DERMATOSURGICAL PROCEDURES FOR ACNE SCARS

DR SWATHY LEKSHMI J L

PATHOGENESIS

Inflammation

Granulation tissue formation

Matrix remodelling

• Proliferation of P.acne• Stimulation of innate immune response

• Activation of complement• Inflammation

• Inflammation extends to dermis • Degradation of dermal matrix

GRANULATION TISSUE

Shift in the balance of collagen type

Type 1 collagen- 80%

MATRIX REMODELLING

Activation of Nf-kb & Aps

Up regulation of MMPs

Procollagen synthesis

CLASSIFICATION OF ACNE SCARS

MACULAR

Erythematous

Hyperpigmented

Depressed

Ice pick- Depressed scars

wider at surface

narrower at base

Rolling- Distensible,

depressed scars with

sloping edges

Boxcar – Shallow or

deep, punched out

scars, wide at surface

and base

ELEVATED

Hypertrophic-Elevated fibrotic scars

Mandibular area, back

Keloidal-Back and

chest

Papular-Raised,

papular and fibrotic

Chin and nose

Bridging scars and sinus tracts-

Multiple linear scars , joined by

epithelial tracts

Surgical procedures

PREOPERATIVE ASSESSMENT

HISTORY

HSV infection

Recent use of Isotretinoin

Keloidal tendency

Current medication

Previous surgery

Degree of sunexpusre

Immunocompromising condition

EXAMINATION

General

Skin type

Keloid or Hypertrophic scar

Presence of infection

Activity of acne

Antiviral therapy 2 days prior and for 7-10 days after

procedure

Sun screen, HQ, Glycolic acid

Consent form

Photograph- mandatory for resurfacing with laser,

dermabrasion, chemical peels

Microneedling

Subcision

Punch technique

TCA CROSS

Dermal grafting

Indication

Rolling and Boxcar scars

MICRONEEDLING

CONTRAINDICATION

Active herpes labialis

Keloidal tendency

Isotretinoin therapy in the preceeding 6 months

Bleeding disorders

DERMAROLLER

Drum shaped roller

192 microneedles of 0.1 mm dia.

Needle length 0.5 – 2 mm

Motorised Dermastamps & Home

care dermastamps

PROCEDURE

Topical anaesthesia

Stretch the skin perpendicular to direction of movement of

derma roller

Roll the tool 4 times in 4 different directions

250-300 Pricks/cm sq.

Needle penetrates at an angle, then goes deeper, and

extracted at a converse angle

End point- uniform bleeding points over scarred area

POST PROCEDURE

Clean with NS

Oral analgesic

No need of phtoprotection

3-4 sessions at 4-8 wks intervals

SUBCISION

HISTORY

1957- Spangler

1995- David Orentreinch and Norman Orentreinch

Subcutaneous incisionless surgery

PRINCIPLE

Releasing fibrotic strands underlying scars

Organization of blood in the induced dermal

pockets

Connective tissue formation in the area

INDICATION

Rolling scars

PROCEDURE

Mark the scar

Local infiltration anaesthesia

18 G,1.5 inch Nokor Admix

needle

Insert the needle at periphery of scarred area

Move back and forth, fanlike motion

Firm pressure for 5 mts.

Avoid preauricular, temporal and mandibular areas

Repeat at 6 wkly intervals

2-3 sessions

COMPLICATIONS

Bleeding

Hematoma

Hypertrophic scarring

Scar recurrence

PUNCH EXCISION AND CLOSURE

Ind- Ice pick and Boxcar scars

PROCEDURE

Local anaesthesia

Select appropriate size punch

Traction at right angles to RSTL

Descend upto s/c fat and excise scar plug

Undermine the wound edges

Suture

PUNCH INCISION AND ELEVATION [Punch floatation]

