interpretation of microscopic findings and the selection of good therapeutic modalities. J Eur Acad Dermatol Venereol. 2011; Nov 5 [Epub ahead of print].
13. Bencini PL, Tourlaki A, Galimberti M, et al. Nonablative fractional photothermolysis for acne scars:clinical and in vivo microscopic documentation of treatment efficacy. Dermatol Ther. 2012;25:463-7
14. Weber MB, Machado RB, Hoefel IR, et al. Complication of CROSS-technique on boxcar acne scars: atrophy. Dermatol Surg. 2011;37:93-6
15. Leheta T, Tawdy AE, Hay RA, et al. Percutaneous collagen induction versus full-concentration trichlroaceti acid in the treatment of atrophic acne scars. Dermatol Surg. 2011:37:207-16
16. Ramadan SAER, E-Komy MHM, Bassiouny DA, et al. Subcision versus 100% trichloroacetic acid in the treatment of rolling acne scars. Dermatol Surg. 2011;37:626-33
17. LaTowski B, MacGregor JL, Dover JS, et al. Prevention and treatment of scars in evidence-based procedural dermatology: Murad Alam. Springer Science 2011:149-70

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