SURGICAL TREATMENT OF ACNE SCARS

1. DERMATOSURGICAL PROCEDURES FOR ACNE SCARS
DR SWATHY LEKSHMI J L

2. PATHOGENESIS
Inflammation
Granulation tissue formation
Matrix remodelling

3. • Proliferation of P.acne
• Stimulation of innate immune response
• Activation of complement
• Inflammation
• Inflammation extends to dermis
• Degradation of dermal matrix

4. GRANULATION TISSUE
Shift in the balance of collagen type
Type 1 collagen- 80%

5. MATRIX REMODELLING
 Activation of Nf-kb & Aps
 Up regulation of MMPs
 Procollagen synthesis

6. CLASSIFICATION OF ACNE SCARS
 MACULAR
Erythematous
Hyperpigmented
 Depressed
Ice pick- Depressed scars
wider at surface
narrower at base

7.  Rolling- Distensible,
depressed scars with
sloping edges
 Boxcar – Shallow or
deep, punched out
scars, wide at
surface and base

9.  ELEVATED
Hypertrophic-Elevated fibrotic scars
Mandibular area, back

10.  Keloidal-Back and
chest
 Papular-Raised,
papular and fibrotic
Chin and nose

11.  Bridging scars and sinus tracts-
Multiple linear scars , joined by
epithelial tracts

12. Surgical procedures

13. PREOPERATIVE ASSESSMENT
 HISTORY
 HSV infection
 Recent use of Isotretinoin
 Keloidal tendency
 Current medication
 Previous surgery
 Degree of sunexpusre
 Immunocompromising condition

14. EXAMINATION
 General
 Skin type
 Keloid or Hypertrophic scar
 Presence of infection
 Activity of acne

15.  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

16.  Microneedling
 Subcision
 Punch technique
 TCA CROSS
 Dermal grafting

17. Indication
 Rolling and Boxcar scars
MICRONEEDLING

18. CONTRAINDICATION
 Active herpes labialis
 Keloidal tendency
 Isotretinoin therapy in the preceeding 6 months
 Bleeding disorders

19. DERMAROLLER
 Drum shaped roller
 192 microneedles of 0.1 mm dia.
 Needle length 0.5 – 2 mm
 Motorised Dermastamps &
Home care dermastamps

20. 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

21. POST PROCEDURE
 Clean with NS
 Oral analgesic
 No need of phtoprotection
 3-4 sessions at 4-8 wks intervals

23. SUBCISION
HISTORY
1957- Spangler
1995- David Orentreinch and Norman Orentreinch
Subcutaneous incisionless surgery

24. PRINCIPLE
 Releasing fibrotic strands underlying scars
 Organization of blood in the induced dermal
pockets
 Connective tissue formation in the area

25. INDICATION
 Rolling scars
PROCEDURE
 Mark the scar
 Local infiltration anaesthesia
 18 G,1.5 inch Nokor Admix
needle

26.  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

27.  Repeat at 6 wkly intervals
 2-3 sessions
 COMPLICATIONS
 Bleeding
 Hematoma
 Hypertrophic scarring
 Scar recurrence

29. 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

31. PUNCH INCISION AND ELEVATION [Punch floatation]
Depressed scars with normal surface texture
Boxcar scar>3mm

32. 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

33. PUNCH REPLACEMENT AND GRAFTING
 INDICATION
 Deep irregular pits
 Tethered boxcar scars with altered skin
texture

34. 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

36. 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

37. 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

38.  Avoid spillage
 Keep the skin stretched until frosted
 Wash the face
 Photo protection
 3 sessions , 4 wkly intervals

39. COMPLICATIONS
 Transient post inflammatory hyper& hypo pigmentation
 Priming skin with HQ and tretinoin for 2 wks

41. 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

42. PROCEDURE
 Conventional
 Enzymatic

43. 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

44. 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

45. RESURFACING TECHNIQUES

46. CHEMICAL PEELING
 Salicylic acid 20-30%- active acne and
superficial scars
 TCA 10%, 15%, 25%
 Glycolic acid 25-35%
 Jessener’s peel

47.  Medium depth & deep phenol peels –
effective but not recommended

48.  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

49.  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

50.  Hemostasis
 Non adherent dressing for 1 wk
COMPLICATIONS
 Infections
 Persistent dyschromia
 Hypo/ hyper pigmentation
 Erythema & scarring

51. LASER ABLATION
 CO2 laser (10,600nm)
 Er: YAG laser (2940nm)

52. RESUEFACING – NON ABLATIVE OR MINIMALLY
ABLATIVE

53. 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

54.  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

55. COMPLICATION
 Erythema, oedema, infection, purpura,
pigmentary changes and scarring
 Conjunctival congestion
 Crystal adherence to cornea
 SPK

56. DISADVANTAGES
 Does not improve deep scars
 Multiple sittings
 Maintenance therapy

57. 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

58. 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

59.  Hyalouronic acid fillers
 Autologous fat
 PLLA
 Calcim hydroxyapatite

61. INTRALESIONAL STEROIDS AND CYTOTOXICS
Ind- Hypertrophic and keloidal scars
Triamcinolone 10-20 mg/ml + 5FU

62. SILICONE GEL SHEETING
 Useful in flattening keloid and hypertrophic scars

63.  SCAR REVISION
 Ind- Linear and extensive scarring
 Z, M and Y Plasty

64. CRYOTHERAPY
 Cryoslush
 Cryopeel method

65. FRACTIONAL PHOTOTHERMOLYSIS
 Non injured part of skin is the source of
keratinocytes
 Migration begins within 24 hrs
 Keratinocytes facilitate removal of MENDs

66. NON ABLATIVE
 1550nm erbium doped fibre laser
ABLATIVE
 Fractional CO2laser
 Direct vaporizing effect on epidermis and some part
of dermis

67.  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

68. COMPLICATIONS
 Erythema and crusting
 PIH
 Dryness of skin
 Pruritus
 Bronzing of skin
 Aggravation of acne

69. THANK YOU