Depressed scars with normal surface texture

Boxcar scar>3mm

PROCEDURE

Punch that match to inner dia. of crateriform scar

Rotating motion release bound down scar

Elevate the plug and free from underlying tissue

Elevate the plug and position to lie slightly higher than

surrounding skin

Secure in position by cyanoacrylate tissue adhesive

PUNCH REPLACEMENT AND GRAFTING

INDICATION

Deep irregular pits

Tethered boxcar scars with altered skin texture

PROCEDURE

Scar plug is removed and graft is transferred to the

plug site

Donor site- post auricular area and inner arm

Donor punch graft size> 0.5mm larger

CROSS

Technique using high strength TCA focally on atrophic acne

scars to induce collagenisation and cosmetic improvement

PRINCIPLE

Precipitation of proteins

Coagulative necrosis of epidermal cells and collagen

Dermal remodelling

INDICATION

Ice pick scars

PROCEDURE

Mark the scar

Clean with spirit and degrease with acetone

Patient in sitting position

Stretch the skin and apply 100% TCA focally

Avoid spillage

Keep the skin stretched until frosted

Wash the face

Photo protection

3 sessions , 4 wkly intervals

COMPLICATIONS

Transient post inflammatory hyper& hypo pigmentation

Priming skin with HQ and tretinoin for 2 wks

DERMAL GRAFTING

Placing dermal grafts into precise pockets under skin

ADVANTAGES

Not susceptible to infection

Can be tailored accurately

Creates a permanent space

Readily available

Easy to perform

PROCEDURE

Conventional

Enzymatic

CONVENTIONAL

Local anaesthesia

Subcsion 10- 14 days before

Donor tissue from post auricular area or from

dermabraded site

Defective area is tunnelled

Trim the grafts according to shape

Insert the graft and suture slit

ENZYMATIC TECHNIQUE

Graft in 0.25% trypsin in EDTA solution

Incubate at 37⁰ C for 75 mts.

Transfer to phosphate buffered saline and remove

epidermis

Insert the graft by conventional technique

or inject using a wide bore needle

RESURFACING TECHNIQUES

CHEMICAL PEELING

Salicylic acid 20-30%- active acne and

superficial scars

TCA 10%, 15%, 25%

Glycolic acid 25-35%

Jessener’s peel

Medium depth & deep phenol peels –

effective but not recommended

ABLATIVE

DERMABRASION

Ind- superficial acne scars

Spot dermabrasion can be done in office setting

Full face dermabrasion needs an operation theatre facility

Topical or infiltrative anaesthesia

Mark scars and stretch the skin

Dermabrade till the base of scars

Maximum level- Jn of upper and mid reticular dermis

Manual dermabrader to feather the edges

Hemostasis

Non adherent dressing for 1 wk

COMPLICATIONS

Infections

Persistent dyschromia

Hypo/ hyper pigmentation

Erythema & scarring

LASER ABLATION

CO2 laser (10,600nm)

Er: YAG laser (2940nm)

RESUEFACING – NON ABLATIVE OR MINIMALLY ABLATIVE

MICRODERMABRASION

Superficial minimally invasive technique of mechanical

abrasion of skin using a pressurised stream of abrasive

particles

Aluminium oxide crystals

Disposble diamond tip

Ind- Superficial scars

CI- Active infection

Concurrent dermatoses on face

Eye protection

Set machine parameters with pr. level 10-30 mm of Hg

Stretch the skin under tension

Move the hand piece in a sweeping, outward motion

2nd pass in a direction perpendicular to first pass except in

neck

End point- erythema

Topical antibiotic

Repeated weekly

COMPLICATION

Erythema, oedema, infection, purpura,

pigmentary changes and scarring

Conjunctival congestion

Crystal adherence to cornea

SPK

DISADVANTAGES

Does not improve deep scars

Multiple sittings

Maintenance therapy

NON ABLATIVE RESURFACING LASERS

Ind- atrophic acne scars

Nd :YAG LASER(1320 nm, 1064 nm)

Diode laser(1450 nm)

Flash lamp pumped pulsed dye laser(585 nm)

Er: glass laser

SOFT TISSUE AUGMENTATION

Ind- soft atrophic scars with loss of dermal tissue

Dermal filers are placed under scars

Elevate and bring the surface of scar in level with

surrounding skin

Subcsion or microneedling can be done prior

Hyalouronic acid fillers

Autologous fat

PLLA

Calcim hydroxyapatite

INTRALESIONAL STEROIDS AND CYTOTOXICS

Ind- Hypertrophic and keloidal scars

Triamcinolone 10-20 mg/ml + 5FU

SILICONE GEL SHEETING

Useful in flattening keloid and hypertrophic scars

SCAR REVISION

Ind- Linear and extensive scarring

Z, M and Y Plasty

CRYOTHERAPY

Cryoslush

Cryopeel method

FRACTIONAL PHOTOTHERMOLYSIS

Non injured part of skin is the source of keratinocytes

Migration begins within 24 hrs

Keratinocytes facilitate removal of MENDs

NON ABLATIVE

1550nm erbium doped fibre laser

ABLATIVE

Fractional CO2laser

Direct vaporizing effect on epidermis and some part of

dermis

Free of any active acne lesions

No history of keloidal tendency

PROCEDURE

Clean the skin with 70% alcohol

LA cream for 1 hr

No. of passes and fluence depending on skin type &

severity of scarring

Cool the skin with ice packs after procedure

Non comedogenic Abs for 3-5 days +sunscreen

COMPLICATIONS

Erythema and crusting

PIH

Dryness of skin

Pruritus

Bronzing of skin

Aggravation of acne

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