ACNE SCARACNE SCAR

BYBY::Dr.Mohammed Abd Alhussein Dr.Mohammed Abd Alhussein

LaftahLaftahResident of plastic and Resident of plastic and reconstructive surgeryreconstructive surgery

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Acne scarAcne scarintroductionScar is defined as ‘‘the fibrous tissue that replaces normal

tissue destroyed by injury or disease.’’ Causes of acne scar:

formation can be broadly categorized as either the resultof increased tissue formation or, more commonly, lossor damage of

local tissue.clinical classifications:

Acne scars are classified into three basic typesdepending on width, depth, and 3-dimensional architecture:

��Icepick scars: narrow (diameter < 2 mm), deep, sharplymarginated and depressed tracks that extend vertically tothe deep dermis or subcutaneous tissue .

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Boxcar scars: round to oval depressions with sharplydemarcated vertical edges. They are wider at the surfacethan icepick scars and do not taper to a point atthe base. These scars may be shallow (0.1–0.5 mm) ordeep (≥ 0.5 mm) and the diameter may vary from 1.5to 4.0 mm.

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••Rolling scars: occur from dermal tethering of otherwiserelatively normal-appearing skin and are usuallywider than 4 to 5 mm in diameter. An abnormal fibrousanchoring of the dermis to the subcutis leads to superficialshadowing and to a rolling or undulating appearanceof the overlying skin

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Other clinical entities included in this classification are:

hypertrophicscars, scars are raised within the limitsof primary excision ,

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keloidal scars scars transgress the boundary and may show prolonged and continuous growth

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sinus tracts may appear as grouped open comedones histologically showing a number of interconnecting keratinized channels.

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Prevalence of acne scarring:One study reported acne scarring in 14% of women and 11% of men among 749 patients aged between 25 and 58 years.Other publications suggest that between 30% and 95% of patients with

acne develop some form of associated scarring

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Treatment options:

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Topical agents:Topical retinoids:

Whether or not the use of topical retinoids improves acnescars that are already present has not been evaluated or quantified in an appropriately controlled study.

Topical retinoids, such as tretinoin, have been shown to increase dermal procollagen and collagen synthesis, and hence may provide some benefit in preventing scar development and potentially reduce the extent of scar formation that is in progress (“unfixed scarring”).there is no cogent evidence demonstrating that topical retinoidsreduce scars that are already fully formed in the dermis (“fixed

scarring.(”

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•Topical antimicrobial agents:•Of no benfit on fixed scar.•Topical corticosteroids:

•Intralesional triamcinolone injection for treatment ofhypertrophicand keloidal scars is well established

•Long-term topical corticosteroid application is not recommendedas local side effects, such as atrophy and telangiectasia

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Superficial peeling: • �Very useful for treating pigmented macular

scars • �Useful for improving boxcar scars

• �Improve active acne lesions • �Can be utilized for dark skin

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Superficial peelings include salicylic acid, 25% to 30%; glycolicacid, 70%; piruvic acid, 40% and/or 50% to 60%; trichloraceticacid, 20% to 30%; and combination of salicylic acid or Jessnerpeel with trichloracetic acid

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PathophysiologySupercial peelings are utilized to induce a damage limited tothe epidermis and papillary dermis. This results in epidermalregeneration and postinflammatory collagen neoformation

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ControindicationsControindications to superficial peelings include

•�connective tissue disorders • �active skin disorders on the treatment sites

•�history of treatment with systemic retinoids in the previous

4 months • �oral anticoagulant treatment

• �pregnancy

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Photographic documentationIt is mandatory to obtain good-quality pictures before startingthe procedure. This is an essential documentation for follow-upand for possible medicolegal issues

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Superficial peels are a cosmetic procedure that has the purpose of exfoliating the skin through the application of chemicals that induce skin irritation and damage.

•�Expect severe burning during the procedure. This will usually last for 3 to 4 minutes.

•�Expect skin redness for 2 to 3 days • �The skin will turn red brown and start to peel, 2 to 3 days after

peeling. Though rare, you can expect blisters and crusts. •�The procedure can cause pigmented or white spots that are usually

temporary and resolve in 1 to 3 months. In some skin types, however, thesepigmentary changes may persist and require specific treatments.

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•�For the first week after procedure apply a moisturizer 3 to 4 times a day.

• �Don’t scratch or remove the scales as it may result in scarring.

• �Avoid sun exposure, as it will cause development of pigmentary spots. Wear a high-protection sunscreen all the time for at least 2 months afterprocedure.

•�Superficial peels improve the skin, but may not completely eliminate acnes scars

• �You may need to repeat the procedure 3 to 6 times for optimal results.

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Boxcar scars before (A) and

combined 25% salycilic acid and 30% trichloracetic acid peeling.

after (B) 5 sessions with

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Boxcar scars before (A) and after (B) 5 sessions with 25% trichloracetic acid peeling.

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•white frosting indicates that it is time to neutralize with cold water.

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Medium depth and deep peeling:Agents include:

Trichloroacetic acid (TCA) , Croton oil, septisol, water, vegetable oils (glycerin, olive, sesame.

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32-year-old woman:(A) before and (B) 4 weeks after deep peeling (Exoderm method combined with mechanical dermabrasion

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Dermabrasion for acne scars:Dermabrasion is one • of the most effective therapies for�acne scars

• �Dermabrasion involves mechanically removing the epidermisand papillary dermis, creating a newly contouredopen wound to heal by second intention

• �Reepithelialization of dermabraded skin occurs byupward migration of cells from the adnexal structuresincluding hair follicles, sebaceous glands, and sweatducts.

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• �Patient selection is key to obtaining excellent results.

• �Patients must have realistic expectations of the anticipatedimprovement, possible side effects, and potentialcomplications of dermabrasion prior to treatment.

• �A familiarity with perioperative care and proper operativetechnique is instrumental to optimal cosmeticoutcomes.

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Dermabrasion of acne scars. (A) Severe acne scarring present in an African American male prior to dermabrasion.

)B (Postoperative appearance of the treated area. (C)Appearance of the treated area 4weeks after dermabrasion.(D)Moderately severe acne scarring present in a Caucasian female. (E) Appearance of the treated area 12 weeks after dermabrasion

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Endpieces commonly used in dermabrasion. From leftto right, wire brush, diamond fraize and cone-shaped diamond

fraize.

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Photograph demonstrating correct hand position ofthe operator on the dermabrasion hand piece

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Fillers and fat transfer for treatment of acne scarring:Better used in atrophic depressed scars.Agents include:

CollagensZyderm, Zyplast, Cosmoderm, Cosmoplast, Evolence, andEvolence Breeze are all collagens.

Hyaluronic AcidsPoly-L-Lactic AcidCalcium hydroxyapatite

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Fat TransplantationFat transfer can be helpful in acne scarring by restoring the loss of subcutaneous fat and replacing volume, which stretches the overlying skin and distends the acne scars. Patients who are particularly good candidates for fat transplantation include the acne-scarred patient who has a thin, atrophic face. Many of these older patients can benefit from a pan-facial lipoaugmentation concurrent with the specific injections designed to minimize the acne scarring.

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A) Before and (B) 2 weeks after treatment with injectable bovine collageninjected intradermally into the atrophic scars

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Needling: useful technique for acne scars treatmentas an alternative to laser, chemical peelings, anddermabrasion.

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• �Induction of new dermal collagen synthesis and depositionby activation of a local inflammatory response.

• �The skin is not damaged. The epidermis and particularlythe stratum corneum remain intact.

• �There are no risks of hyperpigmentation. • �The healing phase is short and the treatment can

beRepeated

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Method:Skin needling is a procedure that involves using a sterileroller comprised of a series of fine, sharp needles to puncturethe skin. Performed under local anaesthetic with sedation, thedevice is “rolled” over the surface affected by acne scars to create many microscopic channels deep into the dermis of the skin, which stimulates your own body to produce new collagen.

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Indications –Acne scarring: By treating acne rolling scars (Grade

2–3 (with skin needling, the skin becomes thicker,and the results are superior to dermabrasion.

–Scars, if they are white, they can become more skincolored.

–To restore skin tightness in the early stages of facialaging.

–Stretch marks. –Fine wrinkles.

Lax skin on the arms and abdomen

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•Application of a topical anesthetic (EMLA) on the facial skin in a patient affected with

acne scars

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Dermaroller

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The professional device is rolled on the areas affectedby acne scars in all possible directions

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in a

female patient after skin NeedlingFacial acne scars

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Fractional photothermolysis for acne scars:

Nonablative and ablative devices for the treatment of acne scars:

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Surgical techniques: Excision, grafting, punch techniques, and subcision:

Patient characteristics that are possible contraindications for surgical scar treatmentHistory of poor wound healing or tendency toward keloidformation/hypertrophic scarringUnreasonable expectations for improvementActive or recently resolved acne lesions

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• �Subcision: is a simple, well-tolerated procedure capable ofproducing long-term improvement of rolling acne scars .

IndicationThis technique is best used to treat rolling acne scars with normal-

appearing overlying skin and a lack of sharply delineatedborders. It is contraindicated for areas of active infection andin patients with bleeding diathesis or a tendency toward keloidformation. Other cutaneous depressions, such as rhytids,depressed skin grafts, surgical wounds, and cellulite dimples arealso considered valid indications for subcision.

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Immediately following subcision, there may bebleeding and ecchymosis at the treated sites. This is expected,

and it may be beneficial in promoting the formation of newcollagen beneath the depressed scars

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collagen beneath the depressed scars • �Dermal grafts are autologous implants that

may providepermanent augmentation of depressed acne scars.

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IndicationDermal grafting is indicated for the correction of broad (3

mm–2 cm in diameter) and linear scars that are soft and distensible).17 ,19 (Like subcision, dermal grafting can augment

depressed scars while leaving the overlying epidermis largelyintact, so it is best suited to treat scars with normal overlyingskin and a lack of sharp walls. Dermal grafting has also beenused to augment wider, deep rhytids such as nasolabial foldsand glabellar creases

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•�Excision and punch techniques remain the treatments ofchoice for deep, sharply punched-out acne scars.

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Thank you